– Puerperal sepsis (R. C. Allen)
In presenting this subject to your attention I do it, first, because it is important, and secondly, that I wish to tell you what I know about the causes, symptoms and treatment of sepsis from my experience.
Many valuable papers upon this matter have been presented and discussed before this honorable body, and as a result of their teachings, we can point to our marvelous success of treatment with cases of sepsis in our practice.
We have cases of sepsis in which it is most difficult to locate the primary lesion, or fix upon a time of its occurrence, or that the lesion is the result of traumatism or of disease of recent or remote origin.
In making a diagnosis of cause we should carefully inquire into the general health of the patient that antedated the recent symptoms of sepsis.
The local conditions which exist to favor absorption of septic toxine are influenced by the state of health of the subject.
Septic matters must have favorable ground in which to grow and to produce effects.
The same conditions that produce dire results in one case are powerless in another case. This must be due entirely to the conditions of general health of the two cases.
The natural efforts of our nature are to ward off destructive influences by building barriers to their introduction.
We see this exemplified in those cases of sepsis from local traumatism, wherein nature limits the spread of sepsis to narrow bounds within the pelvis.
In other cases where the general health is run down, the dynamic force of the local pathogenesis is stronger than the resisting force of nature, then we have a more extensive spread of sepsis through the body.
Scrofula, consumption, erysipelas, and other general dyscrasia are conditions which favor the absorption of sepsis in the post-parturient. Parturition in the earlier periods of gestation, up to the fourth month, also favors the introduction of sepsis, by the failure to establish sufficient drainage.
Although cleanliness, asepsis and antisepsis may have been used, an infection of the uterus frequently happens from certain pathological lesions which are beyond the control of the attending physician.
These pathological lesions may exist during pregnancy, and precipitate sepsis after parturition. The tubes weakened from an old infection may rupture during parturition and then the toxine of pyosalpinx-is absorbed into the blood, or the rupture of a dermoid cyst, or the dissolution of some other tumor situated in the uterus or its appendages. These and others are some of the internal causes which give rise to a virulent sepsis after delivery.
Equally important are the causes which are introduced from the outside, chief of which are the pathogenic toxine placed in the vagina by the unclean examining finger which has recently been in contact with erysipelas or other disease, or the lesions made in the uterine wall by instruments in the hands of abortionists, or by the putrefactive changes of blood-clots in the uterus and vagina, or by pieces of adhering secundines undergoing putrefaction.
The severity of the symptoms depends upon the virulency of the infection absorbed. Especially virulent is the toxine from putrefaction of blood-clots and shreds of decidua.
The third or fourth day after expulsion is the period at which you should give close attention to the patient to discover the beginning of septic symptoms.
A chill is the first symptom that marks the beginning of sepsis, but it may be so slight as to escape detection by the patient.
Anorexia, however, usually precedes the chill, and is an important prognostic symptom of the coming chill.
The chill of sepsis recurs every day, usually in the morning, followed by afternoon fever, mild or severe, and a dry skin that has a peculiar dryness with little heat.
At the beginning the tongue is coated more or less white, with some dryness, an anxious expression soon appears in the face, the pulse is accelerated to a hundred or more, the temperature reaches a hundred and one or two, and the tout ensemble is the typhoid appearance.
As the symptoms progress, the tender spot in the hypogastrium, which marks the location of septic development, increases in hyper-esthesia and revulsion to touch upon the skin surface, and the digital examination per vagina discovers a tender swelling, usually at the top of the vagina behind the cervix.
This tender swelling has a full, round, dough-like resistance, and if easily indented is ready for opening, which is accomplished by an incision at the posterior vault of the vagina close to the cervix.
If, however, the tender swelling in the hypogastrium points prominently, I advise an opening through the skin surface just above Poupart’s ligament. This abscess results from septic infection which has traveled along the Fallopian tube, starts septic peritonitis of the adjacent parts, develops outside of the peritoneum, and points in one of the two places just mentioned.
It is the perimetric or the abscess that you most frequently meet with in septic cases.
When the occasion presents to open the abscess through the skin surface above Poupart’s ligament, a spacious opening is made by cutting through the successive tissues from the skin surface to the peritoneum by strokes of a scalpel. An opening into the abdominal cavity should never be made by pushing the point of a bistoury through the different tissue layers of the abdominal wall.
This injunction is highly important. After the abdominal opening is made and the contents of an abscess has escaped, do not close the opening, but allow it to remain open its entire length. The abscess cavity should first be thoroughly washed by a gentle stream of normal salt-solution and then packed with aseptic gauze for drainage.
A septic abdomen should be treated as an open wound, and free open drainage encouraged.
The open drainage should continue until the internal parts are restored to a normal, healthy condition. When the opening of the abdominal wall is sufficiently long to permit, the muscular and fat layers should be covered by stitching the edges of the peritoneum to the skin surface on both sides of the wound at the time the opening is first made.
Sometimes an abscess burrows down between the folds of the ligament and produces a swelling which is felt at the side of the uterus. The fact that the abscess is limited between the folds of the broad ligament makes no difference to treatment.
If the septic infection starts an inflammation which does not limit itself with an abscess, but continues to spread, the case assumes a serious condition.
I have never had an abscess limited to the vesico-uterine pouch.
To open an abscess in the recto-uterine pouch the crevice should be elevated by a tenaculum and an opening made close to the cervical wall with a pair of sharp-pointed scissors.
The cavity of the emptied abscess is then washed with hot, normal salt-solution by means of a long, narrow irrigator. I would advise against packing an abscess cavity in this locality, as free drainage is usually assured.
The irrigation should continue each day for a few days, when the discharge of pus will discontinue.
After a reasonable time, the opening in the vault of the vagina closes spontaneously.
Septic endometritis, or inflammation of the lining membrane of the cavity of the uterus, may occur after parturition at any period of gestation, but most frequently up to the fourth month.
In these cases the endometrium is thickened and inflamed by the degeneration of pieces of adhered membranes and retained blood-clots in the cavity of the uterus. The symptoms are local at first, and quite amenable to treatment if taken in time. The lochia is foul, the temperature of the vagina is elevated, the pulse increased, chilly feelings now and then, thirst and frequent hemorrhages.
In the proper management of these cases by removing the decaying contents of the uterus the attending physician can prevent the spread of serious complications.
Either the vagina is filled with a large fibrinous blood-clot, or the os cervix is obstructed by a plug of fleshy after-birth, the early removal of which is demanded.
Prompt, effective measures are indicated and success depends upon intelligent, skilful application of the means for relief. As the treatment implies the use of some mechanical measures, I would first suggest the finger as the best curette, with the aid at times of a dull curette, bearing in mind always that it is only necessary to empty the uterus of decomposing matter. In the aggressive use of the curette with forcible removal of attached membranes you break down the barriers which nature has built against the introduction of infection, and you have done harm instead of good to the patient.
To cleanse the vagina and the cavity of the uterus of the decomposed debris, I recommend the normal, hot salt-solution above all other means.
Bring the buttocks of the patient to the edge of the bed, with her feet resting upon chairs, an oil-cloth reaching from the buttocks to a receiving pan on the floor, elevate the retort containing the solution, and then use the uterine douche with skilful manipulations until the parts are clean.
Chronic salpingitis and old lesions of the peritoneum may complicate those cases in which the sepsis has a primary origin in the pathogenic changes of the contents of the uterus, and which I have just termed endometritis.
When the conditions of septic endometritis extend to involve the entire uterine walls, we have a phlebitic state of the muscular tissue. The uterus is enlarged, painful, resistant to touch, with fulness in either vaginal vault indicating a similar condition of the broad ligaments. There is a purulent, blood-stained discharge from the womb, the vagina is hot to the touch, constitutional symptoms are well-marked, rapid pulse, irritable stomach and high temperature – 103 or 104. Don’t curette that case, but give constitutional treatment with the indicated remedy and proper diet, hot-saline vaginal douches, and wait until an abscess forms in either vaginal vault, the indications and treatment of which have already been pointed out.
Some cases of puerperal sepsis pass into a chronic state, with symptoms which have occasional exhibitions of aggravation. The uterus, tubes, ovaries, broad ligaments and peritoneum are in a condition of degeneracy, that a cure by remedial means is beyond hope. The treatment that offers relief is the total removal of the uterus and the entire field of infection.
The surgical treatment which I have described is that which the average physician in general practice is competent to perform, but for those cases which require abdominal section I should advise the employment of a competent surgeon.
Study your cases carefully and attentively, and seek to know when the remedial means need surgical assistance.
A good clinician is appreciated by the profession and respected by his patients.
The spread of puerperal sepsis is checked by the remedial means that stimulates the resisting forces of nature to obstruct and overcome the pathogenic force of the septic toxine. In some cases of sepsis the pathogenesis of the toxine is stronger than the therapeusis of the remedy, then the result of the pathogenesis is the destruction of tissue life, and the formation of abscesses.
Unless the range of therapeusis of the remedial means covers the same pathogenic sphere of the toxine little or no benefit is obtained.
Arsenicum stands at the head of the list of remedies for the successful treatment of puerperal sepsis. The symptoms of sepsis and those of arsenicum are so analagous that many cases require no other remedy. It is efficacious in the first stage of sepsis, with the fever and dry skin; and in the period of collapse, with the cold clammy skin and irritable stomach. The pulse is quick and feeble.
In cases of sepsis in women of nervous temperament, I desire to emphasize the value of Nux vom. Women of nervous or hysterical temperature are quite susceptible to the influences of sepsis.
Their symptoms aggravate and ameliorate to extreme points suddenly from causes slightly apparent. Give Nux.
Some other remedies to use are: Belladonna, Bryonia, Secale, Verat alb., Stramonium and Aconite.
A light liquid diet is preferred. Give plenty of pure cold water. Cold applications to the abdomen – ice bag – are recommended.
H. E. Spalding, M. D.: The importance of the subject of puerperal sepsis has been impressed upon our minds by our experiences, because I believe that nobody who has much obstetrical practice has escaped having cases of puerperal fever. I presented a paper to this honorable body about five years ago on auto-infection. These five years past have impressed upon my mind even more fully that we get many cases of puerperal fever for which the physician is not to blame. I think I then referred to the condition of the alimentary canal, the normal contents of the alimentary canal being allowed to remain in the bowel, and that the secretions of the liver, if allowed to remain in the liver, are harmful, and we often get a poisoned condition. There are pathogenic germs that find their way into the alimentary canal, and they easily find their way thus through the intestines. Also, there are frequently benign tumors within the abdominal cavity, which are perhaps connected to the uterus, a change may take place in them and absorption may result, and we get a septic condition. Endometritis may exist before confinement, and when the patient is delivered we get a systemic infection. Besides that there may be lacerations of the muscles of the pelvis, they may take on a gangrenous condition, and we get sepsis. Now, in the ordinary case of the healthy woman nature has provided against septic infection, leucocytes being abundantly supplied to attack the disease. In the process of delivery the vagina is rinsed out with the liquid amnii, scrubbed out with the child, and finally scrubbed off with the membranes after a flow of germ-sterile blood. Now, aside from this provision of nature against infection, we have tried different ways. First, there is the douche, but that has been given up. I believe they are productive of evil rather than good. We have found in our work in Boston that those cases that are let alone do better than those that are rinsed out with lysol and other antiseptics.
At the present time there is rather a disposition to interfere with the natural process and resort to instruments. I am a strong advocate of forceps when they are necessary, but I believe there is a strong inclination on the part of physicians to apply the forceps too soon in order to save his time.
Another custom which I think is gaining in prevalence more than is warranted, and that is bringing on delivery at the 8th month in order to avoid a hard delivery. I do not know just how prevalent it is, but it is going on to some extent. I have had other cases come to me where the woman died, and I have had other cases where disastrous results followed this violation of nature laws. At 8 months the pelvic joints are not capable of giving as much as they should give. I think the man who does this puts himself in a position of extreme liability to cause trouble and criticism. One case came to me during my service at the maternity hospital. The husband came to the hospital with her, and they brought bag and baggage. She had been advised to have her child delivered at 8 months, as she had had hard labors. I examined her and found a slightly narrowed condition, but no perceptible change from the normal. I advised her to allow pregnancy to go to the natural time of labor, and told her that we would not induce premature labor for her. They went home, and allowed pregnancy to go on, and when the child was born it came so quickly that we hardly had time to get her into the hospital. I speak of this because I want to enter my protest against anything of this kind.
Now, in regard to puerperal sepsis. I have had cases where an opening in the Douglas cul-de-sac may let out the matter and relieve septic infection. But when you have a systemic poison from streptococcus pyogenes, removing the uterus will not help at all. I do not believe it is advisable to attack the case, because I think the woman will die anyway.
Z. T. Miller, M. D.: I wish to make a few remarks upon this subject. I would place as first cause of sepsis, trauma. Next, I think I would place decidua left in the cavity; then we have anaemia and infection. The speaker has also spoken of blood-clot. I doubt if blood-clot causes sepsis unless there is trauma. If we have no trauma we have less absorption. If we have decidua left there we get absorption of poison into the system, and as the last speaker has said, I believe when the case reaches the surgeon it is too late to do anything anyway. If you take it early, before infection spreads, you could do whatever was necessary to save your case. The essayist has spoken of opening the cul-de-sac to relieve the condition. Now it appears to me that if there is any opening at all it should be done earlier. I believe that authorities agree that it is better to open the cul-de-sac and pack with gauze. Some prefer iodoform gauze. The essayist speaks of opening the abdomen, but it seems to me that this would be a very much neglected case.
These cases of sepsis are the kind that we always wish some other man had charge of, and we are apt to think afterward that we might have treated the case differently. Perhaps a great many of them recover. Of course if there is any decidua remaining that should be removed. I believe he has spoken of internal medication I think there is no remedy in the treatment of these cases as good as Arsenicum which he has mentioned.
I wish to say something about temperature. Do not wait for temperature, but watch the pulse. You may get a septic condition without either pulse or temperature showing.
B. G. Clark, M. D.: I want to enter my protest against the curette. I think it is about the meanest thing possible to put in any place.
Another point which has not been touched, and that is, mental emotion. One case I think of had a child before she was married; and on the 10th day her father went into her room, gave her a good talking to, and that girl had the worst case of septicaemia I ever saw. I opened five abscesses on her back and on her hands. I gave Arsenicum and other remedies without any benefit, and on the 6th week and after careful individualization of the case, I decided that it called for Aconite, and that cleared up the case.
R. E. Tomlin, M. D.: I cannot help speaking about this question when I think of the awful complications that arise from these conditions. When I hear such a statement as that made by Dr. Foote – that he had 600 cases, and never had a septic case, it appears, to me that the man who says this is guilty of one of two things – either of ignorance or from willful mis-statement of facts. Dr. Walton made a statement some years ago that all operations are not attended by the best results, and I think he is sufficient authority to give it some attention.
I want to say a word about mid-wives. I think that those brethren who are at the head of the colleges ought to raise a protest in the state boards against the practice of incompetent men and more incompetent women. The matter is to be brought up by the medical society before the Pennsylvania legislature. Some time ago I was called to a case which had been attended by a midwife some two or three days previously. I found her suffering from septicemia. I had her removed to the hospital at once, and she died immediately. It was just like one of the cases mentioned by Dr. Danforth. It is simply impossible to expect results unless we take better precautions. I think one of the greatest difficulties is that we are too careless. I have frequently known of men to attend cases without removing their cuffs, or even with gloves on. There is not one general practitioner in a dozen that can sew up a great tear that goes up to the cervix. They may sew up the outside and they are satisfied, and the infection goes on. Now if some dear brother has a record of 600 cases with such wonderful results I am glad for the sake of women.