of Rhodes. Spurious works Andronicus.

The American journal of obstetrics and diseases of women and children online

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Dr. Broun. — At the Woman's Hospital we have found by ex-
perience that in a case of criminal abortion admitted to the
hospital, before any operation is done the coroner's office should
be notified that such a case is in the hospital, and that she needs
an operatidn. His answer is: Does she wish to make an ante-
mortem statement? The patient having expressed no desire to
make such, the office of the coroner has no interest in the matter.
In two instances where they were not notified and the patients
died, the hospital was given much annoyance. So we find it is
wiser and very much easier to notify them at once of the presence
of the patient instead of waiting until the patient is expected
to die or until after her death.

Dr. Collyer. — This is approved only so far as hospitals are
concerned. It is natural they should notify the coroner, but it is
different in private practice where we are brought face to face
with a case of abortion that may or may not have been induced.
We are likely to get into very serious trouble if we on every
occasion not&y the coroner; the law does not require it, so the
attorney states, unless the case dies by criminal acts. A
couple of my friends, one of whom is here to-night, were arrested
and taken to the station-house and would have remained there
all night had it not been for the aid of the assistant district
attorney who was called upon and obtained their release. That
woman, I believe, had not died. These doctors were in perform-
ance of their duties to save life, and the police had no authority
to arrest them, if I understand correctly.

Dr. Coe. — I must confess that J have always had a great
respect for the law, but I have less after hearing the statutes
read by our esteemed legal brother. They are very vague.
That word *' quickening" is a most mischievous expression. I
think that we must admit that the morality of most women is,
in the matter of abortion, not of a high standard, and practically



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500 TRANSACTIONS OF THE

every woman has the idea there is not any harm in emptying the
uterus before quickening. Unfortunately, we find among some
gentlemen of our profession the same erroneous idea. It is sur-
prising to see the cases brought to us in which we are urged to
terminate a pregnancy for trivial reasons. This law is imperfect;
we ought to revise the whole thing. It is an absurd system,
that of these coroners, absurd to anyone who has lived in
Massachusetts under the system of medical examiners. Coroners
certainly seem to be mediseval.

Mr. Vandiver. — It is the survival of a mediaeval system.

Dr. Coe. — My own recent experience is briefly this: I was
called one evening to a strange patient, in a hurry, and at great
personal inconvenience. I found a young girl bleeding profusely
and in great pain. Her mother was with her. She said she had
skipped a period and she absolutely denied any interference,
attributing the symptopis to a fall. I sent her at once to the
Woman*s Hospital, put in a tampon, and next morning curetted
the uterus, in the presence of two of my colleagues, removing
some decidual membrane. The temperature (loi*' on entrance)
dropped to normal, and after two or three days the case gave me
no anxiety. She was a reputable, unmarried girl; her mother
knew nothing about her condition, nor did her brother, and I
could not see that there was any reason why I should bring dis-
grace to the family. On the fourth day she had a violent chill,
her temperature rose to 105°, and, in spite of all we could do, she
died of general septicemia on the sixth day.

I saw no reason why I should bring that family into the case
by sending for the coroner to take an antemortem statement
which was not requested by the patient or family. The same
afternoon (Sunday) he came up with blood in his eye; his physi-
cian made an autopsy, absolutely swore that it was a case of
criminal abortion which was something I couldn't have sworn to
myself. He acknowledged afterward that there was no lesion or
anything in the tissues to indicate the origin of the septic
endometritis.

When I reached home three reporters were waiting for me.
The next day, during office hours, three detectives lay in wait
for me, one from the central office, one from the homicidal
bureau, and the third from somewhere else.

Then I began to get mad and went down to see Mr. Jerome.
I asked him to tell me if I was liable for not having sent for the
coroner to take the woman's antemortem statement. He said
no, but I was nevertheless exposed to all the annoyances inci-
dent upon a rather disagreeable inquest.

In such a case it would seem as if a reputable physician was
justified in proceeding against the coroner legally for defamation
of character. Each one of those detectives who came to my
office looked upon me and treated me as if I was the guilty party.
I did not know the abortionist at the time, nor do I now. I said,
in concluding my testimony, ** What I did I will do every time



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ALUMNI SOCIETY OF THE SLOANE MATERNITY HOSPITAL. 501

when a similar case comes under my care," and the coroner said,
•*Thatwilldo."

Dr. Brettauer. — I certainly do not think it is our duty to
report these cases. We take care of them as patients; must we
also play detective?

Mr. Vanpiver. — No, sir. That is entirely in the hands of the
board of health, department of health, which is composed of
the health commissioner and the police commissioner. They
have the authority under the law to draft the sanitary code.

It is a matter you medical gentlemen know better than I. I
agree with Dr. Coe that the law should be amended and made
clearer, and that it should be done by medical men. The present
law has been put through by amateur legislators and amateur
lawyers — some were neither (laughter).

On motion a rising vote of thanks was tendered Mr. Vandiver
for his comprehensive paper and discussion covering the legal
questions involved in the production and treatment of cases
of abortion.



TRANSACTIONS OF THE SOCIETY OF THE

ALUMNI OF THE SLOANE MATERNITY

HOSPITAL.



Meeting of January 29, 19 10.
The President, O. P. Humpstone, M. D., in the Chair.
Dr. Jas. D. Voorhees reported a case of
pyelitis occurring late during the puerperium.

The patient, Mrs. B., was thirty-nine years of age. The pre-
vious history was negative except for more or less intestinal
indigestion and constipation.

She had had four children without any trouble or complica-
tions. The last one was born July 17, 1909. The patient did
well, except for gas, intestinal discomfort, and constipation with
large amounts of mucus in the stools. She nursed, but the baby
did not gain steadily. Her physician thought her quite well
and about September i went to Canada for his vacation.

On September 12 she took a fairly long motor ride and in the
evening complained of backache. The next morning, the forty-
eighth day after delivery, she felt chilly, and at noon her. tem-
perature ran up to loi® and at 8 p. m. was 102*^, the pulse rising



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502 TRANSACTIONS OF THE

to 128. She complained of sharp pain in the right iliac fossa
with backache and was severely prostrated by her fever. A
local physician (the case being out of town) was called in. He
made a diagnosis of puerperal sepsis and advised an immediate
curettage. This alarmed the relatives and I was sent for. I
arrived at 1 1 p. m. At this time the patient was better. Her
temperature had fallen to 99.8® and the pulse to no. She was
perspiring profusely. The abdomen was considerably dis-
tended, with no rigidity, but marked tenderness in the right
iliac fossa was elicited. This tenderness ran up to the right
kidney on deep palpation. This kidney was quite tender and
slightly enlarged. The left kidney was somewhat sensitive.
The urine was cloudy, with odor, and a marked sediment.

I ordered calomel followed by a saline the next morning; uro-
tropin grs. viiss every three hours; large draughts of water by
mouth; and an ice bag locally.

I spent the night in the house and on the next morning, Septem-
ber 14, the temperature was normal, the pulse 96. There was
less pain over the kidney. A diagnosis of pyelitis was made
before the urine could be examined and I returned to New
York. The urinalyses made in town showed an acid reaction,
sp.gr. 1022, 15 percent, albumin by volume with 10 per cent, pus,
a decided bacteriuria and a few studded epithelial casts. The
patient's physician had been telegraphed for and he arrived to
take charge of the case during the evening, when she was better,
the temperature being only 99 . 6® F.

September 15. The patient continued to improve, the tem-
perature was only 99 . 8° in the evening.

September 16, I saw her again. She was much better in
general and she was passing large quantities of urine containing
only a trace of albumin, but considerable pus. There was less
pain and distention, but her temperature had risen to 100.4° F.
It looked as if she was going to have a short infection. How-
ever, at noon the next day after a saline colonic irrigation she
complained of intense abdominal pain and felt chilly later in the
evening. At 8 p. m. the temperature was 101° F., rising further to
103*^ F. at 10 p. M. Her own physician could not be reached so
I was again sent for. The whole abdomen was tender but espe-
cially in the right iliac fossa. The patient spent a wretched
night and at 4 a. m. the temperature was 104*^ F. As the hus-
band could not understand why this severe relapse came on
under appropriate treatment, and realizing the possibility of a
concurrent appendicitis, it was decided to have a general con-
sultation, especially as the temperature had risen higher, to 105°,
so another obstetrician and a surgeon were summoned. I think
only the presence of the obstetricians, possibly together with the
blood count, which was not conclusive, prevented an immediate
appendicectomy. Delay and close observation in town were
determined upon. Accordingly the patient was brought to Bull's
Sanitarium. The temperature did not begin to fall until the next



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ALUMNI SOCIETY OF THE SLOANE MATERNITY HOSPITAL. 503

morning when it was 102°, but in the evening it rose to 103° F.
A complete urine examination by Sondern showed a pyelitis due
to the colon bacillus. The symptoms referable to the appendix
were less marked, and on the whole the patient was much better.
This improvement continued, and in three days the temperature
was practically normal. The pus was found continuously in the
urine for a long time. I saw her again October 20, a month
later, with a slight attack of pain and tenderness over the left
kidney with a temperature of 100.2° F., and with still a slight
P3airia. This vanished on the next day and since that time I
believe the patient has been in fair health.

I cite this case of pyelitis: i. on account of the very late appear-
ance during the puerperium, and 2. on account of the different
diagnoses made. I believe the patient must have had a bacteri-
uria and a pyuria fairly soon after her delivery. If this had
been discovered early, under appropriate treatment, and, I
must say, under a successful management of her intestinal indi-
gestion, the acute illness could probably have been prevented.

Besides sepsis and appendicitis, I have seen cases of pyelitis
mistaken for »*cold,'* grippe, malaria, typhoid, and in one case a
kidney was incised for an abscess. Diagnoses of stone in the
kidney and in the gall-bladder have also been made. When
the general practitioner realizes the frequency of pyelitis and the
possibility of this complication during pregnancy and the
puerperium, he will make fewer such mistakes in diagnosis.

DISCUSSION.

Dr. E. B. Cragin said that he was impressed by three things
in this report. The first, that there was no time in either preg-
nancy or during the puerperium in which there was no danger
from pyelitis. It may come on, as reported, as early as the
sixth week of pregnancy or it may develop at the very end of
the puerperium. The second point was its resemblance to appen-
dicitis. He referred to a case which was seen in consultation
and in which he agreed with the attending physician in the diag-
nosis of appendicitis. Somewhat later on his way home he real-
ized, however, that he had to do more probably with a case of
pyelitis than appendicitis. He communicated this opinion to the
physician who had attended the case and a subsequent exami-
nation of the urine showed the truth of his suspicions. One of
the reasons why these cases resembled appendicitis was the fact
that the ureter was tender and pressure on McBurney's point
pushed the uterus back upon the tender ureter. The third
point was the value of conservatism.

Dr. Cragin*s first paper on this subject before the American
Gynecological Society closed with the sentence ''induction of labor
is seldom if ever indicated.*' Since then he had had two cases in
which it seemed right to empty the uterus and those were the only
ones in which he had ever felt the necessity of interfering. He



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504 TRANSACTIONS OF THE

believed that induction of labor was very rarely indicated. Now,
after labor or during the puerperal period, however, he admitted
that the danger of involvement of the kidney substance was a little
more marked than before, and in two of his cases it was necessary
to remove the kidney. These cases constituted rare exceptions
and the more instances of pyelitis met with, the more we must
realize that they usually recover under palliative treatment.
Another interesting feature about this condition was the fact
that, although exceptions occur, the patients were unlikely to
have any recurrence. The worst case he had ever seen was a
woman who had been sick a very long time, but went to term,
and since then had had two children without any signs of pyelitis,
with the exception of one day when a little pus was found in the
urine and in addition there was a slight rise of temperature.
In closing, Dr. Cragin emphasized the relief which comes to the
obstetrician when from a rise of temperature he suspects puer-
peral infection and finds on examination of the urine the presence
of pus and the colon bacillus, together with an acid reaction.

Dr. E. a. Gallant believed that awoman whohas been recently
delivered was particularly susceptible to displacements of the
kidney. The dragging to which the ureter is subjected usually
results in a kinking of that tube, producing an obstruction,
which results in the retention of urine in the pelvis of the kidney.
This retention favored the growth of any bacteria which might
be present and resulted in the production of a pyelitis. When
the patient assumed the recumbent posture the kidney slipped
back, the retention was relieved, and the temperature fell, only
to rise again when the patient sat or stood up. He thought that
without some form of obstruction to the urinary stream, even
pyogenic bacteria would not give rise to temperature.

Dr. Sampson believed that it was usually unsafe to generalize
from an individual case, yet he wished to report the following
as having a bearing on the treatment of the condition under
discussion. A patient was referred to him about a year ago, a
diagnosis having been made of either extrauterine pregnancy
or pregnancy complicated by appendicitis. On examination
the patient was found to be between four and five months preg-
nant and the urine contained pus. A diagnosis of pyelitis
complicating pregnancy was made which was later confirmed by
making urinary cultures from the pelvis of the right kidney by
ureteral catheterization. The patient was treated conserva-
tively and made to assume the knee-chest posture several times
a day and at other times was directed to lie on the left side with
pillows under her hips. This treatment relieved the patient
of the pain. After remaining in the hospital for two weeks she
returned home and was able to go to term. The idea of the
knee-chest posture and the elevation of the hips was not to permit
a displaced kidney to assume its proper position, as the organ
was apparently not displaced in this instance, but that the gravid
uterus, which probably pressed on the right ureter, would be



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ALUMNI SOCIETY OF THE SLOANE ^UTERNITY HOSPITAL. 505

made to fall forward and away from it, in order that the urinary
flow would remain unobstructed from the kidney to the bladder.

Dr. Voorhees referred to the fact that Dr. Cragin must be
given the credit for bringing the subject of pyelitis during preg-
nancy and the puerperium before the medical profession of
this country. Dr. Voorhees agreed entirely with Dr. Cragin's
remarks and especially with the statement that induction of
labor was rarely, if ever, indicated. It seemed remarkable how
sick these patients could be, how much pus and albumin might
be in the urine and yet they would yield to appropriate treatment
and go to term. It seemed to him that those rare cases which
develop a pyelonephritis with multiple abscesses in the kidney
were not due to the colon bacillus but to an ascending pyogenic
infection from the bladder. Dr. Voorhees had not induced labor
for pyelitis and had seen only one case where the kidney was
subsequently so involved as to necessitate a nephrectomy. He
carried this patient through a pregnancy, through a miscarriage,
and then later, during an early pregnancy which was not appre-
ciated, the kidney was removed because the patient developed
violent chills and fever. The organ was found to be the seat of
multiple abscesses. The speaker could not agree with Dr.
Gallant's statement that movable kidneys were more liable to
develop a pyelitis; but, as Dr. Cragin had said, pregnancy pushed
these kidneys into place and was therefore beneficial. Postural
treatment, however, is undoubtedly helpful in the management
of pyelitis and should be a routine treatment. Patients should
be taught not only to lie on the abdomen and on the opposite
side to the kidney aflfected, but also to assume the knee-chest
position in order to relieve the pressure obstruction of the growing
uterus on the ureter. He always expected and prepared for the
recurrence of a pyelitis during subsequent pregnancies. He had
one case which probably presented a pyelitis during four preg-
nancies, but had no urinary symptoms in between. During the
first pregnancy, because of fever and of pain over the kidney,
the organ was incised, but nothing found. The wound was
sewed up and the patient promptly miscarried. During the
second pregnancy, after three or four weeks of fever, a premature
labor took place at about six months. In two later pregnancies
the patient developed pyelitis about the fourth month, but in
each case she could be carried through to term under appropriate
treatment.

Dr. J. Douglas presented a specimen from a case of

CONGENITAL OBSTRUCTION IN A NEW-BORN INFANT.

The specimen was from a baby thirty-six hours old, brought
into the St. Luke's Hospital with a history of absolute constipa-
tion and continuous vomiting since birth. The doctor who had
delivered the child said that he had removed a grayish mass the
size of a hazel nut and resembling a phosphatic calculus, from
the rectum.



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506 TRANSACTIONS OF THE

Examination showed marked distention of the abdomen, par-
ticularly in the epigastric region. There was no abdominal
rigidity or elevation of temperature, but the pulse was very rapid.
Rectal examination was negative. A diagnosis of intestinal
obstruction was made and as the cause could not be determined
an operation was advised.

After gastric lavage an incision was made in the median line,
extending about one-half inch above and below the umbilicus.
Exploration showed that the small intestine, greatly distended,
63 cm. from the pylorus, ended in a blind pouch in the region
of the umbilicus. From the end of this a mass of soft connective
tissue in which were many fibrous bands ran up to the umbilicus.
Within this mass of connective tissue two distinct segments
of undeveloped intestine closed at both ends could be made out,
one empty and one filled with soft material. From the same
mass ran the continuation of the small intestine, undeveloped
and undistended, being only 7 mm. in diameter. The large
intestine (colon) was 9 mm., the sigmoid 5 mm. in diameter,
while the distended small intestine above the pouch was 2.5 cm.
in diameter.

The obstruction was evidently due to lack of development
caused by pressure of the remains of the omphalomesenteric duct
or vessels, and the only possible treatment was enterostomy or
an attempt at enteroenterostomy, neither with much promise
of success. While determining which course was the best to
pursue, the child vomited a large amount of grayish fluid (not-
withstanding its previous lavage), and inspired a quantity of
the vomitus. Its condition became so bad that the abdomen
was closed without further treatment and the child died about
four hours later.

There have been a number of cases of congenital obstruction
reported, but of a series of thirty-two operations which have
been performed (twenty-six enterostomies, four enteroenteros-
tomies and two perineal enterostomies) the mortality has been
100 per cent.

The difficulty of performing an enteroenterostomy and the
small chance of keeping up the child's nourishment with an
enterostomy, especiaJly if the obstruction were in the small
intestine, would seem to indicate that the only chance of making
the mortality less than 100 per cent, would be to bring both ends
of the intestine at the point of obstruction into the wound. A
temporary enterostomy should be done rapidly. Then if the
child's condition improved in a day or so, an attempt might be
made to dilate the undeveloped or undistended intestine below
by injecting saline solution in the hope of subsequently perform-
ing an enteroenterostomy if the dilatation were successful.
Dr. Douglas had found no record of any such operation, but, as
all other methods have failed, would attempt it were he to meet
with another similar case.

Dr. G. W. Kosmak stated that his personal experience in cases



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ALUMNI SOCIETY OP THE SLOANE MATERNITY HOSPITAL. 507

of this kind was limited to one which he had met with in his
service of the Lying-in Hospital last summer. The baby in
question was admitted two days after birth with the history of
not having had any stool. An examination with a soft rubber
catheter disclosed an apparent obstruction in the rectum about
two inches from the anus. The baby had nursed some, had
not vomited at all, and the abdomen was very much distended.
Thinking that the cause of the obstruction was perhaps a septum
in the rectum, an attempt was made to reach it from below with
the finger, but this was unsuccessful. A left inguinal colostomy
was then attempted, and after incising the abdomen the large
intestine was brought into view. It was found to be nothing
but a thin ribbon-like structure. The artificial anus was com-
pleted and as the baby did not seem to mind the operative pro-
cedures, a similar incision was made on the right side, and the
ascending colon was found to be in the same condition as the
descending colon on the other side. From the ileocecal junc-
tion upward, the small intestine was about as large as the little
finger and filled up with a hard mass. Nothing else seemed
feasible, so the small intestine was opened about two inches from
its junction with the colon and sutured into the abdominal wound .
The mesentery of the small intestine was very long. The child
lived about forty-eight hours after the operation, vomited a few
times and did not nurse. After death an examination through
the colostomy wound also showed the presence of a volvulus
in the section of small intestines just above the point where the
opening had been made. Dr. Kosmak believed that there was
absolutely no hope for these children, but was inclined the next
time he had to do an operation, to make an exploratory incision
in the median line first.

Dr. Dorman said that for a number of years he had been
pessimistic about this class of cases, because at the Post-gradu-
ate Hospital he had seen two autopsies that showed a similar
condition excepting that there were portions of the large intes-
tine lacking, with intervals of fibrous tissue showing where the
gut should have been. The portions of the intestine between
the strictures contained a whitish secretion.



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 51 of 109)