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By J. R. LOSEE, M.D., Pathologist.

THE bacillus mucosus capsulatus, when first described by Friedländer was considered to be the exciting cause of pneumonia but the later investigations of Fränkel and Weichselbaum showed that the diplococcus lanceolatus was the most frequent cause of the disease and that the bacillus mucosus capsulatus was occasionally a secondary invader of the lungs. This organism is at times a saprophytic inhabitant of the normal intestine, mouth, nose, bronchi and may also be found in the soil and air. It has been observed as the exciting cause of aphthous stomatitis, otitis media, tonsillitis, arthritis and other infectious conditions.

Of the many cases reported in which this organism was the exciting cause very few have been mentioned as occurring in infants. Fox and Lavenson have reported a case of pneumonia in an infant which died when four days old and at autopsy many hemorrhagic lesions were observed beneath the visceral pleura and peritoneum. Etienne has reported a case of ulcerative enteritis in an infant with hemophilia from which he obtained a pure culture of bacillus mucosus capsulatus from the umbilical artery.

A thick mucous-like substance is characteristic of the exudate produced by this organism and in cases that are observed at autopsy there are many petechial hemorrhages beneath the serous surfaces. In the case here reported on the other hand the inflammatory process is characterized by extensive necrosis.

The infant was delivered normally at term and did well up to the fifth day when it developed certain gastrointestinal symptoms, lost weight and died on the ninth day. At autopsy twelve hours after death a fluctuating tumor was observed extending from below the free border of the ribs upwards in the axillary line on the left side. This mass could be varied in size by pressure on the abdomen. Section of the body showed two openings about two centimeters in diameter in the rectus muscle. The edges of these openings were irregular and presented a sloughing appearance. The subcutaneous tissue on the left side of the thorax and abdomen was necrotic and a sinus extended into the peritoneal cavity. The peritoneal cavity was filled with a large amount of dark fluid containing many necrotic particles. There was an opening in the left side of the diaphragm about 1.5 cm. in diameter. A perforated ulcer was observed in the posterior wall of the stomach. The mucosa of the small and large intestine did not show any lesions but there were a few hemorrhagic areas beneath the capsule of both kidneys. Culture from the heart blood, liver and spleen all showed Gram negative encapsulated bacilli with the cultural characteristics of the Friedländer group. In

noculation of a small amount of the exudate from the peritoneal cavity of the infant into guinea pigs and rats resulted in their death in less than thirty-six hours. Postmortem examination of these animals showed a mucous-like exudate in their pleural cavities, smears from which showed a Gram negative encapsulated bacillus. Cultures of the heart blood of the animals that died after innoculation all showed a bacillus mucosus capsulatus.

The interesting features in the case were the extent and character of the lesions and the fact that the infection was probably of gastrointestinal origin.


By J. W. MARKOE, M. D., Attending Surgeon.

THIS being the first case at this hospital in which a child has been delivered through the abdominal wall without opening the peritoneal cavity, it was deemed worthy of recording in the BULLETIN. The following brief account will be elaborated in greater detail at a later date.

Mrs. A. B; age 33 years; para VIII. Born in Italy. Admitted to the hospital on January 16th, 1915. Patient examined under ether. Head above brim. It was decided that she could not be delivered vaginally as the pelvis was generally contracted and flat. On the afternoon of January 16th, patient was again etherized and the abdomen opened in the median line from the pubes to umbilicus. After passing through the fascia and separating the recti muscles, the bladder was exposed and found to contain a small amount of urine, which was of decided advantage. By blunt dissection, the fascia was separated from the peritoneum, and the anterior wall of the bladder laid bare almost down to the urethra. Moderate bleeding occurred from the plexus of veins just posterior to the symphysis. The peritoneum at the fold formed by the juncture of the parietal and visceral layers was then dissected up. The bladder loosened from its support on the left side, was dissected loose posteriorly and carried over to the right of the median line. It was then held out of the way by the fingers. The peritoneum was next dissected up farther on the anterior wall of the uterus so as to give sufficient room to extract the child. On the anterior wall of uterus, a small vein was caught and tied. This was the only vessel of any size on the anterior wall of the lower uterine segment. All the dissection was done by the use of gauze and fingers. An incision ten centimeters in length was then made in the lower uterine segment. The uterine wall was very thin and not very vascular. Because of this thinness, a small cut was made in the baby's scalp. Using the left blade of the forceps as a vectis, the head was raised through the

incision and the body of the child delivered. Cord clamped and cut. The child weighed 5,810 grammes. There was a large amount of meconium in the uterine cavity. Placenta delivered manually. The uterus relaxed and filled with blood but by pressure through the abdominal wall and packing the fundus with gauze, the uterus contracted and most of the hemorrhage ceased. The uterus was then closed with two layers of interrupted sutures of number two chromic gut after the packing was removed. In freeing the bladder, from its anterior attachments, a space about 3 inches deep was made just posterior to the symphysis. In this space was placed a large cigarette drain which was brought out through the lower end of the incision. The bladder was then returned and sutured in place with continuous sutures of number one chromic gut. A rubber tube containing iodoform gauze was placed above the bladder and to the right and brought out just above the cigarette drain. The fascia

was closed with interrupted sutures of number two chromic gut, leaving a space for drains. Two silkwormgut sutures were inserted, one above and one below the drains and they were tied in bow knots. The remaining skin was drawn together with skin clips. Culture of uterine cavity through incision showed staphylococcus aureus and a non-hemolytic streptococcus.

At the time of writing mother and child have passed the tenth day postpartum and are living and well. Both have had some fever and the mother's superficial wound has not as yet closed but their ultimate recovery seems certain.


May, June, July, August,
September, October, November, 1914.


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