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days before. I cut down and tied the artery just below the apex of Scarpa's triangle, evacuated the clots and drained. During the first thirty-six hours circulation was much impaired, but after forty-eight hours improved rapidly. Three days later a large spot of moist gangrene, involving the tissues down to the bone, appeared on the outer aspect of the leg; on the end of each toe there was also a spot of dry gangrene. The sloughs developed in what appeared to be perfectly healthy tissues, and certainly those on the toes were not due to pressure. He made a fairly rapid recovery under anti-syphilitic treatment.

CASE 3.-It was reported to me that a beggar was going around the streets with a pair of “black legs and feet like a Chinaman's dress boots,” and a few days later he appeared at the hospital gate. He was suffering from symmetrical gangrene of feet and legs. The line of demarcation had formed slightly above the junction of the lower and middle third of each leg, and the bones at this point were quite bare for nearly an inch. The tissues were shrivelled, blackish, and almost dry, except in vicinity of line of separation.

The condition came on suddenly, following convalescence from an attack of fever. He had been exposed to cold while soldiering, but the possible effect of frost was excluded by the fact that he was in Szchuan several months before he was taken ill. Both legs were amputated just below the point of election, and the tissues, including the arteries, especially of one leg, were found friable and apparently of low vitality. He made a good recovery and grew fat on free anti-syphilitic treatment.

I have now in the hospital ward another case of diffuse popliteal (?) aneurism, extending from apex of Scarpa’s triangle to within five inches of heel. The history pointed to a rupture of the artery forty days before he came to the hospital, and his leg was in a terrible condition; in fact, he seemed to be dying. On the inner aspect of the calf was a large livid spot two and a half by three inches, which he said had developed within four or five days, and which next day began to separate in the form of a slough, leaving a punched out ulcer, extending to, but not involving, the muscles. Owing to the late date of observation, I simply mention this case as being at least suggestive.

In conclusion, I would present the following summary as pointing to syphilitic gangrene:

1. With one exception the patients were young men, and were not, so far as could be detected, suffering from general atheroma.

2. In each case there was reasonable proof of syphilitic taint.

3. In each case the rupture or occlusion came on suddenly, and if this occurring in the brain points to syphilis, as is claimed by some authorities, may not the same hold good for other parts of the body?

4. No apparent or sufficient cause. This applies specially to Cases 1 and 3.

5. The éschars in their development, color, separation, and the resulting ulcers closely resembled the description given by the author quoted.

6. The therapeutic test.

On account of space, I have confined myself to a bare outline of each case, but trust I have said sufficient to draw attention to an apparently frequently overlooked sequel to this extremely prevalent disease.The China Medical Missionary Journal.




ALICE S., aged 10, always delicate, was taken ill with diphtheria Dec. 27th, 1904.

She was a mouth breather, and had suffered most of her life from adenoids and very large tonsils. Was called to see her Dec. 30th, and found a thick membrane covering the tonsils and extending downwards into the larynx and up through the nose. There was commencing laryngeal stenosis, and it was because of the croup that medical aid was sought.

She was given 2,000 units of Mulford's antitoxine between the scapulæ, a tent was improvised, and 20 grains of calomel evaporated every three hours. In the interval between the calomel fumigations, the tent was kept filled with steam containing tr. benzoin co. and ol. eucalyptus. This fumigation was kept up for about two days, and the steam ten days.

On the third day after the antitoxine was administered the membrane had for the most part separated. A spray of hydrogen peroxide was used every two hours from the first. After the membrane had separated, it was re-formed to some extent. This was thought to be due to the irritation of the spray, and the peroxide was changed for a solution of boric acid and alum, with satisfactory results.

There was some swelling of the glands of the neck, especially on the right side. On Jan. 1st this glandular enlargement was distinctly less, but the neck in this situation was more swollen than before and a marked crackling sensation was felt on palpation. This emphysema extended up over the right side of the face and then appeared in the left upper eyelid. The right eyelids were not affected to more than a slight extent, neither was the lower lid on the left side. The arms and trunk became swollen to the depth of about one-half inch. The legs were not affected. Temperature at first visit was 100.8 F.; respiration 45 and pulse 96. This was the third day of illness. On the fourth day of illness temperature was 99 deg., pulse 108, respiration 48. Fifth day, on the morning of the appearance of the emphysema, temperature was 98 deg., pulse 100, respiration 40. Sixth day, pulse 112, temperature 99 deg., respiration 40 in the morning, but at 7.15 p.m. pulse was 112, temperature 103.2 deg. F., and respiration 52. This was the highest temperature reached during the illness, although on the eighth day of illness tempera

a mild

In an

ture reached 102 2-5 deg., pulse 140, and respiration 62. From this time onward for days the temperature ranged from 100 to 102 deg. F., and the pulse a little over the hundred. The respirations varied from 46 to 52 for about a week longer. Voice was only a whisper all this time.

During the greater part of the illness there was delirium, with at times a good deal of drowsiness. Patient took liquid nourishment with stimulants fairly well, and was given a mixture of iron and nux vomica. There was no albumin in the urine. The respirations remained rapid for about thirty days, when they came down to 18 to 22. The emphysema disappeared entirely about this time, having remained longest over the lower part of the abdomen and flanks.

In a swab from the throat Dr. Harold Parsons found a bacillus answering the description of the gas bacillus. anaerobic culture in agar, gas was produced in the depths of the media. Gas was also found to a slight extent in an inoculated rabbit. The rabbit, however, seemed to show rather good resisting powers against the germ.

Culture was not taken from the emphysematous tissue, as we did not wish to disturb the patient.

The appearance of the emphysema on the side of the neck, and not at the site of injection of the antitoxine, as also the finding of a gas-producing germ in the throat swab, would seem to free the antitoxine from the suspicion of infection from that source.

No efforts at intubation had been made, and patient had no violent coughing or straining likely to either produce a tear in the laryngeal mucosa or force respiratory air into the tissu This, with the appearance of the gas in the left upper eye-lid without a perceptible spread across the face from the right side, the length of time the gas remained in the tissues, the finding of a large rod with a capsule in the swab, and the bacteriological findings, weigh strongly against the theory that ordinary air was the source of the emphysema.

Surgery. ex





BY ARTHUR E. BARKER, F.R.C.S. Professor of Surgery, University College ; Surgeon to University College Hospital, London.

MR. ARTHUR E. BARKER, F.R.C.S., in a recent British Medical Journal, gives some useful notes on local analgesia. He says:

To obtain the best results from the injection of B eucaine many facts have to be kept in memory, although this drug is the only local analgesia employed in the method under consideration. We have first the discovery by Corning, in America, and simultaneously (1885) by Feinberg, in Russia, that cocaine applied to the trunk of a sensory or mixed nerve abolished sensation throughout the whole distribution of the same. The practical significance of this last fact is still apparently not fully realized by many who try to carry out the procedure in question. Schleich, who undoubtedly did much to popularize local analgesia, gave it too little weight in his rather 'cumbrous procedure. But later Cushing gave it its full value in his very interesting observations. Of equal importance was the discovery of Oberst that if the circulation of a part was retarded by a ligature or the application of cold, the action of the analgesic compound injected into it was maintained and even intensified so long as the circulation was controlled or retarded.

Based upon these observations, the employment of local anal gesia has grown considerably during the last few years and has improved in proportion to the full recognition of the importance of each. But its employment has been limited by two considerations. First, by the fear of the toxic effects of cocaine, which restricted the use of this drug to small quantities over comparatively narrow fields of operation, and, secondly, the relatively short analgesia in those parts of the body where Oberst's method of restraining the circulation by band could not be applied. But the discovery of B eucaine, which is far less dangerous than cocaine, while possessing analgesic properties little if at all inferior to it, has removed the first of these objections, while Braun's suggestion of the concurrent use of adrenalin for the purpose of securing a retardation of the circulation equivalent to Oberst's constriction of the part, has removed some of the objections both as to the duration of the analgesia, the extent of the area which can be dealt with, and the amount of the toxic drug to be employed.

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