circumspection. They are not indicated by a simple rise of
temperature. A very large proportion of the febrile attacks which
occur in childbed run an absolutely favorable course. Unless the
infection--and this is not the rule, but the exception--proceeds from
the uterine cavity, they are unnecessary. In circumscribed
inflammations, where the morbific poison loses its virulence at a
short distance from the puerperal lesion, they are often injurious. It
is difficult, if not impossible, to so conduct them as to avoid
opening up afresh recent granulating wounds. Yet the practice of local
disinfection is warmly advocated by Fritsch, Schüller, Langenbuch, and
Schroeder as a prophylactic against puerperal affections. On the other
hand, Braun von Fernwald, with his vast opportunities for judging
obstetrical questions, writes with reference to this: "We must protest
against injections made by physicians into the uterine cavity. Such
meddlesomeness is more likely to do harm than good." This corresponds
with my own experience. In theory, the proposition to treat the uterus
as one would any other pus-secreting cavity seems rational, but I have
found that every attempt to carry the theory to its logical conclusion
in hospital practice has been followed by a rise in the puerperal
death-rate. Runge reports an epidemic of puerperal fever in
Gusserrow's clinic brought about by the employment of intra-uterine
irrigations, during which the mortality rose to 3.8 per cent. With the
abolition of the irrigations the mortality sank to .39 per cent. In
1880, Fischel[70] introduced the so-called permanent irrigations into
the Prague maternity. Of 880 patients, 9 died of sepsis. The
irrigations were then prohibited. The following year, of 933 patients,
only 2 died from the same cause, and in 1882, of 521 patients, there
were no deaths from sepsis. Fehling, who limited the use of
intra-uterine injections to special momentary indications, reported,
in 1880, 415 confinements without a single death.
[Footnote 70: "Zur Therapie der Puerperalen Sepsis," _Arch. f.
Gynaek._, vol. xx. p. 41.]
Among the accidents which have been referred to the use of injections
are convulsions, shock, and carbolic-acid or corrosive-sublimate
poisoning; but the chief danger lies in the possibility of conveying
the infectious materials from the vagina to the previously normal
uterus. There seems to be no question as to the superior effectiveness
of corrosive sublimate as a germicide. It not only acts more rapidly
than carbolic acid, but its action is more permanent. In the usual
proportion of 1:2000 it is apt, when repeated frequently as a vaginal
douche, to corrugate the vagina and cervix. When used for
intra-uterine irrigation great pains should be taken that no portion
of the fluid remain behind in the uterine cavity. Since its
introduction into the Emergency Hospital there has been one death from
ulceration in the colon, which possibly was attributable to its use.
It is to be hoped the claim that corrosive sublimate is an efficient
antiseptic in the proportion of 1:10,000 may prove well founded.
In pressing the necessity of caution and discrimination, I have not,
however, intended to discourage the employment of intra-uterine
antisepsis in cases where it is strictly indicated. Thus, it would be
folly, in a fever due to the decomposition of placental débris, of
shreds of decidua, of strips of membrane, or of retained coagula, or
in diphtheritis of the mucous membrane, to treat the general symptoms
and neglect {1030} the local cause of difficulty. In a specific case
it may prove difficult to decide as to the correct course to pursue.
In general it may be stated that it is proper to wash out the entire
length of the genital canal when fever follows prolonged operations
conducted within the uterine cavity or the birth of a dead foetus, and
in cases of fever associated with a fetid discharge which persists in
spite of the vaginal douche, with the presence of recognizable
portions of the ovum or its dependencies in the lochia, with the
repeated discharge of decomposed coagula, or with a large, flabby
uterus. It will, however, be seen that with proper disinfection during
and immediately after labor, the occasions for late intra-uterine
injections are extremely rare.
The operation of cleansing the uterus should be conducted with the
most scrupulous care. The syringe employed should produce a continuous
and not an interrupted stream, and all air should be expelled from the
pipe. The tube to be passed through the cervix should be of glass, of
the size of the little finger, and bent somewhat to conform to the
pelvic curve. The vagina should first be subjected to a thorough
disinfection, by way of precaution against conveying septic materials
into the uterus. The introduction of the tube should be made with the
guidance of two fingers passed through the external os. But slight
force is requisite to reach the internal os. It is neither necessary
nor desirable to push the tube to the fundus. The fluid injected
should be tepid, and, if carbolic acid is used, of the strength of two
or three drachms to the pint; if corrosive sublimate is employed, the
strength should not exceed 1:3000. It should be introduced very
slowly, and pains should be taken to ensure its unimpeded escape,
which can usually be accomplished by pressing the anterior wall of the
cervix forward by means of the glass tube. Langenbuch recommends
securing permanent drainage by leaving a bit of rubber tubing in the
cervical canal--a plan concerning the merits of which I am not able to
speak from experience. The tube is said to be well tolerated, and to
possess the advantage of enabling subsequent injections to be
performed without disturbing the patient.
In many cases the results of intra-uterine treatment are very
striking. Often the temperature falls notably within an hour or two of
the operation. This result is, however, rarely permanent. Usually the
fever recurs, and the operation has to be repeated. The patient should
be carefully watched, and with the first sign of returning danger the
injection should be repeated. Two or three injections may thus be
called for in twenty-four hours, and they may require to be continued
for a week. Still, by the means indicated a certain pretty large
proportion of women seemingly destined to destruction in the end make
favorable recoveries.[71]
[Footnote 71: The admirable monograph of Dr. T. G. Thomas, entitled
_The Prevention and Treatment of Puerperal Fever_, has already done
much good in calling the attention of the profession at large to the
practice of local disinfection. His experience, however, based upon a
very large consulting practice, has perhaps been of a kind to furnish
him with an undue proportion of puerperal cases calling for
intra-uterine treatment. With increasing care in the management of
labor and of the birth of the child there seems reason to hope that
the necessity for the treatment he so eloquently advocates may, in the
near future, disappear entirely.]
Ehrendorfer[72] relates a case of septic endometritis and erysipelas
{1031} starting from the genital organs, in Spaeth's Clinic, where,
after seven days of ineffective uterine irrigations, two bacilli,
containing together ten grains of iodoform, were introduced into the
uterus. The washings with carbolic acid were then stopped. On the next
day the discharge was diminished and the odor was less marked. On the
fourth day two new iodoform bacilli were introduced. The patient, in
spite of the fact that the erysipelas spread over nearly the entire
body, eventually recovered.
[Footnote 72: "Ueber die Verwendung der Jodoform staebchen bei der
intrauterinen nach behandlung im Wochenbette," _Arch. f. Gynaek._,
vol. xxii. S. 88.]
Of the symptoms, the first in order which calls for treatment is
usually the peritoneal pain. It is, as we have seen, commonly of a
lancinating character, and is associated with hurried breathing and
extreme frequency of the pulse. So soon as the pain is once fairly
under control the violence of the onset begins to abate. It should be
met, therefore, by the hypodermic injection of from one-sixth to
one-third grain of morphia in solution. The anodyne action should be
maintained by doses administered by the mouth in quantities and at
intervals suited to the severity of the case. The most important
object to be secured is freedom from spontaneous pain. It is,
moreover, good practice to push the opiate until pain elicited by
pressure is likewise controlled, provided it can be accomplished
without producing narcosis. In susceptible patients and in localized
inflammations the quantity required may not be very great, while in
acute general peritonitis the tolerance of the drug exhibited by
puerperal women is sometimes extraordinary. Thus, a patient of Alonzo
Clark took the equivalent of 934 grains of opium in four days; a
patient of Fordyce Barker 13,969 drops of Magendie's solution in
eleven days; and one of my own, at the Maternity, the equivalent of
over 1700 grains of opium in seven days.[73] In this latter instance
the patient was to all appearance moribund when the treatment was
begun. Thus, the features were pinched, the face was drawn, the pupils
were dilated, the finger-tips were blue and cold, the respirations
were rapid, and the pulse was scarcely perceptible. In this condition
the large doses of opium did not produce narcosis, but were followed
by restoration of the circulation, by normal breathing, and by the
disappearance of the symptoms of shock. Any attempt to relax the
treatment was at once succeeded by a recurrence of the alarming
symptoms. At the expiration of the disease the opium was discontinued
abruptly without detriment to the patient.
[Footnote 73: The details of this case have been reported in the _Am.
Jour. of Obst._, Oct., 1880, p. 864, by Dr. F. M. Welles, who
conducted the administration of the opium.]
In contrast to cases of acute peritonitis an extreme susceptibility to
opium is often observed in the pyæmic variety. Here opiates seem to me
rarely to do good. They do not hinder the migrations of the round
bacteria, there is rarely pain to relieve, and I have sometimes
thought that their administration was simply the addition of a second
poison to the one which already was overwhelming the nervous system.
In pelvic peritonitis, in the course of forty-eight hours plastic
exudation is thrown out and the pain to a great extent subsides. From
this time very moderate doses of opium, as a rule, are needed to make
the patient comfortable.
In France leeches applied to the abdomen are much used as a means of
relieving peritoneal sensitiveness. That they do this is beyond
question. {1032} Their disuse in this country is due probably more to
popular prejudice than to their inefficacy.
In the beginning of an attack a turpentine stupe to the abdomen is a
source of comfort to many women, while the sharp counter-irritation
exercises possibly a favorable influence upon the course of the
disease. At a later period I commonly employ flannels wrung out in
water and covered with oil-silk to prevent speedy evaporation. It is
an old experience that in the beginning of a puerperal fever the
provocation of loose stools by purgatives is frequently followed by a
fall in the temperature and a great improvement in the patient's
condition. The result, however, is far from uniform, as in other cases
these artificial diarrhoeas have a tendency to aggravate the
peritoneal symptoms. Owing to this uncertainty in their action,
purgative remedies should be administered with caution, not from any
theory as to their eliminative powers, but because of the ascertained
existence of fecal accumulation. In pelvic inflammations castor oil in
two- or three-tablespoonful doses, or five to ten grains of calomel
rubbed up with twenty grains of bicarbonate of sodium, as recommended
by Barker, may be given when thus indicated. After the bowels have
once been freed, however, the purgative should not be repeated. In
cases of intense local inflammation and in general peritonitis enemata
should alone be employed for the removal of constipation.
Every increase of body-heat is associated with rapid tissue-waste,
with enfeebled heart-action and with exhaustion of the nerve-centres.
Since the modern recognition of the deleterious effects of high
temperatures per se, antipyretic remedies in place of the old-time
cardiac sedatives have come to play the leading rôle in the treatment
of fevers.
Of internal antipyretic agents quinia enjoys a deservedly high repute.
In the remitting forms of fever it may be administered in five-grain
doses at intervals of four to six hours. Given thus in medium doses,
it moderates the fever, diminishes the sweating, and in most patients
lessens gastric and intestinal disturbances. In continued fevers it
should, on the contrary, be given in a single dose large enough to
procure a distinct remission. By making a break in the febrile
symptoms, if only of a few hours' duration, a retardation of the
destructive processes is accomplished. At the first administration
twenty to thirty grains may be given. In favorable cases the
temperature falls in the course of a few hours below 101°. When the
high temperature is only temporarily held in check, at the end of
twenty-four hours, if all symptoms of cinchonism have disappeared, the
same dose should be repeated. If the doses mentioned, given in the
manner prescribed, produce no perceptible effect upon the fever, their
continuance may be regarded as unnecessary.
C. Braun and Richter speak favorably of the action of salicylate of
sodium.[74] It possesses antipyretic properties, though in a less
degree than quinia. It is, however, rapidly absorbed, circulates
through all the parenchymatous organs, and finally is discharged
unchanged in the urine. It is said by Binz, in small doses, to hinder
the action of the disease-producing ferments, while it leaves
untouched the normal ferments of the organism. It is of special
service where quinia is not well tolerated, or when given fifteen to
twenty grains at a time every four to six hours as {1033} an adjuvant
to large single doses of quinia. The remedy should be continued until
all traces of febrile disturbance have disappeared.
[Footnote 74: Richter, "Ueber intrauterine Injectionen," etc.,
_Zeitschr. für Geburtsk. und Gynaek._, Bd. ii. Heft 1, p. 146.]
A more powerful remedy than salicylic acid, where quinia has failed,
is the Warburg's tincture. Some patients find, however, that it is
somewhat difficult to retain upon the stomach.
Not many years ago, owing to the encomiums of Fordyce Barker,[75] the
tincture of veratrum viride was in great favor in puerperal fever as a
means of reducing the excited pulse of inflammation. The plan
recommended was to administer five drops hourly, in conjunction
usually with morphia, until the pulse was brought down to 70 or 80
beats to the minute. If the pulse had once been reduced, then three,
two, or one drop hourly would be found sufficient to control it.
Vomiting and collapse from its use were no cause for alarm, as they
were temporary symptoms, and were followed by a fall of the pulse to
30 or 40 a minute, which was rather of favorable prognostic
significance. In the rapid pulse of exhaustion, however, veratrum
should not be given. Since the introduction of the thermometer into
practice the reduction of the pulse by veratrum has been found to be
associated with a fall in the temperature of the body. Of late,
however, veratrum has gone rather out of vogue, not because it is not
a very effective agent, but because its administration is an art to be
acquired, and cannot safely be entrusted to an unskilled assistant.
Then, too, in the last ten years there has grown up a better
acquaintance with less dangerous remedies.
[Footnote 75: _The Puerperal Diseases_, p. 347.]
Braun recommends in severe cases, where quinia alone is without
effect, to give in addition from twelve to twenty-four grains of
digitalis in infusion per diem until its specific action is produced.
Unlike veratrum, digitalis effects a permanent slowing of the heart.
By prolonging the cardiac diastole and contracting the arterioles it
allows the left ventricle to fill, restores the arterial tension,
diminishes correspondingly the intravenous pressure, and promotes
absorption. Its tendency to produce gastric disturbances and the
distrust felt as to its safety have prevented its becoming popular in
practice.
Alcohol as an adjuvant to treatment is indicated in all cases, whether
quinia or salicylic acid or veratrum be simultaneously employed. It
stimulates and sustains the heart, it retards tissue-waste, and is in
itself an antipyretic of no mean value. Usually I give it in
conjunction with quinia, one or two teaspoonfuls hourly of either
whiskey, rum, or brandy, in accordance with the recommendation of
Breisky.[76] But many years before I had learned from my friend Prof.
Barker that the specific influence of veratrum was in many cases not
obtained until the use of alcohol was combined with it.
[Footnote 76: _Ueber Alcohol und Chinin-behandlung_, Bern, 1875.]
The antipyretic action of drugs is probably due for the most part to
some direct influence they exert upon the oxygenation of the tissues.
Of course the less the fire the less the heat. It is well, however, to
support their internal administration by the external employment of
cold. Cold owes its effect in fevers partly to the abstraction of heat
from the body-surface, and in a still more important degree to the
impression which it produces upon the nervous system. In healthy
persons the action of cold is to increase the consumption of oxygen
and the production of carbonic {1034} acid. The additional heat thus
generated renders it possible to sustain the vicissitudes of climate.
In fevers the primary effect of cold is similar in character. Its main
therapeutical action is derived from its secondary influence upon the
nerve-centre which regulates the body-heat. If the cold employed be
sufficiently intense or sufficiently prolonged, there follows, not
always immediately, but in the course of an hour or two, a marked
lowering of the temperature, which can only be accounted for by
assuming an indirect influence exerted through the sympathetic nerve
and the medulla oblongata. This peculiarity renders the external
application of cold a most valuable addition to the therapeutical
resources available in fevers.
In cases of moderate severity frequently sponging the patient with
cold water will be found to be a grateful practice. An ice-cap to the
head, where the blood lies near the surface, will often affect the
entire temperature of the body. From immemorial times it has been
employed to control delirium and promote sleep. An ice-bag placed over
the inguinal region is locally beneficial to deep-seated pelvic
inflammations, and, according to Braun, is capable of effecting a
rapid fall of temperature. Ice-cold drinks should be freely allowed.
Schroeder recommends a permanent stream of cold water in the uterine
cavity by means of a large irrigator and a drainage-tube; others
advise cold rectal injections maintained for long periods by the aid
of a tube with a double current.
In fevers of great violence the systematic application of cold by
means of baths or the wet pack is capable in some cases of rendering
important service. The temperature of the bath should range from 70°
to 80°. Its duration should not exceed ten minutes. The patient
should, when removed to the bed, be wrapped in a sheet without drying,
and should be comfortably covered. In employing the wet pack two beds
should be placed side by side. The body and thighs of the patient
should be wrapped in a sheet wrung out in cold water, and be allowed
to remain in the pack from ten to twenty minutes. As the sheet becomes
heated the patient should be placed in a fresh one upon the second
bed, and the transfers should be continued until the desired fall of
temperature is effected. Braun claims that four packs are equivalent
in action to one full bath.
Both these methods are, however, open to the objection that they
cannot be carried out without considerable disturbance of the
patient--a point of no small importance in cases of peritonitis. G. B.
Kibbie has invented a fever-cot which obviates the ordinary
difficulties of this mode of treatment. The cot is covered with "a
strong, elastic cotton netting, manufactured for the purpose, through
which water readily passes to the bottom below, which is of rubber
cloth so adjusted as to convey it to a vessel at the foot." T. G.
Thomas,[77] who has employed this apparatus extensively to reduce high
temperatures after ovariotomies, explains as follows the modus
operandi: "Upon this cot a folded blanket is laid, so as to protect
the patient's body from cutting by the cords of the netting, and at
one end is placed a pillow covered with india-rubber cloth, and a
folded sheet is laid across the middle of the cot about two-thirds of
its extent. Upon this the patient is now laid; her {1035} clothing is
lifted up to the armpits, and the body enveloped by the folded sheet,
which extends from the axillæ to a little below the trochanters. The
legs are covered by flannel drawers and the feet by warm woollen
stockings, and against the soles of the latter bottles of warm water
are placed. Two blankets are then placed over her, and the application
of water is made. Turning the blankets down below the pelvis, the
physician now takes a large pitcher of water, at from 75° to 80°, and
pours it gently over the sheet. This it saturates, and then,
percolating the network, it is caught by the india-rubber apron
beneath, and, running down the gutter formed by this, is received in a
tub placed at its extremity for that purpose. Water at higher or lower
degrees of heat than this may be used. As a rule, it is better to
begin with a high temperature, 85°, or even 90°, and gradually
diminish it. The patient now lies in a thoroughly soaked sheet, with
warm bottles to her feet, and is covered up carefully with dry
blankets. Neither the portion of the thorax above the shoulders nor
the inferior extremities are wet at all. The water is applied only to
the trunk. The first effect of the affusion is often to elevate the
temperature--a fact noticed by Currie himself--but the next affusion,
practised at the end of an hour, pretty surely brings it down. It is
better to pour water at a moderate degree of coldness over the surface
for ten or fifteen minutes than to pour a colder fluid for a shorter
time. The water slowly poured robs the body of heat more surely than
when used in the other way. The water collected in the tub at the foot
of the bed, having passed over the body, is usually 8° or 10° warmer
than it was when poured from the pitcher. On one occasion Dr. Van
Vorst, my assistant, tells me that it had gained 12°. At the end of
every hour the result of the affusion is tested by the thermometer,
and if the temperature has not fallen another affusion is practised,
and this is kept up until the temperature comes down to 100°, or even
less. It must be appreciated that the patient lies constantly in a
cold wet sheet, but this never becomes a fomentation, for the reason
that as soon as it abstracts from the body sufficient heat to do so it
is again wet with cold water and goes on still with its work of
heat-abstraction. I have kept patients upon this cot enveloped in the
wet sheet for two and three weeks, without discomfort to them and with
the most marked control over the degree of animal heat. Ordinarily,
after the temperature has come down to 99° or 100°, four or five hours
will pass before affusion again becomes necessary."
[Footnote 77: "The Most Effectual Method of Controlling the High
Temperature occurring after Ovariotomy," _N.Y. Med. Jour._, August,
1878.]
Since reading this account, I have made a good many trials of the
method upon puerperal women, and have not found that it agrees with
all in an equal degree. In some instances the affusions have been
followed, in spite of hot bottles to the feet and the administration
of stimulants, by such a degree of depression and impairment of
cardiac force, as shown by the persistent coldness of the extremities,
that it has been necessary to discontinue them. On the other hand, I
can look back upon cases, apparently so desperate that the condition
of the patients was looked upon as hopeless, where they proved the
means of saving life as by a miracle. Of course, the difference
depends upon whether the high temperature is the sole cause of the
alarming symptoms, or whether the latter are in part due to
blood-dissolution and secondary changes in the parenchymatous organs.
{1036} The use of the coil in fever, whether of rubber or of metal
tubing, I can highly recommend. Either the night-dress or a towel
should be placed between the coil and the skin. A current of cold
water passing through the tube rapidly abstracts the surface heat, and
is usually grateful to the patient. The lowering of the temperature by
this means is much slower than by cold affusions. Disturbance of the
patient is, however, avoided, and the method, so far as I have tried
it, has been free from the objections incident to the direct
application of water to the skin.
It is hardly necessary to state that in puerperal, as in other fevers,
the patient's strength requires to be sustained and the waste of
tissue to be repaired, as far as possible, by the regulated
administration of liquid food, as milk and beef-tea, in such
quantities as can be borne by the stomach, and at one to two hours'
intervals.