INFECTION BY THE BACILLUS AEROGENES IN AN OPEN FRACTURE OF THE RADIUS AND ULNA.
Dr. John Roberts said that he desired to put on record a case of gangrene of the forearm after an open fracture, which ap pears to have been due to infection with the gas bacillus.
A young girl, aged twelve years, slipped and fell on August 31, 19oo, sustaining a fracture of the left radius and ulna about the junction of the middle and lower thirds. One of the frag ments of the ulna made a small wound through the skin. Dr. J. H. Hardcastle, who had charge of the cleansed the wound with soap and water and solution of corrosive chloride of mer cury (i to moo), and dressed it with iodoform gauze and cotton. He says that there was a little dirt over the site of the wound when he first saw the patient, and that the bone did not protrude through the small opening, though he believed that the tear in the skin, which was perhaps a third of an inch long, was caused by the projection of the bone against the soft parts at the time of the injury.
When first seen by Dr. Roberts, on Friday, August 31, three days after the accident, the left hand was bluish black or slate color, and cold. A small wound of the skin existed on the palmar surface of the wrist over the lower part of the shaft of the ulna, perhaps one inch above the joint. It was a small puncture, and not gaping. The skin around this opening was blue and darker than the rest of the skin of the wrist or hand. The discoloration extended up nearly to the elbow, farther posteriorly than an teriorly. The arm was swollen and tense and crepitated on press ure. The arm above the elbow was swollen but not dark. The patient was etherized, and several long incisions were made from elbow to hand, through the skin and deep fascia, exposing bluish gangrenous muscles at places. Bleeding occurred from the upper part of the incisions, but not from the gangrenous areas in hand and forearm. The wound was dressed with wet mercuric chloride dressing. The patient had a temperature of 103.8° F., and albu men with casts in urine. She was clear-headed and did not com plain of very much pain.
The next day he amputated about the middle of the upper arm, making first a circular incision about two inches below the elbow, hoping to save the joint and part of the forearm. This showed the disease in the deep muscles to extend higher than in the overlying skin. The tissues over the olecranon were blue, while in front the disease was not so high up. Finally, an irregu lar amputation was made by anteroposterior flaps above all gan grenous structures. The tissues left were, however, slightly crepitant. There was not much fluid in the tissues. He dissected the specimen along the radial and ulnar arteries near the injury, but found no rupture or laceration of vessels. The arteries seemed to have clot in them and were discolored. There was not much fluid and not a great deal of gas in the tissues. There was some gas, however, and a few blebs had shown themselves on the -hand. The most active focus of death was near the small punc ture, which suggested that infection had been caused by a gan grene-producing germ. Both bones were broken at the line of wound.
Two days after the operation urticaria was noticed upon the limbs and trunk. About half an inch of one of the flaps showed gangrene. An examination of the axilla showed no enlargement of the lymphatic nodes. The stitches were removed and the lips of the wound allowed to gap ; and the arm was again dressed with solution of corrosive chloride of mercury, which had beeu used since the time of operation.
On the next day the patient spat about half a drachm of blood, which she thought came from her nose ; but the tempera ture had fallen to about me F. The wound was the seat of a very offensive odor, and the gangrenous process in the flap had extended slightly. The dressing was changed to a solution of per cent. formaldehyde. The urine still contained albumen. From this time the patient's condition rapidly improved. The foul odor was destroyed by the formaldehyde, the gangrenous process ceased, and the dead tissues became mummified. The albumen and granular casts disappeared from the urine, and the child was discharged from the hospital on the twentieth day after ampu tation, with, however, the wound not entirely healed.
The rapidity of the gangrenous process, the fact that the at tending physician stated that the splint and dressings had not been applied unduly tight, the evident activity of the morbid con dition around the site of the wound, and the crepitant condition of the limb above the seat of gangrene suggested that the un fortunate result of the fracture was due to infection with some gangrene-producing micro-organism. An examination of the am putated arm at the Pepper Laboratory was made by Dr. S. S. Kneass, who found the bacillus aerogenes capsulatus in the tissues. Dr. Hardcastle had recently informed the operator that at the time he dressed the wound and fracture, he was assisted by a girl who had been nursing a case of what was supposed to be erysipelas, the result of a wound of the arm from a meat-hook. Dr. Hardcastle did not know this at the time he accepted her as an assistant.
DR. M. B. MILLER said that, as far as he had been able to learn, this was the first case of infection by the bacillus aerogenes capsulatus recorded in Philadelphia or its vicinity. All the work on this bacillus in this country had been done in the neighborhood. of the Johns Hopkins Hospital.
He had seen the patient with Dr. Roberts. There were two features about it which particularly impressed him,—one was the curious feeling of the gangrenous arm. The only thing that he could compare it to was the crepitant feeling of pulmonary tis sue. The other feature that impressed him was that this gas formation was not only in the tissues themselves, but also in volved the blood-vessels. Both in the radial and ulnar arteries the gas had formed in the form of long bubbles, with smaller areas of blood-clots in between, giving a beaded appearance that could be seen through the blood-vessel walls.
DR. HENRY R. WHARTON said that he noticed in Dr. Rob erts's case a similarity between the clinical symptoms presented and those of traumatic spreading gangrene that surgeons used to see formerly, but which is rarely seen at the present time. Certainly there were a great many symptoms in common with the infection produced by the bacillus aerogenes capsulatus and the infection that was present in cases of spreading gangrene—traumatic spreading gangrene—which was often seen in compound frac tures, the form of gangrene described by the French writers as "bronzed gangrene." He had never seen cases in which the pres ence of the bacillus aerogenes capsulatus was demonstrated, and yet, from the description of these cases, there is a similarity to the cases of spreading gangrene. He remembered a compound frac ture of the forearm in which this form of gangrene developed in twenty-four hours and spread rapidly from the forearm up to the shoulder. In this by prompt amputation at the shoulder joint, the patient's life was saved. He formerly saw a good many cases of spreading gangrene, not only in his own hospital experi ence, but in that of Professor Ashhurst, in which prompt ampu tation saved many lives.
DR. J. B. ROBERTS rejoined that Dr. Miller had just reminded him that Dr. Kneass reported to him that he found a pure culture of the bacillus aerogenes capsulatus. It was not a mixed infection. He had seen spreading traumatic gangrene where there was a great devitalization of cells from the injury itself ; and he had seen cases of spreading gangrene, not after such crushing in juries ; but he did not recollect ever having seen gangrene spread with such great rapidity as here, unless there was something in the extent of the injury or in the damage to the vessels to cause it. There was here a little wound, an insignificant thing, yet in three days the girl's arm was gangrenous irregularly up to the elbow ; the temperature was 103.8° F.; and albumen and tube casts were present in the urine. He believed that what used to be called hospital gangrene would, under the present bacteriological methods, be found to be an infection of this bacillus, the bacillus of malignant cedema, or some similar organism. The so-called bronze gangrene he was not familiar with. He had never seen angina Ludovici, which is probably an infection with the bacillus of malignant oedema. Many of the old descriptive names for various forms of gangrene have fallen into disuse, because bacteriological investigation has enabled surgeons to discard them for more accu rate designations founded on the bacterial character of the infec tions.