A Lecture ON AMPUTATION FOR DIABETIC GANGRENE.

A Lecture ON AMPUTATION FOR DIABETIC GANGRENE.

349 diminution in the size of the glands, but subsequently they Langdon Brown, entitled " Physiological Principles in again enlarged, and by August, 1...

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349 diminution in the size of the glands, but subsequently they Langdon Brown, entitled " Physiological Principles in again enlarged, and by August, 1906, they were as large as Treatment." I observe on almost every page written about ever they had been. There was now noted a swelling of the diabetes some reference to the lack of oxygen," to the size of a marble in the roof of the mouth, and some weeks "deficiency of oxygen," to the want of oxygen.’ This later subcutaneous nodules over the right pectoral region. lack of oxygen plays a very profound part in the causation Towards the end of September the breathing became noisy, of diabetic gangrene. Presently you see that the want of with spasms of dyspnoea, and the patient died early in oxygen is not only general, as may be betokened by the blue October. There was no anæmia in this case and no leuco- lips, the purple face, and the blue extremities, but is also cytosis ; the proportion of polynuclear cells was 81 per cent., local, for there is a local asphyxia of the tissues which’may end in them dying. In diabetic gangrene the peripheral of mononuclears 18 per cent. Necropsy.-At the post-mortem examination a large tumour conditions favour the death of the tissues. They are blue, the larynx, trachea, and ill-supplied with oxygen, and saturated with sugar. mass was found surrounding oesophagus, and extending upwards through the base of the Calcareozcs Condition of Arteries, skull and forwards into the roof of the mouth. This growth But in addition the arteries are oftentimes inflamed or was found to be a round-cell sarcoma, and the nodules in the pectoral region had the same structure. It was impossible calcified and ill-suited for the circulation of the blood. Here are some calcified arteries from the museum, It to determine the point of origin of the primary growth, or that the glandular enlargement was not from the first might be thought that they are exaggerated specimens of sarcomatous in origin, for microscopic examination failed to calcified arteries, but one of the patients for whomI pergive evidence of there having been any previous lesion in the formed amputation of the leg for diabetic gangrene had arteries which were so calcified that Mr. H. R. Wadd aptly glands affected. compared them to a bird’s trachea. Another patient with In concluding, I wish to express my great indebtedness to diabetic gangrene had arteries which were so brittle and my colleagues at the Royal Infirmary for their able assistance calcified that they would not tie, and in the end the vessel in investigating the above cases-to Mr. Paterson, who was secured by passing a piece of silk underneath it and the excised the glands in the various cases ; to Professor Teacher surrounding tissues, and then tying it with extreme caution. for the histological examination of the glands ; to Dr. And in these cases of gangrene the calcareous vessels can be Campbell for the bacteriological examination; and to Dr. seen in an X ray photograph, as in a patient who was in the McNicol for his study of Cases 4 and 8. Without the aid of casualty ward with gangrene of his leg. all these gentlemen the records of the cases would have been Albuminuria.-Neuritis very incomplete. with diabetes who have reached the of

Many stage gangrene have also albumin in the urine, and in the notes you will frequently find that the urine contained sugar in quantities and also albumin. Albumin may mean little or it may mean much, but it will tell you this : a patient with sugar and with albumin in his urine ’ is of necessity in greater danger than is one with sugar alone. When the urine has renal casts in it the kidneys are gravely and permanently diseased and may :not continue to function. Some who are supposed to die from diabetic coma may have died with ursemic poisoning. Lastly, in diabetic gangrene the peripheral nerves are in an unsatisfactory state, probably before the gangrene supervenes.": But if the gangrene has supervened the neuritis is intense, and those with diabetic gangrene suffer the most horrible anguish; a very good reason why they should have prompt

A Lecture ON

AMPUTATION FOR DIABETIC GANGRENE. Delivered at St. Bartholomew’s

Hospital on Dec. 13th, 1911, BY C. B. LOCKWOOD, F.R.C.S. ENG., SURGEON TO THE HOSPITAL.

GENTLEMEN,-I lecture to-day upon a most dangerous surgical help. a most dangerous disease-diabetic gangrene. A Case ot Diabetes following Cholangitis. CASE l. -As bearing on the causation of diabetes. A patient PRELIMINARY REMARKS. The word diabetes does not in itself afford much infor- had an acute septic inflammation of the gall-bladder, which

complication of

mation. It means the passer through " or syphon, and one was drained. Then the liver became swollen and tender, of the patients about whom I am going to speak certainly and the gall-ducts were probably inflamed. During the was "a passer through."In these vessels Mr. Grange has put course of the cholangitis the pancreas became inflamed. the quantity of urine passed in 24 hours, and it amounts to one The stools were full of fat and starches, and at the same timeand a quarter gallons; sometimes it was at least one and a there were obvious swelling and tenderness in the region of the pancreas. The patient must have had great tenacity of half gallons. because she recovered from these conditions. There is life, and its Results. Glyeoswia This urine was of high specific gravity, because it one point which I will mention now, because it may be of contained a huge quantity of grape-sugar or dextrose. In service: it is that her recovery began after she was dosed with this large basin Mr. Grange has kindly put the quantity of: urotropine. I think that is a drug which is not only excreteddextrose which was contained each day in the urine. Thatby the kidneys, but also by other glands and by the pancreas. basin full of sweet substance has in it 13 ounces. I cannotSo urotropine was given, and whether by chance or not shebegan to improve. But then it was discovered tha1t help thinking that a human being who is passing out one and certainly the urine contained’sugar in considerable quantities. a half gallons of urine in a day, even if he drinks over a as this man his must be tissues of Site ot Gangrene. fluid, did, gallon, draining and no wonder he is thirsty. And if instead of using the’ Towards the end of diabetes a time arrives when the tissuessugar for the nutrition of the tissues it is passing out, those which are in the condition that I have described may tissues will be starved and weight will be lost. Doubtless the die. The gangrene most often takes place in the lower’ blood and the tissues have in them quantities of sugar. extremities. But one of my patients with gangrene of theSugar passing through the vessels is likely to damage them ;; leg also had patches of gangrene on the back. Another presently I will tell you about the condition of the arteries. had a patch of gangrene upon the thumb. It is possible’ But more than that, the sugar passing along the vessels and that so-called spontaneous gangrene of the penis andl into the tissues makes them more susceptible to septicscrotum is allied to diabetic gangrene. You may not have infection. A broth or gelatin culture with sugar in it is anaheard of spontaneous gangrene of the penis and scrotum, but extra good soil to grow bacteria upon. every now and then a patient is brought into the surgery whose penis and scrotum have become black and gangrenous, Laok of Oxygen. There is one other point which has struck me very without obvious cause. AMPUTATIONS. much about the patients who have been operated upon1 for diabetic gangrene-that many of them were exceedAmputations for diabetic gangrene are not very common. ingly blue. Here is an admirable book written by Dr. But out of 54 major amputations-interscapulo-thoracic, F2 ,



.

350 the other day had a large cystic adenoma of the thyroid gland; the pulse was rapid and intermittent. It was of importance, in view of such a grave operation, to know what would happen to the heart during the performance of the operation. So she was made to get up and walk about the ward, and we found her heart became steadier. A little boy had acute appendicitis ; he was a delicate little creature, and his pulse intermitted. He was sat up in bed, and walked about the room, and then the pulse became steady. So the intermittent pulse of this old man had to be taken very much into account. He was taking alcohol and continued it. And in addition he was dosed with strophanthus. This is a drug which makes the ventricles of the heart beat more strongly, and, of course, strophanthus has an advantage over another drug which is used for the same purposedigitalis-that it does not contract the peripheral vessels. It would not be rational medicine to give a person with gangrene of the leg a drug which contracted the peripheral vessels and impeded the peripheral circulation. There was I have told one other point in the preliminary treatment. The you what a danger the formation of acetone is. formation of acetone is preceded by the formation of diacetic acid, and therefore considerable doses of bicarbonate of soda were given, at least half an ounce in the 24 hours. As soon as possible after this preliminary treatment the patient’s thigh was amputated. Why should one who has a foot which is gangrenous and dead keep the limb ? It is a source of great danger and the toxins absorbed from it add to the dangers of acetonasmia and diabetic coma. In this case no X ray photographs were taken, but the peripheral arteries The femoral artery, although thickened were not calcareous. and chronically inflamed, was not calcareous. But here comes the application of some of the things that I have told you sepsis may be brought about by some trivial cause. We amputated in the way in which I am now CASE 2.-For instance, a lady who had 4 per cent. of about. We did not apply a tournisugar in the urine applied strong sulphuric acid to a corn accustomed to amputate. Think of upon the little toe, and that resulted in a small septic wound. quet, Esmarch’s or otherwise, to the thigh. From that the diabetic tissues became infected, the infection applying a band of that sort to one of those calcareous I No wonder after the use of Esmarch’s bandages spread up the leg, and amputation was performed. She died arteries But tournifrom shock through loss of blood. The femoral artery was and bands gangrene recurs in the flaps. held by the fingers, the fingers did not control it properly, quets, besides crushing these arteries, are very apt to and there was considerable loss of blood, from the shock of press and injure the vein which runs at the side of the which she never recovered. Shock is one of the dangers of artery. Again an elastic tourniquet, besides asphyxiating the whole limb, causes arterial paralysis. When Esmarch’s operations for diabetic gangrene. bandage has been used blood goes on dripping from the S’eptic Infeataon. muscles and flaps, and much valuable time has to be spent in In another case the onset of diabetic gangrene was due putting on ligatures, when after all it was better that the I can recall another in to suppuration beneath a corn. patient should be back in bed. which the diabetic gangrene was caused by a tack which Operation.-For this operation the patient was laid on ran into the foot whilst the patient was walking about withhis back on a table and an incision was made at the lower out shoes or stockings on. When once septic infection has end of Hunter’s canal. The superficial femoral artery started it spreads with great rapidity. The foot becomes red and vein were then and there secured. When you think and cedematous, and the sepsis spreads up the lymphatics about it, the main arteries in an amputation have to be and up the tendon sheaths. The last might not be noticed secured at some time or another, and why the surgeon should because the tendon sheaths are beneath the deep fascia, so not the great vessels and be finished with securing begin by that the inflammation may have spread high without being them I am at a loss to imagine. There was one little comseen. This has a practical bearing when we have to decide plication in the ligature of these vessels. The superficial where to amputate. If the seat of election be infected femoral artery and vein were so fastened together tissues the sepsis continues in the stump, and the patient is inflammation that I thought it better not to waste in horrible danger of gangrene of the flaps and of aceton- by in trying to separate time them, but tied them æmia and diabetic coma. The infection occasionally spreads with ordinary chromicised gut ligature. The together by way of the veins, for clots form in them, and these are, of next step after securing the great vessels was to leave infected. course, the patient in the same position, and with a scalpel to cut Notes of Case of Ampitation. flaps quietly and slowly, and secure each vessel the moment CASE 3.-Some time ago a patient, aged 65, after having it bled, as in other operations; then to saw through had diabetes for several years, got gangrene of the toes. In the bone and put the drainage-tube in, and finish the addition to the gangrene there were inflammatory oedema of amputation in the usual manner. the dorsum of the foot and deep-seated tenderness in the Everyone is prejudiced about his own ideas, so I asked Mr. leg. This was suspected to be due to sepsis passing up the Richard Gill, who gave the anaesthetic, what he thought about deeper tissues, especially the sheaths of the tendons. He the shock in this case, and Mr. Gill was very emphatically of was profoundly ill. Owing to septic absorption the pulse opinion-perhaps he was kind in saying so-that there was none at all-but certainly there was singularly little shock. was at least 125 and intermitted. Intermittent pulses are to be studied. We often have This patient, after the operation, was put back in bed. patients in the wards whose pulses are beating quickly And observe what a parlous condition he was in. He and intermit, and you will have to be able to form had a pulse which was very rapid for an old man or for If the anybody else; he had a very high temperature; he had an estimate of what that intermittency means. patient has obvious mitral or aortic disease, an intermittent 4 per cent. of sugar in his urine ; so aoetonasmia was impendpulse is a serious matter. If a patient has an intermittent ing. He had some patches which were very blue in colour pulse which, when a strain is put upon the heart, intermits on the other foot and on the thumb. Of course, the But if a patient has a pulse which treatment which he had had before the operation was more, that is serious. ’intermits, and becomes steady when a strain is put upon the continued-the bicarbonate of soda, the alcohol, and heart, clearly that is not important. A patient in the ward the strophanthus. But now he had a treatment which

were operated upon for gangrene, and of those half were operated upon for The mortality in these eight was diabetic gangrene. Five had amputation performed at very high indeed. the junction of the upper and middle third of the leg for diabetic gangrene, and only one of them is known It is possible that another survived, to have survived. but it is not in my notes ; and we are safe in assuming that four out of five succumbed. The patient who did not The urine contained die had not got diseased arteries. 4 per cent. of sugar at times and a moderate quantity of albumin. Three patients had amputation performed through the thigh for diabetic gangrene. One of these died, but two recovered. The one who died had exceedingly calcareous arteries, a very unfavourable complication. Causes of Death after Amputation. Death after amputation is brought about either by septic infection or diabetic coma. The flaps have, not infrequently, sloughed, and the stump has become profoundly septic. Diabetic coma may follow the sepsis or come on by itself. The patient, after smelling of acetone, becomes apathetic, then drowsy, comatose, stertorous, and at last dies. You are familiar with the smell of acetone, for acetone collodion is frequently used. Once familiar with the smell it is easily detected, and is a profoundly unfavourable sign -the precursor of diabetic coma. Shook. have those curious black asphyxiated A patient may patches about the foot. and yet they may not become gangrenous. Inky black they may exist for weeks or months, but the onset of sepsis is most serious and dangerous. The

shoulder, hip, thigh, leg-16

.

,

351 must be of great importance in these cases. The moment the operation was over we began the conHe had oxygen to tinuous administration of oxygen. inhale for nearly a fortnight. He liked it very much indeed and was pleased to have it ; asked for it, and it obviously did immense good. Remcarkable Effects of Oxygen Inhalation. Do you remember what I said about Dr. Langdon Brown saying in his book on nearly every page relating to diabetes something about the want of oxygen in the tissues and the need for oxygen ? And yet it seems strange to me that at the end of that chapter he does not say, "Therefore you must give these patients as much oxygen as you can get them to take." The administration of oxygen has a most extraordinary effect. I was about to amputate the breast of a stout female whose face and lips were blue. Although most unfavourable, yet it was not right to leave her to die of carcinoma of the breast, which was on the point of ulceration. So before the operation oxygen was ordered to be ready. During the operation the blood which flowed from the wound was deep purple. Then the oxygen was turned on, and at that moment all the wound became vivid red. The blood became arterial instead of being of the colour of dark treacle. That experience has made a most profound impression on my mind. If the tissues are in a condition such as that in diabetic gangrene, perhaps livid, with those dark patches on the heels and back, surely the more oxygen given to those defective tissues the better. I cannot help associating the recovery of that old man with this supply of oxygen, and I should say that the stump did unusually well ; it healed by first intention, and the patient lived for 16 months. Another Illustrative Case. I will briefly refer to another case which was treated in the same manner. Many of you might have seen the

surely

operation performed. CASE 4.-The patient was in Paget ward. He was certainly in a parlous state. There was extensive gangrene of the left foot and leg. One gallon of urine was passing out of him every day, and it contained 13½ ounces of sugar. He was not very thirsty, although he sometimes drank a gallon of fluid a day. At the time of the operation the pulse was accelerated to 104, and the temperature had been nearly 102° F. The respirations, too, were accelerated, being 24 before the operation. His thigh was amputated in the same way as the last. The main vessels were tied and the bleeding stopped; he was never moved about on the table; and the moment he returned to the ward the continuous inhalation of oxygen was begun. He was very apathetic and sleepy, and was obviously on the verge of acetone poisoning. The urine contained diacetic acid, so that everything was in readiness for acetonasmia, but he survived and

improved.

For

charge of the

some

inscrutable

reason

the house surgeon in

stopped the oxygen ; perhaps he thought a hospital which was running into debt had no right to spend money on oxygen. But when the oxygen was stopped the patient became worse and I tnought he would die. It was begun again and the patient improved, and slowly mended until we were able to send him out of the hospital. His wound, I thought, did remarkably well. Except for the places where case

the drainage-tube was put in, it healed by first intention, but the drainage opening shortly closed, and he did exceedingly well for such a class of case.

Site of Amputation. But observe I amputated through the thigh. And I have told you of five cases in which I amputated through the leg, and three or four of them died. I have not time now to go into the reasons of their deaths. One died from shock and haemorrhage due to the operation, one died from diabetic coma, and one died probably from sepsis. The dangers of dying from sepsis seem to me far greater if you amputate through the leg, because you have still to deal there with calcareous vessels, and there may be still some infection of the lymphatics, veins, or tendon sheaths. I have clearly made up my mind now, from my limited experience of diabetic gangrene, chat the amputation is better performed through the thigh and in the way I have described to you, and better Derformed at the earliest possible stage of the disease. Do not wait until the gangrene has spread, until the patient has become septic, and until the chances of prolonging life are vastly diminished.

THE TREATMENT OF PUERPERAL SEPTICÆMIA BY BACTERIAL VACCINES.1 BY G. T. SENIOR ASSISTANT

WESTERN, M.D.CANTAB.,

IN

THE

INOCULATION HOSPITAL.

DEPARTMENT, LONDON

(From the Inoculation Department, Bacteriological Laboratory, London Hospital—Dr. W. Bulloch.) IN the

course

of

a

discussion

on

° ° vaccine-therapy "

held

by the Hunterian Society in the spring of 1910 I made a preliminary report on a series of 20 cases of puerperal sepsis which had been investigated in the bacteriological laboratory of the London Hospital. Of these 20 cases 13 had been treated by inoculation. Since then we have continued working on the same lines, with the result that we have now a series of 100 cases which have been investigated, and 56 of these have been treated with vaccines. The cases in the present series have, with few exceptions, been patients admitted to the puerperal septicaemia ward at, the London Hospital. These patients are drawn from the neighbouring districts after confinements in their own homes, often under the most unfavourable sanitary conditions. In many cases they have been attended by a midwife and in others by a private doctor. It will be realised, therefore, that the present series includes only those cases which are looked upon prognostically as of such gravity as to necessitate removal to hospital. It should be added that these cases are all notified under the Act. As I pointed out in my previous report, the very wide, difference in mortality given by different authorities indicates that there is a considerable difference of opinion as to what should be included in the term "puerperal septicæmia." Clinically, a diagnosis of septicasmia rests largely on the temperature, the pulse, or a combination of temperature pulse. Bacteriologically, a diagnosis of septicaemia may be If the result of blood made on a positive blood culture. culture is negative it does not follow that the case is not a septicaemia. It is well known that a blood culture may be. done on one and the same case on several occasions, and be positive one time and negative another time. Further, if several tubes of media be inoculated at the same time some Again, may show growth while others remain sterile. special precautions with regard to media or quantity and dilution of blood may give a positive culture in a case which has been negatived by ordinary routine methods. I would suggest that the explanation of these facts is that a septicaemia, is not in most cases a condition in which multiplication of bacteria takes place to any great extent in the blood stream, but rather a condition in which there is a local bacterial infection around which the tissues have not reacted to form a localising barrier, and, consequently, bacteria are more or less continually being carried away into the general circulation. Here they probably do not survive very long unless they form an embolus or get caught in a thrombus, in which cases pyasmic abscesses may occur. If this is so we have included under the clinical term "puerperal fever" at least two different conditions : (1) a localised bacterial infection in the genital tract which is associated with more or less toxæmia; and (2) a local infection in the genital tract from which bacteria are being carried into the blood stream, continuously or discontinuously. These latter cases constitute the group of true septicaemias, but it must be realised that the two groups merge into one another and clinically cannot always be separated, and this doubtless explains the extraordinary variations of opinion as to the mortality. The determining factors would appear to be the relative balance between the virulence of the infecting agent on the one hand and the resistance of the tissues on the other. In tabulating the cases which we have investigated and treated an attempt has been made to record those points which are of especial interest without making the tables too full of detail to be easily read. Further, the order in which the cases have been placed has been chosen as far as possible to simplify the deduction of conclusions. The cases are divided into two tables : (1) cases treated by vaccines ; and (2) cases untreated by vaccines. In each table the pati- nts

and

1

the

A paper read before the Obstetrical and Gynæcological Section of Royal Society of Medicine on Feb. 1st, 1912.