« PreviousContinue »
By a special arrangement with the publishers we are able to offer the following magazines in conjunction with the Medical Fortnightly for one year at an unheard of price. Your order may be either NEW or a RENEWAL, and each publication sent to a different address if desired. The only restrictions are that you must send cash with order and send it at once, as our offer is limited and subject to withdrawal at any time.
Or Variation in Vigor of Treatment, is Secured
Certainly nothing can be so eminently desirable in an instrument of therapeutic value than to have it instantly respond to the will of operator in varying the quality of treatment.
FLUID VIBRATORY APPLICATORS are patented and manufactured exclusively by us. They open a new era in the development of sensitive organs. All fully described in our catalogue. Sent FREE UPON REQUEST.
SAM J. GORMAN & CO., 520 Baltimore Building, CHICAGO.
A careful physician and an honest pharmacist-a strong combination united for the patient's welfare.
THE PHYSICIANS' VIBRAGENITANT is provided with a small lever, against which the index finger rests as the hand grasps the machine. This lever works like a throttle. A slight pressure of finger starts the machine, and a further pressure reduces the length of stroke from 3-16th down to a mere tremor.
Papers for the original department must be contributed exclusively to this magazine, and should be in hand at least one month in advance. French and German articles will be translated free of charge, if accepted.
A liberal number of extra copies will be furnished authors, and
reprints may be obtained at cost, if request accompanies the autoinfection, gives strength to this view
True some of these cases flooded to the point of almost complete exsanguination, and many of them carried putrid placental tissues and membranes for many weeks, occasionally, were quite sick with fever of a moderate degree and an occasional slight chill, but they did not die. I have, in my earlier practice, seen this condition accompanied by a putrid odor that made it almost impossible to remain in the same room with the patient, and yet they recovered.
ST. LOUIS, JANUARY 25, 1906.
Engravings from photographs or pen drawings will be furnished when necessary to elucidate the text. Rejected manuscript will be returned if stamps are enclosed for this purpose.
ALBERT ABRAMS, M. D., San Francisco.
ARTHUR R EDWARDS, M. D., Chicago, Ill.
Mr. REGINALD HARRISON, London, England.
HOBART A. HARE, M. D., Philadelphia.
C. E. RUTH, M. D.
Professor of Surgery, Keokuk Medical College, College of
at term were almost never fatal from sepsis. Leopold's report of 919 puerperal cases not examined, with only two cases of possible
PUERPERAL SEPSIS in abortion and labor at term undoubtedly always existed, though I am convinced that through our pioneer population it was rare compared with the percentage of deliveries. It became a fearful Scourge when in the more populous districts the dirty midwife and almost equally dirty doctor attended most of the cases. With the advent of criminal abortion by instrumentation, self-induced or by a professional abortionist, it became frightfully common, and though a large number died, a larger number were permanently invalided.
While many abortions have occurred, and will occur, from cervical laceration, weakness, subinvolution, falls, etc., I am convinced that fatal sepsis was very rare when digital and instrumental genital manipulations and examinations were not done. In other words, spontaneous, unattended abortions and labors
Read before the Mississippi Valley Medical Association, at Indianapolis, Ind., October 12, 1905.
Why did they not die? Because they were suffering from a toxic influence due to saprophytic germs which could only live and propagate in dead tissues and whose toxines gained entrance into the circulation and produced constitutional symptoms only when drainage was interfered with and they were forced into the circulation; provided with free drainage, these cases always obtained relief whether placental tissues, membranes and detached necrotic decidua were removed, or not.
The profession rightly presumed that the symptoms were produced by the retention of the secundines and began their removal by finger and curette, and if it were done early, very gently, and no additional and more dangerous germs were introduced by dirty hands and instruments, the patient recovered at once. But many of the cases became suddenly very much worse, curettement was repeated more vigorously under the supposition that the former effort was not sufficiently thorough. In many cases, this resulted in a great increase in the intensity of all symptoms and speedy death. In some cases post-mortem proved the uterus to be free of all secundines and with nothing to show the cause of death except evidences of inflammation of the uterus, sometimes some edema and softening of the uterus and periuterine tissues. In other cases, less virulent, the uterus was extensively softened and numerous abscesses had formed in the uterine muscularis or periuterine structures. In the chronic cases, extensive peritoneal adhesions had taken place. Often in the fulminant cases, bloody serum was found in the peritoneum with but slight changes in the uterus or periuterine tissues. The cause in each case was held to be due to too late removal of the placenta. Later, the suspicion began to overtake the profession
that manual and instrumental manipulations were responsible for the introduction of germs which were more virulent than saprophytes, and that could pass through and multiply in living tissues as well as circulate in the blood, destroying the vitality of tissues where massed together, producing abscesses when enough time had elapsed, and in other cases, multiplying in the circulatory system so rapidly as to cause death without pronounced microscopical local changes.
We had not then learned, in fact are just now learning, how to cleanse our hands. When they were cleansed, they were reinfected on the way to the interior of the uterus by the bedding, foul labia, hairs on the vulva, etc. The vagina was known to be its own sterilizer if it had a chance to use its own physiological laboratory, but we were taking it at a disadvantage and planting our cultures where they got in their work to the greatest danger to the patient.
In the best maternity hospitals where preparation, position, attendance and dressing can be perfectly controlled, puerperal sepsis has been almost entirely eliminated. While this is true of perfectly ideal surroundings, some infection will sometimes occur, but more especially where the majority of cases are not and can not be placed in ideal surroundings, but every effort should be made to approximate the ideal as nearly as possible
If the infection be saprophytic, we may expect foul odor in which dead tissues in the interior of the uterus, namely, placental tissues, membranes and detached decidua, are attacked. This must of necessity be local and if the infection remains saprophytic, it will not endanger life and the temperature will not likely go very high. It certainly will not if good drainage is maintained. It is a well-known fact that dead tissues, that is, necrotic fetus, may remain in the uterus indefinitely without infection.
The next degree of severity of infection will result from anerobic bacilli, at the present time the least perfectly understood. In this connection should also be mentioned the bacillus aerogenes capsulatus and bacillus of malignant edema. While saprophytic bacterial infection must attack and live on dead tissues, being unable to invade living tissues, it will not markedly soften or disintegrate the uterine structure. It is in this variety of infection only that clean curettement may be done without danger. The anerobic bacilli may be, in fact are, able to penetrate somewhat into the living tissues and one or two deaths have been attributed to infection of this nature, while streptococci, staphylococci, colon bacilli, bacilli of diphtheria and typhoid can also invade living tissues. Infec
tion with streptococcic germs is especially virulent, but is sometimes mixed with staphy-, lococcus. Examinations of patients in maternity hospitals by Professor Edgar revealed the fact that the upper part of the vagina showed no pyogenic germs. This was true to the entroitus except where germs had been introduced less than forty-eight hours previous. It was found that some pyogenic germs would live four days in the upper vaginal secretions, but in forty per cent of the cases examined by the same author, in the same emergency hospitals, the vulvar canal below the entroitus contained pyogenic germs. It therefore becomes necessary that physicians should not only as thoroughly as possible sterilize their hands, but that external genitalia should also be thoroughly cleaned up to and including the vulvar entroitus before anything is carried high up in the vagina, because of the liability of contamination by pyogenic germs on fingers or instruments. If this be done by every physician with every possible care, there yet remains the possibility of infection by sexual indulgence up to and even including the commencement of labor. If this takes place, there is no question that in some cases it will be the cause of infection in cases otherwise treated by skillful and painstaking obstetricians.
When we have eliminated the two principal pyogenic germs, there yet remains to be considered the greatest scourge and most resistant of all, the diplococcus of gonorrhea, so that, in spite of all care, we will occasionally, because of germs in the vaginal canal viable at the time of labor or introduced by self-examination of the patient, by the hand of the obstetrician or his instruments, come into contact with various infection agencies and we must be prepared to deal intelligently with them and, if possible, exclude the production of uterine and periuterine phlebitis, puerperal metastic pyema, septic pneumonia, septic endocarditis, septic arthritis, phlegmasia alba dolens, pelvic cellulitis, and pelvic peritonitis or perimetritis, as well as the milder saprophytic intoxications involving only dead tissues within the uterus. This form should be called sapremio intoxication, not infection.
Prevention must always be the most important treatment. No instrumentation in any variety of puerperal sepsis should be considered which denudes the uterine mucosa and opens up tissues not in any sense protected from septic infection, the utmost gentleness being used to avoid any possibility of puncturing the softened or disintegrated uterine wall. The curette, I believe, in such cases should never be used, certainly not a small
or sharp one, and then only in the least serious of these cases, namely, saprophytic intoxication which is not sepsis.
The use of antipyretics, which depress the beart action and interfere with the oxygenizing process of the blood, can scarcely ever be indicated, sponging and cold packs, when the temperature runs high, being much safer. Cool or cold water bottles are best of all. The use of antistreptococcic serum, while it acts like magic in some cases, will prove entirely worthless in others, can do no harm, and is, therefore, always indicated.
Streptococcic and staphylococcic puerperal infections have, on the manifestations of symptoms, passed beyond all possible reach of removal by any form of currettage. While curettement can do no good, it may do much harm in disseminating infection, and in uterine perforation. This latter element is important because I have known cases in which perforation of the uterus was done by a man of several years' experience and above the average in ability; by another of very large experience and national reputation, ncted for care in operations and original research, and by five men of international reputation, one of whom had previously declared that the penetration of the uterus with the curette was a crime, and at his next operation of this kind, put the curette through the uterine wall. Within the last two and a half years, I have operated upon four cases of puerperal sepsis illustrating the dangers of curettage. The first was five weeks after delivery in which the uterine wall was honey-combed in every direction on one side, and I could put my finger through without meeting with marked resistance. In this case, I did a complete hysterectomy and lost my patient in three days. A few weeks later, I operated on
a second case and found that I could run my finger through the uterus with great ease. In this case, I removed the adnexa on the side that was most damaged, and passed drainage tubes through the posterior wall of the vagina surrounding them with an abundance of gauze. Abscesses in the uterine tissue were freely drained out into the vagina through the cervix, or by way of gauze and tube drain through Douglas' cul-de-sac. This patient recovered without special incident and remains well at the present time, two and a half years after the operation. I believed it safer in this case to provide drainage and leave the uterus and adnexa badly damaged than to run the risk of further spread of septic infection and lessened resistance of my patient by a heavier operation.
In my third case I operated in almost the identical manner of the second case, except
that the operation was done in stages, owing to the critical condition of the patient. Evacuation was done first through the uterus and vagina by dilating the cervix and pus tracts in the uterine wall. Three weeks later, I made a suprapubic incision and drained through the posterior vaginal vault, as well as above the pubes with through and through drainage, removing the right adnexa, which were suppurating. The uterus in this case, as in previous ones, was readily punctured by the finger. Recovery was tedious but complete now after eighteen months.
In my fourth case, that of Mrs. P. S., aged 36 years, the family history was negative, she had had no serious illness, was the mother of a child born nine years ago, had had two miscarriages, the first one two years ago and the second one four months ago. Her general health was good until the abortion in December, 1904, since then she had not been. well. Locomotion was interfered with from pain and weakness through the lower abdomen. Examination was negative as to heart, lungs and upper abdomen. Her pulse was 96, full, soft and regular; temperaure 99%. Examination revealed cervical and perineal laceration, retroflexion with prolapse of uterus. The uterus was found to be large and tender with preternatural immobility from inflamed exudate about it; the cervix was patulous. I did a curettement, and while carefully cleaning the fundus, the curette passed through the soft uterine tissues into the peritoneal cavity. I repaired the perineum and opened the abdomen, finding the perforation on the anterior portion of the fundus. The ovaries, tubes, bladder and rectum were united in a mass of adhesions with pus sacs and both tubes were dilated with pus an inch in diameter. A complete panhysterectomy was done, recovery was uneventful, though the operation taxed her endurance pretty severely. On July 15th, there was slight cystitis, renal elimination was below normal and there was some nervous disturb. ance, evidently due to the removal of the adnexa. Diuretics and powdered ovarian substance gave immediate relief. On Sept. 4th, the annoyance from heat flashes and frequent urination as greatly relieved, she had gained twenty pounds in weight, and gave every appearance of being in perfect heatlh.
In view of the history of these cases, and the conditions found at the time of operation, I have realized with greater force than ever before what I previously believed, that curettement in such cases exposes the patient to greater dangers and removes no risk whatever. The greatest danger in the management of these cases has seemed to me to be indiscriminate curettage and failure on