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Vol. XX179

St. Louis, JANUARY 25, 1906.

No. 2

Papers for the original department must be contributed ex at term were almost never fatal from sepsis. clusively to this magazine, and should be in hand at least one month in advance. French and German articles will be trans Leopold's report of 919 puerperal cases not lated free of charge, if accepted. A liberal number of extra copies will be furnished authors, and

examined, with only two cases of possible reprints may be obtained at cost, if request accompanies the autoinfection, gives strength to this view proof.

Engravings from photographs or pen drawings will be fur True some of these cases flooded to the point nished when necessary to elucidate the text. Rejected manuscript will be returned if stamps are enclosed for this purpose.

of almost complete exsanguination, and many

of them carried putrid placental tissues and COLLABORATORS.

membranes for many weeks, occasionally, ALBERT ABRAMS, M. D., San Francisco. M. V. BALL, M. D., Warren, Pa.

were quite sick with fever of a moderate de. FRANK BILLINGS, M. D., Chicago, Ill. CHARLES W. BURR, M. D., Philadelphia.

gree and an occasional slight chill, but they C. G. CHADDOCK, M. D., St. Louis, Mo.

did not die. I have, in my earlier practice, S. SOLIS COHEN, M. D., Philadelphia, Pa. ARCHIBALD CHURCH, M. D., Chicago.

seen this condition accompanied by a putrid N. S. DAVIS, M. D., Chicago. ARTHUR R EDWARDS, M. D., Chicago, Ill.

odor that made it almost impossible to reFRANK R. FRY, M. D., St. Louis.

main in the same room with the patient, and Mr. REGINALD HARRISON, London, England. RICHARD T. HEWLETT, M. D., London, England. yet they recovered. J. N. HALL, M, D., Denver. HOBART A. HARE, M. D., Philadelphia.

Why did they not die? Because they were CHARLES JEWETT, M. D., Brooklyn.

suffering from a toxic influence due to sapro. THOMAS LINN, M. D., Nice, France. FRANKLIN H. MARTIN, M. D., Chicago.

phytio germs which could only live and prop. E. E. MONTGOMERY, M. D., Philadelphia. NICHOLAS SENN, M. D., Chicago.

agate in dead tissues and whose toxines FERD C. VALENTINE, M, D., New York.

gained entrance into the circulation and proEDWIN WALKER, M. D., Evansville, Ind. REYNOLD W. WILCOX, M. D., New York.

duced constitutional symptoms only when H. M. WHELPLEY, M. D., St. Louis, WM. H. WILDER, M. D., Chicago, I.

drainage was interfered with and they were forced into the circulation; provided with free

drainage, these cases always obtained relief LEADING ARTICLES

whether placental tissues, membranes and de. tached necrotio decidua were removed, or not.

Tbe profession rightly presumed that the PARTURIENT SEPSIS. *

symptoms were produced by the retention of

the secundines and began their removal by fin. C. E. RUTH, M. D.

ger and curette, and if it were done early, very

gently, and no additional and more dangerous KEOKUK, IOWA,

germs were introduced by dirty hands and inProfessor of Surgery, Keokuk Medical College, College of struments, the patient recovered at once. Physicians and Surgeons.

But many of the cases became suddenly very PUERPERAL SEPSIS in abortion and labor much worse, ourettement was repeated more at term undoubtedly always existed, though vigorously under the supposition that the I am convinced that through our pioneer former effort was not sufficiently thorough. population it was rare compared with the In many cases, this resulted in a great inpercentage of deliveries. It became a fearful crease in the intensity of all symptoms and scourge when in tbe more populous districts speedy death. In scme cases post-mortem the dirty midwife and almost equally dirty proved the uterus to be free of all secundines doctor attended most of the cases. With the and with nothing to show the cause of death advent of criminal abortion by instrumenta. except evidences of intlammation of the tion, self-induced or by a professional abor. uterus, sometimes some edema and softening tionist, it became frightfully common, and of the uterus and periuterine tissues. In though a large number died, a larger number other cases, less virulent, the uterus was exwere permanently invalided.

tensively softened and numerous abscesses While many abortions have occurred, and bad formed in the uterine muscularis or peri. will occur, from cervical laceration, weakness, uterine structures. In the cbronio cases, ex. subinvolution, falls, etc., I am convinced tepsive peritoneal adhesions had taken place. that fatal sepsis was very rare when digital Often in the fulminant cases, bloody serum and instrumental genital manipulations and was found in the peritoneum with but slight examinations were not done. In other words, changes in the uterus or periuterine tissues. spontaneous, unattended abortions and labors The cause in each case was held to be due to

too late removal of the placenta. Later, the *Read before the Mississippi Valley Medical Association,

suspicion began to overtake the profession

at Indianapolis, Ind., October 12, 1905.

that manual and instrumental manipulations tion with streptococcic germs is especially were responsible for the introduction of germs virulent, but is sometimes mixed with staphy, wbich were more virulent than saprophytes, looocous. Examinations of patients in ma. and that could pass through and multiply in ternity hospitals by Professur Edgar revealed living tissues as well as circulate in the blood, the fact that the upper part of the vagina destroying the vitality of tissues where showed no pyogenic germs.

This was true massed together, producing abscesses when to the entroitus except where germs bad enough time bad elapsed, and in other cases, been introduced less than forty-eight hours multiplying in the circulatory system so rap- previous. It was found that some pyogenic idly as to cause death without pronounced germs would live four days in the upper microscopical local changes.

vaginal secretions, but in forty per cent of We had not then learned, in fact are just the cases examined by the same author, in now learning, how to cleanse our bands. the same emergency hospitals, the vulvar When they were cleansed, they were rein canal below the entroitus contained pyofected on the way to the interior of the genic germs. It therefore becomes necesuterus by the bedding, foul labia, hairs on sary that physicians should not only as thorthe vulva, etc. The vagina was known to oughly as possible sterilize their hands, but be its own sterilizer if it had a chance to that external genitalia should also be thor. use its own physiological laboratory, but we oughly cleaned up to and including the vul. were taking it at a disadvantage and plant var entroitus before anything is carried bigh ing our cultures where they got in their up in the vagina, because of the liability of work to the greatest danger to the patient. contamination by pyogenio germs on fingers

In the best maternity hospitals where prep or instruments. If this be done by every aration, position, attendance and dressing can physician with every possible care, there yet be perfectly controlled, puerperal sepsis has remains the possibility of infection by sexual been almost entirely eliminated. While this indulgence up to and even including the is true of perfectly ideal surroundings, some commencement of labor. If this takes place, infection will sometimes occur, but more es there is no question that in some cases it will pecially where the majority of cases are not be the cause of infection in cases otherwise and can not be placed in ideal surroundings, treated by skillful and painstaking obstetri. but every effort should be made to approxi cians. mate the ideal as nearly as possible

When we bave eliminated the two prinoi. If the infection be saprophytic, we may ex pal pyogenic germs, there yet remains to be pect foul odor in which dead tissues in the considered the greatest scourge and most re. interior of the uterus, namely, placental tis sistant of all, the diplococcus of gonorrhea, sues, membranes and detached decidua, are so that, in spite of all care, we will occasion. attacked. This must of necessity be local ally, because of germs in the vaginal canal and if the infection remains saprophytic, it viable at the time of labor or introduced by will not endanger life and the temperature self-examination of the patient, by the hand will not likely go very high. It certainly will of the obstetrician or his instruments, come not if good drainage is maintained.

It is a

into contact with various infection agencies well-known fact that dead tissues, that is, ne and we must be prepared to deal intelligent. crotic fetus, may remain in the uterus indefin. ly with them and, if possible,exclude the proitely without infeotion.

duction of uterine and periuterine phlebitis, The next degree of severity of infection will puerperal metastic pyema, septic pneumonia, result from anerobic bacilli

, at the present septic endocarditis, septic arthritis, phlegmatime the least perfectly understood. In this sia alba dolens, pelvic cellulitis, and pelvio connection should also be mentioned the peritonitis or perimetritis, as well as the bacillus aerogenes capsulatus and bacillus of milder saprophytic intoxications involving malignant edema. While saprophytic bac. only dead tissues within the uterus. This terial infection must attack and live on dead form should be called sapremio intoxication, tissues, being unable to invade living tissues, not infection. it will not markedly soften or disintegrate the Prevention must always be the most imporuterine struoture. It is in this variety of tant treatment. No instrumentation in any infection only that clean curettement may be variety of puerperal sepsis should be consid. done without danger. The anerobio bacilli ered which denudes the uterine mucosa and may be, in fact are, able to penetrate some. opens up tissues not in any sense protected what into the living tissues and one or two from septic infection, the utmost gentleness deaths have been attributed to infection of being used to avoid any possibility of punothis nature, wbile streptococci, staphylococci, turing the softened or disintegrated uterine colon bacilli, bacilli of diphtheria and ty. wall. The curette, I believe, in such cases phoid can also invade living tissues. Infec. should never be used, certainly not a small

or sharp one, and then only in the least seri. that the operation was done in stuges, owing ous of these cases, namely, saprophytic in to the critical condition of the patient. Evactoxication which is not sepsis.

uation was done first through the uterus and The use of antipyretics, which depress the vagina by dilating the cervix aud pus tracts heart action and interfere with the oxygeniz in the uterine wall. Three weeks later, I ing process of the blood, can scarcely ever be made a suprapubio incision and drained indicated, sponging and cold packs, when the through the posterior vaginal vault, as well temperature runs high, being much safer. as above the pubes with through and through Cool or cold water bottles are best of all. drainage, removing the right adnexa, which The use of antistreptococcic serum, while it were suppurating. The uterus in this case, acts like magic in some cases, will prove en. as in previous ones, was readily punctured tirely worth less in others, can do no harm, by the finger. Recovery was tedious but and is, therefore, always indicated.

complete now after eighteen months. Streptococcic and staphylococcio puerperal In my fourth case, that of Mrs. P. S., aged infections have, on the manifestations of 36 years, the family history was negative, she symptoms, passed beyond all possible reach had bad no serious illness, was the mother of of removal by any form of ourrettage. While a child born nine years ago, had had two curettement can do no good, it may do much miscarriages, the first one two years ago and harm in disseminating infection, and in uter. the second one four months ago. Her gen. ine perforation. This latter element is im. eral health was good until the abortion in portant because I have known cases in which December, 1904, since then she had not been perforation of the uterus was done by a man well. Locomotion was interfered with from of several years' experience and above the pain and weakness through the lower abdo. average in ability; by another of very large men. Examination was negative as to heart, experience and national reputation, ncted lungs and upper abdomen. Her pulse was for care in operatione and original research, 96, full, soft and regular; temperaure 99%. and by five men of international reputation, Examination revealed cervical and perineal one of whom had previously declared that laceration, retroflexion with prolapse of uter. the penetration of the uterus with the curette us. The uterus was found to be large and was a crime, and at his next operation of tender with preternatural immobility from this kind, put the ourette through the uterine inflamed exudate about it; the cervix was wall. Within the last two and a half years, patulous. I did a curettement, and while I have operated upon four cases of puerperal carefully cleaning the fundus, the curette sepsis illustrating the dangers of curettage. passed through the soft uterine tissues into The first was five weeks after delivery in the peritoneal cavity. I repaired the peri. which the uterine wall was honey.combed in neum and opened the abdomen, finding the every direction on one side, and I could put perforation on the anterior portion of the my finger through without meeting with fundus. The ovaries, tubes, bladder and recmarked resistance. In this case, I did a com. tum were united in a mass of adhesions with plete bysterectomy and lost my patient in pus sacs and both tubes were dilated with three days. A few weeks later, I operated on pus an inch in diameter. A complete pana second case and found that I could run hysterectomy was done, recovery was un. my finger through the uterus with great eventful, though the operation taxed her en. ease. In this case, I removed the adnexa durance pretty severely. On July 15th, there on the side that was most damaged, and was slight cystitis, repal elimination was below passed drainage tubes through the posterior normal and there was some nervous disturb. wall of the vagina surrounding them with ance, evidently due to the removal of the ad. an abundance of gauze. Abscesses in the nexa. Diuretios and powdered ovarian subuterine tissue were freely drained out into stance gave immediate relief. On Sept. 4th, the vagina tbrough the cervix, or by way of the annoyance from heat flashes and frequent gauze and tube drain through Douglas' urination as greatly relieved, she bad gained cul-de-sao. This patient recovered without twenty pounds in weight, and gave every ap. special incident and remains well at the pres. pearance of being in perfect beatlh. ent time, two and a half years after the In view of the history of these cases, und operation. I believed it safer in this case to the conditions found at the time of operaprovide drainage and leave tbe uterus and tion, I have realized with greater force than adnexa badly damaged than to run the risk of ever before what I previously believed, that further spread of septic infection and less. curettement in such cases exposes the patient ened resistanoe of my patient by a heavier to greater dangers and removes no risk operation.

whatever. The greatest danger in the man. In my third case I operated in almost the agement of these cases has seemed to me to identical manner of the second case, except be indiscriminate curettage and failure on

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