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Two unusual cases of puerperal sepsis with gangrene of extremities
560
THE SMERICAN
JOURNbL
OF OBSTETRICS SND GYNECoLOQY
This was made and it was t.hen decided to do a nephrectomy and uretereetomy. I did through a Iumbar incision which exposed an enormously distended kidney Kidney and ureter were removed and drains and ureter. (Specimen shown.) inserted one to the bed of the ureter, where it had been ligated and the other to the kidney bed. The pus from the ureter showed a streptococcus hemolyticus. The patient made an uneventfu1 recovery and was discharged from the hospital well. On discharge her kidney function was normal.
DR. H. D. FUR~NISS.-I think it is usual in all these cases of vesicovaginal fistula, especially if the tract is long from the opening in the vagina to the end of the ureter, to get dilatation of the ureter as a result of constriction of the traet. In this ease we have a pointer that the traet was at least 3.5 cm., because he could get a catheter only that far in the ureter. That means it was at least that, but it may have been more. I think in the treatment of these eases we must establish more than the fact that we have a ureterovaginal Cstula. We must know the functional damage which has been done to the kidney and whether or not there is infection. In this particular ease there was normal elimination of indigo-carmine and phthalein from the left side, but none from the right, which indicated a marked deterioration of the function of the kidney. I would like to say right here, however, that indigo-carmine shows lessened function quicker than phthalein, and that you get a complete absence of indigo-carmine at times, especially if there is pus in the urine, when the phthalein elimination will be only moderately depressed. My criticism is that with a long fistulous tract and evidence of functional damage to the kidney, it was unwise to attempt an implantation and that the better procedure would have been to plan a nephrectomy.
I’XW YORK ACADEMY OF MEDICIXE SECTION ON OB,STETRICS AND GYSECOLOGY STATED MEETING, HELD XAY 24, 1921 DR. HAROLD BAILEY
IN THE CHAIR
DR. F. W. RICE reported Two Unusual Casesof Puerperal Sepsis with
Gangrene of Extremities. CASEl.-Thirty-eight years of age, married, para-iii, colored, born in the West Indies, entered Bellevue Hospital April 15, 1921, in the first stage of labor. She had previously had one full term delivery and one spontaneous two months’ misFor the past ten days before admission, she had carriage, both uncomplicated. When seen in the clinic three days had sore throat and an irritating cough. previously, her tongue was coated, cervical glands enlarged and tender, throat slightly congested; heart and lungs negative. Her Wassermann reaction was negative. Labor began at 1 A.M., April 15, the membranes ruptured spontaneously at 3 d.x., and she was delivered spontaneously at 5 :35 A.M., after four and onehalf hours, of a normal, living female child, weighing 4055 grams. The position was an R. 0. I?. which rotated spontaneously to R. 0. A. Delivery of the head was diffieult due to slight narrowing of the anteroposterior diameter of the outlet, caused by a prominent tip of the saerum. Manual pressure on the fundus aided
NEW
YORK
ACADEMY
OF
MEDICINE
561
A mucous membrane laceration resulted, delivery of both head and shoulders. requiring two superficial interrupted sutures of No. 2 chromic catgut. Light chloroform anesthesia was used throughout. The placenta was separated by Schultze’s mechanism and delivered by simple expression; the secundines were complete; there was no’ postpartum hemorrhage. One cc. of pituitrin wa,s given hypodermically, followed by one-half a dram of aseptic ergot. No vaginal examinations were made. On the second day postpartum, the temperature, previously normal, rose to 103.9” F., and the pulse to 130. The eoryza and cough became more severe. There was headache; the conjunetiva were injected; the skin was dry; abdomen slightly distended, the fundus at the umbilicus, hard, but there was tenderness over the bladder. On the third day postpartum, the temperature went to 105” F., the face and entiro trunk became hyperemic, the lips dry and craeked. The fundus was then five fingers, up, with scant lochia and perineal repair clean. On the fourth day the temperature was still 104”; white cells 14,000; polymorphonuclears 74 per cent; lymphocytes 24 per cent, and transitionals 2 per cent. The catheterized urine sho’wed two plus albumin, with many granular casts, quite a few pus and epithelial cells and some unorganized debris. On the fifth day the coryza, cough and rash were all improved, but the patient was irrational; the lochia were thin, watery and odorless; the uterus four fingers up, not tender, and the perineum clean. The tongue was hea.vily coated, white, with small red areas. A diagnosis of scarlet fever was made based on the rash, tongue and throat conditions. On the sixth day the temperature dropped to loo”, the rash disappeared, but the patient became more irrational, refused liquids and complained of feeling very weak. Her pulse was almost imperceptible, and she plucked at the covers and removed her gown repeatedly. On the seventh day, the blood culture was reported sterile She appeared markedly improved, though the eyes and throat A. catheterized specimen of urine showed a trace of albumin and a few granular casts and much unorganized debris.
at forty-eight hours. were still congested. with a few yus cells
On the eighth day the patient was still expectorating white mucus. The night before restraints had had to be applied. The pulse continued imperceptible. For the first time she complained of “sticking pains like pins and needles’ ’ in the soles of both feet. There was tenderness and pressure just beneath the internal malleoli of both ankles, none elsewhere. That night there was numbness in the left foot, most marked in the toes and inability to move the toes; no swelling was present. There were sharp intermittent pains and tenderness over the calf muscles and feet. The ninth day postpartum the patient had a chill in the early morning with a rise in temperature to 102.4”. The loehia became yellow but remained odorless. The eyes and thro’at were about normal. The fundus was still three fingers, soft, not tender, and the perineum was clean. The left foot showed small, hard, tender veins over the dorsum. Thrombophlebitis was diagnosed. Local treatment included dry heat, cotton covering, and elevation. On the tenth day, the temperature was 104O, white blood cells 24,000, with 57 per cent polymorphonuolears; the lochia pro’fuse yellowish brown in color. There were marked cyanosis and coolness of the left foot, from the ankle down; edema of the dorsum and a hyperesthetic area, lx\2 inches wide, from a beginning line of demarkation in the metatarsal region down. She complained of pain in the right foot and was incontinent of feces. On the eleventh 102”, the pulse from
day postpartum, 140 to 150, the
the heart
temperature sounds were
ranged between 101” and weak and a systolic apical
murmur had appeared. The area on the left foot had spread ahove the ankle; there There was a was complete anesthesia below- and some maceration of the skin. new estcnsion of the edema to the knee with redness and tenderness to the middle of the calf. The right leg showed redness rind tenderness over a third The right cheek showecl a swelling in the morning which by of t.he calf and down. afternoon had become ecchymotic, with a similar metastatie area on the third finger of the left hand. The patient perspired freely. That evening the right foot became cold and cyanotic, but the dorsalis pedis iIrtl?rv was still plainly palpable; this could not be done on the left, however, which was black aud eolci with the area extending higher mediaIly. There was tenderness higher on bot:h legs. On the twelfth day postpartum, the rectal temperature was 108”; pulse 148. The patient was unable t,o speak. The left foot showed extension and bloody discharge. The patch on the right check was bleeding. There was a new area of ecehymosis on the right buttock. The left arm was painful >vhen moved and the right was cold. The patient became unable to swallow; clyspnea and pulmonary edema developed rapidly; the pulse became weak and t,he patient died at I:00 P.M. CASE 2.-Thirty years of age, married, para iv, horn in the United States, admitted to Bellerue Hospital on April 21, 1919, in the first stage of labor. Her past history leas negative except that she stated that she had had puerperal troubles with all her previous children, though her three labors had been normal and spontaneous. Onset of labor Aas at 12 M., and at 9 :& t.he fetal heart became irregular and one vaginal exmlination was made. Finding the cervix fully dilated, the membranes were ruptured artificially. She was delivered spontaneously of a normal, full term female child, in L. 0. 4. position, at 10 :15 P.M., and the seeundincs were removed by the Crede method at lo:%. No postpartum hemorrhage or perineal tear. Half a dram of ascpt,ic ergot was given hypodermically. Only one rectal and one vaginal examination had been made. Preparation included a soapsuds enema. Ether was used. The patient had au uneventful history the first two days after delivery cxwept for cough on the night of the second day which persisted for two days. On the morning of the third day her temperature was 101”; at 2 P.M. she ha.11 a. chill of five minutes’ duration, headache, a.nd a temperature of lo-?” I”. The fundus was three fingers below the umbilicus, firm and slightly tender. The lochia were slightly foul. The lungs were negative. The fundus remained high and firm, and not tender thereafter, until the ninth day when it was much lower. From the fifth to the ninth day the lochia were profuse, thick and fouI. That night the patient had chilly feelings. At 4 o’clock the nest morning t.he temperature was 106” by mouth, and that day a blood culture was taken and reported sterile in forty-eight hours. The severe headache persisted. The tongue was moist and only slightly coated. A soft systolic apical murmur had appeared. The abdomen was distended and a. palpable spleen made out. On the fifth day postpartum, a catheterized specimen of urine was negative for albumin. The white blood cells numbered 15,000 with ‘i6 per cent polymorphonnclears. The Wasserma.nn test was negative. The patient was perspiring freely, the temperature being between 101” and 103” F. From the sixth to the ninth days the temperature ra.ngec7 from 101” to 101;” I?. The abdomen remained distended slightly. The patient’s general condition improved. Another blood culture taken on the seventh da.y was reported sterile after fortgr-eight hours.
NEW
YORK
ACADEMY
OF
IklEDICINE
563
On the ninth day the patient said that during the previous night she had had by motion in ‘the lower gradually progressive i ‘ drawing pains, ’ ’ aggravated shin and outer side of the left ankle. Examjnation revealed a slightly reddened iarea two inches in diameter, on the anterior surface, of the right tibia, just About 2l/ inches above above the ankle, not elevated, tender on pressure. the left ankle on the external surface of the calf there was a localized swelling That evening these involved slightly reddened and extremely tender on pressure. the processes were spreading rapidly, and areas showedl definite lyml)hangitis, the swelling in ‘the left leg was much worse. On ‘the tenth day postpartum, with temperature still 102O, the local condition became more marked, and from this time the pain was severe and persistent. Later the right ankle improved, while the left showed increased swelling, redness and tenderness, and in the aft,ernoon ecchymotie spots appeared over the external ,and dorsal surface of the foot and ankle. The temperature fell to normal. The twelfth day found the area on the left more ecchymotic and the temperature rising. The catheterized specimen of urine showed no albumin. The white bldod cells were 20,000 with polymorphonuclears 90 per cent. The following day a definite line of demarkation appeared at the left ankle laterally and over the dorsum of the foot, with coldness, cyanosis and anesthetic zone below it. Some pain reappeared on the right side, with redness and swelling persisting. On the thirteenth day a quick guillotine amputation was performed at the junction of the middle and upper third of the left calf. No attempt was made at closure for pus had burrowed along the muscle sheaths and fascial planes. The culture showed gra.m positive cocci, sOme sho’l-t chains and some diplocoeei forms. The The day after the operation blood plate report was “ hemolysis, no chain cocci.” the. temperature was 104” and continued to run a septic course. The patient continued to have severe pain in the left leg, causing insomnia and restlessness. Treatment had been symptomatic except for the operation and Dakin’s irrigation. On May 12, the leg became more painful and showed signs of inflammation. Under gas anesthesia an incision was made On t,he following day it was worse. and several ounces of crea.my odorous pus were evacuated from the extensor Three incisions were made and ample drainage afforded. The tendon sheaths. white blood cells were then 18,000. On the 14th day the amputation stump showed streptococci in both culture and blood plates while pus from the incision on the right leg showed gram-positive cocci-no chain effects. Subsequently the patient’s temperature has ranged between 101” and 103”. The stump and the wound on the right leg aImost healed. A delay in giving transfusion was eaused by difficulty in obtaining a donor. There seemed to be no apparent reason for the continued temperature. The general condition remained about the same. DISCUSSION DR. BAILEY.-In the same hospital service I saw a third case almost a duplicate of the one Dr. Rice presented. The blood culture was at first negative but later showed a nonhemolytic streptococcus. Amt about the tenth day postpartum she had severe pain in the middle of the tibia. Nothing was found on palpation, but tenderness. On the third day after the beginning of the tenderness there was slight lymphangitis below the area. On the basis of the resemblance of this case to the previous ones, the patient wa.s transferred to the An incision was made and there was no pus but the tissues were surgical side. On the third day the nonhemolytic streptococcus was found. The edematous. temperature dropped after opening ‘the leg and did not rise again. These are
564
THE
I~MERICAN
JOURNAL
OF
OBSTETRICS
BND
GYNECOLOGY
probably three cases of streptococeie blood infection with abscesses occurring at a distance from the wound. I saw the leg that was taken off and the loeation of the abscess was along the peroneus longus tendon, apparently its origin was from a biood infection. DR. WILTLIAM M. FORD.-1 might mention similar conditions ‘that I saw on one occasion just before the epidemic of influenza of 1915. On a Dutch steamship Nieu Amsterdam a. large number of persons died on the way to this port and there were a number of eases of influenza aboard when the boat reached New York. A dozen of these patients (more or less) were admitted to St, Vincent’s Hospital; a.bout half of them eame to the surgical side with a history of having had influenza on the trip over, from which they had about recovered, but they had infections about &he hands and feet, more particularly about the feet. The majority of these cases were similar to those reported. In each instance the condition followed a few days after influenza before convalescence was established. We were at a loss to say exactly how ,the infection occurred. We attributed it to streptocoeeic influenza; it was either coincident with or followed the influenza and the lowered resistance of the patients probably played a part. One patient died of empyema. The similarity of the eases just reported to ‘those cases leads me to believe that there is no specific connection with labor, that the same thing might follow in any open wound or following an infectious disease, when the patient’s vita1it.y is unduly lowered.
DR.
F. W. Recovery
also reported a case of Eclampia without Delivery.
RICE
at the Sixth Month:
The patient was a I’orto Rican woman, twenty-five years of age, married, para-i, admitted to Bellevue Hospital on April 19, 1921. Her past history obtained from her husband was ,that she was a healthy girl in every respect, except for appendectomy in 1919. She had been married nine months. Her last menses occurred on September 8. For the past two months she had had some edema af the ankles. The day before admission she complained of occipital headache for the first time at. 1:OO P.M. That afternoon and throughout the night it continued with increasing severity. At 8:30 A.M. on April 19, the patient had her first eonvulsion, followred by a second one at 10 8.X. She was admitted on a stretcher at 4345 P.M. in a semicomatose condition, evidently in deep shoek and could not be aroused by supraorbital pressure. There was some edema about the eyes and ankles, the heart was irregular, the sounds poor, the pulse almost imperceptible, 128; the temperature 101.6”. The blood pressure ‘taken at three different times was 50-40. The abdomen was that There was a floating head and a fetal heart of of a seven months’ pregnancy. 144, left and below. Vaginal examination revealed .CLlong rigid cervix of 2.5 em., the external o’s admitting the tip of the finger; the internal os was closed. hmbar puncture revealed a clear fluid under normal pressure; some sugar was present; globulin was negative; the cell count was 6. The Wassermann taken later on was reported one plus; the colloidal gold reaction wa,s negative. The catheterized urine boiled solid, with hyalinc and some granular casts. Ten grains of camphor in ether were administered and #the patient improved at once; the pulse became stronger, SS, and the blood pressure rose to 140.100. As high eolonic irrigations were begun, the first convulsion since she had been in the hospital occurred. The second came on with gastric lavage of soda bicarbonate solution, The Magendie given from 7:3O leaving three ounces of castor oil in the stomaeh.
THE SMERICAN
JOURNbL
OF OBSTETRICS SND GYNECoLOQY
This was made and it was t.hen decided to do a nephrectomy and uretereetomy. I did through a Iumbar incision which exposed an enormously distended kidney Kidney and ureter were removed and drains and ureter. (Specimen shown.) inserted one to the bed of the ureter, where it had been ligated and the other to the kidney bed. The pus from the ureter showed a streptococcus hemolyticus. The patient made an uneventfu1 recovery and was discharged from the hospital well. On discharge her kidney function was normal.
DR. H. D. FUR~NISS.-I think it is usual in all these cases of vesicovaginal fistula, especially if the tract is long from the opening in the vagina to the end of the ureter, to get dilatation of the ureter as a result of constriction of the traet. In this ease we have a pointer that the traet was at least 3.5 cm., because he could get a catheter only that far in the ureter. That means it was at least that, but it may have been more. I think in the treatment of these eases we must establish more than the fact that we have a ureterovaginal Cstula. We must know the functional damage which has been done to the kidney and whether or not there is infection. In this particular ease there was normal elimination of indigo-carmine and phthalein from the left side, but none from the right, which indicated a marked deterioration of the function of the kidney. I would like to say right here, however, that indigo-carmine shows lessened function quicker than phthalein, and that you get a complete absence of indigo-carmine at times, especially if there is pus in the urine, when the phthalein elimination will be only moderately depressed. My criticism is that with a long fistulous tract and evidence of functional damage to the kidney, it was unwise to attempt an implantation and that the better procedure would have been to plan a nephrectomy.
I’XW YORK ACADEMY OF MEDICIXE SECTION ON OB,STETRICS AND GYSECOLOGY STATED MEETING, HELD XAY 24, 1921 DR. HAROLD BAILEY
IN THE CHAIR
DR. F. W. RICE reported Two Unusual Casesof Puerperal Sepsis with
Gangrene of Extremities. CASEl.-Thirty-eight years of age, married, para-iii, colored, born in the West Indies, entered Bellevue Hospital April 15, 1921, in the first stage of labor. She had previously had one full term delivery and one spontaneous two months’ misFor the past ten days before admission, she had carriage, both uncomplicated. When seen in the clinic three days had sore throat and an irritating cough. previously, her tongue was coated, cervical glands enlarged and tender, throat slightly congested; heart and lungs negative. Her Wassermann reaction was negative. Labor began at 1 A.M., April 15, the membranes ruptured spontaneously at 3 d.x., and she was delivered spontaneously at 5 :35 A.M., after four and onehalf hours, of a normal, living female child, weighing 4055 grams. The position was an R. 0. I?. which rotated spontaneously to R. 0. A. Delivery of the head was diffieult due to slight narrowing of the anteroposterior diameter of the outlet, caused by a prominent tip of the saerum. Manual pressure on the fundus aided
NEW
YORK
ACADEMY
OF
MEDICINE
561
A mucous membrane laceration resulted, delivery of both head and shoulders. requiring two superficial interrupted sutures of No. 2 chromic catgut. Light chloroform anesthesia was used throughout. The placenta was separated by Schultze’s mechanism and delivered by simple expression; the secundines were complete; there was no’ postpartum hemorrhage. One cc. of pituitrin wa,s given hypodermically, followed by one-half a dram of aseptic ergot. No vaginal examinations were made. On the second day postpartum, the temperature, previously normal, rose to 103.9” F., and the pulse to 130. The eoryza and cough became more severe. There was headache; the conjunetiva were injected; the skin was dry; abdomen slightly distended, the fundus at the umbilicus, hard, but there was tenderness over the bladder. On the third day postpartum, the temperature went to 105” F., the face and entiro trunk became hyperemic, the lips dry and craeked. The fundus was then five fingers, up, with scant lochia and perineal repair clean. On the fourth day the temperature was still 104”; white cells 14,000; polymorphonuclears 74 per cent; lymphocytes 24 per cent, and transitionals 2 per cent. The catheterized urine sho’wed two plus albumin, with many granular casts, quite a few pus and epithelial cells and some unorganized debris. On the fifth day the coryza, cough and rash were all improved, but the patient was irrational; the lochia were thin, watery and odorless; the uterus four fingers up, not tender, and the perineum clean. The tongue was hea.vily coated, white, with small red areas. A diagnosis of scarlet fever was made based on the rash, tongue and throat conditions. On the sixth day the temperature dropped to loo”, the rash disappeared, but the patient became more irrational, refused liquids and complained of feeling very weak. Her pulse was almost imperceptible, and she plucked at the covers and removed her gown repeatedly. On the seventh day, the blood culture was reported sterile She appeared markedly improved, though the eyes and throat A. catheterized specimen of urine showed a trace of albumin and a few granular casts and much unorganized debris.
at forty-eight hours. were still congested. with a few yus cells
On the eighth day the patient was still expectorating white mucus. The night before restraints had had to be applied. The pulse continued imperceptible. For the first time she complained of “sticking pains like pins and needles’ ’ in the soles of both feet. There was tenderness and pressure just beneath the internal malleoli of both ankles, none elsewhere. That night there was numbness in the left foot, most marked in the toes and inability to move the toes; no swelling was present. There were sharp intermittent pains and tenderness over the calf muscles and feet. The ninth day postpartum the patient had a chill in the early morning with a rise in temperature to 102.4”. The loehia became yellow but remained odorless. The eyes and thro’at were about normal. The fundus was still three fingers, soft, not tender, and the perineum was clean. The left foot showed small, hard, tender veins over the dorsum. Thrombophlebitis was diagnosed. Local treatment included dry heat, cotton covering, and elevation. On the tenth day, the temperature was 104O, white blood cells 24,000, with 57 per cent polymorphonuolears; the lochia pro’fuse yellowish brown in color. There were marked cyanosis and coolness of the left foot, from the ankle down; edema of the dorsum and a hyperesthetic area, lx\2 inches wide, from a beginning line of demarkation in the metatarsal region down. She complained of pain in the right foot and was incontinent of feces. On the eleventh 102”, the pulse from
day postpartum, 140 to 150, the
the heart
temperature sounds were
ranged between 101” and weak and a systolic apical
murmur had appeared. The area on the left foot had spread ahove the ankle; there There was a was complete anesthesia below- and some maceration of the skin. new estcnsion of the edema to the knee with redness and tenderness to the middle of the calf. The right leg showed redness rind tenderness over a third The right cheek showecl a swelling in the morning which by of t.he calf and down. afternoon had become ecchymotic, with a similar metastatie area on the third finger of the left hand. The patient perspired freely. That evening the right foot became cold and cyanotic, but the dorsalis pedis iIrtl?rv was still plainly palpable; this could not be done on the left, however, which was black aud eolci with the area extending higher mediaIly. There was tenderness higher on bot:h legs. On the twelfth day postpartum, the rectal temperature was 108”; pulse 148. The patient was unable t,o speak. The left foot showed extension and bloody discharge. The patch on the right check was bleeding. There was a new area of ecehymosis on the right buttock. The left arm was painful >vhen moved and the right was cold. The patient became unable to swallow; clyspnea and pulmonary edema developed rapidly; the pulse became weak and t,he patient died at I:00 P.M. CASE 2.-Thirty years of age, married, para iv, horn in the United States, admitted to Bellerue Hospital on April 21, 1919, in the first stage of labor. Her past history leas negative except that she stated that she had had puerperal troubles with all her previous children, though her three labors had been normal and spontaneous. Onset of labor Aas at 12 M., and at 9 :& t.he fetal heart became irregular and one vaginal exmlination was made. Finding the cervix fully dilated, the membranes were ruptured artificially. She was delivered spontaneously of a normal, full term female child, in L. 0. 4. position, at 10 :15 P.M., and the seeundincs were removed by the Crede method at lo:%. No postpartum hemorrhage or perineal tear. Half a dram of ascpt,ic ergot was given hypodermically. Only one rectal and one vaginal examination had been made. Preparation included a soapsuds enema. Ether was used. The patient had au uneventful history the first two days after delivery cxwept for cough on the night of the second day which persisted for two days. On the morning of the third day her temperature was 101”; at 2 P.M. she ha.11 a. chill of five minutes’ duration, headache, a.nd a temperature of lo-?” I”. The fundus was three fingers below the umbilicus, firm and slightly tender. The lochia were slightly foul. The lungs were negative. The fundus remained high and firm, and not tender thereafter, until the ninth day when it was much lower. From the fifth to the ninth day the lochia were profuse, thick and fouI. That night the patient had chilly feelings. At 4 o’clock the nest morning t.he temperature was 106” by mouth, and that day a blood culture was taken and reported sterile in forty-eight hours. The severe headache persisted. The tongue was moist and only slightly coated. A soft systolic apical murmur had appeared. The abdomen was distended and a. palpable spleen made out. On the fifth day postpartum, a catheterized specimen of urine was negative for albumin. The white blood cells numbered 15,000 with ‘i6 per cent polymorphonnclears. The Wasserma.nn test was negative. The patient was perspiring freely, the temperature being between 101” and 103” F. From the sixth to the ninth days the temperature ra.ngec7 from 101” to 101;” I?. The abdomen remained distended slightly. The patient’s general condition improved. Another blood culture taken on the seventh da.y was reported sterile after fortgr-eight hours.
NEW
YORK
ACADEMY
OF
IklEDICINE
563
On the ninth day the patient said that during the previous night she had had by motion in ‘the lower gradually progressive i ‘ drawing pains, ’ ’ aggravated shin and outer side of the left ankle. Examjnation revealed a slightly reddened iarea two inches in diameter, on the anterior surface, of the right tibia, just About 2l/ inches above above the ankle, not elevated, tender on pressure. the left ankle on the external surface of the calf there was a localized swelling That evening these involved slightly reddened and extremely tender on pressure. the processes were spreading rapidly, and areas showedl definite lyml)hangitis, the swelling in ‘the left leg was much worse. On ‘the tenth day postpartum, with temperature still 102O, the local condition became more marked, and from this time the pain was severe and persistent. Later the right ankle improved, while the left showed increased swelling, redness and tenderness, and in the aft,ernoon ecchymotie spots appeared over the external ,and dorsal surface of the foot and ankle. The temperature fell to normal. The twelfth day found the area on the left more ecchymotic and the temperature rising. The catheterized specimen of urine showed no albumin. The white bldod cells were 20,000 with polymorphonuclears 90 per cent. The following day a definite line of demarkation appeared at the left ankle laterally and over the dorsum of the foot, with coldness, cyanosis and anesthetic zone below it. Some pain reappeared on the right side, with redness and swelling persisting. On the thirteenth day a quick guillotine amputation was performed at the junction of the middle and upper third of the left calf. No attempt was made at closure for pus had burrowed along the muscle sheaths and fascial planes. The culture showed gra.m positive cocci, sOme sho’l-t chains and some diplocoeei forms. The The day after the operation blood plate report was “ hemolysis, no chain cocci.” the. temperature was 104” and continued to run a septic course. The patient continued to have severe pain in the left leg, causing insomnia and restlessness. Treatment had been symptomatic except for the operation and Dakin’s irrigation. On May 12, the leg became more painful and showed signs of inflammation. Under gas anesthesia an incision was made On t,he following day it was worse. and several ounces of crea.my odorous pus were evacuated from the extensor Three incisions were made and ample drainage afforded. The tendon sheaths. white blood cells were then 18,000. On the 14th day the amputation stump showed streptococci in both culture and blood plates while pus from the incision on the right leg showed gram-positive cocci-no chain effects. Subsequently the patient’s temperature has ranged between 101” and 103”. The stump and the wound on the right leg aImost healed. A delay in giving transfusion was eaused by difficulty in obtaining a donor. There seemed to be no apparent reason for the continued temperature. The general condition remained about the same. DISCUSSION DR. BAILEY.-In the same hospital service I saw a third case almost a duplicate of the one Dr. Rice presented. The blood culture was at first negative but later showed a nonhemolytic streptococcus. Amt about the tenth day postpartum she had severe pain in the middle of the tibia. Nothing was found on palpation, but tenderness. On the third day after the beginning of the tenderness there was slight lymphangitis below the area. On the basis of the resemblance of this case to the previous ones, the patient wa.s transferred to the An incision was made and there was no pus but the tissues were surgical side. On the third day the nonhemolytic streptococcus was found. The edematous. temperature dropped after opening ‘the leg and did not rise again. These are
564
THE
I~MERICAN
JOURNAL
OF
OBSTETRICS
BND
GYNECOLOGY
probably three cases of streptococeie blood infection with abscesses occurring at a distance from the wound. I saw the leg that was taken off and the loeation of the abscess was along the peroneus longus tendon, apparently its origin was from a biood infection. DR. WILTLIAM M. FORD.-1 might mention similar conditions ‘that I saw on one occasion just before the epidemic of influenza of 1915. On a Dutch steamship Nieu Amsterdam a. large number of persons died on the way to this port and there were a number of eases of influenza aboard when the boat reached New York. A dozen of these patients (more or less) were admitted to St, Vincent’s Hospital; a.bout half of them eame to the surgical side with a history of having had influenza on the trip over, from which they had about recovered, but they had infections about &he hands and feet, more particularly about the feet. The majority of these cases were similar to those reported. In each instance the condition followed a few days after influenza before convalescence was established. We were at a loss to say exactly how ,the infection occurred. We attributed it to streptocoeeic influenza; it was either coincident with or followed the influenza and the lowered resistance of the patients probably played a part. One patient died of empyema. The similarity of the eases just reported to ‘those cases leads me to believe that there is no specific connection with labor, that the same thing might follow in any open wound or following an infectious disease, when the patient’s vita1it.y is unduly lowered.
DR.
F. W. Recovery
also reported a case of Eclampia without Delivery.
RICE
at the Sixth Month:
The patient was a I’orto Rican woman, twenty-five years of age, married, para-i, admitted to Bellevue Hospital on April 19, 1921. Her past history obtained from her husband was ,that she was a healthy girl in every respect, except for appendectomy in 1919. She had been married nine months. Her last menses occurred on September 8. For the past two months she had had some edema af the ankles. The day before admission she complained of occipital headache for the first time at. 1:OO P.M. That afternoon and throughout the night it continued with increasing severity. At 8:30 A.M. on April 19, the patient had her first eonvulsion, followred by a second one at 10 8.X. She was admitted on a stretcher at 4345 P.M. in a semicomatose condition, evidently in deep shoek and could not be aroused by supraorbital pressure. There was some edema about the eyes and ankles, the heart was irregular, the sounds poor, the pulse almost imperceptible, 128; the temperature 101.6”. The blood pressure ‘taken at three different times was 50-40. The abdomen was that There was a floating head and a fetal heart of of a seven months’ pregnancy. 144, left and below. Vaginal examination revealed .CLlong rigid cervix of 2.5 em., the external o’s admitting the tip of the finger; the internal os was closed. hmbar puncture revealed a clear fluid under normal pressure; some sugar was present; globulin was negative; the cell count was 6. The Wassermann taken later on was reported one plus; the colloidal gold reaction wa,s negative. The catheterized urine boiled solid, with hyalinc and some granular casts. Ten grains of camphor in ether were administered and #the patient improved at once; the pulse became stronger, SS, and the blood pressure rose to 140.100. As high eolonic irrigations were begun, the first convulsion since she had been in the hospital occurred. The second came on with gastric lavage of soda bicarbonate solution, The Magendie given from 7:3O leaving three ounces of castor oil in the stomaeh.