ON THE TREATMENT OF PHLEGMONOUS ERYSIPELAS AND OTHER FORMS OF SUPPURATIVE INFLAMMATION BY IMMERSION IN ICE WATER.Read in the Section on Surgery and Anatomy at the Forty-fifth Annual Meeting of the American Medical Association, held at San Francisco, June 5-8, 1894
Journal of the American Medical Association (JAMA)
nuclear. According to certain authors, there are mononuclear pus cells, but Ziegler's " Pathology " in the last German edition says : " Among the cells emigrating from the circulatory system, two forms may be distinguished, viz : mono-and polynuclear, and the term pus cell refers to the polynudear forms." Fiirbringer, in his classical work, "Die Inneren Krankheiten der Harn u. Geschlechtsorgane," edition 1890, states, that pus cells may appear plentifully in prostatic secretion as a result of a
... on as a result of a catarrh confined to one gland follicle, and not of the entire organ. Under all circumstances the finding of the large and beautiful Böttcher crystals, determines the secretory involvement of the prostate. The addition of a drop of a 1 per cent, solution of ammonium phosphate to a drop of the expressed fluid on a slide, should show these crystals after the lapse of an hour. Further, he says: "It must be admitted, that these crystals may not be found in true prostatorrhea, because of extensive chemic changes in the gland secretion, es¬ pecially in those forms tending to form necrotic areas and abscesses, also because of the admixture of urine." But the failure of this reaction by no means weakens the proof in the positive results afforded by their presence. We have endeavored to demonstrate the presence of these crystals in each of our cases, according to the method indicated, but as yet without success, perhaps owing to the obstacles mentioned. Likewise in each case we have searched through many speci¬ mens for gonococci in the pus cells of the expressed secretions, but without success. Undoubtedly, with the advantage to be derived from examination of greater clinical material, our efforts in this direction should be successful. Our method of staining for gonococci is one which has given us beautifully clear pictures, and generally brilliant results. It is that recommended by Lanz in No. 9 of the Deutsche Medicinische Wochenschrift, of this year. Briefly it is as follows : Spread on the cover-glass, dry and fix in the usual manner, being particularly careful not to overheat in fixing. Im¬ merse from one-half to one minute in a 25 per cent, solution of trichloracetic acid. Wash, dry, and fix again. Then immerse for about five minutes in a solution of thirty cc of distilled water, to which add enough of a saturated aqueous solution of methyl blue to give a deep blue tint, and one or two drops of a 5 per cent solution of caustic potash. The gono¬ cocci will appear deep blue, and the rest of the cells a lighter blue. A double stain may be produced by immersing the cover-glasses for a few minutes in a dilute solution of Bismarck brown. The cell proto¬ plasm will take on a greenish or brownish hue, while the gonococci will remain unchanged. As a negative •criterion in cases in which all other methods of de¬ termining the presence of gonococci fail, cultures may be made. They grow only on such media as blood-serum, serum-agar or blood-agar, in the form of minute dewdrop-like colonies. It is a distinguish¬ ing characteristic of gonococci, that they do not grow on plain nutrient gelatin or agar. In conclusion, we must express our regret that our limited time and clinical material have not enabled us to give you more extensive results, but we trust that the little we have presented will serve as a stim¬ ulus to our colleagues to devote more time and pains¬ taking methods to the examination and treatment of this hitherto somewhat unsatisfactory class of cases. If by definitely excluding all possibility of infection after an attack of specific urethritis, we may lessen the misery entailed on young wives through innocent contact with husbands pronounced free from infec¬ tious possibilities by their medical advisers, we may feel some degree of satisfaction ; if in no other way, at least by curtailing some of the work of the gyne¬ cologists. Phlegmonous erysipelas, phlegmonous inflamma¬ tion, or pseudo-erysipelas, as Billroth terms it, I, in my earlier experience, found an intractable and destructive affection materially interfering with the future usefulness of the hand, the part most com¬ monly affected. After having treated a number of cases by the old method of free incision, local applications, hot fomentations, etc., with the usual results, it occurred to me that the rapid destruction of tissue was due to excessive heat, and that if some method of reducing the temperature were adopted the effect would be prevented. Cold has always been used as a method of treatment, with the added caution that it was liable to produce gangrene, as in these cases there is a natural tendency to that result. Pressure, such as would be produced by the application of ice would increase that danger, so the thought occurred to me to use immersion in ice water, and I will now cite a couple of cases treated in this manner: In December, 1875, J. M., a half-witted fellow, becoming alarmed at something in the night, thrust his hand through a pane of glass. He came to my office the following morn¬ ing, and I found an incised wound extending along the back of the hand from between the second and third fingers to the wrist. I brought the parts together with four silk liga¬ tures, and giving him a carbolized lotion,told him to return in a day or two. He returned on the second day and I found the hand enormously swollen. The skin, of a roseate hue, with the well-known doughy feeling of erysipelas. I at once removed the stitches, and quite a quantity of ichorous pus escaped. I painted the surface with iodin, gave him the tincture of the chlorid of iron internally and ordered the application of flaxseed poultices. He returned on the following day, and the quantity of pus had greatly increased; the hand having assumed the well-known feeling of a bag filled with loose bones. I directed him to go home, fill a basin with water, and after putting in a large lump of ice to keep his hand completely and constantly immersed, and when he was ready to sleep, to wrap a towel, which had been previously dipped in ice water, around his hand and to renew the application every time he awoke, and, as in his mental condition he slept but little, it was kept pretty constantly immersed. In addition to the iron I had pre¬ viously ordered,I gave him liberal doses of quinin, together with wine and nourishing diet. For the first twenty-four hours, I was rather uneasy about the treatment, visiting him every few hours to watch its progress. To my delight, suppuration ceased almost immediately, and to my amaze¬ ment on the following day I found granulations springing up in various portions of the wound, which continued to do well and I discharged him at the end of twenty-one days, the wound being completely healed and the hand unim¬ paired.