CÆSAREAN SECTION IN A COTTAGE.

1089 tion often present and now and then leads to corneal ulcerati .and loss of sight. Aphasia occasionally develops. It m nay .appear at any stage of the disease and recovery is usual. A - few patients develop a condition of extreme irritability ; th they sent lie on one side with the legs drawn up and vigorously rese ttby ,any interference. The converse condition of extreme apat f -is also occasionally seen ; the patient lies motionless for

it.

In

a

few

cases

there

is

the

rusty sputum of

pneumonia, but this is quite exceptional. Definite physical signs of consolidation are absent in the great majority of patients. Rhonchi and railes can be heard but dulness and tubular breathing are seldom present. The patient may rapidly pass into a stupid dulled condition which On the other soon lapses into complete unconsciousness. days, responding only to strong stimuli, never speaking or hand, he may be quite conscious when the above symptoms lty. are well marked. The patient’s aspect then is not easily fortaking notice of anything and is only fed with difficult in some of these the ient gotten. His face, drawn with pain and full of fear and has taken cases, patie Recovery place ion. anxiety, makes a striking picture as he gasps out his comvery gradually returning to a normal mental conditio rSkin lesions are infrequent ; large blisters occasional ally plaint of intense pain. Unconsciousness supervenes, the ;hs. pulse, rapid and small from the first, becomes quite imperappear and frequently the area covered by them slougl: Faruncles are sometimes seen and sloughing of areasI of ceptible, and death soon occurs. Death is always rapid and a almost always occurs within three days from the onset, some.-skin is a rare complication. Subcutaneous haemorrhages are nes times within the first 24 hours. A bubo is occasionally ’3xtremely rare. Haemorrhage from the mucous membran red made out during life and in those cases where none was has occurred in a few fatal cases. Vomiting of bright-rc and perceptible glandular swelling has been found post mortem. blood or of altered blood (black vomit), melsena, at unt The diagnosis of pneumonic plague from lobar pneumonia uterine heamorrhage are all rare and death from the amom Mt and from broncho-pneumonia with which it was confounded of haemorrhage alone is still moreljncommon. Pregna] women generally abort, and this event, though usually faa al, before it was fully recognised is very easy. The onset with ich severe general symptoms without anything definitely pointr:s not always so. Arthritis is fairly frequent in cases whic recover. It generally appears when the patient is enterin ing ing to disease of the respiratory organs and the extreme ’he severity of the respiratory symptoms when developed, quite the convalescent stage and the temperature has fallen. Tt ?re out of proportion to the amount of disease as indicated by symptoms are pain, tenderness, and effusion into one or mot mthe physical signs in the chest, are both distinguishing joints, the knees being especially liable to be affected. Con )ns features of great importance. The general condition of the ,plete recovery is usual. The most important complicatior are those which involve the lungs or heart, and these mos )st patient, the great prostration, with weak rapid pulse, is quite often lead to a fatal issue. These complications may, an nd different from that in pneumonia. The sputum is charactert, often do, develop in cases which appear mild and likely to istic, only very rarely does it resemble the rusty sputum of nl. lobar pneumonia. Finally, the discovery of the bacilli of recover, and thus the prognosis in plague is always doubtful Gradual weakening of the heart’s action sometimes occurs rs. plague in the sputum is conclusive. nt The patient may at first not appear to be seriously ill, bu from day to day the pulse increases in rapidity and decrease in force until it fails altogether. Sudden heart failure is not infrequent. It generally occurs when the patien CÆSAREAN SECTION IN A COTTAGE. lobar

-

seems on the road to recovery. It may be the termina tion of the gradual weakening described above, but now anc then there is nothing in the pulse just before the fatal even1 to lead to many suspicion of the nearness of death. SomE slight effort is made : the patient sits up or tries to get out of bed, or perhaps has just taken food, when he falls back dead. ,Secondary pneumonia, though not so fatal as the primary form, is still a dangerous complication. Physical signs sometimes point to a lobar pneumonia, but broncho-pneumonia similar to that present in pneumonic plague has been found post mortem. Very few necropsies have been made on these cases which constitute, of course, only a very small proportion of the total number and are by no means always fatal, A most remarkso that exact knowledge is still wanting. able condition of oedema of the lungs sometimes causes the death of the patient. It occurs frequently with the greatest rapidity. The lungs appear to be choked with secretion, there is intense dyspnoea with no pain or rise of temperature, nd the condition of the patient soon resembles that of the last stage of chronic bronchitis, with the exception that a - few hours produce a state which only results after years of - bronchitis. This complication most often appears towards the end of the first week of illness but it may develop earlier. Post mortem the lungs are full of secretion but there is no pneumonia. The explanation of the condition is very dimonlt. Pressure upon the pulmonary veins by enlarged It occurs too mediastinal glands has been suggested. -rapidly to be satisfactorily explained by hypostatic

BY FRANCIS WILLIAM

JOSHUA, L.R.C.P., L.R.C.S., L.M. EDIN.,

SURGEON ACCOUCHEUR TO THE GREAT MALVERN SAMARITAN CHARITY.

THE following case is, I account of the rare form of

think, worthy of record on deformity which was present,

the case being one of spondylolisthesis, and also that a successful result was obtained, as the patient lived with her husband in one room in a small cottage which was extremely dirty and insanitary. The patient, an ansemic, spare little woman, aged 21 years, when a child and learning to walk was dropped, causing injury to the spine which necessitated protracted rest in the recumbent position. It was not until three years later that She went into domestic she was able to attempt walking. service at the age of 17 years and remained so employed until her marriage in June, 1898. Menstruation commenced at the age of 15 years and had been perfectly regular since She had had no miscarriages. until she became pregnant.

Her family history was unimportant. On May llth, 1899, at 10 A.M., I was sent for by the midwife to the Samaritan Charity, who had been with the patient for about an hour. From the patient’s statement labour must have commenced at 10 o’clock on the previous night. The pains on my visit were frequent, almost continuous. She was much exhausted and was evidently in great suffering. I found the right hand of the child protruding through the congestion. Pneumonic plague.-This form is, as already mentioned, vulva ; it was dark purple in colour. The vagina contained -almost invariably fatal. The lungs are primarily attacked besides the arm a loop of the cord, which was pulseless, and by the disease which produces a diffuse broncho-pneumonia. following the arm up I came upon a hard mass which I Areas of consolidation are scattered throughout both lungs could not define clearly. Having obtained the assistance of -and plague bacilli are present in large numbers in these Dr. Jacob, who administered chloroform, I introduced my patches and in the sputum. The onset resembles that in hand into the vagina and found a hard rounded mass above bubonic plague ; respiratory symptoms are not generally the promontory of the sacrum, apparently the last two or present at the outset and may not be marked for a day or three lumbar vertebras, bulging forward, and in front of this two. but in most cases severe symptoms develop with great was the posterior lip of the os uteri much swollen, then the tip sapidity. The most striking is the dyspnoea, which soon of the shoulder tightly impacted against the symphysis pubis. becomes most urgent. The respiratory rate may be as much I managed to pass my finger over the shoulder, and found -as 90 per minute and the movements very shallow and the head of the child flexed on it. I estimated the condistressed. There is great pain in the chest, not usually jugate diameter to be not more than two inches. localised to one place, but general, and occasionally this Dr. Jacob agreeing with me that the only mode of delivery no pain at all is was by Cassarean section and that the patient was too ex- pain is referred to the abdomen. - complained of. In addition there are cough and expectoration. hausted to permit of her removal to more healthy surroundThe sputum is generally scanty and streaked with bright-red ings, I obtained the services of Dr. Shaw Bond, who ’.blood. It may be profuse or watery or uniformly coloured administered chloroform, and of a trained nurse, who, with -with the Mood which is more intimately mixed with the midwife, rapidly prepared the room and improvised a

-

Rarely

1090 T table.

The

patient

was

given

douche, 1 in 2000, the urine

a

perchloride

drawn

of mercury

off, and the surface of thoroughly cleansed, first with soap-andwas

proved that (experimentally, at any rate) the " enteric’’ micro-organism can be cultivated in organically polluted In the same paper I expressed the belief that Sl soil.

hhave n

the abdomen was water and then with ether. I proceeded to open the abdomenI"summer diarrhoea" was caused under somewhat similar in the usual way in the middle line by a four and a half inch cconditions, a belief which, to my mind, is probably a reality I is certainly beyond doubt a fact that " summer diar-incision, commencing one inch above the umbilicus. There It were no vessels to tie and the oozing was insignificant and rhoea" is in evidence, at any rate, in many localities as soon, r a certain elevation of temperature has been noted for a, a easily stopped by pressure. The uterus at once presented as and having located the placenta in the posterior part cdefinite time. It seems hardly likely that this complaint. of the fundus Dr. Jacob applied the edges of the in- is i simply the direct result of a high temperature upon the’ cision in the abdominal wall to the sides of the uterus so individuals i attacked; the symptoms are so distinctly difas to shut off the abdominal cavity. I commenced by making f ferent from those of simple sunstroke or heatstroke. an incision in the wall of the uterus of the same size as ’JThen, again, there is every reason to believe from the symthat in the abdominal wall, and was proceeding to dissect ptoms that the illness is a definite disease allied to the1 down to the membranes, but the bleeding was great, and sspecific fevers, which are now universally acknowledged 1 be due to the action of micro-organisms. I mean that it, having in view that the child was dead I plunged the knife to i not merely an exhausted state of the system caused. into the uterine cavity and slit up the uterine wall rapidly is on my fingers. Dr. Jacob then held the edges of the uterinesimply f by the increased alvine discharges, nor indeed areincision apart, which controlled the haemorrhage, and seizing1the symptoms similar to those which follow the ingestici the right arm which presented I proceeded to extract the (of unwholesome food. The sudden invasion with marked* and facial expression, indicative of toxic effects; child. This required considerable force as the left arm was prostration ] completely wedged between the projecting substance and the4even before the diarrhoea is copious or even after it isI suggest a definite affection of the whole system.. pubes. The placenta and membranes quickly followed thechecked, child. Having sponged out the uterine cavity and cleared it Iover and above the mere exhaustion consequent upon theof clot it was kneaded and contracted to the size of a cocoanut. diarrhoeal discharges. At this time the bowels protruded rather freely, but were If, then, we admit that the disease in question is due toeasily controlled by folded towels wrung out of hot carbolisedmicrobic development, in what direction are we to look for water. The uterus was then turned out of the abdominal the production of the presumed micro-organisms or for their cavity and 12 silk sutures were inserted through the sub- sudden and definitely pronounced activity, causing these stance of the muscle, but not through the mucosa. It was well-marked and pronounced symptoms ?7 The disease can then dropped back into the abdomen again and the pelvic scarcely be spread by infection from person to person, for cavity was thoroughly cleansed. The abdominal incision was it is so universally present in various localities almost, closed with silk sutures, including the peritoneal membrane simultaneously. For the same reason, it call" scarcely be alternated with superficial ones of silkworm gut, strapping due to water, the affection prevailing where quite different was applied, and dressed with several layers of carbolised supplies exist. It can scarcely be due to any particular gauze and a layer of Gamgee tissue, the whole being held in article of diet for it prevails amongst breast-fed children, place by an ordinary binder. The patient was much hand-fed children, agricultural labourers who scarcely touch collapsed and on being placed in bed she was injected hypo- milk, rich people and poor people, although certainly not dermically with ether, strychnine, and ergotin, and was equally severely. It is of course not improbable that thesurrounded by hot bottles. Five hours later reaction had hypothetical micro-organism may be capable of causingset in. some changes in the articles of food or drink consumed, and, The after course of this case was uneventful. The abdominal that this change may be more readily produced in certain wound healed by first intention. Some of the stitches were kinds of foods and drinks than in others, either by favouring’ removed on the seventh day and the rest on the tenth day some injurious fermentative changes in them or possibly by. after the operation. The temperature in the evening of the exerting some changes in the alimentary secretions permitday of the operation was 100’5°F. and never subsequently ting some toxic influences during the then altered conditionrose higher. There was some trouble with the breasts lasting of the digestive secretions. The disease can scarcely be due about a week and also with the passage of a few decomposed to the much-abused sewers of towns, for it occurs in villages’ clots. She was douched every four hours with a solution of and lonely cottages where sewers do not exist. It is quite evident that the disease is prevalent at those Condy’s fluid. The patient menstruated for one day on June 8th and then again on J one 27th, which on this seasons when from the temperature conditions there is occasion lasted five days and was free from pain. She has mown to exist an increase in fermentative activity in lower been quite regular every month since and is now in perfect vegetative micro-organisms ; and it seems to me difficult to health. et away from the conviction that it is caused by the Naturally my sole regret with regard to this case is that I products of these active processes among organic impurities was unable to remove the ovaries. The woman was, however, wherever such exist in quantity and surroundings, as may be so much exhausted before the operation and by the subFavourable and congenial for the cultivation of the particular sequent loss of blood, although this was promptly checked, micro-organism or micro-organisms concerned. That the parthat it was deemed advisable to close the abdomen as rapidly ticular germ or germs flourish mostly amongst dirty, closely It is curious that on crowded, and ill-ventilated habitations is simply what may as possible and to get her back to bed. subsequent examination of the patient there was no apparent be expected from our general knowledge of the behaviour of distortion that would lead one to suspect a diminution of the other specific fevers. But the problem at issue is that this "summer diarrhcea"affects a whole neighbourhood, Of conjugate diameter of the pelvis. My thanks are due for the able assistance which I received indeed a whole country, rich and poor, clean and dirty, at the hands of Dr. Jacob and Dr. Shaw Bond. in towns and villages, old and young, persons following Great Majvern. different habits and modes of living and eating and drinking. All such classes are certainly not equally affected nor are all localities equally attacked, but that the epidemic ia indefinitely widespread is manifestly evident. The only one SUMMER DIARRHŒA: ITS PROBABLE condition essential on the face of it is a certain definite CAUSE. elevation of temperature. That the elevated temperature BY H. POOLE BERRY, M.B. LOND., M.R.C S. ENG., then is capable of producing a rapid increase in the particular MEDICAL OFFICER OF HEALTH OF THE BOROUGH OF GRANTHAM. germs or of endowing them with sudden virulently infective powers seems to me an unavoidable conclusion. The difficulty still remains as to where the culpable microIN THE LANCET of Dec. 5th, 1896, p. 1597, I narrated an organisms live and flourish. They most probably live in the outbreak of typhoid fever due, in my opinion, to a specific surroundings of the dwellings in which the sufferers reside, infection of the superficial subsoil and expressed the belief and inasmuch as the disease prevails in all manners and conthat the specific micro-organism had been cultivated in this ditions of houses, houses with every sanitary advantage and reverse (although, truly, not to the same extent), it seems subsoil under conditions of temperature and surroundings the almost irresistible to conclude that they must live in the soil congenial to itself. Since this outbreak many epidemics which is beneath us all. That all soils are not equally have been traced presumably to a similar cause, and the favourable would appear evident from the different severity the diseate in different localities. Methods of sanitation experiments of Dr. Sidney Martin and Dr. John Robertson -

,

of