werner@aecom.UUCP (Craig Werner) (11/17/86)
<> > In a 'historical' case: > > A young woman is brought into the emergency room in severe distress, > pelvic pain, and profound shock. An examination of the pelvic area reveals > bloating, crepitus (gas trapped within the tissues), and a dark discoloration > of the skin around the perineal (between the pubis and the anus) area. > Aspiration of the subcutaneous space yields a brown-black liquid with a > sickeningly sweet odor. A culture of the liquid is sent off to confirm > the diagnosis. Aggressive treatment is started, although the chances > are very likely that the woman will die despite all effort. > > 1) What is the condition called? > 2) What is the cause of the condition? > 3) What is the cause of the condition? > Note: #2 is a difficult question whereas #3 is straightforward. > 4) What, in a rough way, would treatment consist of? > 5) Why is this condition no longer commonly seen? The condition is called gas gangrene - the brown-black liquid is necrotic and liquified tissue. It is causes by the organism Clostridia perfringens, to answer the first two questions. After that, there seemed to be some misunderstanding of the word historical. Most responders assumed historical to mean the last century, and guessed that it was probably "childbed fever", a disseminated staph infection (aka sepsis), but that would not produce local gangrene, and certainly not crepititus. Where a staph sepsis would produce gangrene is in the extremities (esp. fingers) where bacteria-immune complexes lodged in small vessels and cut off circulation. No by historical, I was referring to prior to the early 1970s. That big hint given, the answer to 3 is easy. The woman had undergone a septic abortion. This is the way it used to be done: induce an infection of the pregnant uterus, the infection spread to the chorion, and the fetus spontaneously miscarried. If you were lucky, the placenta was expelled completely. If you were not, the portion of the retained placenta became dead tissue in what was essentially an anaerobic environment, a ripe target for secondary infection by such an anaerobic organism as clostridia. This could also occur after a normal birth if part of the placenta was retained (although less frequently because it was not already infected.) Treatment would consist of treating the massive shock that accompanies the infection, debriding the necrotic tissue, fasciotomy (removing the fascia, connective tissue, that the infection usually spreads along), massive amounts of antibiotics (Clostridia is usually pencillin sensitive), and possibly even hyperbaric oxygen. Note that debridement would most likely include removing the woman's entire reproductive tract. Even with such drastic measures applied timely, the death rate was about 30-50%. It is probably obvious therefore why this condition is no longer seen. Therapeutic abortions are now legal (and the right to one for the present time is constitutionally protected) and so women do not have to resort to criminal (in many cases septic) abortions. Making abortions once again illegal would probably bring a resurgence of such cases, most probably among the poor, the rich just taking a plane trip to Canada or Europe as they did in the 1960s. [Substantially correct guessea by Matt L. Fitchenbaum and Debbie Wolden. Joseph S.D. Yao was the only person to get both question #2 and #3 right. Those guessing childbed fever included Jerry Hollombe, Hank Buurman, and Michael C. Berch. Other guesses included Toxic Shock Syndrome, PID due to tampons (thought I should note that it is Toxic Shock where tampons increase risk, not PID. PID is caused by Gonnorhea or Chlamydia and was increased by certain IUDs no longer marketed). Finally, there were suggestions of an overly tight chastity belt, or perhaps Coca-Cola.] -- Craig Werner (MD/PhD '91) !philabs!aecom!werner (1935-14E Eastchester Rd., Bronx NY 10461, 212-931-2517) "My philosophy, like color TV, is all there in black and white."