Etiology is important in prognosis. In Tuffier's table of 71 cases coming to operation, in 53 cases where gangrene resulted from inflammatory affections, the mortality was 28 per cent. When the result of bronchiectasis, the mortality was 75 per cent, foreign bodies 50 per cent, embolus 71.5 per cent. The causes of death in these cases were, septicemia, exhaustion, cerebral complications and secondary hemorrhage. TREATMENT. The statistics of Skoda relative to the medical treatment of this disease first cast doubt on the tendency to relegate this affection to the incurable diseases. Lung gangrene is curable in not a few instances, and this auspicious tendency occurs when least expected insomuch as the lung tissue resents invasion, specially when fortified by roborant methods. Even in apparently desperate cases pursuing a septicemic course with atypic temperature, prostration, dyspnea, diarrhea, perspiration, etc., much can be done by judicious medication. The treatment is somewhat similar to that pursued in lung abscess and bronchiectasis, which chapters can be advantageously referred to. Skoda achieved good results with inhalations of turpentine. Other antiseptic inhalations are preferable, notably carbolic acid (4-5 per cent), creosote (4-5 per cent). The steam atomizer will reduce these percentages one-half. Balsamic preparations internally are of decided value, viz., myrtol, oil of eucalyptus, menthol, balsam of peru or tolu. Quinin, according to Binz, in 7 grain doses every three hours is both antipyretic and disinfectant. For control of the cough, caution should be exercised, as it is not wise to suppress the excretion of a highly septic material. It is, however, necessary to control the cough in many instances, as the lesser of the two evils, and then morphin, codein or heroin may be used. Heroin is not always reliable in its action, nor can it be depended on in overcoming a drug habit. One of my patients became addicted to the heroin habit. For the hemoptysis, consult the treatment under this symptom. A nutritious diet and stimulants are absolutely necessary. Surgery promises many triumphs in this affection, but the brilliant results thus far attained are not wholly due to the surgeon, insomuch as he has been most careful in the selection of his cases for operation. From the literature on the surgery of lung gangrene, the following conclusions may be formulated: 1. The indications for operation are: (a) imperfect drainage of a gangrenous cavity through the bronchus; (b) excessive irritation due to the discharge; (c) rapid emaciation and toxemia; (d) empyema; (e) repeated hemorrhages; (f) gangrene of lung apex. 2. Operation is not indicated: (a) when the gangrenous foci are multiple, or when both lungs are involved; (b) in acute gangrene following esophageal rupture, and when grave complications exist. 3. Operation should be delayed if possible: (a) until nature has limited the disease by a line of demarcation; (b) until the gangrenous focus has been localized, its depth ascertained, and adhesion of the pleural surfaces determined. Traversing healthy lung tissue to reach the gangrenous area increases the risk from septic absorption. 4. Chloroform is the best anesthetic, and Murphy considers the Schleich method of local anesthesia indicated. 5. The danger due to the absence of pleural adhesions has been variously regarded by surgeons. Some contend that the danger is exaggerated, whereas the more conservative contend with reason that it is very great. Opening a gangrenous cavity when pleural adhesions are absent exposes the patient to the grave danger of pneumothorax and acute purulent pleuritis, and death from rapid septic absorption. 6. The gangrenous cavity should be opened at its most dependent part to permit of good drainage, and to prevent the escape of septic matter into the bronchus. In deep seated focus of gangrene the lung should be freely incised, hemostasis secured, and the surface protected by the cautery of Paquelin. If, after resection of a rib and exposure of the parietal pleura no adhesions are present, one of three procedures may be attempted: (a) More ribs are resected, the parietal pleura carefully detached from the thoracic wall and a search made for some point where adhesions exist. If found, the lung is incised over this point. (b) A small opening is made into the pleura, and with the finger introduced into the opening search is made for adhesions within the pleural cavity. Having ascertained adhesions with the finger, the latter is withdrawn, the opening in the pleura closed, and with new or an extension of the first incision, the lung is opened over the point of adherence. (c) If no adhesions are found after the manner already indicated, search should be made for some indurated area on the surface of the lung, and artificial adhesions created by stitching the lung to the parietal pleura. The wound is then packed with gauze, and at least four days allowed for the formation of adhesions, at which time the operation may be completed. Even in the presence of soft and incomplete adhesions, it is better to tampon the wound with gauze and complete the operation later. 7. The gangrenous focus is usually surrounded by a zone of infiltrated inflammatory tissue, and it must be sought for by the finger, the knife, and the aspiratory needle introduced in various directions. If negative results are obtained, further search should be discontinued, and a drainage tube is left in the lung incision with the hope that the contents of the gangrenous area will eventually find its way to the drainage tube. 8. The trocar and canula do not permit of free drainage, and the injection of antiseptic agents are useless. 9. If the sphacelus is detached at the time of the operation, it should be removed, otherwise it should be left alone, as it will detach itself at the time of demarcation. Waiting for the sphacelus to separate lessens the tendency to hemorrhage by securing thrombosis of the vessels. 10. Irrigation must be interdicted at the time of the operation, for suffocation may be induced by flooding the bronchial tubes or instigate an infectious process by disseminating the septic material. 11. The after treatment is mainly concerned with cough and secondary hemorrhage. The former is usually produced by the mechanic. irritation of the tube, the position of which may be changed, or even withdrawn for a time at least. The hemorrhage is usually due to ulceration from pressure of the tube, the position of which must be changed daily, so that it will come in contact with different areas of the lung. Hemorrhage demands withdrawal of the tube and packing the cavity with gauze, and an opiate given to allay the cough, which the presence of the packing induces. SWEDEN'S last census records the lowest death-rate yet attained by a civilized nation. During the last ten years it averaged only 16.49 per 1000. GERM OF HYDROPHOBIA.-Professor Sormani of the University of Pavia, Rome, is reported in the daily papers to have discovered the hydrophobia microbe, which has so long eluded absolute demonstration. IN FRANCE medicine appears to have charms for the old as well as for the young and energetic mind. It is said that a Frenchman lately became a qualified practitioner at the age of fifty; that another scientifically inclined man at seventy-two began preparing for the degree of Bachelor of Science with a view of thereafter taking up medicine; while a French navy surgeon was still faithfully performing his duties on board ship at the ripe age of eighty-one. 1 SPREAD OF THE SLEEPING SICKNESS.-According to press cable despatches the London School of Tropical Medicine has issued a report on the sleeping sickness which is now devastating Uganda, Africa. Although discovered only a few years since it is stated that 20,000 or 30,000 people have died from the disease, and that it is spreading to new areas with increased virulence. The only step which seems to have any effect in preventing the spread of the disease is the isolation of new cases. METHOD OF GIVING MERCURY IN SYPHILIS.-Fournier (in Sem. Med.) rejects fumigation, baths, mercurial plasters and other such methods as being scientifically obsolete, and gives the three possible methods of today as: I, internally (by the mouth); 2, inunction; 3, hypodermic injections, with the following advantages: Advantages of ingestion are: 1, ease of administration; 2, well tolerated; 3, proved activity. Disadvantages of ingestion are: 1. May upset digestion; 2, can only use moderate doses, heroic ones causing intestinal irritation; 3, hence not suited when quick action is necessary. Advantages of inunction: 1. Very active; 2, only occasionally disturbs digestion; 3, does not interfere with administration of other medicines. Disadvantages of inunction: 1. The trouble of applying; 2. secrecy difficult; 3, likely to occasion stomatitis; 4, curative effects variable according to thoroughness of administration. Advantages of injection: 1. Active and easily regulated; 2. does not disturb digestion; 3, stomach free for other agents; 4. if occasional large injection, remarkably active. Disadvantages of injection: 1. Dangers of local complications; 2, pain (sometimes very intense); 3, trouble of regular administration. Society Proceedings. WESTERN SURGICAL AND GYNECOLOGICAL ASSOCIATION. Proceedings of the Twelfth Annual Meeting, held at St. Joseph, Mo., December 29 and 30, 1902. [CONTINUED FROM PAGE 82.] TREATMENT OF INJURIES OF THE PELVIC FLOOR OCCURRING DURING PARTURITION. Dr. William E. Groud, of West Superior, Wis., read a paper with this title. His conclusions were that almost every woman during her confinement suffered injuries from 'which she did not recover unless she was subjected to a secondary operation for repair of lacerations of the pelvic floor; that immediate suture of apparent lacerations did not restore pelvic support in the vast majority of cases; that from one to two months after labor the woman should be subjected to a thorough examination and any relaxation corrected, before it had time to impair her health. LUNG SURGERY; HISTORICAL AND EXPERIMENTAL. Dr. B. Merrill Ricketts, of Cincinnati, Ohio, presented an elaborate contribution on this subject, which was illustrated by lantern slides. We give the author's conclusions in his own words: Conclusions.-1. Severing one blood vessels results in instant death. or more of the larger pulmonary 2. If death does not result in a few minutes, bleeding will be slow and gradual. 3. If bleeding is slow and gradual, it may require hours or days to cause fatal exhaustion. 4. If death does not occur until after the end of the second day following severe bleeding, infection is the cause. 5. All, or part of the escaped blood, may pass through the opening in the chest into the bronchus or alimentary tract. 6. The blood may escape into the pleural cavity or cavities, pericardial or peritoneal cavity, or all, and thereby become concealed. 7. Pneumonotomy. More definite knowledge of conditions and symptomatology is necessary that surgery of the lung may be perfected and made more aggressive in general. 8. Abnormalities, congenital or acquired, must always be considered in dealing surgically with the lungs. 9. Atalectasis and apneumatosis should be cared for by relieving the compression by removing the cause. 10. The same surgical principles can be applied to the lung as to other organs of the living body. 11. The bony chest may be opened for exploration of the lung with as little danger as opening the abdomen, cranium, articulating capsule, kidney, liver, pancreas, spleen, stomach, gut, or hepatic duct. 12. Hermetically closing the chest is irrational, unscientific and dangerous. 13. Closing the chest wound by any means does not prevent the escape of blood from injured pulmonary vessels into the pleural cavity. 14. All wounds of the chest wall, whether penetrating or non-penetrating, should be treated aseptically, and with reference to drainage. 15. No instrument or needle should be made to enter the lung tissue for exploration, or the removal of fluid, unless the bony chest has previously been opened. 16. Foreign bodies in the bronchia or parenchyma of the lung may be detected with a fine exploratory needle through an open chest with the lung contracted. 17. Foreign bodies in the lung and bronchia, when causing serious symptoms, should be removed. 18. Some small foreign bodies becomes encysted and remain harmless. 19. The position of a foreign body in the lung changes with expansion and contraction of the lung. 20. Hemorrhage, when due to pulmonary tuberculosis, should not be allowed to become fatal without opening the bony chest, and the application of pressure by forceps, gauze or otherwise. 21. Bleeding of the lung from any cause will, in many cases, cease when the lung is allowed to contract upon itself, with an open chest. 22. Blood clots within the pleural cavity should be removed at the time they are discovered, whether infected or not. 23. Blood clots in the pleural cavity may become organized with or without adhesions of the parietal and visceral pleura, or they may become infected and cause more serious consequences. 24. Hemoptysis may be absent in the most severe lacerations of the lung. 25. If bleeding from larger pulmonary vessels results, forceps should be applied; if not, gauze should be securely packed in the cavity. 26. Drainage of pulmonary cysts of any character can be effected with the same success as in any other organ. 27. Incision for drainage should be done with or without the presence of adhesions. If without adhesions, the opening in the chest should be at the lowest point of the pleural cavity for drainage by gravity. 28. Many incisions of the lung may and should be made with and without even local anesthesia. 29. It is probable that but a few will necessitate the use of general anesthesia. 30. Abscess of any character and of any location in the lung should be found and opened. 31. Gangrene of the lung demands most radical surgical measures, such as opening the chest, drainage, and the removal of all necrotic tissue. 32. Polypi of bronchia seldom necessitate removal, but they may cause conditions which may require surgical intervention. |