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DAY OF MONTH
DAY OF ILLNESS
21 Sponge 25m 70
22 Sponge 25m 70
23 Sponge 25m 70°
faint systemic murmur over apex transmitted a short bag applied. Knee is very painful and patient is restdistance to left; second aortic accentuated. Lungs, less and delirious. Nauseated and vomiting. Stop negative. Liver, dulness to one-half inch below free hydrochlorate of quinine. Salicylate of soda, ten grains border. Edge felt here. Spleen and abdomen negative. every four hours.
. Suppurative glands slightly enlarged. One or two faint November 18th.-Urine acid, specific gravity, 1.028 ; rose-colored spots on abdomen and back, disappearing albumin, thirty per cent., hyaline and granular casts. on pressure. "Right knee rather hot to the touch, Whiskey one-half ounce after sponge baths. Condition slightly swollen, patella floats. Some tenderness and same, but delirium increasing. pain on motion, also slight pain on moving hip. Tongue November 19th.-Patient wildly delirious during thickly coated with white fur and slightly tremulous. night. Marked strabismus of left eye. Pupils conPulse, regular, full, soft. Urine acid, specific gravity,
Urine acid, specific gravity, tracted, right the smaller. Conjunctivæ congested. 1.130 ; five per cent. hyaline casts. Milk diet and cal- Skin slightly cyanotic. Pulse irregular. Leucocytes, omel stat.
145,000. Patient in alternating stupor and delirium all November 14th. -Tincture of strophanthus, 5 minims, day. Pulse, very irregular. Right pupil smaller than three times a day. Pain in knee and headache severe. left. Fluid in knee found to be purulent serum.
No Patient very restless.
tubercle bacilli found.
November 20th.—No change in condition. Distinct tenderness in back of neck, pain and rigidity on flexing head. Tache cerebrale present. Slight rigidity of limbs most marked on right side. Strabismus in left
eye more marked. Bicarbonate of soda, ten grains,
water, two drachms; lemon juice, one drachm with ice,
November 21st.- Patient still remains delirious, his
amination of eyes by Dr. C. S. Bull. Fundus normal
in each eye. Strabismus thought to be due to irritation
of Knee-Pyæmia-Acute En-
docarditis — Suppurative Pneumonitis — Suppurative
November 21st.-Operation by Dr. Curtis. Two in-
to the joint ; also two smaller incisions on posterior as-
pect of knee. A large quantity of pus was evacuated.
November 22d.—Twitching of muscles of face and
arms. Strabismus unchanged, little stiffness of neck.
Entire dressing, packing, and drainage-tubes removed.
strength. Drainage-tubes cleaned and replaced. Packed
with iodoform wicking ; iodoform gauze and bichloride
November 23d. - Very restless and somewhat delir-
F. Pulse weaker, more rapid, and irregular. URINE 3 18+
November 24th.—Patient has been restless and de
lirious most of night. Did not sleep at all. Whiskey MILK 3
one ounce every three hours. Fluid extract of digitalis
Stop when temperature is below 102° F. Lungs :
Right, anteriorly resonance to sixth rib. Subcrepi
tant râles at end of inspiration, except in first two November 15th.-Salicylate of soda, ten grains every spaces. In axilla and posteriorly there is dulness befour hours. Leucocytes, 6,000 ; urine acid, specific ginning at angle of scapula and ending with flatness at gravity, 1.030 ; albumin, ten per cent.; hyaline and gran- last four inches at base. Here the breathing is feeble ular casts. Hot pack given. Local application to knee. and there are crepitant and subcrepitant râles at the
November 16th.-Patient delirious during night and end of inspiration, with a few scattered areas of faint at times during day. Stop salicylate of soda. Hydro
broncho-vesicular breathing. Lungs, left : Subcrepchlorate of quinine, three grains every three hours. itant râles anterior and posterior. Posterior feeble Spleen percusses large. For sponges, see temperature breathing and subcrepitant râles with dulness at last chart. Bowels are constipated.
three inches at base. Patient fairly rational. Vomited November 17th. - Urine acid, specific gravity, four ounces of undigested milk. Urine acid, specific 1,030 ; albumin, twenty-five per cent., hyaline and gran gravity, 1.015; albumin, trace; no sugar. Leucocytes.
Sputum -en; patella floats and distinct fluid were made out. Ice
streaked with blood. Cough
Cough a little troublesome.
Cups applied to chest. Usual dressing. Free dis- few fresh adhesions in left lung and many on right charge of pus.
lung. Many purulent foci in both lungs. Brain-pia November 26th.—Apex : Beat diffused over area of congested and contains much serum. On section, some 2 by 2 inches. Here are heard inconstant rubbing and congestion. Gall-bladder contains pale yellow serous grazing sounds, synchronous with heart action. In bile. Liver : Four pounds two ounces.
Rather pale, left axilla there is good resonance, but many friction with faint nutmeg markings. Spleen : Six ounces ; sounds. Otherwise signs in chest unchanged except rather soft. Left kidney : Ureter and adrenal normal, that flatness in right posterior chest extends above also pelvis ; capsule free, surface smooth, color normal. angle. For past four days the abdomen has been mod- Several purulent spots size of pin's head. On section erately distended and tender. There is subsultus and cortex a little pale, markings fair. Right kidney the occasional carphologia. To-day general hyperæsthe- same. Meckel's diverticulum, three inches long, three sia. Strabismus unchanged. Moderate general rigid- feet above valve. Bladder, normal. No dictation on ity. Usual dressing. Very slight discharge.
knee by Dr. Thacher. A large abscess ran up posteNovember 27th.—Patient much weaker and pulse rior aspect of knee-joint for about five inches. feebler. Takes nourishment with difficulty. Ice coil The temperature had been very irregular, ranging stopped.
between 101° and 106° F., averaging about 104.5° F.
3 Sp. 15 m 70 100
Temp. after death 100
November 28th.-Respiration labored and very shal- Dr. Robinson said he had had such cases before, allow. Extremities considerably cyanosed.
though not necessarily with joint suppuration ; had A.M. patient was very much cyanosed. Pulse almost found endocarditis at death, and had thought he would imperceptible ; and at 6.25 A.M. patient died quietly. bear them in mind and make the diagnosis in subseAutopsy.-Frame large; muscles well developed ; adi
quent cases, but the same experience had repeated itpose fair. Heart weighed nine ounces; recent patch of self. fibrinous exudation on anterior surface. Section shows Replying to a question from Dr. Draper, he said normal heart muscle ; just above attachment of cusp of there was no history of recent gonorrhæal rheumatism. tricuspid valve is a pea-sized nodule containing pus, run- DR. DRAPER said the temperature chart in this case ning down about an inch in the muscle of the septum ; suggested to him a point which he had found of diagabundant small vegetations on under surface of tricus- nostic value in endocarditis, namely, an up and down pid and mitral valves. Lungs : Right, one pound ; left, temperature several times a day. It was sometimes fifteen ounces. Left congested, especially lower lobe; accompanied by chill, sometimes not. Some days
there were three or four paroxysms of fever, a thing intestines firmly adherent over the tumor, he made a which was not usual in any infectious fever with which lateral incision above Poupart's ligament, introduced he was familiar.
the finger, broke down material which was too thick to Grape Seeds in a Healthy Appendix.—Dr. McBur- wash out, then irrigated and introduced two yards of NEY presented a vermiform appendix containing two iodoform gauze. By venous infusion of saline solugrape seeds, removed under the following circum- tion and stimulants the patient was saved. A hæmastances : He was operating upon a patient for abdom- toma in what appeared to be a sealed cavity undergoing inal tumor ; the healthy-looking appendix thrust itself purulent degeneration, was contrary to what was usually into view, and on feeling of it he appreciated two con- taught. It was not improbable the infection had cretions. Thinking it wise to act in time, he removed entered it from the intestine to which it was adherent. it, and the bodies which had been felt were found to Unintentional Induction of Abortion.—DR. A. E. be two grape seeds. The notion had been very preva- GALLANT related a case in illustration of the difficullent that grape seeds were dangerous on account of ties attending the diagnosis of pregnancy. The case their liability to lodge in the appendix and set up in- was one of cessation of menses for some weeks, then fiammation. Dr. McBurney had received letters re- hemorrhage, the recognition of an enlarged uterus garding this matter from various parts of the country, whose walls were flabby-circumstances leading to the a recent one being from a large horticulturist in the diagnosis of abortion with retention of membranes. West, who said he would be greatly indebted to him if He introduced the sound, brought away fungosities, he could state that grapes were not dangerous. Dr. prepared for curettement next day, but found that soon McBurney had always been able to reply that he after she had returned home a fætus had been exthought grapes were harmless, since he had never seen pelled. Dr. Gallant presented Outerbridge's combined a grape seed in the concretions contained within the dilator and irrigator, which he had found very useful in appendix. It had so happened that the first exception opening the cervix and washing out the uterus after to this experience was in a case in which he had inci- curettement. dentally removed the healthy appendix and found Ligature Carrier.—DR. A. Goelet presented a modiwithin it two grape seeds.
fied ligature carrier, so made that the ligature could Dr. Polk remarked that he had seen grape seeds not slip as it did in other instruments. cause appendicitis in but one case.
Double-Current Uterine Irrigator.—Dr. Goelet also Dr. Biggs made some remarks upon the work of the presented a double current uterine irrigator, the imporBoard of Health in producing diphtheria antitoxin for tant feature of which was its conical form, enlarging use in the city.
toward the end next the handle, and thus obviating tendency to become clogged by débris.
DR. GARRIGUES had given up the use of doubleNEW YORK ACADEMY OF MEDICINE. flowing catheters, finding them unnecessary. In ob
stetric cases there was plenty exit for the fluid, while SECTION ON OBSTETRICS AND GYNECOLOGY.
in other cases one could dilate and retain the cervix Stated Meeting, February 28, 1895.
open with a speculum or dilator while irrigating with a HENRY C. CoE, M.D., CHAIRMAN.
single-current catheter. Larger débris would thus es
cape than with a double-flowing catheter. Hollow Cylindrical Uterine Dilator.-Dr. A. M. LESSER Coeliotomy for Puerperal Septicæmia and Peritonitis. presented a set of uterine dilators, made of steel, cylin- -DR. CHARLES P. NOBLE, of Philadelphia, read the drical in form, and differing from the ordinary dilator paper. He divided cases of puerperal sepsis, or puerin being hollow, the object being the avoidance of peral peritonitis, into two classes : 1. Those in which forcing the uterine contents into the tubes.
some pathological condition existing in the pelvis beDr. S. Marx thought the instrument could have no
fore labor was the cause. 2. Those in which these orplace in obstetrics, whatever it might have in gynecol- gans were normal at the beginning of labor. In the ogy; that in obstetrics the hand was the best dilator. first class sepsis might exist prior to labor, or be in
Improved Tarnier Basiotribe.DR. E. A. TUCKER duced by bruising of the pathological tissue, or by presented a modified Tarnier basiotribe, or combined causing rupture of pus - sac.
In this class of cases perforator and cranioclast. The improvement related operation was indicated, and if performed prior to chiefly to doing away with some screw joints in the labor promised a high percentage of recoveries. In a perforator, and in substituting a metallic for a wooden correspondence with a large number of operators, only handle, thus aiding cleanliness. Without raising the three had stated that they had operated for peritonitis question of craniotomy on the living child, it was well due to pus-tube which had been present before labor. known that there were cases in which the operation had The rarity of the complication was probably to be exto be performed, and this he had found to be the ideal plained by the fact that few women with a pus-tube instrument for the purpose.
became pregnant. Modified Ligature Carrier.-Such an instrument was
The second class, those in which there had been no presented by a gentleman who failed to give his name, preceding pathological condition, was subdivided into the modification relating to the spring and catch at
those in which the infection spread to the peritoneum, tachment.
etc., through the lymphatics and veins, and those in Puerperal Septicæmia ; Abscess in Right Broad Liga- which it spread through the tubes. The author knew ment; Abdominal Section Followed by Recovery.-DR. of no positive way to determine between the two ANDREW F. CURRIER related the case.
The patient classes, but he believed that where the infection spread had had a normal and easy labor, and everything had through the tubes, the inflammatory element was more gone well until the fourteenth day, when she was sud- marked, the septic element less marked, the reverse denly seized with pelvic pain which increased almost to being true in the other class of cases. In the lymphatic collapse. The following day a tumor appeared in the
form the peritonitis was of secondary importance to right iliac fossa, and went on to extend over to the left septicæmia, and operation gave little encouragement. side. The doctors who saw the patient diagnosed
Simple cæliotomy with washing out the peritoneal hæmatoma. She afterward suffered from violent chills, cavity did not influence the principal seat of the trouble, diarrhea, loss of flesh, etc. About two months after which was in the uterus and pelvic lymphatics, and the confinement Dr. Currier saw her, and made the necessarily it could not influence the germs which had diagnosis of hæmatoma of the right broad ligament already entered the circulation. The more radical degenerated into abscess. Notwithstanding the pa- operation of hysterectomy offered but little, since by tient's extremely low condition, he ventured to open the time peritonitis had become a marked feature either the abdomen, first in the median line, but finding the the patient was so reduced that she could not with
stand the serious shock of the operation, or was already be offered against the classification was that it sug-
men, but it should be remembered that this, as a last from operation was most favorable in local peritonitis resort, did not promise a great deal. He had saved where the inflammatory process had become well local- one patient by cæliotomy without hysterectomy, operized, sepsis being absent, the case having resolved it- ating not later than the seventh day. In pus accumuself into one of pyosalpinx or pelvic abscess of some lations existing before labor operation was indicated. form.
Dr. H. J. GARRIGUES thought laparotomy would have What should be done in cases of infection of the an extremely limited field in puerperal affections. He birth canal when, in spite of curettement, irrigation, would hardly care to take the responsibility of opening and drainage, the disease went on from bad to worse ? the abdomen the first two or three days, as suggested in Cases in which septic infection or beginning septicæmia a certain class of cases by the author. It was known were marked features of the absorption of ptomaïnes that many patients with bad forms of puerperal perior micro-organisms taking place from the uterus or tonitis recovered without operative interference, and he vagina, while cellulitis and lymphangitis were absent or doubted whether the surgeon could secure a better rein their incipiency? Some years ago treatment would sult. Some years ago he had saved seven out of thirhave been continued by irrigation or internal medica- teen cases of general peritonitis by enormous doses of tion. But in the great majority of the cases the issue opium. He believed in cleaning out the uterus, prefwas fatal. Abdominal hysterectomy had been per- erably by hand in fever after labor at term, by instruformed by Kelly and Smith with success, while Mont- ment after abortion and cleansing with antiseptic ingomery had lost his patient, and pus was found in the jections. uterine sinuses. Dr. Noble would defend the operation DR. W. E. PORTER thought a large.percentage of in this class of cases. Regarding the route to be chosen, cases of puerperal fever could be saved by early rehe thought that in puerperal cases it was usually best moval of septic matter from the interior of the uterus, to enter above the pubes.
but unfortunately the specialist was not usually called Prefers the Vaginal Method.-Dr. H. J. Boldt until the disease was advanced. If cæliotomy were agreed with the author in the main, especially with re- done at all it should be limited to irrigation and draingard to the hopelessness of operative procedure in age. Hysterectomy would cause shock out of proporpuerperal general peritonitis and septicæmia. In local- tion to the amount of sepsis removed with the uterus. ized peritonitis of puerperal origin he thought no one DR. RALPH WALDO thought very bad cases, menwould dispute the fact that operative interference was tioned in the paper, would die whether the abdomen indicated, and for his own part he would choose the were opened or not, while others treated in time by vaginal route as the one which caused least shock and
emptying the uterus, irrigating, and draining, could be offered the best drainage. Pathological conditions ex- saved without laparotomy. Of course an operation was isting prior to labor belonged to ordinary gynecological sometimes called for to remove local accumulations of work, and called for operation.
pus. Opposes Operative Interference.- DR. WILLIAM T. Dr. Ford, of Philadelphia, impressed the fact that LUSK had seen three cases of tubal trouble present be- the source of infection varied in different cases, being, fore confinement, complicating the puerperium, and in some from a laceration of the vagina, in some from a when to-day he looked back upon the experience, which laceration of the cervix or perineum, in others from occurred some years ago, he wondered whether the absorption within the uterus, and it was not easy to depatients could not have been saved by an operation. cide when operative interference was called for. He He thought it was very questionable whether, in the related a case of extra-peritoneal pus collection similar usual forms of puerperal infection, operative interfer- to Dr. Currier's, treated successfully by incision over ence was ever justified before the tenth day. As the Poupart's ligament. author had stated, in general septic peritonitis the pa- Dr. Brooks H. Wells related a case seen by him tients died anyway. In other cases, where the disease fifteen months ago. The attending physician had dewas localized, he thought it would be better to treat livered the patient with forceps ; sepsis followed ; he them in the old way; many would get well, and if an curetted four or five times, at intervals of five or six operation should be called for it could be done with hours, without antiseptic precautions; the patient grew greater safety after five or six weeks than during the steadily worse, the temperature went up to 106° F., and confinement period. There were a large number of Dr. Wells was sent for when she was in collapse. cases of so-called septic endometritis in which the in- mass was felt in the right side of the abdomen, and fection was limited to the mucous membrane, there was although the patient was almost moribund he decided fever for about a week, and the patients recovered if to operate, which he did in a tenement-house. On let alone. If, however, the curette were used, and irri- opening the abdomen he found that the uterus had gation practised frequently, as had been done, the bar- been perforated anteriorly. The vermiform appendix rier offered to the entrance of micrococci by leucocytes being unusually long, had become adherent across this in the infiltrated membrane would be broken down, perforation, thus proving a life-saver instead of a lifeand general infection would result. He, therefore, destroyer, in this instance. He cleansed out a collecopposed the use of the curette in such cases.
tion of pus with the sponge and introduced gauze, and Pathological Distinctions Easier than Clinical.--Dr. to his surprise the patient recovered. The right tube, W. M. Polk thought the strongest criticism which could which had lain over the abscess, was perfectly normal.
Dr. E. A. TUCKER said that his experience had lutely clear and hardly injected ; some coryza ; no shown the wisdom of Dr. Lusk's remarks. Out of about fetor to breath. four thousand cases of labor which had passed under December 23d.—In the morning slight deposit on his observation, there had been puerperal fever in 150 left tonsil. Glands of neck slightly swollen. Temor 200, and he could recall not more than one in which perature, 10272° F. (groin); afternoon temperature, laparotomy might possibly have been done with bene- 10372° F. Child restless and depression marked. fit. Later operations for pus collections, say a month Ordered tincture of chloride of iron and whiskey in full after labor, should not be spoken of as cæliotomy for doses. puerperal sepsis.
December 24th.-Deposit decidedly more marked on DR. CURRIER remarked that most cases seen by both tonsils, and decidedly diphtheritic in appearance. gynecologists had previously been treated by the gen- Some albumin in urine. Temperature, 102%2° F. eral practitioner, and were not very recent, yet he 8 P.M., II C.C. Pasteur's serum were injected in loin. thought they should not be excluded from considera- December 25th, 8.30 A.M.—An injection of 10 c.c. tion as puerperal cases. There was such a variety of serum was given. In afternoon, temperature (axilla) conditions that it was not easy to make exact classifi- 98° F. The throat gradually cleared. Temperature was cations, yet he thought three main types might be rec- uniform at 98° from December 25th to 30th. Swelling ognized : 1, Cases in which the infection was limited of glands diminished-albumin was disappearing. practically to the uterus ; 2, those in which it had ex- December 31st.—Throat was practically clear and tended into some neighboring structure, but was lim- convalescence appeared to be established. Pulse ited ; 3, those in which there was diffuse peritonitis. ranged from 96 to 106. Iron and whiskey were conLaparotomy was excluded in the first variety, was to tinued throughout. be considered in the second, was hopeless in the third. January 5th.—In afternoon, temperature was 99.6° F., Local pus collections should be removed.
and there was slight swelling of glands on left side of The Chairman, DR. Coe, did not think the author neck behind sterno-mastoid muscle. had intended to raise the question of curettage and January 6th (thirteen days after injection).-Glands irrigation. Of course, Dr. Coe said, everybody re- were swollen on both sides of neck in corresponding sorted to those measures. He had not arrived at the location. Temperature, 101.4° F.; pulse, 112, A disstage where he would remove the uterus, although he crete eruption of raised, fat papules appeared on buthad been tempted to do it twice. There were a good tocks. They were of rather dusky-red color, closely many cases of pus collection the first week after child resembling the eruption caused by antipyrine. There birth, and he would not exclude them from considera- was no rigor ; there was, however, some stupor, somnotion as puerperal cases, as he had understood Dr. Tucker lence, depression, and loss of appetite. Child comto suggest. In one instance he had emptied a pus col- plained that eruption hurt, which probably would be betlection which had extended up to the umbilicus the ter described as itching or burning. There was, also, a first week, and in another instance where he had found general hyperästhesia of the whole surface ; but no it under the lower rib. He supposed the author had distinct joint swelling or pain as in Dr. Seibert's case. not intended to limit the term cæliotomy in this dis- The temperature ran to 102.2° F. (its highest point), cussion to median incision.
with pulse of 145 and respirations of 33. Dr. Noble, in some concluding remarks, said that January 7th.—Temperature ranged from 99.9° to if after curettage, douching, and putting in gauze, the 101.8° F. Pulse, 118 to 130 ; respirations, 28 to 32. patient went on to get worse for twelve or twenty-four The rash next extended to thighs, legs, and feet ; then hours, the septic symptoms becoming more marked, he
attacked the hands and arms, face and neck ; lastly exthought all would acknowledge that the case would tending from buttocks on to the back, abdomen, and terminate fatally unless something more were done, chest. It was more marked on back and chest, and was and it was under those circumstances that he would generally discrete in distribution, although there was perform hysterectomy. Peritonitis and general septi- coalescence at times, with large, white, clear areas, such cæmia had not yet become marked. The chances for as we see in measles. The general appearance varied the surgeon to win laurels were not great, but operation but little. The papules were large-flat and raisedgave the patient about the only chance.
varying in size from that of end of slate pencil to the size of a silver three-cent piece or larger. The color was dusky-red. There were no vesicles or pustules. The hands, forehead, arms, and face showed consider
able ædema. During all this time the throat remained Clinical Department.
perfectly clear, and there was never a suspicion of re
turn of the exudate. The urine was almost completely REPORT OF A CASE OF SEPTIC POISON
suppressed and the amount of albumin much increased. ING FOLLOWING THE USE OF ANTI
This was relieved by cupping the loins and the use of TOXIN.
the hot pack.
January 8th.--The temperature ranged from 99.8° By EDWARD J. WARE, M.D.,
to 102° F. ; pulse, 104 to 122.
January 9th.—Temperature from 101.2° to 102.2° In the MEDICAL RECORD of January 19, 1895, an arti- F. ; pulse, 118 to 130. cle by Dr. A. Seibert, gives an account of the toxic ef- The rash lasted from three to four days. The first fects of antitoxin treatment which are so very similar papules appeared on January 6th, and the skin was to those occurring in a case of my own, and yet having practically clear on the roth.
As each new crop apsome points of marked contrast, that I deem it of inter- peared there was a rise of temperature. est to note them.
January 10th.—Temperature at 1.50 The patient, Elizabeth B-, aged three years and 101.2° F. ; at 8.45 A.M., 98.2° F.; at i P.M., 98° F.; at four months, had not been well for two weeks previous 7.40 P.M., 96.2o. At this time (7.40 P.M.) pulse was 100, to the present illness--having had a persistent cold and fair in quality. Second sound of heart very indistinct; So-called "bilious condition," with clay-colored stools, feet and hands cool ; ordered whiskey, ammonia, and loss of appetite, and general malaise.
hot beef extract. On December 21st, the child was constipated and January ith.- Temperature ranged from 97° to had fever. She was first seen by me December 22d. 97.6° F.; pulse from 96 to 106. Ordered tinct. nux Temperature, 103° F. (groin). Child peevish and som- vomica one drop every four hours ; increased to two nolent; tongue coated; some pallor and loss of appe- drops at 2 P.M. Pulse somewhat better and sounds tite. No swelling of the glands, and the throat abso- clearer.