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INDEX TO SURGICAL PROGRESS. 


GENERAL SURGERY. 

I. Gas Phlegmons. By Dr. A. Stolz (Strassburg). The 
object of this article is to subject to a critical review the organ¬ 
isms which are involved in the production of gas phlegmons. The 
conclusions are that the Welch-Frankel bacillus (an anaerobic 
non-motile butyric acid forming bacillus) is the main factor in 
producing a gas infection. Closely allied to it, though rarely 
encountered, is an anaerobic motile butyric acid bacillus described 
by Wicklein in three instances and encountered by the author 
once. It is doubtful whether in gas phlegmons we have any 
longer to reckon with the formerly recognized bacillus of malig¬ 
nant oedema. 

Among the aerobic bacilli a number of undoubted Proteus 
vulgaris, hauseri, coli and paracoli infections were encountered, 
and on these occasions it was possible to demonstrate that these 
latter bacilli do not require the co-existence of diabetes. Finally, 
exceptional cases are reported that are traceable to other organ¬ 
isms, which will have to be reckoned with hereafter, dependent 
on accurate bacteriological data .—Beitrage sur klinischen Chi- 
rurgie, Band xxxiii, Heft i. 

THORAX. 

I. Pulmonary Embolism after Injuries and Operative In¬ 
terference. By Dr. G. Lotheisen (Innsbruck). Lotheisen was 
able to collect sixty-one reported cases of pulmonary embolism 
with fifty-two deaths, representing a mortality of 83 per cent. 

Following fractures, thirty-six instances are specified, occur¬ 
ring with equal frequency in both sexes between the ages of 
twenty-five and sixty-six, fractures of the leg being most repre- 

639 



640 surgical progress. 

sented. Six instances are reported after contusions of the 
abdomen and extremities, the male sex being favored; and four 
times subsequent to tendon and muscle ruptures. 

Occurring after operative interference, sixteen cases are cited, 
five females, fifteen men, between the ages of seventeen and 
sixty-seven. Embolism occurred as early as twenty-four hours 
and as late as the fourth week. Embolism has an affinity for 
advanced years, no instances of its occurrence during infancy 
being reported. Women are particularly prone, as testified by 
the reports of gynaecologists, but in this summary males predomi¬ 
nate. As a post-mortem finding, pulmonary embolism is more 
frequently encountered than in clinical reports, and, notwith¬ 
standing its rarity, itself is deserving of attention just because 
of its extremely sudden onset. 

A particular disposition is favorable to embolism, thus anae¬ 
mia incident to great loss of blood after uterine haemorrhages, 
or after infectious diseases of long standing or cachexia, all are 
predisposing factors. The slowing of the blood current as the 
result of cardiac degeneration in alcoholics and pregnant women 
is likewise contributory to thrombosis. The thrombus which 
forms while the patient is recumbent is displaced with any strenu¬ 
ous movement upon arising. The diminution of intra-abdominal 
tension upon removal of fluids permits of a greater flow, whereby 
the thrombus can be displaced. 

In view of the sudden onset of thrombosis, a sign foreboding 
its approach might be of value. Mahler describes a pulse-curve 
successively rising while the temperature remains low as being 
pathognomonic of impending embolism. Lotheisen does not give 
this his unqualified support, since an increase of pulse-rate often 
follows laparotomies from the manipulation of the bowel. 

From a prophylactic stand-point it is commendable to avoid 
operations during or after pregnancy, and when these are exe¬ 
cuted, the pelvis should be elevated, massage avoided, and all 
severe and violent motions forbidden. 



THORAX. 641 

Embolism once at hand requires vigorous cardiac stimulation. 
—Beitrage zur klinischen Chirurgie, Band xxxii, Heft 3. 

II. Decortication of the Lung in Chronic Empyema. By 

Dr. Kurpjweit (Konigsberg). The author accords priority for 
this operation to George Ryerson Fowler. Preliminary to per¬ 
forming decortication, Delorme advises irrigation of the cavity 
with antiseptics for several days. Any pulmonary fistula must 
be sewn to obviate any subsequent pneumothorax. 

The majority of operators do not make a trap-door incision 
as originally advocated by Delorme, but resect extensively, if 
necessary. 

The results of the operation are set down by Delorme at 30 
per cent, to 40 per cent, cures. Cestan gives 40 per cent, cures, 
xi per cent, improved, 35 per cent, not improved, and 14 per 
cent, death. Fowler’s report covered thirty cases,—seventeen 
cures, nine cases no cure, three deaths, and one doubtful. The 
interpretation of these combined statistics resolves itself into 
35.7 per cent, cures, 19.7 per cent, improved, 33.9 per cent, no 
cure, 10 per cent, death. In six deaths pulmonary tuberculosis 
was encountered. 

The gaping of the incision of the divided thickened pleura is 
not due to the expansion of the lung beneath, but is due to the 
release of the thoracic tension which permits of a greater ampli¬ 
tude in thoracic excursion, which in turn tears the pulmonary 
pleura, and though the lung appears to expand under forced 
expiratory efforts, such as cough, it does not follow that the 
lung beneath the diseased pleura possesses spontaneous qualities 
of expanding. Permanent expansion is only possible if adhe¬ 
sions between the thoracic wall and lung ensue. 

Where a trap-door flap is made, pneumothorax follows, 
which hinders the expansion of the lung. The approximation of 
the soft parts to the lung is necessary to enable the lung to ex¬ 
pand. 


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642 


SURGICAL PROGRESS. 


Delorme values the trap-door incision, since he claims it 
does not permanently deform the chest wall. 

Compared with extensive resections, the statistics for the 
latter are 56.3 per cent, cured, improved 20 per cent., no cure in 
three, death in twenty. For decortication there are but 33.9 per 
cent, cured. 

In three instances only was the trap-door incision performed, 
wherefore the author is disposed to attribute much of the success 
to extensive resections of the ribs with adaptation of the soft 
parts to the lung .—Beitrdge zur klinischen Chirurgie, Band 
xxxiii, Heft 3. 


GENITO-URINARY ORGANS. 

I. Two Decades of Renal Surgery. By Dr. M. O. Wyss 
(Zurich). The author analyzes 113 operated cases from the 
stand-points of etiology, symptomatology, diagnosis, etc. 

Etiology .—Traumatism may produce the most varied results. 
Its main interest centres in its producing but slight perirenal 
haemorrhage, which in turn is capable of loosening the connective 
tissue and causing floating kidney, or, eventually, cicatrices that 
are likely to press upon the renal pedicle. 

Hydronephrosis is always caused by a secondary pathologic 
factor that brings about obturation of the ureter, but this alone 
does not suffice. The author, supported by the observations of 
Israel and Landau, shows that still other factors must be active 
to effect hydronephrosis such as he sees in displacements of the 
kidney, which at the same moment affect the renal circulation in 
respect to its nutrition. Nephropexy permanently cured four 
cases of intermittent hydronephrosis. 

In tuberculosis of the kidney heredity plays the usual role, 
particularly in the transmission from the father, whereas compli¬ 
cation of other viscera was relatively seldom. The observation 
of fifteen operated cases showed no clinical evidence of systemic 
tuberculosis before operation, and because of the lasting cure