PUERPERAL SEPTICEMIA; ITS CAUSE AND

TREATMENT.

BY J. D. CHASON, M.D., IRON CITY, GA.

It has been well said that the best treatment for a disease is its prevention, but despite all our preventive measures that science can bring to bear in our art, we are still called upon to treat puerperal septicemia; hence, owing to limit of time, I only enter into the cause and treatment.

Puerperal septicemia is due to a poison probably produced by microbes. The now well ascertained fact that in almost all cases, by the local use of certain drugs, we can prevent septicemia, and if it has made its appearance most effectually combat it, shows that this disease is due to a poison which enters the genitals as such, or is produced there by a substance coming in from without.

By microscopical examinations of wounds of the genitals caused in the living puerpera is found the peculiar microbe that produces the disease.

We also find the microbe circulating in the blood of the living patient, and after death it may be found in almost all the organs of the great cavities.

Most dangerous of them are said to be the round micrococci in chain-like group.

Chains of micrococci are found in the blood of those suffering from erysipelas, diphtheria, scarlet fever and pyemia. The poison that produces puerperal septicemia may be derived from different sources; such as patients affected with the same disease, patients suffering with suppuration

or decomposition of tissue, or patients affected with zymotic diseases or putrefying substances.

The contagiousness has been proved beyond a doubt by an enormous amount of evidence. The origin by suppuration was pointed out by Semelweiss in 1847, and in this country the case of Dr. Rutter, of Philadelphia, who suffered from ozena and had forty-five cases of puerperal septicemia in his own practice in one year, is one of the most re markable instances of the kind. By close shaving of beard, close cutting of hair, thorough disinfection and change of apparel would not avert septicemia in his patients. Semelweiss showed how the poison in a number of cases was produced by the infection from the hands of students engaged in autopsies. The emanations from the decaying body of a dead rat some years ago was found to be the cause of a small local epidemic that broke out in the New York infant asylum. In the vast majority of cases, the infection takes by absorption through the wounds of the genital canal.

Depaul describes the case of a pupil midwife in the maternity hospital of Paris, who, while washing the genitals of one of her patients suffering from grave puerperal fever, felt instantly an unpleasant sensation, was taken sick on the same evening, and died on the third day with all the symptoms of the most characteristic puerperal fever. A postmortem of the case corroborated the diagnosis, and she was found to be a virgin and not at a menstrual period. Therefore a rational inference is that in this case the poison, gained access by the absorption through the mucous membrane of the lungs. The posion is mostly brought into direct contact with the genitalia by the hands of doctors, midwives, nurses, instruments, sponges, rags, cotton, oakum, or any other material brought into direct contact with the genitals, before, during or immediately after labor.

Unsanitary and unhygienic apartments or surroundings

may quite as well communicate the poison to the puerperal patient that produces infection and oftentimes death. The patient's clothing, her skin, vagina and surrounding parts may be very uncleanly, which would furnish a source for the infection. Patients suffering from venereal diseases of any kind would be highly subject to infection. Lawson Tait, in his admirable work on gynecology, states that most puerperal patients who suffer from gonorrhea in its acute, chronic or latent stage, suffer from puerperal poisoning manifested in some way. In quite a large number of cases it will be found that fragments of membranes or placenta are retained, and especially after abortions.

Retained blood in utero causes the trouble in many instances, developing poisonous properties; also the lochia may develop poisonous properties when the temperature is raised from any cause, such as malaria, etc. Therefore a fair inference is that acute septicemia is caused by absorption of an animal poison evolved from decomposing tissue or lochia.

Whether this evolution is due to micrococci, to chemical or electrical changes, is a secondary matter, except as it influences prevention. If the entrance of micrococci causes the changes, it is logically proper to seal up the vulva with antiseptic dressings, and change them only under spray; but if not we rely upon common cleanliness.

TREATMENT.

I regard a patient with puerperal septicemia in a condition strikingly analogous to that of one bitten by a snake. A poison is introduced into the blood that causes minute changes in the tissues and also produces a sharp shock to the nervous system. The patient may be prostrated by the primary depression. If this can be averted, here, as in snake-bite, the patient will recover, unless the diffuse changes have involved vital organs too deeply.

In puerperal septicemia we must stop the generation and absorption of poison, and if we can do this we need not fear the slight damage done by the poison already absorbed as a rule.

The indications for the treatment in acute septicemia are therefore threefold. First, we stop the generation and absorption of the poison; second, we must neutralize the poison already absorbed by free stimulation, and thirdly, we must increase the action of the excretory organs with a view to the elimination of the poison already absorbed and to prevent the further absorption.

For a stimulant to protect the nervous system against the shock of poison already absorbed, I use good whisky or brandy internally given every one or two hours, just as the emergency of the case in hand requires; also in doses from one half to one ounce, according to the effect produced upon the pulse, temperature, respiration, skin, etc. Patients suffering from genuine acute septic poisoning will tolerate an almost unlimited quantity of stimulants with a beneficial effect producing rest, lowering temperature and increasing activity of skin. The first attention of the physi cian should be directed to the cleansing of the uterus and removing clots, retained fragments of membranous placenta or tissue of whatever character that is acting as a source of infection, and to making the cavity of the uterus antiseptically clean. For the latter purpose an intra-uterine injection should be administered. A fountain syringe is the best instrument for this purpose, though the ordinary rubber ball syringe will do if the former cannot be obtained. I use a large flexible catheter for this purpose, attached to the nozzle of a syringe by means of a piece of rubber tubing, one or two inches in length, then introduce the flexible catheter into the womb. A finger should be kept at the os uteri to see that there is as ready an exit as entrance for the fluid used as a douche.

When injections are greatly needed the os will be found quite open as a rule. The solution first used is a gallon of warm water that has been previously boiled. With this the cavity of the uterus should be thoroughly cleansed. Then use one half-gallon of water previously boiled, rendered antiseptic with bichloride of mercury, 1 to 5000 and 1 drachm of iodoform. I do not use carbolic acid in the douche for intra-uterine injection as a rule,because I regard the use of it somewhat dangerous, as I have seen some very unpleasant symptoms produced by it after intra-uterine douche. In the majority of cases the patient is at once made comfortable, the temperature falls, and what is more important, the ax is laid at the root of the disease. The repetition of the intra-uterine injection depends upon the nature of the case and the effect produced. If we have reason to suspect decomposing fragments inside the uterus, the intra-uterine injection should be used every six hours until all danger has passed. When the poison is due to temporary retention of the lochia, one or two injections will suffice, though vaginal injections should be used several times a day.

Having protected the nervous system against the shock by free stimulation and prevented further generation and absorption of the poison by injections, we should next endeavor to aid the excretory organs in expelling the poison and repair the damage already done to the blood.

Calomel grs. 1, pulv. ipecac gr. 1-4, given every hour for six hours, to be followed by Rochelle salts one hour after, last powder in dram doses, and repeated hourly until bowels have moved freely. Dover's powders may be of service if there is any decided pain, as it would allay pain and produce activity of the skin. If there is any suspicion of malarial poisoning, quinine dissolved in sulphuric acid should be given freely.

In the following case, Julia R., multipara, was deliv