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By James Bell, M.l)., Siirg(M)n to the Royal Victoria Hospital ; Assistant Professor of Surgery and Clinical Surgery McQill University. I beg to submit the following very brief history of a series of cases of streptococcus infection which have recently come under my observation. The first case of the series was Mrs. U. Neill, aged 34, who was admitted to the Royal Victoria Hospital at 6 o'clock p.m. on the 8th of January, 1893, in a condition of great dyspnoea and partial stupor. There was a family history of tuberculosis. The patient had been confined on the first of January, being attended by a midwife. On the 4th of January she had a violent chill with suppression of the lochia, and on the fifth, cough and pain in the right side set in. On the 6th, she was first seen by a physician, who found evidences of acute peritonitis and pleurisy. On admission to the hospital on the 8th, she was found to be in a very desperate condition. Temp. 104°F. Pulse 140, weak and thready. Respiration 62. There was present dyspnoea with cyanosis and suppressed cough. Examination of the chest showed dulness with enfeebled breathing at both bases, but more marked on the right side. Dulness was also found in front on both sides. The abdomen was much distended and tender, especially over the hypo- gastrium, and the skin was covered with red erythematous rash. r i During the ni;^ht the patient continued to grow worse, diarrhoea set in with greenish and very offensive stools. Respiration became more difficult and laboured and cyanosis increased. Delirium was followed by coma, and death occurred at 10 o'clock a.m., on the 9th, 16 hours after admission. At the autopsy, which was held at 1 o'clock p.m. on the 10th of January, 27 hours after death, considerable effusion of blood stained serum was found in both pleurae. The lungs were congested and oedematous, but there was no pneumonia. There was some fluid in the peri cardium and recent lymph on the valves of the heart. The peritoneum, more especially in the neighbourhood of the uterus, was covered with a thick, almost purulent lymph. The intes tines were matted together. The uterus was enlarged and its substance softened. On the inner surface at the placental site was a small patch of broken down tissue — probably a portion of the placenta. There was no thrombosis noted anywhere. (I am indebted to Dr. VV. A. Brown, Senior House Physician of the Royal Victoria Ilosiiital for the above facts.) Cultures of the peritoneal fluid made by Dr. Adami showed abundance of streptococci. Dr. F. R. England, who saw this patient at her home, informs me that there was no infectious disease in the house at the time of confinement, but that scarlatina was very prevalent in the immediate neighbourhood. The second case in the series was that of Dr. J. W. Scane, Senior House Surgeon, Royal Victoria Hospital, who has written to me the following account of his illness : — " I attended the autopsy on Wednesday, Jan. 10th, as a spectator only. After remaining in the room a short time, I left to get measur- ing glasses for Dr. Adami, and on my return I jan.med my right index finger in the door, knocking off a small portion of skin at the root of the nail. I did not touch anything in the room — on the contrary, knowing the case to be septic, I at once put my hands in my pockets and left the room. I was quite well till next morning (Thursday), when I had a severe attack of diarrhoea. I felt miserable all day with headache and general soreness all through my body. About four o'clock p.m , Dr. ^M r i Brown took ray temperature. It was then 99.0'^F. At 8 o'clock Dr. Weeks took it, and it was then 101. 8° F. Next day (Friday), in the morning, I first felt soreness in the rii^ht axilla and on examination found the glands considerably enlarged and tender. I also felt soreness about the jaw, the ascending rami being quite tender ^o the touch. There was no indication of any trouble about the finger wound at all. It healed as an ordinary abrasion would, and there was no redness of the skin of the arm. All went well till Saturday night, when I experienced a very severe pain over the region of the heart, extending also down the left arm. This was accompanied by a feeling of constriction about the throat, making breathing difficult. These symptoms were relieved in about half an hour by hot applications and morphia hypodermically. Next morning (Sunday) I felt much better in every way. The swelling in the glands had almost disappeared and the tenderness was very slight. I got up on Sunday evening and have been (piite well since. My tem- perature never exceeded 101.8*^F. I had no definite chill and no other glands were enlarged except those of the right axilla. This illness ot Dr. Scane's is perhaps susceptible of some other interpretation, and at best the evidence of its having been due to streptococcus infection is very incomplete. Some of the symptoms, indeed, suggest rather a mild attrck of tetanus, but the rapidity and completeness with which th< y disappeared, as well as the shortness of the incubative stage, render this theory untenable. On the other hand, the incidence of the symptoms within twenty-four hours of the injury, and the enlargement of the glands in the axilla, together with the character of the symptoms themselves, leave no doubt as to the illness having originated in septic infection of some sort, and as this was the very first autopsy ever performed in the building, it is only possible to attribute the infection to this case. The third case is that of Mr. Fred. Carron, a student, who assisted at the autopsy in the Royal Victoria Hospital. During the autopsy he pricked the palmar surface of his left index finger with a scalpel. In the course of the evening the finger became painful, and- at night it prevented ,h'm from sleeping. Durin;]; the ni^^ht ho <;ot up ami prickoil it with a noedio, think in^ that sometliiii;^ had ;^()t into tho wound. In the niornin'^ he called u[)()n Dr. Roddick, who made a deep incision throu^^h the site of the wound. There was no pus and no redness of tho arm, althou;j;ii the a.xillary ;j;lands were sli;^htly enlar;;od and tender. The followin;.; day, Jan'y. 12th, ho went to tho (iencral Hospital. His temperature was then lOli.d'^F at noon, h\it ;;radualiy fell until at S o'clock p.m. it was only l^!)*"'!^'. Durin;; the next live days the temfjor.iture remained normal, and the wound in the finder comjjletcly healed. He complained, however, of some pain in tho axilla, and on the loth of some sore throat. On the ni;j;ht of tho 18th he complained of more pain in the axilla, and in tho early morning (ll>th) he had a chill and at ni^iht a slight epistaxis. The temperature rose on tho 19th to 101. 2°F., and the next nine day.s it ran^^ed from 101 to 108.<)^F., the [)ulse ran^e heing between 1)0^ and lOO^F. During this time I saw him daily with Dr. Roddick. We examine' 1 him carefully every day, but found no indications for operative intotrcrctiCL'. On ihe 20th the axilla was swollen and tender. On the 21st the swelling had diminished in the axilla and was greater just below the clavicle and under the pectoral muscle. On the 22nd the swelling and tenderness had greatly diminished again in this region, and the most painful spot, which was also swollen, was just at the inner edge of the deltoid muscle. There were now some spots ot redness on the arm. On the 23rd a red patch, as large as the palm of the hand, appeared in the pectoral region. This was painful and tender. These areas of redness were at this time attributed to the hot poultices, On the 25th we decided to explore the axilla. This was done under ether by an incision in the centre of the axillary space through skin and fascia. Another incision was made at the edge of the deltoid directly down to the bone, and a third along the outer edge of the scapula. Nothing was revealed by these incisions. Next day other areas of redness (dermatitis) had appeared over the forearm and back, and a diagnosis of erysipelas was finally made. On the 2Gth Dr. Adami collected some serum and blood from some of the newer areas of ei', aipelas for examinatidii, hut with n iie;,'ntlve result. From tills time he he;;aii to im[»rove and is now convalescent. The fourth ciise is that of a man named Michael Smith, aiiod 44, on whom I operated in the hospitiil for inveterate cluh foot, one ho\ir after havin;; o[)erated upon Carron, the patient hein;; on the same tahlc and itj the same operatinj^ room, and my assistant heing the same llouso Surgeon as in Carron's o[)era- tion. The tahle, a wooden one, covered with ruhher, had heen scruhhed as usual after operation, and my assistant and myself had taken the routine precautions to cleanse our hands. The operation consisted in the removal of the astragalus, scaphoid, cuboid and portions of the two inner cuneiforms and the liead of the 08 calcis, as well as the overlying bursa whicli had been in a suppurating condition with sinuses for seven years. The operation was long and tedious ajid recjuircd much manipulation. The patient was as comfortable as could be expected for tlie next three days. On the 29th, as he was complaming of pain, the dressing was changed. There was some redness and swell- ing of the skin of the loot whicli I then thought was possibly duo to the rough manipulation during the operation. For the next four days the patient was not so well, lie comj)lained of much pain and his temperature ran up to 102'*'F. at night. On the second of February the dressing was again changed, when the whole foot and leg were found to be red, swollen and vesicated — an undoubted erysipelas. Then for the first time the connection of this with the {)revious case (Carron's) was brought home to my mind. On the r)th instant, the dressinjj: was again changed in order to enable Dr. Adami to collect some serum for exami- nation. The inflammatory process had, however, so definitely subsided that nothing was done, except to collect from a vesicle which had remained unbroken. The serum thus collected has yielded a negative result. No suppuration whatever occurred about the wound, and the j)atient is progressing most satisfac- torily. It is, of course, much to be regretted that the conditions were not recognized earlier in the third and fourth cases in order that bacteriolomcal investi;iation miiAit have been systematically and successfully carried out, and the presence or 8 alKscnco of the atrcptoooccus tloliiiitcly (Icterminctl. Clinically, liowcvcr, the picture is a very sii;,';^estive ono, and readir.ns the absolute necessity for the cuiujjleto sterilization of the operating table, the surgeon's hands and of everything that may come in contact with the operation wound. Scarcely less important, perhaps, is the demonstration that the inoculation of the streptococcus produced erysi[)ela8, in one case remotely through the lym[)hatics, and in the other case directly, but in neither suppuration.