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JNWTNTHEE BMrAnY2_ WlHITE GANGRENE

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JNWTNTHEE BMrAnY2_ WlHITE GANGRENE Powered By Docstoc
					  756     M     JNWTNTHEE
     756 UDIcALJOURNA   *                        BMrAnY2,
                                                    WHITE GANGRENE.                                                  (MAY 27, 1916
                  Descriptiont of Cardiac JVounitds.                   phlegmasia alba dolens. Foot cold, and no pulsation to be felt
  The pericarldium showed an entrance and an exit wound over           in distal vessels of ankle; wound foul with sauious discharge;
the right venitricle. Oni openinlg the sac a small piece of khaki      temperature ]02°, pulse 124. Bacteriological examinationi showed
cloth was found, together with a small- qnantity of clotted and        streptococcus. Amputation through lower third of thigh;
fluid bloodl. The pericardium presenited the appearance of early       recovery (Lieutenant S.'s case).
pericar(litis. The left velntricle was distenided, but the right         CASE II.-Pte. L. was shot through the calf on September 24th
was partially collapsed, and niear the celntre of its aniterior sur-   and admitted to a base hospital on September 25th. There
face was a small circular wound of, enitrance which passed             was a small wounid of entrance and a wound of exit the size of
obliquely through the muscle to a wounid of exit very near to          half a crown, through which muscle bulged; the leg was white,
the riglht border of the lheart; an initerval of ain inch separated    the skin tense and cold. Incisions, 3 in. long, were made on
the two wounds, anid rounld each was a small circular area of          each side tlhrough the bullet track, capillary bandages were
bruiised tissue. The right ventricle was opeined posteriorly and       inserted, and COntinuous saline irrigation applied. The next
found to conitain some very brighit red blood clot. No wound           day the skin was much more swollen, it pitted on firm pres-
was visible from the initerior, and oni passing a proble it was        sure, and had the appearance of a limb containing deep-seated
founid that the wounud passed througlh one of the lacunae be-          pus but was white in colour. Very little pus came from the
tween the pillars of cardiac muscle, having just penetrated the        wounds ; a thin, foul-smelling discharge exuded. The patient's
ventricular cavity.--                                                  temperature was 1030; he was restless, and Iiis general condi-
                                                                       tion was very much worse. Numerous incisionis were made
  The cause of deatlh was severe liaemorrlhage, compli-                into the subcutaneous tissue. The patient's coindition did not
cated with pulmoniary collapse and interference witlh the              improve, the pulse became rapid, shock was very pronounced.
heart's action. Tlle enornious amount of blood in the                  The limb turned blotchy black aind was extremely foul. The.
                                                                       usual remedies were employed, including rectal salinie injection.
pleural sacs came from the hjeart; the lung wounds were                The patient died eight hours after the secoln(d operation.
not capable of causinig miiuch haemorrlhage. With each                   CASE iII.-Cpl. W., admitted to hospital sufferinig from a shell
systole somne blood would be forced through the small                  wound of thigh. There was a compound fracture of femur and
openinigs in the riglht ventricle into the pericardial sac, and        severe destruction of the knee-joint. The woun(ds had been
froin there blood would ooze through tlle p6ricardial open-            cleaned and dressed with cyanide gauze at a clearing station.
                                                                       About fifty-six hours after the injury the patienit lhad a rigor.
ings into the pleurae. There was no attempt at closure                 His temperature rose to 1040F.; vomiting alnd collapse occurred.
of tlle openings by clot. Tlleir small .size accounts for the          The limb became cold alnd no pulse could be detected. The
lengtlh of timue tlle patient survived.                                skin was wbite in colour, and a firm oedema rapi(dly occurred
   The occurrence of pericarditis and pleurisy (tlhe latter            in the whole limb. No crackling was present, indicative of gas.
being curiously localized) showed the beginning of an                  The patient's condition did not admit of- surgical interfereice,
                                                                       and he died twelve hours after the appearance of the gangrehe.
infective process.                                                     Bacteriological examination discovered streptococci in the
  Thle wounds of the left lung were no doubt closed by                 blood and in the discharge from the wound.
blood clot, wlhile that of the right was kept open by the
shrapnel on tlle surface causing collapse.
  An x-ray photograplh of the specimen was taken bv
Captain F. H. Gibson, R.A.M.C, and no foreign body other               SIMPLE AND INEXPENSIVE METHODS FOR
than the one described was found.                                          FERMENTATION TESTS AND FOR
   The specimen lhas been sent to the War 'Museum of the
Royal College of Surgeons, London.                                             OBTAINING CULTURES OF
                                                                                      ANAEROBES.
                                                                              By J. M. BEATTIE, M.A., M.D.,
                 WlHITE GANGRENE.                                           PROFESSOR OF BACTERIOLOGY, UNIVERSITY OF LIVERPOOTL.
                                 BY
          MAJOn A. J. HULL, F.R.C.S., R.A.M.C.                         Iiw most bacteriological laboratories the worlk luring tlle
                                                                       war has been very nmuch increased, anid witlh tlle increased
 IN addition to gas gangrene and gangrene due to direct                cost of apparatus and media various devices have had to
 interference withl thje blood supply, septic gunslhot wounds          be employed to reduce expenditure. It myy, tllerefore, be
 may be attacked by a very acute iiif sctive process wlich             of interest to record two metlhods whiclh I am using, and
 is a formn of gangrene. The condition appears to be an efficient.     which are simple, inexpensive, and, at tlle same time,
 acute streptococcal infection, and is, in appearance, not                         1. For Fermentation Tests.
 unlike phlegmlasia alba dolens, but is attended by the local       For these I use small test tubes, wllich can be made in
 circumstances associated with gangrene and tlle general tlle laboratory from ordinary glass tubing of I in. or 3 in.
 effects of an acute toxaemia.
    Tllis form of gangrene has only been seen in the lowver of the sugar media. into these tubes about -- c.cm. of any
                                                                 diameter. Introduce
                                                                                          These tubes, plugged and sterilized
 extremity.                                                      in tlle ordinary          are inoculated with tlle organism
    The skin is. glazed and white, moist, cold, and pits on whose reaction isway,be tested, and tllen some sterilized
                                                                                      to
 firm pressure. A very firmu oedema is present, and tlle vaseline, whichl lhas a nmelting point of about 550 C.,
 distal pulse in the limlb canlnot be felt. The glazed wlite
 appearance of the distended skini, instead of tlle usual poured inlto the tube. The vaseline solidifies and forms
                                                                                              with the fluid media. Thje tubes
 redness, seems particularlv clharacteristic. Early in the are thenlying in contacttlle ordinary way, and wlhere gas
                                                                 a plug,
                                                                            inicubated in
 condition the patient is extremlely ill, with clammy, is
 sweating face, and running pulse. The condition is if form-ed the is cold when inoculated,up in tlle tube, and,
                                                                     the media
                                                                                 vaseliine plug is puslhed
                                                                                                             thlere is sufficient
 extremely fatal, and deatlh occurs in about twelve hours. absorbed oxygen to allow the free growvtl of the organism
 The infection is so rapidly fatal tlhat little change in the and to allow the reddening (the acid reactioni) to slhow.
 colour of the limb lhas been noticed. In those cases whicl In twenty-four hours, with the ordinary acid and gas.
 have survived somewhat longer, it lhas been found that,
 during the last few lhours, the limub has become mottled producing definite. Later, typhoid-colitakes place reactions
                                                                             inembers of the
                                                                                                reduction
                                                                                                            group, tlle
                                                                                                                         anid the
 black and tlle disclharge exceedingly foul. No gas has are very
 been noticed in the disclharge, and no crackling hias been the vaseline plugcolouirless, ingress aoflhole is bored reaction
                                                                 media becomes
                                                                                      to allow
                                                                                                but if
                                                                                                           air the red
                                                                                                                         through
 detected in the tissues. The appearance is somewhat reappears in a few minutes, starting at the upper part of
 sug,gestive of deep-seated pus, owing to tlle tension of the the media and
 skin, but, on making an incision into the limnb, the wound metlhod is simplegradually spreading downwards. added
                                                                                       and inexpensive, and it has tlle
                                                                                                                             This
mnerely oozes serumn.
    In the more severe and extensive forims the infection is advantage over the ordinary method thjatby the quantities
                                                                 of gas, which may             be indicated
                                                                                                                small
so severe and the patient's condition so serious that no Durlham tube method, not always detected, tlle gas ordinary
                                                                                          are                            slhowing
treatment appears practicable.
   Amputation gives tlle only chiance of recovery, and Tllesmall bubbles at tlle lower accurate the vaseliineof the
                                                                 as
                                                                       metlhod
                                                                                                     part of
                                                                                                              estilnatioln
                                                                                                                             plug.
is successful wlhen thle infection is more localized, as amount of gasmay be used for given organism.
                                                                                  produced by any
happened in Case I.
                     Whr/ite Gangrene of the Leg.                                 2. For Ana!robic Cultinr-es.
   CASE I.-Pte. S., wounded March 9th 'with rifle grenade,          Ordinary test tubes containing peptone broth or glucose
dressed at field ambulanice and tranisferred to base. Shell peptone broth are
wound of left leg witlh comminuted fracture of upper third of                          used, and for tlle collmmon ana6robes
tibia and fibula, anid flesh woun(ds in the region of knee. Leg I find tlle peptone brotlh quite satisfactory. Melted
iwollen and white, exte'nding well up to thigh, and looking like sterilized vaseline is poured into the tube till it forms a
  MAY 27, I9I6]                                         MEMORALNDA.                                            J.D.Tt1 tn
                                                                                                                   3Us       75
Vplug about twenty tololng. The broth and vaseline are then
boiled for
            1to 4 in.
                       tlhirty miniutes, so as to
                                                                  myiake it large and flabby, just like an uncontracted uitetis
                                                                  after confinemnent; whilei on fruit it is stuall aidtl firnm, l
                                                expel any
absorbed air, and allowed to cool. Trle vaseline solidifies       the well-contracted uto'rUS.
very rapidly anid forms a very effective plug. 'T he tubes           It was by miiere accident that I came to the conelusion
can be kept for any length of tinte and are perfectly             that animal food was.not good for me, and I lhave been w
airtiilt.                                                         vegetarian sinice 1896.-
   Wlhen they lhave to be inoculated, they are put in a              Professor Shattock from hlis researclhes concludes that
water bath at about 550 C. in order to melt the vaseline,         vegetarianism-tlle k4cent rise of wlhichi lhe lhas recog-
*and the infective material is introdutced into tlhe broth by     nized-mav be the cause of appendicitis, leaclingu to au
means of a sterile pipette. Immnediately after tlle tube          increase in the formnation, of appendicuilar colleretions.
hbas been inoculated it is my practice (tlhouglh I tlhink in      That conclusion, takeil in connexion with my observationm
most cases this is unnecessavy) to hleat thle vaseline over       on the differenit effect 6f vegetables and of frIIit Upon tlhe
the Bunsen flame before puttling in tlle incubator, in case       caecum, points towards food as laving to do witl tlhe
of infectionl of the surface vaseline.during inoculation.         increase in tlle number of cases of appencdicitis, and mi-iay
   I have used tlle metliod for tlle conmmon ana6robes, and       lhelp to direct the attention of plhysiologists to thle plhysio-
I have never faIled to get a good growth in twenty-four           logical action of our commnon foods-a subject lhitlherto
lhours. The iuetliod lias the advantage over the ordinary         entirely neglected.
anaerobic methods of simplicity and clheapness, and I               Denholm, Hawick.                     JOhiN HADDON, M.D.
really adopted it because of the increased cost of and the
difficulty of obtaining the reagents wlhich are usually
employed in anaerobic culttire. It lhas a further advantage
that tlle developmsent of even mere traces of gas can be
detectecl. For exmminaticon of the culture, the plan I use
iS to pluncture the vaseline witlh a thlinly drawn-out
                                                                               Urtiortss       of *0rittirs*
pipette sealed at the lower end, anid constricted about half      TOXIC CAUSES OF IDIOCY AND IMBECILITY.
an inell from the sealed end. By pushling the pipette             AT the ordinary quarterly miieeting of' tle Medico-Psyclho
agailnst tlhe bottomn of tlhe tube it easily breaks at the con-   logical Association of Great Britaini and Ireland, lheld at
striction, and any quantity of the fluid culture can be           the roonms of the Medical Societv of London on May 16th,
drawn up. After the pipette is withdmTawv the vaseline -is        wlhen Lieutenant-Colonel DAVID G. THO05SON, President,
melted and tlle tube is agrain tightly sealed.                    was in the cllair, two papers were read by Dr. Orr
                                                                  (Prestwichi) and Major Rows, 'R.A.M.C. (Maglhull, Liver-
                                                                  pool), on experimental toxic lesions in tlle rabbit's brain
                                                                  and their bearing on tlhe genesis of acquired idiocy and
                                                                  imbecility in mlian. Dr. OaR said tllat tlle conmmiiunication
                                                                  was a continuation of experimental worlk on tlle action of
MEDICAL, SURGICAL, OBSTETRICAL.                                   bacterial poisons oni the nervous system. In tlie former
                                                                  work the induced toxic action was studied in the spinal
             THE CAUSE OF APPENDICITIS.                           cord only ; in the present series the researellclad been
PROFESSORI SHATTOCKI'S paper in the Section of Pathology          extended to tlhe brain, a capsule containing Stacplhylo-
in the Royal Society of Medicine, wllic' treats of thle           coccus autreuts being placed in contact witlh thle commlon
nmeehaniical causation of appendicitis (p. 690), is of special    carotid artery in thle neck. The positive results so far
interest to me. Having lhad it miyself, a few facts as to         obtainied lielped to explaini the patlhogelesis of certain
imy experience may lhelp those who are tryino to finid out        obscure lesions of the cenitral nervous system in man.
the true cause. Towards the end of 1881, wlhen in practice        Rabbits were used for experiment. The alterations seen
at Eccles, I began to suffer fronm insomnia. If I fell asleep     as the result of the poisonl were typically tllose of coagula-
wlhen I went to bed I awoke about 4 o'clock next mornina          tion necrosis. T1'lie nenroglia participated actively in thle
anid could not sleep again; whereas if I did not sleep on         inflammatory reaction, and around tlle area of softening
going to bed, it was about 4 o'clock before I slept. That         there was fountd to be nmuch nieuroglial proliferation anld
fact points to a periodicity wlich ouLglht not to be over-        lhypertroplhy. There was a hiiglh degree of proliferation of
looked. I did lnot feel ill, aldv about muy work as
                                    went                          thle adventitia of 'tle small vessels in the immediate vicinity
usuial until about the middle of Decenmber, wlhen I went to my    of the softeniina. The research slhowed that tlh two
ancestral home in Scotlanid for a lholiday, hoping to get rid     factors, degree aud situation, -could produce dissimilar
of the insomnia. While there I was out all day, generally         patlhological results altlhouglh tlle pathogenesis was the
with the gun. I ate as usual and the bowels acted every           samiie. Applying this to clinical neurology it becanie-evident
 Torning, but I was con1scious that there. was somne              that certaini lnervouis syndromiies, tliouglh widely different in
clifference in the miiotion. It was a spluttering myiotion,       symptomatologv, were, pathogenetically, olle and tlle same
from flatus passing withl thje faeces. After ten days I i.e.      dlsease, the different symiiptoinatoloay being largely due to
turned to Eceles on Decemliber 24tlh. Having had breakfast        the aniatoinical site of the lesion. 'The experiients also
before starting, I miglht lhave lhad a sandwich on the            slhed light on tlle genesis of tlhe infantile corebropatliies'
journey, and vwhen I got lhom-e I lhad an egg, a slice of         now recarded as dcue to toxi-infections of miiedium intensity
wlhite toast, a cup of tea, and went to see a patient wlho        contracted betweeni tlle fiftlh anid the eighlth month of fetal
was very ill. Going to bed at my usual timne I fell asleep,       life, or, more ravely, in early infaicy.
and awvoke about 4 a.m. witlh pain in the left side of the           Major Rows, M.D., said that thle term "-vegetative
abdomen. I took a dose of castor oil, anid was sick, but          systenm " com1prised( botlh the sympathetic and tlle auto-
had no motion. In tlhree days, having been in bed all the         nomic systemns. Under th0 terini "vecgetative nervouts
time, appenidicitis was diagnosed by the late Sir William         system" were includedl all thle fibres wllich wrevt to the
Roberts, wh1o advised me to keep to peptonized miilk as           organs lhaving simootlh llLuseles, sudh as initestines, blood
food and to ha;ve morpline to relieve pain. I lhad general        vessels, glands, ducts,' and skin, as well as tlle nerve- strue-
peritonitis, and for twelve montlhs afterwards could feel a       tures exerting a secretory influence upon glands; it also
lurmp, tlle size of a lien's egg, just inside the superior        embraced 'ceitain' organs witlh cross-striated-musces, nLuch
crest of the ilium, where, according to my observation,           as the heart, tlhe beginning and the Cnd of lthe alimentary
and not at McBurney's spot, the appendix lies. Havinjg            canal, and tlle muscles of tlle genital apparatus. Ainasto-
been about tlhr ee weeks in bed I wvent to Scotland to            moses were commnon among the nerve ftbre of the vegeta-
recruit. I was astonisled to find tlat my melorv, whicl           tive system. This system also had a muiel more indepen-
was very good before that illness, lhad failed. I lhave never     dent action, and it reacted to d-uggs in an altogether
lhad anotlher attack, but ever siDce lhave lhad to be careful     different manner; indeed, it was from the latter that so
as to diet, and was induced to study thie plhysiological          muchl had been learnit about it. A sort-of balance seemed
action of foods for miy own sake. As a result I publishted        to be mnaintained betweeni tlle autonoinic and the sympa-
whlat I called A Doctor's Discovery, whiclh, altloullgh not       thetic systems, so that one ass-amed an exaggerated action
newv, was quite original on miiy part; and thlere I thlink I      if the influenlce of tlle otlher were interfered witlh. Both
prove that food is the chief cause of disease. Having got         systems were miuch affected by the secretions of variotis
rid of all utinnecessary fat I can feel miiy caecum, and,         enlidocrinic glands. Dr. Orr andi lhe lhad demnonstrated that
watchina thle effect of food on it, I find that vegetables        chalnges could be pr-oducedl both fi the vegetative system

				
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