The Treatment of Infection Following Abortion,

Miscarriage and Labor.

CHARLES A. MONAGAN, M.D., WATERBURY, CONN.

The ideal treatment for this condition is preventative—the development of a complete, rigid aseptic technique in the management of labor and the puerperium.

Most observers claim the gravid uterus contains no pathogenic microorganisms and many of them claim also that the normal puerperal uterus does not. Therefore, when we have a septic condition present, the infecting material must have been introduced from without-usually either by the hands or instruments of the attendants.

In 1846, when Semmelweiss, a young doctor connected with the Vienna Hospital, observed the striking difference of ten to one in the death rate of two maternity wards in the same hospital, he began to look about for the cause. One ward was conducted by medical students; the other by midwives. He found that medical students often came directly from their work in the dissecting-rooms to the delivery-room. He issued an order that no student should examine a case without first washing his hands in chlorine water, with a result that the mortality fell from 11.4 to 1.27 in a year.

When rubber gloves were introduced and began to be generally adopted, I hoped the solution of the septic infection problem had been found. Their universal use would go far toward bringing an end to sepsis, but, unfortunately, their general use cannot be enforced and those who need them most will not adopt them.

Much may be done by our medical schools in the way of enlarging the practical side of the maternity work. Many of the younger doctors can pass a perfectly satisfactory examination on the theory of asepsis as applied to maternity work, but

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when it comes to the practical carrying out of this knowledge, they are unable to do it.

Every maternity case should receive the same painstaking care in its preparation and management as abdominal section; and, until this is done, we will continue to meet this discouraging and often hopeless condition, and many times when we are fairly certain it is due to the negligence of the attending physician.

When the condition is actually present, the first signs are an increase in the pulse rate and a change in the character of the lochial discharge. This is the best and often the only chance we have to arrest the spread of infection before the system is loaded down with the products of sepsis.

I have come to the conclusion that every case seen early should be curetted with a blunt curette. The operation can do very little harm and certainly seems, sometimes, to work almost miraculously.

The uterus should be emptied under general anæsthesia: washed out with salt solution. If sutures are present in the perenium, they should be removed. Any suppurating areas should be curetted and thoroughly disinfected.

Now, if at any time intrauterine douches may be of service, three or four douches daily for two or three days may be used. It probably does not make any difference which particular antiseptic is used in the douche. After two or three days it is hard to see what useful purpose their use accomplishes, because by this time the poisons are circulating in the system and local treatment cannot reach them.

The employment of antistreptococcic serum has been extensive in recent years, especially in our hospitals. Its results have been rather disappointing, although the remedy is still on trial, and more may come of it.

The prognosis in this grave condition changes very rapidly. Sometimes undue credit is given the remedy last used for the improvement and then we expect too much from it. This is the case, I think, with the employment of antistreptococcic

serum.

The autogenous vaccine treatment of puerperal sepsis was expected to furnish us with an accurate scientific remedy to combat the poison from any particular culture of microörganisms.

Theoretically the treatment should be successful in every case, but so far the results have not, been good, especially in the acute type. In the more chronic type, they may be of greater service, either because the virulence of the infection may not be so great, or because there is more time for the development and employment of the remedy.

The production of a hyperleucocytosis by the employment of nuclein was a method formerly very much used; it failed to arrest the spread of the infection and is not generally used to-day.

The application of the unguentum crede has been advised. I have not seen any good results follow its use; neither have I seen it do any harm. It might be of service in those desperate cases where we must avail ourselves of every means of overcoming the septic poisoning.

The use of ergot is strongly recommended, at least for the first two or three days. It does good by contracting the uterus, thus preventing further infection and expelling blood clots and broken down material from the uterus.

The medical treatment is the ordinary supporting treatment employed in fighting any toxic condition.

Strychnine, from 1-60 to 1-30 of a grain, every six to three hours, depending upon the condition present. Alcohol and digitalis may be employed, especially when the pulse rate is high. The bowels should be opened with calomel and epsom salts. Diarrhoea should not be checked unless it becomes excessive, because this is Nature's method of elimination.

In general, all drugs irritating to the stomach should be avoided, because vomiting is one of the worst conditions to be met with.

The patient's strength can be maintained only by a liberal supply of nutritious food and it is very necessary that the stomach be kept in a condition to properly care for this food.

Milk (peptonized or predigested), peptonoids, eggs, broths, beef juice, etc., should be given as often and in such quantities as the patient can tolerate.

Salt solution, in large quantities, I consider the greatest single means we have with which to combat the inroads of sepsis. The best method for its employment is the drop method (popularized by Murphy), kept up continuously for several days-where one and one-half pints are placed in the reservoir every two hours; this takes from forty to sixty minutes to run out, so that eighteen pints will be absorbed in twenty-four hours. The tube is kept in the rectum the entire twenty-four hours, but the salt solution is running only one-half that time. Sometimes it is impossible to make the patient retain the solution in the rectum. In these cases subcutaneous or venous infusion may be tried. They are of value only in a crisis, because they cannot be repeated often and only a small amount can be used at one time.

The temperature should be controlled by the wet pack-cold sponging-cold bath and abdominal coil. Drugs should not be used.

Pryor advocates opening into Douglass pouch and packing with iodoform gauze. Hysterectomy has been advised in those cases which fail to improve after curettage. It would be of some service in cases where the condition was caused by a suppurating uterine tumor.

In septic peritonitis: multiple incisions-thorough drainage by posture and otherwise-constant use of the rectal saline infusion offer the best means at our disposal.

Trendelenberg has recommended the legation and excision of the pelvic veins to prevent the spread of the disease. The operation itself is so serious and so many cases can get well without it that it would seem better to wait.

Whenever a collection of pus can be located, it should be immediately opened and drained.

Thanks to the teaching of Semmelweiss, and those who succeeded him, we see these cases much less frequently, but of those infected about the same proportion die. We should not