THE PREVENTION AND MAN- AGEMENT OF PELVIC IN- FLAMMATION IN PUERPERAL WOMEN. BY HORACE TRACY HANKS, M. D., Professor of Diseases of Women, New-York Post-Graduate School and Hospital; Surgeon to the Woman's Hospital in the State of New York; late President New-York Obstet- rical Society ; late Vice-President New-York Academy of Medicine, and Member American and British Gynaecolog- ical Societies, etc. RMPRINT FROM American Medico-Surgical Bulletin, May, 1893. TO EVERY PHYSICIAN. Dear Doctor: Contributions of Original Thought and Experiences, on Medical Topics, are desired by the A.M.-S. BULLETIN on the following conditions : 1.-Authors of Scientific Papers or Clinical Reports accepted by us will receive-according to their own preference, either: a:-A number of Reprints of their article in neat pamphlet form (pocket size); or, b :-Instead of the above, an Equivalent value therefor in Cash. Please state, with each communication, which is preferred ; and-if Reprints- how many are desired. 2.-All contributions are understood to be received only on the express understanding : a :-That they have not been printed anywhere ; b:-That if they have been read anywhere to an audience, this fact be stated in full detail by a note on the manuscript. Contributors will serve their own interest by heeding the following suggestions: Write Concisely and Clearly. What we desire to print, and what medical men like to read, is information, not verbiage. An article will stand better chances of acceptance, of recognition, and of being widely read and copied and discusse t in Medical circles and Medical journals, the fewer its words are, in proportion to the facts or ideas it embodies. Of course, a thought too thinly clad must suffer. Use, therefore, cheerfully, as many words as appear needed to convey your meaning,- but no more. It is not to be expected that every Medical report should be a mere array of statistical data, hospital records, tabulated figures, or graphic summaries ; some room must be allowed to theory, or even conjecture, in its proper place ; but the true aim of theory should never be left out of sight,-which is, ultimately, to lead to fact; to a rule or result of practice.-And it should be likewise borne in mind that the Medical reader will attach little weight to mere generalizing statements (such as, that a certain remedy or line of treatment has uniformly proved efficacious, etc );-to be con- vinced, he wants to see positive evidences recorded in clinical detail of cases: con- ditions found, course pursued, and results achieved. Aim at Fact, however, that a communication you may be inclined to make would be devoid of Value because you have but little time to spend on writing it! If your thought be a good one to yourself and for your patients' benefit, it will be equally so to your colleagues and their practice, and will be worth communicating. It need not come in the garb of an elaborate Scientific treatise: a simple " Letter to the Editor" will often be just as acceptable. Do Not Fear, Some Rules of Order we should like to have our esteemed Contributors comply with: Do not write on both sides of.the sheet Write as legibly as you conveniently can (names especially so). Leave a liberal margin on the sheet, or space between the lines. (Close writing is not conducive to correct typography ; and what you save in writing material has to be expended a thousandfold by us in eyesight, labor, and expense for printer's corrections.) Address:-P. O. Box, 2535, .New York City. Yours, fraternally. Editor American Medico-Surgical Bulletin. THE PREVENTION AND MANAGEMENT OF PELVIC INFLAMMATION IN PUERPERAL WOMEN.* I.-Importance of the Pyogenic Factors in THE PuERPERIUM. Bv HORACE TRACY HANKS, M.D. IN puerperal women, we have learned from actual post-mortem examination, that the lymphatics and veins are the channels through which sepsis is conveyed to other and even distant organs. This fact accounts for the very various pathological changes which are discovered at the bed- side,-so different from the few pathological changes which follow a deposit of sepsis in the vagina in the non-puerperal woman. In this latter condition, the septic infection is in the gonococci; a vaginitis may follow, probably a cervicitis, possibly an endome- tritis, or a salpingitis ; but generally only these conditions and in this order. Oc- casionally, the sepsis passes into the urethra. If the septic infection is that of syphilis, the * Read before the Obstetrical Section of N. Y. Academy of Medicine, Feb. 23, 1893. immediate local manifestation will be the ulcer, and some of the inflammations of the glandular tissue adjacent. But when the sepsis is filled with the streptococcus pyo- genes, and is deposited on an abraided sur- face in a puerperal woman, a general sep- ticaemia follows. This will be more or less profound, according to the amount of viru- lence of the poison, or the powers of resist- ance of the patient. Because many of our best lying-in asy- lums report less than one per cent of deaths from puerperal diseases, it must not be taken as a fact that no more puerperal diseases have been present. Thanks to the practice of absolute cleanliness, plus the use of ger- micide fluids, the deaths from diseases of the puerperal state are greatly diminished,- and in fact almost eliminated from these in- stitutions. The septic diseases, also, are very infrequent, although not entirely banished. In a recent discussion at the New-York Obstetrical Society, Feb. 7th, a distinguished Fellow argued that, as the death-rate was so small in our lying-in hos- pitals, and as all physicians and nurses in these institutions were obliged to practice antiseptic cleanliness, therefore it proved 2 that all puerperal infection was from with- out, and was always conveyed to the parts by the fingers, linen, instruments, orsponges. " No infection from without, therefore no deaths." This reasoning may be pleasing, but it is not correct. On making inquiry at several of our ma- ternity hospitals, I find that there has been evidence of septicaemia, in a more or less pronounced form, in about 6% of all cases admitted. This is a fact we must not over- look ; for it teaches us that we must watch for and cure these cases of mild sepsis in private practice, as well as in crowded ma- ternities, if we would prevent the more over- whelming attacks of puerperal septicaemia. The general practitioner may, therefore, take courage from these figures. For if, in a maternity hospital, mild cases arise and are cured, so that the mortality is less than 1%, then he must adopt their methods if he wishes the same results. Formerly, the poor patient had to fight this battle with only the aid of debilitating medicines and unsatisfac- tory food, in a miserably ventilated room, often with unchanged bed-linen, reeking with foul odors. I make this statement in order that the general practitioners, who 3 have the charge of the vast majority of all the obstetrical cases, may understand that the lying-in asylums have to fight sepsis. Be- cause there is but one per cent of deaths in the best of these institution •, is far from proving that there is but one per cent of cases requiring extra treatment. There was nearly one in sixteen who had a tempera- ture and pulse above the normal, and who had pain and tenderness and induration in thj pelvic region. These symptoms-in 95% °f puerperal women-mean puerperal septicaemia, or puerperal fever, in a more or less severe type. And, as stated above, they do occur in these model institutions, and they always will occur. But they are treated in a scientific mann r, at the first ons t of threatening symptoms, long before the ] atient is fully under the influence of the infection, which becomes more and more intense as the disease advances ;-as is well illustrated in the cases to be described further on. Rubeska (24 *) has shown that there is a decided change in the septic qualities of the II.-Significance of the Fever Element. *See Bibliography at the end of this paper. lochial discharge whenever any fever is present. When no fever is present, it is al- most free from streptococci. As soon as fever is developed, then the change takes place in the discharge in the vaginal tract; and this condition is not always due to an endometritis, but to fever from other causes, showing that the streptococci develop more rapidly in a temperature of ioo° than in a temperature of only 990. He finds strepto- cocci in all exudates in puerperal peritonitis. Doderlien (21) has demonstrated that there is a healthy and an unhealthy vaginal dis- charge the one of a decidedly acid nature, while the other gives almost an alkaline re- action. Given an abrasion and the presence of an unhealthy discharge, which passes over the traumatism, and a septic fever will follow. Or, given a slight fever from other causes, and the healthy lochial discharge becomes poisonous, even though the odor is unchanged and no infection from without has been permitted. III.-Asepsis the Mainstay of both Prophy- laxis and Treatment. It is not my purpose to discuss all of these several lesions. I only desire to take 5 a few of the more common pelvic inflamma- tions of puerperal origin, and discuss their best methods of treatment; that the general practitioner may be able to pursue his treat- ment of these several conditions on a well- grounded, pathological basis. There was in the not very remote past, a well-established, well-approved, but not successful method of treating all these severe complications as one sui generis disease. "Puerperal Fever" covered the whole list, and the whole list of separate lesions was wonderfully small. All of these conditions were treated, at that time, with opium and depleting medicines, and hot fomentations of turpen- tine, with more or less regularity. Since the germ theory of disease has been so unani- mously accepted, and since the pathologists have found an attentive pupil in the general practitioner, we have completely changed our methods of treatment of the puerperal state. We are now as anxious to keep the uterus and the vagina absolutely free from sepsis and putrefactive changes, as our early teachers were to cover the abdomen with poultices, or to deaden the pain and check the diarrhoea with opium. To this end we, to-day, use the curette, or curette forceps, in 6 the uterine cavity, and intra-uterine irrigation and the vaginal douche, as each case de- mands ; and seek by all means to remove all possible foci in which the streptococcus pyogenes rapidly multiplies. We never ap- proach the bedside of our patient without be- ing absolutely sure that our fingers, our hands, our instruments, our ointments, our linen, and everything which is to come in contact with our patient's genital tract, is absolutely aseptic. Asepsis, by whatever means attained, is the watchword which must never be forgotten, if one's best results are to be reached, in surgery or obstetrics. Those of us who have been trained in gynaecology and abdominal surgery, and are often called upon as consultants in puer- peral cases, have not failed to see in what variety of organs the septicaemic poison is lodged, when it has left its first point of at- tack. We have seen, too, how our oper- ations, when performed during the puerperal period, are constantly liable to prove failures, owing to a chemical change in the blood, due to direct infection from without, or with- in. The many failures in the attempts at restoring lacerated perinaei, when performed on the second or third day, fully illustrate 7 this point. The knowledge that there can be development of poison in one organ, from the discharge of a latent or chronic disease in another organ, and that the puer- peral woman must, necessarily, be liable to have fissures and abrasions in the genital tract, and that the diseases of this period are additionally severe because of the de- praved condition of the blood and the high tension of the nervous system,-has led the pathologist, the gynaecologist, and the gen- eral obstetrician, to carefully study these lesions, and to arrive at some very definite and satisfactory conclusions as to treatment. We have thus learned that if we are to cure puerperal septicaemia, we must prevent the general dissemination of puerperal sepsis. To do this, we must find its place of origin early, and prevent the possibility of more sepsis being developed in this locality. IV. -The Etiology of Septicemia. The question as to just how the infection enters the body of the patient, is a very in- teresting and a very important one. But the limits of this paper will not allow its satisfactory discussion. Suffice it for me to say at this time, that in a majority of cases we can trace the infection to some patient 8 who has but just had the disease. But I am equally as certain as all the old authors are, that there is air auto-infection in a small per- centage of cases. I believe some women will have a mild form of puerperal septicae- mia, even if no hand is introduced into the vagina, and no sepsis is allowed to pass the antiseptic gauze-pad. The following has often been demonstrated : Given an abra- sion of the finger, given lochial dis- charge, vaccinate the one with the other, and a mild septicaemia, or lymphangitis, may result. The disease will vary, of course, as the quantity and quality of the sepsis varies. It is possible for pus to be found in closed cavities, and in large solid organs, appar- ently as the result of a pressure or a blow, when no infection of a like character has been present from without, to act as the exciting cause. If a latent catarrhal, or purulent salpingitis is present before con- ception, and this condition is aggravated by a possible direct injury from pressure, or contusion during the delivery of the child, causing a tearing-up of adhesions,--an ex- cessive discharge is sure to follow. When this discharge passes over an abraded sur- face, which is filled with lymphatics, and is an entirely different tissue from that in which 9 the discharge originated, it is capable of causing, and most liable to excite, a more or less severe form of septicaemia. Dela- field and Prudden give in a very few words the most that is known of the lesions of pueperal fever. I quote their conclusions : "As a result of some injury to the "uterus or vagina during or after the "labor, and the action of some infectious "material which may gain access to "these tissues, the puerperal uterus is "liable to become the seat of severe and "often destructive inflammatory and "necrotic changes. These may be con- "fined to the uterus; they may induce "serious alterations in the surrounding "parts; they may lead to an involvement "of the peritonaeum, or to pyaemia "and its accompanying lesions in the "most distant parts of the body. In one " series of cases, a more or less gangren- "ous inflammation of the mucous mem- " brane, and the underlying parts, may "lead to a casting-off of larger or smaller "shreds of necrotic tissue, and the for- " mation of deep and spreading ulcers, "which may be accompanied by severe 10 " parametritis and fatal peritonitis. This "condition may be due to injury, or to "the presence of decomposing portions "of retained placenta. In other cases " the inflammation has a croupous char- " acter, which may affect the vagina and "lead to necrosis and gangrene, ulcer- " ation and peritonitis. In connection "with either of the above forms of in- " flammation, or without them, there may "be thrombosis of the uterine sinuses, ' purulent inflammation of the veins, " suppuration and abscess in the uterine "wall, suppurative inflammation of the "ovaries and tubes; and, owing to the " generalization of the infectious material, "metastatic abscesses in the lungs, "spleen, kidneys, etc.; or, acute pleurisy, " ulcerative endocarditis, purulent in- " flammation of the joints, hyperplastic "swelling of the spleen and lymph-nodes, "may furnish characteristic features of "the presence of an acute infectious dis- " ease. In some cases which pass "rapidly to a fatal termination, the local "lesions may be but slightly marked, and "the general alterations characteristic of "pyaemia, such as metastatic abscesses, 11 " etc., be entirely wanting. Life seems "to be overcome by an acute septic in- "toxication. Micrococci are very con- "stantly present in the exudation, in the " lymph-vessels, veins, and inflamed tis- " sues of the uterus; often in enormous "quantities in the peritoneeal exudation ; "and in the metastatic inflammatory "foci. There is good reason for believing "that the destructive local processes are "due, in the majority of cases, to the "presence of the streptococcus pyogenes ; "and that the general infection is depend- "ent upon the same cause." V.-Classification of the Principal Puerpe- ral Lesions. I shall briefly call your attention to a few of the more common lesions which may be present in the puerperal state. And we may find it convenient to consider them in the order here mentioned. A. We find a Lacerated Perinceum and Floor of the Vagina, as the field which allows of sepsis entering the body. I need not cite cases, for we have all seen them. The treatment should be, therefore, to close all lacerations in the perinseum and vagina, 12 primarily. If called to the case after fever is present, such an operation will fail. We should therefore, in these cases, cauterize the parts thoroughly, or cover them carefully with aristol, bismuth, iodoform, or iodole. If the nurse is trained or intelligent, and can be trusted, order her to do this regularly, observ- ing absolute cleanliness.-Saline laxatives and sustaining medicines should be given. B. A Lacerated Cervix is another very com- mon lesion, and one which in itself causes a slight rise of temperature. [Hance (i).] If this lacerated surface is allowed to rest in a pool of blood and debris, on the injured floor of the vagina, there will most certainly be a septicaemia more or less profound. We should carefully examine for this lesion when it is feared, and before the danger- signals are displayed. The tear should be restored at once, if of alarming proportions; but if only discovered later, then first keep the vagina aseptic by frequent antiseptic irrigations; cauterize the wounded lips if they gap excessively, and place sterilized plain, or sterilized iodoform gauze around the cervix, carefully and methodically. Irrigate the vagina often, and dry thoroughly ; and give saline laxatives and stimulants freely. 13 c. Acute Puerperal Endometritis is a very common form of puerperal disease. The source of the infection we may not always discover at once, but it seems to develop generally at, or near, the site of the placenta, or from retention of some portion of the placenta. The most decided and putrefac- tive changes take place in the endometrium in a very few hours when the disease is de- veloped. The putrefactive odor is quite characteristic. But we must remember that it is often absent. By irrigating with a germicide fluid, and using the curette for- ceps of Emmett, or a Sims's sharp curette -the thickened, dark-red necrotic tissue removed, gives evidence that the disease is spending its force primarily in the uter- ine cavity. The wonderful results of in- tra-uterine irrigation in puerperal fever, as taught by Thomas (13), led many obstetricians to suppose that in the uterine cavity would be found the only field for the septic deposit. And thus other lesions have often been overlooked, and the uterine cav- ity has been unmercifully irrigated when it was not the offending body at all. The diagnosis of puerperal endometritis can be made with great certainty. To do this, irrigate the vagina first, and the uterine 14 cavity second, with a 1-4000 solution of bi- chloride, or a 1% per cent of creolin ; then introduce the Emmett curette forceps, while the patient lies on the edge of the bed or table, and remove every shred of endome- trium which is easily caught in the jaws of the forceps. Then irrigate again with a germicide fluid, either bi-chloride 1-6000, or a full-strength per-oxide of hydrogen. The character of the debris will confirm your diagnosis. A Sims's sharp curette will certainly [Grandin (8)] be required if placental tissue is present and firmly attached. The irriga- tion of this cavity should be resorted to again, if the pulse and temperature are high and continue high. A full-strength per-oxide of hydrogen should also be used,-throwing it in very slowly but thoroughly. Often, one thorough application will be sufficient. But each case must be treated as the symp- toms indicate, and no one law is applicable to any two cases. If the patient is pro- foundly septic, the uterus large, and the cervix resting on the floor of the vagina,- after irrigating, and curetting with Emmett's forceps, and again irrigating, pack the uter- ine cavity with sterilized iodoform or plain 15 gauze. This treatment can be done much more easily than one would suppose who has never tried it. Place the patient in a good light and in Sims's position ; and, with Sims's speculum, the cervix can be reached easily, and held firmly with a common tenaculum, and the gauze crowded in with forceps or sound, either with or without a Polk uterine speculum. We are now able to save some of the most desperate cases by adopting this plan (see io, 8, 9, 14, 13). The disease which to-day may have been in the uterine cavity, may to-morrow have passed along the lymphatics, and be the focus of a phlegmon, soon to end in sup- puration. We should never rest easy if we find after a puerperal endometritis, that an exudation, or an induration, has appeared un- der either broad ligament, or in the perito- naea! cavity. We must prevent more sepsis being sent out from the uterine cavity, or w.e will not succeed in stopping the devel- opment of these phlegma and exudations. Destroy the poison whenever found, and before it enters in great quantity into the circulation. (24). Stimulate all these pa- tients ; feed them generously with easily digested food; change the bed often ; and 16 change the room whenever a better one can be secured. The nurse must be intelligent, and must not be overworked. I could re- late very many most interesting cases to il- lustrate this type of puerperal disease. We have all seen them. D. *Puerper al P' erimetritis is quite a different dis- ease-to diagnose and to treat-from the more simple and less pronounced salpingitis, or ovaritis, in the non-puerperal woman. The point of entrance, and the cause of the sepsis, do not correspond in the two. The fever is of a more intense and alarming type in the puerperal cases ; and the danger of other and more distant organs becoming affected is much more imminent. In puerperal peri- metritis the sepsis may have reached the circulation via the lymphatics located in a ruptured perinaeum, or a lacerated floor of the vagina, or a lacerated cervix, or from the endometrium, when the site of the pla- centa was not left in a perfectly normal state, or when some tufts of the placenta were left to decompose, thus to cause an endometritis. From whatever site the sep- sis has entered,-if the inflammation ex- tends either by contiguity, or by absorption, to the perimetrium, we do not always find 17 the tubes diseased first. But a phlegmon may develop under, or in the broad liga- ment on either side. Exudation will follow in the immediate neighborhood in the ab- dominal cavity. Nature quickly throws up her breastworks here, to prevent the threat- ened pus-sac from rupturing into the perito- nacal cavity. When this condition exists, considerable and constant fever will be present. If the disease progresses, in a short time the exudation and induration will have reached the abdominal wall just above Poupart's ligament. Or if the inflammation has been so intense as to result early in suppuration, this pus will have dissected upwards, or burrowed downwards, in the direction of the least resistance. And some- times we may find the pouting and fluctua- tion in the vagina. When the pus-sac approaches the abdominal wall near Pou- part's ligament, as it often does, there will be all the objective and subjective symp- toms of exudation and induration in this locality, and later, as positive symptoms of pus. A tumefaction will be felt, tightly ad- herent to the broad ligament. It will be found to completely occupy the space in the lower pelvis, from Poupart's ligament 18 to the cellular tissue on the right, or left, of the uterus, near the internal os. The tumor will be firmly attached to the anterior pelvic wall on one side, rendering it impos- sible to pass the finger from below up to- wards the ligament. Nature here com- pletely shuts off the abdominal cavity by her exudations, and the pus-sac can be easily and safely reached by opening just above Poupart's ligament,-using first the aspirating needle, then the bistoury; fol- lowed by irrigation with a germicide fluid and gauze packing. I have pursued this course in the Woman's Hospital and in private practice. CASE OF PUERPERAL PERIMETRITIS CURED BY TWO MONTHS' TREATMENT. Mrs. M. W. entered the Woman's Hospital in my service, March 21st, '92. U. S., 24 yrs.; one child, 11 days previous to admission. Complained of great pain in abdomen, and fever. Physical examination revealed some lochial discharge from vagina, not foetid. Uterus 5 inches [12% cm.]. Exudation to right of uterus, involving broad ligament and tube and ovary. No fluctuation. Pulse 100, Temp. 100 [37.8 C]. Bowels consti- pated. Ordered saline laxatives, hot rectal douches of plain water daily, and hot va- 19 ginal douches of i :4ooo bi-chloride every six hours. Tonic doses of quinine, and generous fluid diet; with stimulants p. r. n. This treatment, with slight variations, was continued until April 28th. Patient mens- struated April 13th, and was discharged, cured, May 10th. Of this class of cases could be added a vast number of examples, were it necessary. But all of us, who have been obstetricians before we became gynaecologists and ab- dominal surgeons, know that only in excep- tional cases does the abdomen need to be opened to cure this disease. E. Puerperal Abscesses in the Perimetrium, which develop towards the abdominal cavity, can be generally diagnosed, if the patient is thoroughly anaesthetized be- fore the bi-manual examination is made. These cases are far more dangerous, and must not be mistaken for the type just mentioned, where Nature will often evacuate the pus-sac almost unaided, by forming an abs- cess above Poupart's ligament, or by a spontaneous rupture into the vagina. If the type of fever is characteristic of that from a pus-sac, if the growth is in the 20 direction of the abdominal cavity, if the bulg- ing can be felt in the pelvic cavity-then open the abdomen, aspirate and irrigate the pus cavity. Then pack with gauze after the Mikulicz method. If the base of the sac is low down in the pouch of Douglas, as is often the case,-make a counter-opening into the vagina, then pack and drain through this channel, -as I have often practiced and have described on another occasion (26). An anaesthetic must be given in all these cases. No correct idea can possibly be formed of the location and size of the pus-sac, or exudate, until the abdominal muscles are relaxed under ether narcosis. CASE I. Puerperal inflammation resulting in ab- scess, and haematosalpinx. Mrs. B. entered my service in the Woman's Hospital, No- vember, 1890. Born in Ireland, aged 32, multipara; was delivered of a healthy child ten days before. On admission she had a temperature of 101 [38.3 C], pulse no; pain and swelling in lower pelvis; uterus four and a half inches [11 cm.] in depth. Ordered antiseptic vaginal douches, saline laxatives, tonic doses of quinine, nourishing fluid food. General condition 21 improved for twenty days. December 14th, she had great pam, which was followed by a decided chill, sweating and fever. Temp. 106+ [41.1+C] for twenty hours. Ice coil used and morphine given. Fever finally subsided, and patient was again comfortable for nearly a month. Tem- perature and pulse, however, remained above normal. Another rigor and fever on Feb. 9th, even more pronounced than the first. This convinced the patient that she ought to allow me to perform the surgical operation, which I had recommended Dec. 15th. Accordingly, on Feb. 12th, I did a coelio- tomy, and found and emptied an eight- oz. pus-sac, springing-up from the right broad ligament, crowding against the uterus on this side, and firmly adherent to the ovary and tube. On the opposite side, a hsematosalpinx was found and removed. After thorough irrigation with sterilized hot water, a Mikulicz gauze-packing was firmly introduced in the site of the pus-sac. The drainage gauze was removed thirty hours after operation, and a small glass tube inserted and retained for four days more. A perfectly satisfactory recovery followed. 22 Patient reported one year later, as enjoy- ing good health. Similar successful cases have been re- ported by Maury (4), Price (5), Evans (18), Murphy (16), Outerbridge (27), Charpentu (28), and many others. I add another case which has lately been under my care, but in which death resulted. It illustrates a very important type of the perimetritic puerperal disease. We are never sure where the pus is to be found in these patients, when the pus does not point to- ward the vagina, or the pelvic cavity, or the abdominal wall. But-when exudation is dense and general around the uterus-that there is pus, it is fair to infer, if all the sub- jective symptoms are gradually growing more severe. If the average temperature, pulse, and respiration increase daily, the chills become more frequent, the perspira- tion more profuse, the facies more anxious, -even though there is no softening nor fluctuation in the dense perimetric exudation, -the wise abdominal surgeon will not allow the patient to die until he has used the aspirating needle in the vagina, or over the brim of the pelvis above Poupart's ligament, or until he has opened the abdomen and sought thoroughly for the 23 pus-cavity. However difficult this may often be, it is the only course to pursue in such cases. I therefore add this case ; for at the au- topsy we learned that had I used the aspir- ating-needle more freely, varying its direc- tion, even but one-fifth of an inch, I would have reached a pus-cavity, and relieved the patient for the time. I am indebted to Dr. Mallet, one of the house-staff, for the notes ; and, as the condition found is so interesting, I will insert the notes in full. Mrs. K. P., age 34, married twelve years. Admitted Jan. 7th. First menses at 14. Regular; type 30 days, flow 2-4 days; quantity and character of flow, normal ; cramps before flow. 6 children. Confine- ments and labors tedious, never instrumen- tal. Five abortions. Two since last child. Never followed by any trouble, however. Present complaint:-Dec. 12th, patient had cramps, followed by flowing. Flowed for a week (clots). Then passed sac filled with fluid (Ovum P). Patient then got up. The second day following, had a severe chill. This was followed by severe pain in the right side and hip. Jan. 1st, had -CASE II. 24 another chill. After first chill, flowing stopped rapidly, and patient has been con- fined to bed ever since. Now has consider- able pain in the side. Her physician attends her daily. Urine : Red, alkaline, 1022, large amount of albumin ; sediment: blood- cells, urates, pus-cells. Diagnosis.-Jan. 7th, (Dr. Hanks).-Pa- tient had miscarriage and now has probably a pyosalpinx (puerperal). Douches ordered, per vaginam and per rectum ; stimulants and opiates p. r. n. Jan. 8th. Patient's temperature reached 103.5 [39-7 C] last night. Jan. 13th. Dr. Hanks, H. S.: ether ex- amination -Uterus to left. Large mass on right, which did not seem soft enough to drain, but probably will turn out to be an abscess. Uterus dilated and explored. Uterine forceps did not bring away anything but a few blood-clots. No odor about the dis- charge. Application, to uterus, of carbolic acid and glycerin, aa ; cavity packed with gauze. Jan. 14th. Temp, varies from ioo° to 100.40; Pulse 102 to 115. Stimulated. Jan. 15th. Temp, from ioo° to 1020 [37.8 -38.9 C]. Pulse 102 to 110. 25 Patient continued with about the same temp, and pulse until Jan. 25th. Seen by Drs. Cleveland and B. Emmett, who advised exploration. Patient under ether. Mass punctured per vaginam with aspirating needle; negative result. Vagina packed with iodoform gauze. An incision was then made into abdomen, usual position. Omen- tum fully one inch thick. The intestines were so matted together that it was impos- sible to explore pelvis thoroughly. Small mass seen on the right side, punctured with negative result. Pelvis packed with iodoform gauze, with portion protruding from abdominal incision for drainage ; the abdominal incision was closed with catgut. Her temperature reached 109.5 [43+C] on Jan. 27th, at 11:40; and she died ten minutes later. Cause of death : (1) Obstruction of the bowels. (2) General peritonitis. REPORT OF POST-MORTEM EXAMINATION : Abdominal Cavity : Operation wound in anterior walls. Omentum congested and greatly thickened ; the lower end is adherent to both sides of the abdominal cavity, and to the uterus. General peritonitis. 26 Small Intestines : Congested, and cov- ered with fresh exudates. Adherent to the omentum in many places. Pelvic Cavity : All the contents of the pelvic cavity are matted together into a mass by old inflammatory material. The lower end of the omentum-very much thickened is adherent to the fundus of the uterus and to the right side of the sigmoid flexure, which is drawn over to the left side and firmly adherent to the pelvic wall. The omentum finally merges into a mass of thick tissue representing the left broad ligament. On the right side of the uterus, imbedded in a mass of thick tissue, is a small suppurating cyst of the ovary. From the bottom of this cyst issues a moderately broad sinus, which passes behind the uterus, reaching to the bottom of Douglas's pouch, then, turning upward, passes along the left and posterior border of the uterus, and communicates with a small abscess between the folds of the thickened broad ligament, close to the body of the uterus. Through the upper part of this abscess passes the Fallopian tube, the fimbriated end of which is lost in the thick tissue. External, and a little below this abscess, is the left ovary, reduced to a sac 27 of pus, oval in shape, and measuring iXX inch [2XX1cm.]. The above sinus, as it passes in front of the rectum, has thinned its walls ; but no communication between them could be detected. F. In another class of cases, the inflamma- tion seems to be in one or the other broad ligament; and because the locality of the pus-formation is between the folds of the broad ligament, Nature throws up her breastworks in the form of firm exudations on the upper layer of the broad ligament, to prevent the entrance of the pus foe from below. And, therefore, it pushes its course in the direction of the least resist- ance, and approaches the vagina, into which, if assisted, it may rupture, or it may dissect still further backwards and downwards, and finally rupture into the rectum. Whenever a pus-sac can be de- tected pouting into the vagina, and with no evidence of there being a movable tumor in the pelvic cavity, (and this important fact can almost always be positively determined when the patient is under ether narcosis)- then open through the vagina. Open with an Emmett trocar, or with a bistoury, and in- 28 troduce the finger and break the necro- tic tissue, and thoroughly irrigate with a germicide fluid, placing a cross rubber drainage-tube; or thoroughly pack the cavity with iodoform gauze. I believe that the vast majority of pelvic abscesses of this character are of puerperal origin, and the general practitioner needs the help of the skilled gynaecologist in this class of cases quite as much as any other. We ought to be willing to use the aspirating-needle early, if the bad symptoms develop early. will illustrate:-Mrs. K., sent into my service at the Woman's Hospital, by Dr. Banta, December, 1891. She had miscarried a few weeks before. A large fluctuating tumor was distinctly felt, pressing down- wards from the left broad ligament. On making a rectal examination, the tumor ruptured into the rectum, and a full pint of foetid pus was expelled. The patient was at once relieved; but on Jan. 9th, following, the tumor had refilled, and she was placed in the cottage for septic cases. While under ether, the uterine artery was located; and an Emmett trocar was introduced, the pus evacuated, the sinus stretched, and a rubber ONE CASE 29 tube inserted and fastened in situ by two silver-wire sutures. Frequent irrigation with antiseptic fluids was followed by steady improvement ; and in four weeks the tube was removed, and she was dis- charged cured on Feb. 2nd, 1892. G. In another class of cases there seems to be a general intoxication from the puerperal poison, which does not abate, and which is attended with a fever in which the ave- rage temperature and the average pulse increase from day to day, and in which the abdomen is often enormously distended, but where no marked exudation can be felt, and positively no fluctuation under either broad ligament can be discovered. In this class of cases, after the uterus has been thor- oughly disinfected and the bowels unloaded with saline laxatives, I believe the wise abdominal surgeon should operate at once. The results thus far have not been encour- aging : but a few patients have lived. (See 4, 5, 22, ii, 16, 17, 15.) If we could have had the patients placed early in a fresh clean room with an experienced nurse, and given them the same surround- ings as we do other cases of abdominal 30 surgery, our results would have been dif- ferent. These cases of puerperal peritoni- tis are not unusual, but are almost surely fatal if left alone. I have been called to see two cases of this character in one day; and, in both cases, I believe, death resulted from the accumulation of pus in the abdominal cavity. Had I been permitted to open the abdomen of each, early, I would have given them their only chance of recovery. A successful case has been reported by Moore (17), where 6 pints of pus were found in the abdominal cavity. Patient recovered. Another case has been reported by Evans (18). His patient recovered. Several of our own Fellows have had recoveries after operating for puerperal purulent peritonitis. Price (5) reports the following interesting cases : -CASE I. Mrs. B., aged 28. Seen five weeks after labor. High temperature; rapid pulse; rapid progressive emaciation ; profound sepsis.-Abdominal section revealed : thick- ened omentum, adherent over entire pel- vis ; right pyosalpinx; and abscess, the size of an orange, in the ovary ; universal ad- hesions ; six inches of ileum cheesy and dis- 31 organized, to the mucous coat along the line of adhesion on the right side. A knuckle of bowel was opened in enucleating the appendages; it was trimmed and stitched ; there was purulent peritonitis, and one pint of pus free in pelvis, from leakage. Appendages removed ; cavity irrigated and drained. Recovery. Mrs. M., aged twenty-four, seen twenty- one days after labor.-Abdominal section showed : acute puerperal pyosalpinx on the left side, and general purulent peritonitis ; bowel, omentum, and pelvic organs matted together by friable adhesions; left tube gangrenous; right tube congested, but showed no evidence of pus. Only the left tube removed ; irrigation and drainage. Recovery. ■CASE II. H. Puerperal Pyosalpinx is not so common as we would suppose, when we consider the frequency of the disease in the non-puer- peral state. There is no doubt, however, that the tubes are the offending bodies in a certain number of patients. I recall a recent case when a woman who had all the symptoms of a pyosalpinx, after 32 nearly a year of treatment became pregnant; and twenty hours after the delivery of her child she experienced intense pain in the old locality. Symptoms of a puerperal inflammation in the immediate neighbor- hood rapidly developed. Pus was poured out into the uterus, and this organ had to be irrigated frequently, and on two occa- sions, packed with iodoform gauze. So long as the irrigation evidenced that the proxi- mal end of the tube was open, she con- tinued with a temperature below 103^ [39-7 C]- No operation was allowed, how- ever; and on the eighteenth day she de- veloped pneumonia, and died on the twentieth day after delivery. An operation would have given her a better chance for recovery. If pus-tubes are believed to be pre- sent in puerperal women, the abdomen should be opened, the same as for the removal of the pus-tubes in the non-puerperal woman. These cases ought to recover; and the most of us can report successful results. I have in this short paper been obliged to omit many important subjects. I have only tried to give, from the standpoint of the pro- General Conclusions. 33 gressive gynaecologist, some practical hints to the obstetrician, on the more common lesions of the puerperal state. I believe the judicious obstetrician-the obstetrician of the future-by using proper means of prevention, can and will avoid the necessity of treating, much less of operating for, many of the lesions which I have briefly described. He can do this in almost every case, by having a clean patient in a clean bed, by making the vagina aseptic, by using a germicide douche ; if there has been an irritating vaginal discharge, by mak- ing few examinations, and by always hav- ing the hands and instruments aseptic ; by a most careful and methodical examina- tion of the placenta and membranes, that nothing can possibly be allowed to remain which should come away (see Lusk, New York Journal of Gynaecology, 1891); by re- pairing all lacerations of the vagina al once, under aseptic conditions ; by using germicide vaginal douches if there is a bad cervical laceration; by cauterizing the lacerated perinseum, vagina, and cervix-if called first after a slight septic fever has developed. I believe that, by following such rules, and by keeping the patient's bowels thoroughly 34 loose, a vast majority of women will escape puerperal inflammations and their frequent and natural result, viz.: the formation of pus- cavities. But when, notwithstanding such precau- tions, or without any of them, there is positive evidence, so far as subjective and objective symptoms can give positive evidence, of the formation of pus, we are justified in operating on these puerperal women, even though the results are not as promising as in non-puerperal women. Bibliography. I. Hance.-Amer. Journal Obst.; No. 3, 1891. 2. Delafield & Prudden.-11 Pathology," last edition. 3. Lusk.-"On the Nature, Origin, and Prevent- ion of Puerperal Fever."-Reprint, 1877. 4. Maury.-"Indications for Laparotomy in Puerperal Fever." Trans. Am. Gyn. Soc.; 1891. 5. Price- Med. News ; Aug. 9th, 1892. 6. Montgomery.- Trans. Med. Soc. Pennsylvania; 1891. 7. Dorr.-Archives Gyn. (N. Y.) ; 1891. 8. Grandin.-N. Y. Medical Journal; Feb. 16th, 1889. 9. POLK.- Transactions N. Y. Obstetrical Society ; 1892. IO. Charrier.-Archives Generales de Medicine ; Pans. 35 ii. Oliver.-British Gyn. Journal; November, 1891. 12. Ricketts. - Cincinnati Lancet-Clinic; June 20th, 1891. 13. Thomas.-"Treatment of Women in the Puerperal State."-Reprint. 14. Van Ramdohr.-Am. Journal Gynaecology ; 1892. 15. Rhett.-Am. Journal Obstetrics ; 1892, Aug., p. 208. 16. Murphy.-British Medical Journal; April, 1891. 17. Moore.-Australian Med. Journal; April, 1891. 18. Evans.-Annals of Gyncecology and Pcediatry ; September, 1891. 19. Pryor.-Am. Journal Obstet.; July, 1892. 20. Sleigh.-Am. Journal Obstet.; August, 1891. 21. Doderlein.-Reprint. Leipsic ; 1892. 22. Evans.-Med. Record ; April 12th, 1890. 23 Walker.-St. Louis Med. Mirror; August 1891. 24. Rubeska.-Oestr.-Ungar. Centralblatt fur die Medicinischen Wissenschafte'n ; Vienna. 25. Duke.-Provincial Med. Journal; November 1891. 26. Hanks.-"Drainage, etc., etc."-Post-Grad- uate; 1893, May. 27. Outerbridge. - Trans. N. Y. Obstetrical Society; 1892, pp. 444-5. 28. Charpentu.-Med. Press and Circular ; Sept. 25th, 1888. New York City ; 766 Madison Ave. 36 .gfc<£**ify^^,03ys^ OflTOuwnyi *Wf AJaaa^e^^.^^ TK£ BULLETINpa&USBIN6 COMPANY OF NEW YOAK, ■"■"■' NEW YORK, U.S.A. EDITORIAL STAFF. WILLIAM HENRY PORTER, M.D., GUSTAV MULLER, Chief Editor and Department of Gen- Associate Editor, eral Medicine and Pathology. T RJppLg M D SAMUEL LLOYD, M.D., Department of Obstetrics, Gynaecology Department of Surgery. and pediatrics. ' WILLIAM FANKHAUSER, M.D., H. BAILLON, M.D., Paris, Department of Materia Medica and Foreign Department. Therapeutics. ANGELO ZUCCARELLI, M.D., Naples ADOLPH ZEH, M.D., Foreign Departmeat. Pathology and General Medicine. ADOLPH BARON, M.D , WILLIAM C. GUIH, M.D., Diseases of Children. Pathology and General Medicine. VENTURA FUENTES, M.D., GEORGE G. VAN SCHAICK, M.D., General Medicine. Pathology and Clinical Medicine. FREDERICK PETERSON, M.D., W. TRAVIS GIBB, M.D., XT , .. , , . _ , Nervous and Mental Diseases. Gynaecology. GUSTAV A. KLETZSCH, M.D., T' HALSTED MYERS, M.D., Gynaecology. Orthopaedic Surgery. J. CLIFTON EDGAR, M.D., GEORGE THOMAS JACKSON, M.D., Obstetrical Surgery. Dermatology. T. S. SOUTHWORTH, M.D., JONATHAN WRIGHT, M.D., Paediatrics. Laryngology. WILLIAM OLIVER MOORE, M.D. WILLIAhf B. COLEY, M.D.. Ophthalmology and otology. General Surgery. 15,199 ACTUAL SUBSCRIBERS BY SWORN COUNT.