Page images

diabetes, where there was a tendency to the formation of abcesses, carbuncles, etc., which were found to contain micrococci in abundance.

Dr. Belfield then discussed the question as to the possibility of the bacteria gaining access to the system, except by way of solution of continuity of tissue, and reached the conclusion that the answer depended at the present time altogether upon what might be considered a solution of continuity of tissue ; certainly a gross lesion, one sufficiently large to strike the attention of the naked eye, was not required. This was also evident in the case of other animals, as the trichina, which found its way from the intestine into the muscles. Any one familiar with the structure of the alveoli of the lungs could readily conceive how such small particles as bacteria could with facility gain access to the circulation in those organs.

One of the most important questions in pathology at the present day was with respect to what extent the different species of bacteria which were to be found in the human tissues during certain morbid conditions were to be considered the cause of the conditions with which they were respectively associated. Admitting the causal relation of the bacterium to the disease, we must be convinced, the speaker said, that all the observed phenomena could be reconciled with this assumption, and also that they could not be so plausibly explained by any other assumption, Then the assumption must be demonstrated by successive cultures of the bacteria found to exist in the diseased person, and the in. duction of the same disease in healthy animals by inoculation, with a reproduction of the bacteria. According to this standard, the evidence already brought forward warranted the following unscientific, but convenient classification :

First, diseases the demonstration of the bacterial origin of which had been completed through inoculation, with isolated bacteria, by competent observers.

Second, diseases of the bacterial origin of which had been affirmed after inoculation with isolated bacteria by one competent observer ; such as tuberculosis

Third, diseases which were always characterized by the presence of bacteria in the tissues, but which had not been induced by inoculation with isolated bacteria ; such as pyæmia, diphtheria, erysipelas, etc.

Fourth, diseases in which after death bacteria had been found in the tissues; such as variola, scarlatina, typhoid fever, etc.

Fifth, diseases in which the presence of bacteria before and after death had been asserted, such as syphilis, intermittent fever, typhus fever, measels, etc. In the diseases under the fourth and fifth classes, observations had doubtless been more or less imperfect and inaccurate, partly because of those diseases being found exclusively in man.

Dr. Belfield then exhibited some micro-photographs, in illustration of the subject under consideration, part of which had been prepared by his own hand, and part obtained from negatives kindly furnished him by Professor Koch.-N. Y. Medical Journal.

[ocr errors]


A stated meeting was held January 9, 1883, Dr. T. M. Markoe, President, in the chair.

Excision of the Knee-Joint - Dr. C. T. Poore presented three patients upon whom he had performed excision of the knee joint. All the operations were performed with the circular incision. The antiseptic spray was not used. The wounds were thoroughly washed out with a solution of carbolic acid, one to forty. The bones were sutured together with wire sutures, and drainage tubes passed through the anterior flap around the joint, and out through the popliteal space. To secure immobility, the limb was placed upon a posterior splint, and a plaster-of-Paris bandage applied from the toes to the groin, an interval being left at the point of operation.

The first patient was a boy, sixteen years of age, with a rather poor family history. He had pulpy disease of both knee joints. In the right the tibia was dislocated backward and flexed at a right angle with the femur. The right knee joint was excised in 1879, and the result was firm union of the tibia and femur, with two inches shortening. At the time of dismissal from the hospital he had quite good flexion of the left knee, and was able to act as an assistant to a surveyor, which compelled him to do considerable walking. Last summer he fell and injured the left knee. This was followed by swelling and pains, and it had left that joint stiff, in a straight position. Notwithstanding this, he was able to get about very well.

The second patient was a girl, thirteen years of age, who fell and injured the left knee joint six years ago. The injury was immediately followed by swelling and pain, and six weeks subsequently an abscess formed, which was opened in Bellevue Hospital. She was subsequently a patient at Roosevelt Hospital, where several large abscesses formed about the joint and the lower portion of the thigh and were opened. She left there considerably improved, the limb flexed at nearly a right angle. She subsequently was admitted to St. Mary's Hospital, where Dr. Poore operated upon her, in May, 1882, by removing a V-shaped portion of the lower extremity of the femur. There was considerable shortening after the operation, and there still remained a small external ulceration, but no exposed bone.

[ocr errors]


The third patient was a boy who had suffered with abscess from Potts' disease, and also had osteitis of the head of the tibia, which opened into the joint. Excisiov was performed in the usual way, and there was nothing peculiar concerning the subsequent progress of the case, except that on the following day the temperature rose to 105 5° Fahr., but fell to the normal within a few hours, and afterward there were no unfavorable symptoms, except the occurrence of a small slough upon one side of the joint, for which Dr. Poore was unable to account. In this case there still remained a small sinus, into which a probe could be introduced, but he was unable to detect any rough bone.

Dr. Poore had also operated in another similar case, and expected that the patient would be present, but for some reason was absent. In all the cases the wounds healed promptly, and all the patients were up on the fortieth day.

Fibro-Sarcoma of the Parotid. —Dr. H. B. Sands presented a patient who illustrated the fact that, in the case of tumors which are unpromising in character, occasionally the disease does not return after removal, or, least, for a very long period. This man, now thirty years of age, came under his notice in June, 1870. At that time there was a tumor in the parotid region, which was believed to involve the parotid gland. It was situated upon the right side, occupied the entire parotid region, and formed a rather low but extensive growth, which caused prominence of the ear, was exceedingly firm, and entirely immovable. It had then been growing for about five months. The case was regarded as unfavorable, on account of the rapidity of the growth of the tumor, and the extent and firmness of its adhesions to the deep parts as well as to the skin. Dr. Sands decided, however, to attempt to extirpate it. When the flaps of skin had been raised, a small portion of the growth was removed, and was examined with the microscope by Dr Delafield, who found it to be a fibro sarcoma. The piece removed contained a large proportion of fibrous tissue, with cell elements of a round shape. The diagnosis was confirmed by the subsequent examination of the tumor after its removal. The tumor extended into the deeper portion of the neck, and was attached to the styloid process, and was so incorporated with the adjacent tissues as to make the operation very unsatisfactory. The lower surface of the skin was invaded by the morbid growth, being completely incorporated with the whitish tissue of the tumor Notwithstanding the difficulty of the operation the patient made a good recovery. Some sloughing of the cutaneous flaps occurred, but beyond this, no accident followed the operation, and the patient left the hospital six weeks afterward with the wound healed, Before the operation the facial nerve was intact, but immediately afterward the parts supplied by it were found to be completely paralyzed. The paralysis still remained, although hardly noticeable when the features were in repose.

Dr. Sands had watched the case with a great deal of inierest, and made his last note about one year ago, at which time there was no evidence of recurrence of the disease. About three months ago the patient discovered some swellings upon the right side of the neck, and now six or eight flat movable tumors could be felt, extending along the posterior edge of the sterno-mastoid muscle down to the clavicle, the largest being about an inch in breadth and length, and about half an inch in thickness. They are very firm, being in this respect like the original tumor. The skin in the neighborhood of the operation seemed to be sound.

Tracheotomy as a Preliminary to Certain Operations.Dr. Charles McBurney read the following paper:

Mr. President: While I have nothing that is really new to offer upon the subject which I have chosen, it appears to me that there are some points in connection with it which are worthy of discussion. The operations which are referred to in the title of this paper are operations for the removal of the upper or lower jaws, particularly when these parts are involved in the growth of large tumors; operations for the removal of large or vascular naso-pharyngeal polypi, or of tumors springing from the tonsils, or walls of the pharynx, or tongue, or palate ; and also operations which involve the extirpation of the entire tongue, or of the larynx and adjacent parts; in fact all operations in the course of which considerable risk is run of having blood or diseased material pass into the lungs or stomach. The old method—so frequently made use of before the introduction of anæsthetics, and still recommended by someof placing the patient in the sitting posture, with the head upright or hanging forward, offers certainly very slight advantage. Some of the blood lost will, to be sure, flow out of the mouth; but the tendency of such blood, as it finds its way backward, to pass down the trachea and cesophagus is greater in this position than in any other. Moreover, the difficulty of retaining a parient who is under the influence of an anæsthetic in this position, and the awkwardness in applying artificial respiration, or of doing tracheotomy if suddenly demanded in the course of the operation, and the greater liability to syncope, form very serious objections to it.

Rose's position, or the hanging head, was an ingenious device, undoubtedly applicable to certain cases. Rose placed the patient with the head and neck projecting beyond the end of the operating table, allowing the head to fall so far backward that its vertex pointed to the floor. The naso-pharyngeal cavity thus becomes a cup placed on a lower level than the orifices of the trachea and cesophagus, and blood collecting in

it flows more readily out of the nose, provided the nares do not become plugged with clots, than down the pharynx. From this cup-shaped de pendent cavity blood can be sponged and readily removed. This position appears to me to recommend itself in cases where hemorrhage will probably not be great, and when the seat of the operation is the palate or mouth, as in cases of cleft palate, or when portions only of the jaws are to be removed without external incisions. But in cases where hemorrhage is very great, or the disease to be removed involves the nasopharyngeal cavity itself, the Rose position favors the accumulation of blood at the very place where it is most objectionable. Moreover, patients are not infrequently met with who behave very badly when thus placed while under the influence of an anæsthetic, the tension of the larynx and trahea apparently producing a spasm of the glottis, which becomes dangerous if not relieved.

Both the upright and hanging head positions are exceedingly awkward in the administration of the anæsthetic, it being necessary to remove the cone as soon as the operation is begun, and to interrupt the operation at intervals in order to give more anesthetic. This last is a serious objection, for not only is the operation much prolonged, but blood is frequently lost in large quantities, while the mouth and nose are concealed from view. The gravity of extensive and bloody operations about the mouth and adjacent parts has been frequently illustrated in the last few years, not a few such operations having resulted fatally to the patient, either at the time of operation or within a few hours i hereafter. Moreover the nature of the diseases for which most of these operations are undertaken requires that they should be performed not only with expedition, but with great thoroughness.

I have myself seen a patient, from whom one upper jaw was being removed, die on the table from the entrance of blood into the trachea, and the cases are numerous where, in the course of similar operations, tracheotomy has become necessary to save the life of the patient. No operation can be looked upon as unnecessary which promises immunity from such dangers.

I do not know who first suggested a preliminary tracheotomy in the class of cases which I have referred to, but to Trendelenburg is due the credit of giving to the profession an apparatus complete enough to be of very great service in such cases, The original device consisted of a very long tracheal tube surrounded in its tracheal portion with a thin rubber bag, which could be sufficiently inflated, by means of a connected bulb, to completely fill the trachea. To the outer end of the tracheal tube, an elastic one, several feet in length, was fitted, at the free extremity of which was a reservoir to receive the anæsthetic. The objections to this

[ocr errors]
« PreviousContinue »