to the gas forming organisms as possessing some potential for tissue destruction. Not infrequently life is saved in such cases by quick thinking ward attendants applying pressure at the proper point until the surgeon can be summoned. If infection is present, as it usually is, consideration of blood vessel replacement BMS-754807 BMS754807 is out of the question and one is only concerned with controlling the hemorrhage by ligation of the vessel. This requires no special comment. Occasionally, however, the secondary hemorrhage may result from the rupture of an undetected or false aneurysm, secondary to the initial trauma. If this is the case, then replacement of the blood vessel by one of the techniques previously described is in order.
Such an aneurysm might be suspected before rupture, if a pulsating mass is palpated in the region of injury. Should there be any question as to the diagnosis, this may be elucidated further by performing arteriography, providing the patient is not so immobilized in plaster as to make such an attempt out of the question. An arteriovenous fistula may announce its presence by the appearance of dilated and tortuous veins with stasis pigmentation, dermatitis or ulceration distally, the presence of a thrill, palpable over the area of the fistula and the auscultation of a to and fro murmur, characteristic of such fistulae. Here again, if there is any question of the diagnosis, an arteriogram can be performed and may be of tremendous help. The treatment is surgical and depends upon the site of the fistula.
Four point control must be obtained before any direct attack is attempted on the fistula itself. This means control of the artery and the vein involved both proximal and distal to the fistula. Once this is done it may be possible to sacrifice the vein and to repair the defect in the artery with an over and over stitch. On the other hand, arterial repair may not be possible due to the size and shape of the lesion and it may be necessary to resect the fistula and replace the arterial defect with a prosthesis, as before mentioned. Now, we come finally to a large group of disorders which may all be classified under the heading of post traumatic reflex sympathetic dystrophy. When such autonomic disturbances are associated with severe pain, edema, skin changes, tenderness and hyperesthesia, they are called causalgias or the Weir Mitchell syndrome.
When they are associated with marked vasospasm, blanching and sweating of the extremity, they are called reflex, post traumatic Raynaud,s phenomena. And when they are associated with vasomotor disturbances and certain osteolytic changes in small bones they are called Sudeck,s atrophy. In whatever form these disturbances present themselves, the underlying dysfunction is an autonomic nervous one. Here, it is worth while pointing out that the picture is not always a consistent one, but may be phasic. For example, a case of Sudeck,s atrophy may, in the early period, present a picture of an erythromelalgia like state with warm digits and a burning type of pain, later, this may be followed by a vasospastic picture with coldness, blanching and sweating. To me it seems less important to differentiate the different types of dystrophy than to recognize their existe