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number of bacteria on the one hand or antitoxin, which will neutralize the toxin produced by these bacteria, on the other.
Another class of cases that is greatly benefited by the open air are those of anemia caused by the oft-repeated hemorrhages from the various pathological conditions of the uterus; also in cases of placenta previa where, in hospital practice only, they may sometimes be carried through a most critical period by keeping them perfectly quiet and entirely in the open air. I have in mind a case which occurred in our service. The patient had had repeated hemorrhages from a central placenta previa. Her blood-picture showed a very grave anemia. On admission she was so nearly exsanguinated that the important indication was to stop the hemorrhage, and try to tide her over until such time as her condition warranted operation. For three weeks a mild iodoform-gauze packing controlled all bleeding. During this time she was kept on the roof, and given the usual tonics and forced feeding, with the result that we were able to rapidly empty the uterus of a full-term child, with no complications, and with an ultimate and comparatively rapid recovery. At another time a woman was admitted in the seventh month of pregnancy and in a very serious condition, with great emaciation and high fever and chills. Examination revealed a large abscess in the region of the left kidney. Under light anesthesia, this was widely opened, and then for two months she was kept on the roof, resulting in deep bronzing of the skin. Her pregnancy was not interrupted; and at term she was delivered of a living child. A few weeks later, when she had sufficiently recovered, the kidney was removed. Ultimately she made an entirely satisfactory recovery, which I consider due to the effects of her continuous stay in the sunshine and open air.
Again, a woman with marked anemia was admitted to the hospital with a diagnosis of placenta previa. On examination here, however, it was observed that the patient was not suffering from placenta previa but had a large fibroid tumor, which was the size and shape of a uterus pregnant seven months. On admission to the hospital she was immediately placed on the roof, with forced feeding, iron and arsenic, and ergot being given to control the flow. At first her progress was extremely slow, but after three months of continuous living in the open she greatly improved, so that, when her hemoglobin had reached 50 per cent, it was decided that a hysterectomy was indicated, and it was accordingly done. Now, some three years since the operation, her blood-picture is normal, and she is perfectly well and able to do her arduous housework.
Many other interesting cases might be cited in which heliotherapy has been used with good results; but the object of this paper is, not so much to relate what has already been done, but to awaken an interest in its more frequent and systematic use in surgery, not in a haphazard way, but with painstaking efforts to develop all that is beneficial. Do not forget that its unrestrained use is harmful, as is shown by the great
number of sunburns and insolation cases developed at the bathing beaches. Romer has recently pointed out that the damage may be even more serious; and he has reported two cases in which symptoms of a serous meningitis developed after lying several hours in the sun.
Rollier has blazed the trail in developing a system by his careful method of exposure; and it remains for us to apply some such system to general surgical cases. A literature will gradually develop, and then the subject will be discussed at our society meetings. In this way its use in different localities and climates can be compared, and a comprehensive plan will arise, which will be a valuable addition to the surgery of the world.
A CASE OF B. AEROGENES CAPSULATUS SEPSIS.
MEYER ROSENSOHN, M. D.
THE rarity of “gas "bacillus infections occurring in connection with pregnancy warrants the recording of cases as they occur. Originally described by Welch and Nuttal in 1892, the Bacillus aerogenes capsulatus has been encountered in various conditions; the isolation of the organism in surgical affections is by no means infrequent. The occurrence, however, of this bacillus as the causative agent in puerperal sepsis is very unusual. Only the briefest reference to this form of septicemia or "gas bacillus sepsis" as it has been termed, is made in text books on obstetrics; even the explanation that the organism is only a post mortem invader is still referred to.
A fairly extensive literature on the subject has been developed; among others, Little in the Johns Hopkins Hospital Bulletin (1905) gives notes of several cases where the organism was recovered, including cases where the bacillus was present in the lochia or uterus and not in the blood stream. Unfortunately where the septicemia is developed and the organism found in the blood, the prognosis is uniformly and rapidly fatal. The case referred to below was seen on the service of Dr. J. W. Markoe, and it is recorded not only because of the infrequency but also because of the facility with which the diagnosis was made and the prompt verification by culture taken from the blood.
The patient was a para-i, age 29, who was admitted to the Lying-In Hospital February 13, 1913. Her past history was unimportant. She was at term and had begun to have labor pains five days before admission; she claimed that the membranes had ruptured at the very start. Since then there was violent abdominal pain, but no fainting attacks; fetal
movements were felt until one day before admission. Except for the additional facts that she had felt feverish from the onset and that repeated examinations had been made by the midwife in charge, no other definite details could be ascertained. The examination showed a well nourished female in a condition of extreme shock, marked cyanosis, pulse feeble and rapid, heart sounds of poor character, temperature subnormal. The abdomen was considerably distended and there was marked edema of the lower extremities. The most striking feature when the hand was placed on the abdomen, chest and back, was the subcutaneous emphysema which could be readily felt. In the lungs except in so far as the crepitations were transmitted in the stethoscope, no abnormality other than basic congestion was noted; there was no evidence of pulmonary rupture as offering a possible explanation for the subcutaneous emphysema. The cervix was found to be dilated so as to admit three fingers. The perineal, vaginal and cervical tissues were emphysematous, the crackling being felt everywhere. The breech could be felt in the L. S. A. position with the membranes intact, emphysema of the fetal parts could be distinctly felt. No fetal heart sounds were heard.
Treatment to combat the shock was at once instituted with slight reaction. About three hours after admission the membranes were ruptured and the breech rapidly extracted without difficulty. Exploration of the uterus showed a large tear in the fundus, extending through the peritoneum into the abdominal cavity. The uterus was packed and the patient returned to bed, her condition precluding any further interference. Death occurred within an hour. No autopsy was permitted. The fetus was almost twice the normal size, macerated, bloated, with crackling of the tissues everywhere; it had been dead evidently some days.
Laboratory reports: A blood culture taken from a vein at the elbow by Dr. J. R. Losee immediately upon the patient's admission showed the presence of B. aerogenes capsulatus, the organism culturally and biologically giving the usual characteristics. Cultures from the fetal heart too showed the same organism. Cultures from the uterus showed staphylococci and streptococci.
My thanks are due to Dr. J. W. Markoe for the opportunity of reporting the history of this case.
REPORT ON TWO CASES OF ACCIDENTAL HEMORRHAGE.1
LUCIUS A. WING, M. D.,
1. Accidental hemorrhage due to trauma; erythema nodosum developing six weeks post-partum.
The patient S. D., confinement number 31837, was a primipara, 7 to 8 mos. pregnant, age 22, a native of Austria. She was admitted to the Lying-In-Hospital as an emergency case, Sept. 17, 1915, with the following history:
Twenty-two hours before admission the patient fell heavily against the rim of the bath tub, striking her abdomen and left forearm. This was followed at once by abdominal discomfort. This discomfort increased, and in 3 to 4 hours, the patient was having severe abdominal pains with cramp-like exacerbations and severe backache.
A physician was called who ordered a hot vaginal douche, an ice bag to the abdomen, and gave some sedative medication.
The pains continued, and some six hours later, or about ten hours from the time of her fall, she began to bleed from the vagina. This bleeding continued, it did not become profuse, but it was continuous.
This state of affairs continued for twelve hours longer, while the family disputed over various doctors, hospitals, etc.
When brought in by the ambulance twenty-two hours after her fall, she was nearly exsanguinated, and mildly delirious. There was still slight bleeding from the vagina. Examination showed a long cervix which barely admitted one finger, no placenta was felt.
The uterus was of a size corresponding to a pregnancy of eight months, and was tonically contracted, to the degree of having almost the consistency of wood.
No fetal heart was heard. The desperate condition of the patient made it imperative to prevent any further loss of blood.
A small vagina, and the undilated cervix determined the decision to empty the uterus at once by laparotomy, although there were no signs of fetal life.
The blood count on admission showed, red cells 2,210,000; white cells 13,200; polymorphonuclears, 80 per cent; hemoglobin 33 per cent.
Just before the operation was started, an intravenous saline infusion was begun, and 750 cc. given. 1 cc. of pituitrin, m. 25 of ergotole, and gr. of morphin were also given.
Light ether anesthesia was continued during the operation, little anesthetic being required.
1. Presented at a meeting of the Section in Obstetrics, N. Y. Academy of Medicine, December
When the uterus was exposed, it was found firm and somewhat distended, much deeper in color than normal, being a deep purplish red, and showing numerous petechial areas. The uterus was incised and the placenta found in the region of the fundus, almost entirely separated.
The dead fetus, placenta and membranes and a great quantity of clotted blood were quickly removed, and the uterine incision sutured. In making the uterine incision the muscle seemed softer than usual, and deeper in color, as though infiltrated with blood. It bled scarcely at all.
The operation was completed as quickly as possible, the patient given a stimulating enema and returned to bed.
The child was small, weighing 1890 grams, and appeared to have been dead for some hours.
The placenta was circular, measuring 16 x 16 cm., and had become almost completely separated, its uterine surface was almost entirely covered with loosely adherent clot.
The patient rallied well during the 12 hours following operation, but her weakness on the following day was extreme, and she was mildly delirious.
Blood examination 24 hours after operation showed: red cells, 1,530,000; white cells, 14,800; polymorphonuclears, 87 per cent and hemoglobin, 25 per cent.
A blood transfusion was done, 24 hours after operation by Drs. Losee and Truesdell, using the Lindeman method, and 520 cc. was transfused.
Considerable improvement in the patient's condition followed. Blood examination 20 hours later showed; red cells, 3,000,000; white cells, 17,200; polymorphonuclears, 85 per cent and hemoglobin, 42 per cent.
The patient continued to improve, although the blood picture did not show much change, except that the total differential leucocyte count became normal; after six days, both the red cell count and hemoglobin began to rise.
Her temperature was normal on the fifth day, and remained so, the highest temperature recorded was 101°.
The abdominal incision healed by primary union, and the uterus involuted normally, the lochia had practically ceased on the 10th day.
The patient was discharged on the 22nd day, at her own request rather early considering her condition, but she was becoming very fretfull to be with her family, she was still quite anemic, her blood examination showing, red cells, 4,000,000 and hemoglobin, 50 per cent.
The patient was readmitted Oct. 28th, 20 days after leaving the hospital. Her complaints on admission were, illness for 3 days, with weakness, headache, pains in the back and limbs, particularly in the