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yearly growing less frequent, as the causation and prevention are better
appreciated by those engaged in obstetrical practice.

Accidents and the ignorance of criminal abortionists still furnish
enough cases to invest the disease with a keen interest.

Though much has been written in the past decade upon the treat-
ment of acute puerperal infections, we are far from possessing a settled
line of practice. The advocates of curettage and drainage affect to
arrest all cases when seen suflBciently early, while those who prefer
uterine irrigations and. tubular uterine drainage claim the same good
results. The explanation of such statistics is not far to be sought.

A man may have a large experience and yet a very uniform one so
far as the nature of the cases he encounters is concerned. I believe
we are justified in asserting that none of the ordinary methods of prac-
tice, however early and faithfully carried out, can cope with certain
forms of acute organic infection of the uterus.

The great practical difficulty consists in determining the cases
which demand the most radical measures, and those that will yield to
less heroic treatment. If the case is observed early in its progress, we

before the LonisWlle Medlco-Chirurgical Society, October 6, 1899. For discuMion see p. 382.

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362 The American Practitioner and News.

may have time to make the trial of mild methods of treat 111 en t^-curet-
tage, irrigation, and drainage — before resorting to hysterectomy should
these fail. When seen late, time may not permit of this trial, but
force us to a difficult decision at once.

We all know upon what a slender and short string the life of a
patient with profound sepsis may hang, and action must not only be
thorough but very prompt. It has only been a few years since so
radical a method as hysterectomy was practiced in the desperate cases
of this infection. This is not to be wondered at when we consider the
great hazard of performing a major and difficult operation under such
unpromising general and local conditions. That the operation is
justifiable as a life-saving measure all admit at the present time.

The mortality will always remain high, as compared with removal
of the uterus for other conditions, and we have not the satisfaction of
making it much lower by the ancient admonition of ** operate early,"
for this procedure must remain in the category o{ dernier ressorts.

As I said to a professional friend once, I did not think hysterectomy
for acute puerperal sepsis was a method likely to be abused to gratify
operative ambition, for the mortality is necessarily too great.

Per contra^ I do think we should have the courage of our convic-
tions, and in hopeless cases give the patient the benefit of the oper-
ation. My experience leads me to believe that the infection atrium of
a lacerated cervix is by far the most frequent site of the implantation
of septic germs in puerperal infection. If originating above this point,
it would seem almost positive evidence that a dirty fingernail had been
scratching the endometrium in an effort to dislodge placenta or mem-
branes. Implantation of either the staphylococcus pyogenes aureus or
the streptococci in an abrasion of the cervix or uterus gives us true
puerperal sepsis or infection, in contradistinction to the invasion of
blood-clot or retained membranes by saprophytic bacteria, which, though
giving rise to active ptomaine poison, is quickly relieved by thor-
oughly cleansing the birth canal of decomposed blood-clot and mem-
branes.

True or organic infection in a wounded cervix pursues a very dif-
ferent course, according as the infecting organism is the staphylococcus
or streptococcus.

In the first, the tendency is to spread slowly and to localize as
abscess formations in the glands immediately beside the cervix. Such
cases, treated early by cleansing and drainage, usually terminate in



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The American Practitioner and News. 363

recovery, or at most a slowly-forming tubal or pelvic abscess. Not so
with the streptococcus infection. Repeated rigors, fever and sweat,
together with all the evidences of profound general sepsis, such as
mild icterus, tympany, rapid pulse-rate, and great nervous excitation
too plainly indicate the nature of the poison. It is in the cases of this
class that I would advise hysterectomy if other measures had failed.
The vaginal method should be selected.

Rapid but as thorough sterilization of the vagina should be made as
possible. The septic uterus, after being irrigated with one to two
thousand bichloride solution, should be packed with sterile gauze.
Forceps should be used in preference to ligatures, to save time and to
prevent the certain infection that would attack the ligature sites in case
they were employed.

In 1895 I reported to the Southern Surgical and Gynecological Asso-
ciation at Washington, D. C, two cases with specimens of hysterectomy
for multiple abscess of the uterus occurring in puerperal sepsis, with
one recovery and one death. They were among the earliest of the
reported cases. Since that time a number of cases have been reported.
I did my first two by abdominal section, believing as I did that the
condition of the uterus was associated with marked tubal involvement.
This I found not to be the case; the enlarged and abscess-ridden uteri
were standing unadherent in the pelvic cavity, the peri-cervicitis and cel-
lular tissue involvement rendering a diagnosis of the tubal state impos-
sible. These specimens did much to change the views of American
gynecologists as to the method of extension of the infection in such
cases. They at least showed that in many of the virulent streptococci
infections, if the patient survived long enough, the infection spread
directly by lymphatic avenues through the uterine wall, forming sub-
peritoneal abscesses, the patient finally dying of pyemia, and that the
tubes and ovaries might escape entirely, as was the case in the speci-
mens shown.

The position taken by Pozzi, that subperitoneal abscesses do not
form in puerperal sepsis, can only be accounted for by the fact that the
operation of hysterectomy for this condition is so recent in France as
to have precluded an opportunity for him to witness this most interest-'
ing pathologic condition. Most of the patients who die of puerperal
fever do so in the first week of the disease and before such abscesses
form, hence autopsies would not oflFer a favorable way of revealing
them.



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364 The American Practitioner and News.

I wish to present to your notice this evening a specimen with report
of a case which is of exceeding pathologic interest, as representing
another phase of acute puerperal infection of the most virulent type,
and which I believe you will agfree with me would have been most
speedily fatal had not the radical measure of hysterectomy been per-
formed. I must crave your indulgence for reporting the case thus
early, but I feel should the patient disappoint us in her promise of
recovery, the specimen and results up to the present time vindicate in
a striking way the wisdom of the procedure.

The patient from whom this specimen was removed, a lady aged
twenty-two years, came into the hospital one week ago; I was in the
hospital at the time she was brought into the ward. I understood it
was an abortion case, and was told by the patient that the fetus had
been passed, but the afterbirth was still retained, and she was brought
to the hospital on this account. It was supposed to be a pregnancy
which had advanced to three or four months. I was in a hurry and did
not examine the patient, but gave the interne. Dr. Woodburn, some
instructions as to sterilizing his hands, telling him to examine the
woman and remove the placenta, which he would probably find pre-
senting in the vagina ; if not, to watch her carefully if every thing
seemed to be in good condition and wait a little while until the uterus
should crowd the placenta down; if he had reasons to believe the
placenta was adherent, to remove it by the method with which you are
all familiar. I also cautioned him about needlessly interfering with
the processes of nature, etc., if every thing appeared to be normal. In
Dr. Woodburn's examination of the patient after I left he found the
fetus between her legs in such an advanced stage of decomposition that
the odor was exceedingly foul and oflFensive. Whether it had been
born on the way to the hospital in the ambulance, or whether it passed
after she had been taken into the ward and put to bed, we do not
know. He severed the cord, and could feel the edge of the placenta, it
being in no way detached. There was no great hemorrhage, so he had
a bichloride douche given, and the patient was put to bed. That
evening she had a chill and began to bleed. He telephoned me and
said he thought he could remove the placenta ; that the patient was
bleeding. I told him to go ahead and do so. Assisted by one of the
other internes he removed the placenta with a fair degree of success, as
the ultimate record shows. Hemorrhage was checked after this was
done. He washed out the uterus with a 1-10,000 bichloride solution,



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The American Practitioner and News. 365

because the odor was so oflFensive, putting a light tampon in the vagina,
extending out the vulva so as to drain the parts thoroughly. As stated,
she had a chill that night; her pulse rapidly went up. On Monday her
temperature was 101.5^ F., pulse 120 to 124. I did not see the patient,
I am sorry to say, on Monday, but Dr. Woodbum conferred with me,
and I told him probably an intra-uterine douche every four hours of
bichloride solution 1-10,000 or 1-20,000 would be all that was neces-
sary.

I saw the patient first on Tuesday morning, October 3d. I found
her with a swollen abdomen, considerable tympanites, slight jaundice
about the conjunctivae and skin, pulse 128, temperature 101.9® F., with
a haggard expression, and altogether in a most unpromising condition.
I told Dr. Woodburn that we would at once get her ready for thorough
curettment and drainage. It was thought that possibly some of the
membranes had been left and a thorough curettage would be advisable.
The patient was placed on the table for this purpose, and as soon as
she was under the influence of the anesthetic a careful examination was
made. The discharge from the uterus was very offensive, and with the
patient in the dorsal position, after introducing a retractor beyond the
sphincter muscle, it was found that the cervix was torn posteriorly
down about the internal os. She had rather a liberal cervix, but there
was a slit in the center posteriorly. I was inclined at first to think that
possibly Dr. Woodburn had produced this tear in removing the placenta,
but he assured me that he had encountered no trouble in its removal ;
that he had followed my directions, and the placenta was easily taken
away. It then occurred to us that a criminal abortion had been per-
formed upon the woman. The cervix at the posterior lip was in a
gangrenous state; it was green; and there was a horrible, putrid,
grumous fluid escaping from the uterus. I had no diflBculty in dilating
the OS sufficiently to carry in a curette, and began going around the
uterus, scraping the endometrium carefully ; presently I found up in
the left cornu of the uterus a soft substance which I thought must be
some of the placenta, but as a part of it was scraped off" and removed I
saw that it was not placental tissue, but seemed to be gangrenous por-
tions of the uterine wall. To use the common expression, I then saw
that we " were in for it ;" that it was no use to leave the woman with a
uterus in this condition, with a gangrenous cervix. I had intended to
thoroughly curette and pack the uterine cavity, trimming off* the
gangrenous portions of the cervix, bringing the edges together with



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366 The American Practitioner and News.

stitches, and establish drainage. But the curette showed that the
uterus was probably in a state of acute septic necrosis, so the operation
I expected to do was out of the question. I asked for the broad liga-
ment forceps, and decided that I would go ahead and remove the uterus
at once. On incising the posterior cul-de-sac in order to get in behind
the uterus, between half a pint and a pint of turbulent serum gushed
out from the peritoneal sac, showing the beginning of a pelvic peri-
tonitis very much like I have seen in certain stages of appendicitis. I
rapidly removed the uterus, and, as I had suspected, there was abso-
lutely no involvement of the tubes or ovaries, and the peritonitis had
simply resulted by the sepsis extending from the infected uterus ; no
adhesions had taken place.

The uterus was removed in twelve or fourteen minutes, and a
liberal packing of gauze placed in the cavity.

The specimen is one of extreme interest, showing what a case like
this may be expected to do if left for a few hours without operative
intervention. In removing the uterus I was particularly struck with
its color, and had hoped to preserve this by the Kaiserling method, but
it has not remained for a sufficient time in the solution. Some of the
gentlemen present saw the specimen before it was put in the preserving
fluid, and will remember its condition. The fundus was as green as the
skin of a bean pod ; the color can still be seen from the necrosis ; it is
in a sphacelous condition, especially at the left comu ; the lacerated
cervix has been dilated and pulled down, but the gangrenous portion
can still be seen. The tubes and ovaries were healthy. I believe the
Kaiserling preserving fluid will eventually bring these tissues back ta
their original color.

The patient has done better since the operation than we hoped for ;
her pulse and temperature fell soon after the operation was completed.
The infusion of saline solution was practiced. While she did not lose
much blood from the operation, as little as would be lost in a vaginal
hysterectomy, still she had already lost considerable blood, and, sepsis
being present, we used saline solution liberally injected subcutaneously
about the breasts. We kept her bowels open. Her temperature is
now less than 100° F., pulse about 100; her bowels move freely, disten-
sion diminishing; there has been no vomiting, and this is the fourth
day since the operation. So it looks as if she would recover. I
believe if this woman gets well we can safely say that we have saved
her life, because she was simply overwhelmed with sepsis of a most



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The American Practitioner and News. 367

violent form, with a rapidly swelling abdomen, pelvic peritonitis, and
this gangrenous uterus. I think we can safely say that this woman
would have died of general sepsis within forty-eight hours had the
operation not been performed. I am inclined to think she will be
saved. (Has since entirely recovered.)

This is a new phase, and it is probable that in such cases as this we
will not frequently see such violent sepsis where the operation of
hysterectomy is justifiable. We will have a large mortality, at the
same time the saving of a life that in my judgment was absolutely
doomed under such circumstances I believe justified me in the attempt.
I would like to hear an expression from the Society, especially upon
the methods usually employed in these cases in the treatment, whether
they prefer gauze to tubular drains, whether they believe in curettment,
etc. Personally, outside of a blunt curette for scraping off the mem-
branes or portions of adherent placentae, I do not believe much in
cases of infection going in with a curette and scraping the endometrium,
making fresh, raw surfaces for an extension of the morbid processes, and
I can see how it might do a great deal of harm. The practice of
curetting, which is so much lauded, can be of very little utility in
cases of organic infection. It is all right in sapremia, where you have
an infected blood-clot, where you want to get this away, where you
have an excellent pabulum for the saprophytic bacteria that may give
rise to poisonous toxines, etc.; but where you have a true progressive
sepsis, not only giving off toxines, but have the multiplication of
bacteria, then the curette can only make matters worse. Thorough
irrigation in most of such cases would do better than breaking up the
endometrium and making fresh, raw surfaces with the curette.

LOUISVILLB.

DIPHTHERIA: ITS IDENTITY AND TRANSMtSSIBILITY FROM
LOWER ANIMALS TO THE HUMAN SUBJECT.

BY WILLIAM B. MEANY, M. D.

Almost nothing is with certainty known of the beginning of diph-
theria, though much has been learned respecting conditions favoring
its spread, and something, perhaps, of influences fostering its virulence.
The earliest cases in an epidemic of diphtheria are frequently very
mild, and thus easily escape recognition. The first persons to die
(almost invariably children) are generally supposed to have suffered



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368 The American Practitioner and News.

from " croup," and very likely at the commencement of an epidemic
of diphtheria has the appearance mainly as a local disease, killing
rather by suffocation than by general blood-poisoning.

In cities and towns diphtheria, beginning in the above fashion, is,
without doubt, propagated by personal communication, especially by
association of children in schools; and, seemingly, at school slight cases
of diphtheria, and cases that are convalescent, get opportunity for pass-
ing on the malady, with great addition of intensity, to other persons.

It has been found, too, that when a school has been closed on
account of the prevalence of diphtheria among the scholars, the dis-
ease sometimes recurs again and again after the reopening of school,
as the result of the premature return there of children convalescent or
seeming quite recovered of their illness. No child or person should be
permitted to return to school until at least a month, or, better,
six weeks' time, has expired from the commencement of actual
convalescence; or any one coming from a sick-room until strictly
modern methods of disinfection have been employed, with especial
regard to personal hygiene, not only bodily, but of the wearing apparel
of the individual as well. All school books and other paraphernalia
or clothing that may have been brought into the sick-room, or handled
by the sufferer from contagious affections, or during the time of con-
valescence, should be destroyed by incineration.

Of other influences tending to enhance the severity of diphtheria,
unwholesome circumstances of dwelling have been thought of as espe-
cially potent. Thus overcrowding, badly trapped drains, and damp
walls and floors have been cited as influencing the course of attacks of
the disease unfavorably.

But cases of diphtheria occur for which neither personal communi-
cation in the school nor any of the above conditions hereinbefore men-
tioned can be assigned as probable causes. There are cases especially
difficult to account for, from the very fact that they are confined to one
or two families ; and we can not compare the daily life of those who
escape and those who are attacked to see in what respect all the inmates
of a household have differed, and so arrive at the cause of the mischief.
Nor have the children been in contact with the toys and playthings of
former children who have suffered from diphtheria. It is of these cases
that I desire more particularly to speak.

Relation of Human Diphtheria to Diseases of Lower Animals. An
hypothesis of relation of human diphtheria to disease of lower ani-



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The American Practitioner and News. 369

tnals is by no means a gratuitous one; on the contrary, it has much to
recommend it. Thus communication of anthrax and glanders from
lower animals to man has long ago been established, and we know of
the transmission to the human subject of scarlet fever, diphtheria, and
enteric fever by cow's milk.

Without a clear comprehension of the factors that produce disease
in individuals, attempts at prevention must be what a great deal of our
so-called preventive medicine is — a mere sisyphean waste of time.
Now, the various orders of animated nature are so interdependent in
regard to causation and spread of disease that it appears unwise to limit
our investigations to any one family or class. That diseases are not
infrequently traceable to lower animals, such as cats, dogs, various
species of the feathered tribe, or other so-called house pets and house-
hold pests (rodents), is unquestioned. Investigation into the origin
and spread of scarlet fever and other contagion sufficiently illustrates
this point.

I am encouraged, therefore, in what follows to be content with draw-
ing attention to none but broad clinic and pathologic resemblances
between maladies of lower animals and diphtheria in human subjects.

In 1886 Dr. George Turner's (London, Eng.) experience, obtained
in the course of inspection made for the local government board, says
in the year 1882 a pigeon was brought to him for dissection, and to his
surprise — as he hoped to find strongles in the trachea — the whole of the
windpipe was found to be covered with a well-marked, consistent
membrane, which hung loosely in the tube like a wind-sail, just as one
may see it in the body of a child who has died from croup. A healthy
pigeon was inoculated with this membrane and a disease of similar
character resulted, showing that the disorder was communicable, and
he noticed that the affection extended up into the eyes of the pigeon
through its nostrils.

In 1883 an epidemic of diphtheria occurred in the village of Braugh-
ing, Eng., connected with a farm on which the fowls were dying with
a disease seemingly identical with that above referred to as affecting
the pigeon ; and diphtheria made its appearance on other farms, where
it was preceded by a similar affection among the fowls. "At a neigh-
boring village, too, a man bought a chicken from an infected farm ; he
took it home, and diphtheria broke out in his house shortly after. This
was the first case in that village." Dr. Turner says his attention was
called to these facts by the medical attendant, and the man himself
corroborated the information in all particulars.



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370 The American Practitioner and News.

Dr. Turner further states in his official report that he has seen
chickens and pigeons which had been inoculated with diphtheric
membrane from a child's throat attacked with a disease in all respects
resembling what he regards as natural fowl diphtheria.

M. Paulinis mentions an epidemic of diphtheria in 1884 which fol-
lowed the arrival of a flock of turkeys in Skiatos, one of the Grecian
isles, where no case of the disease had previously been known for
thirty years. Some of the turkeys were sick, and it is believed that
the diphtheritic germs were conveyed from them to the first human
victim.

Infection Spread by Cats, Some curious facts, showing that domestic
animals are capable of spreading infection, are recorded on the sustained
prevalence of diphtheria in Enfield, Eng., by Dr. Bruce Low, of the
local government board. He incidentally states, says the Sanitary
Record, that during December, 1887, and January, 1888, there was a
large mortality among cats, so much so that the dustmen (** ashmen ")
said that they had never remembered seeing so many dead cats in
private dwelling dust (ash) heaps before. The following incident
occurred at Enfield at the time, and shows the possible connection
between diphtheria in children and in cats :

A little boy was taken ill with what turned out ultimately to be
fatal diphtheria. On the first day of his illness he vomited, and the
cat which was in the room at the time licked the vomit on the floor.
In a few days (the child meanwhile having died) the animal was
noticed to be ill, and her sufferings being so severe and so similar to
those of the dead boy, the owner destroyed her. During the early
period of its illness this cat had been let out at nights in the back yard
as usual. A few day§ later the cat of a neighbor who lived a few doors
further oflF was noticed to be ill. It had also been out in the back
yards at night. This second animal, which, however, recovered, was
the pet and playfellow of four little girls, who, grieved at the illness of
their favorite, nursed it with great care. All four girls developed diph-
theria, the mother being convinced that they got it from the cat, and,



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 96 of 109)