Ernest Watson Cushing.

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ism, faradism, galvanism, electn
and cataphoresis, which indicates
illustrations are good, the paragr
the descriptions and demonstratio
terested in electricity and its appl
is not — this will prove a valuable j

Text-Book of Medical Jurispri

John J. Reese, M.D. Fifth

Leffmann, A.M., M.D., Ph.D.

Son & Co., 1012 Walnut Street,


This volume of nearly 650 page
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cine and law." It is needless to s
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pages are devoted to a considerati
death, a chapter being given to
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The last 250 pages present a good
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The American Text-Book of G^

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We desire to extend our congrati

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ri- Gynecology and Pediatry

-jiKi Vol. XII. FEBRUARY, 1899. No. 6.



Ex-interne of the Cantonal Hospital, Lausanne, Switzerland.

The two principal indications for curettement after labor are
the following: (1) When there is a retention of a mass of placenta
of small size, either after a labor at term or after abortion. If
the massis of some size, it is far better to detach it with the fingei-,
that is to say, perform a curage, that is to be followed by a curette-
ment so as to be certain that nothing is left in the uterine cavity.
In this case the indication is absolute; it is the best prophylactic
•measure to avoid secondary infection of the uterus from decompo-
sition of the placental debris; it is also an excellent means for ar-
resting hemorrhage which so often accompanies an incomplete
expulsion of the placenta.

(2) When, after a normal labor and an apparently normal de-
livery of the placenta, fever with fetid lochia and other symptoms
of infection of the uterus appear.

We will consider more particularly the second question because
it bears more particularly on the subject of this paper. The older
accoucheurs, when there were signs of infection, simply prescribed
■i^ symptomatic treatment, but at the present time, with the knowl-

edge we have of the genesis of infections and their manner of
\ propagation, we can no longer follow such therapeutics.

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In the first place, is puerperal fever really
of the uterus? Although as yet no special i
been isolated from this complication of the pue
bic nature of this affection is not to be dispu
Doleris, it was Pasteur who first demonstrat
germs in the lochia of women who were sick,
from healthy females remained sterile. The
teur were taken up and confirmed by Goenne
derlein, and more recently by Strauss and Sai
now admit that puerperal infection is more ei
streptococcus pyogenes, which also produces e
masia alba dolens. Where do these orga
Do they normally live on the surface of the
carried in from without? This question is s
and agreement is still far off. Thus Wintei
are pathogenic and non-pathogenic organisms i
while Diihrsen, on the contrary, declares tha
has a healthy vagina ; for him the organisms ar(
from without by the physician's finger or by i
ized instruments. Xo matter what their origi
rious organisms find the puerperal uterine cavi
nidtis for their rapid development and propa
uterus, the infection can reach the parametriu
lymphatic channels and set up a suppurating
inflammation of these organs and tissues; or th
vade the entire organism, producing those cas<
sis without any localization, and which rather r
of the patient from septicemia.

The manner in which the virus is spread
cussed point. Some authorities, for exani])le,
occur without any metritis; others believe th
cervical metritis in the first place and then tli
tends by continuity to the broad ligaments an
the parametrium.

The latter is particularly Fritsch's opinion,
the cervix uteri, wliich presents a lesion at the
natural entrance for infection. T^ow the infe(
parametrium by continuity and contiguity,
(which may be correct in some cases, but man;
shown the erroneous character in the m^jorit;

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is hostile to any intervention with the curette in puerperal fever,
which may be easily understood, since he believes that the endo-
metrium of the corpus uteri always remains intact.

Admitting that puerperal fever is produced by an intra-uterine
infection, we believe that the best means to prevent the extension
of the germs of infection is to combat them at their starting point,
either by a complete and oft repeated disinfection of the uterine
and vaginal cavities by antiseptic irrigations or by scraping away
the diseased mucosa.

Nevertheless, should we at once take up the curette at the least
rise of tepiperature in a post partum case? We do not believe so.
In some eases a few intra-uterine irrigations will be quite sufficient
and it is only in those instances in which this means has remained
without effect that we resort to curettement which, in spite of the
only slight danger when it is done according to all the rules of the
most strict antisepsis, is none the less a disagreeable operation for
the patient.

We shall point out farther on, apropos of the objections that
have been made regarding curettement, what are the complica-
tions to be feared in curetting a puerperal uterus.

The following is the treatment carried out at the maternity of
Lausanne when there is a threatening puerperal infection or when
the infection has appeared. As soon as a rise in temperature has
been found after labor an antiseptic intra-uterine irrigation (pre-
ferably a 1 in 1000 or 2000 sublimate solution) preceded by a
thorough vaginal irrigation. The next morning (rise in tempera-
ture usually occurs in the evening) another irrigation is given and
is repeated several times during the day. If on the next day the
temperature has become frankly febrile, if the lochia are thick
with a tendency to fetor, curettement is done. The following
days we continue the intra-uterine irrigations, at first morning and
evening, then only once a day. AVhen the fever has completely
disappeared, the temperature no longer showing any tendency to
go up in the evening, simple vaginal irrigations are begun.

It is well to change the nature of the solution employed as fre-
quently as possible^ as the organism becomes used to antiseptics
just as it dees to any medicine, and still more, a certain number
of antiseptics cannot be employed with impunity on account of
their toxic effects.'

The liquids we prefer are, besides sublimate in the beginning,

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ereolin, lysol^ solution carbolic acid 3 per cent, turpentine water
(to be particularly recommended when there is a pseudo-diphthe-
ritic membrane on the cervix), permanganate of potassium, and
lastly, a simple sterilized salt solution.

The cases here reported will show the happy results obtained
at the Lausanne Maternity by the above mentioned treatment
We only report those of rather peculiar interest, as all are more
or less similar. The greater number are instances of partial re-
tention of the placenta or a very small portion of the membranes.
It is quite striking to see how frequent these retentions are, either
after abortion or labor at term. In some of the cases the mis-
carriage was not recognized by the patient, and in consequence no
medical treatment was given at the time. From this fact we can
understand why physicians have wished to give as a single cause
to chronic hemorrhagic metritis a miscarriage that had occurred
without the patient's knowledge, as has been pointed out most
clearly by Cumston of Boston a few years ago.

Before detailing my cases, a few words on the danger of cu-
rettement may find their place here. Although curettement
does not enter into the class of major operations, it
should be performed with all the antiseptic precautions that are
employed in more important interferences. Here, in fact, more
than in the majority of operative procedures of minor surgery, an
infraction of the rules of antisepsis may result in extremely seri-
ous consequences. Consequently we do not understand the lack
of antisepsis and even the most elementary asepsis, which is pres-
ent in many institutions, and a uterus curetted in this manner has
a more useless than useful result. Infection of the uterus from a
curettement is one of the dangers of this operation, but will be
easily avoided by observing the rules formulated by Lister.

The second danger is perforation of the uterus, and this is the
only serious reproach that the adversaries of curettement can di-
rect against the operation. This accident is to be particularly
feared when we have a puerperal uterus with soft and pli-
able walls. Consequently in this curettement more than in any
other, much prudence and gentleness must be exercised; the in-
strument should be used without violence and only the! largest size
blunt curettes are to be employed. And for that m atter do we
not all know of perforation occurring with a uterine [sound or an

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irrigator? And still no one would stop the use of these instru-
ments on the ground that they were dangerous.

As to danger from hemorrhage, experience has demonstrated
that it is a pure illusion. On the contrary, curettement arrests
uterine hemorrhage instead of producing it, and if the patient is a
bleeder the operation may be completed by an intra-uterine gauze

Can the uterus be curetted in cases when there is an acute in-
flammation of the adnexa (acute puerperal parametritis) with or
without abscess formation? The opinion of specialists is very
divided on this question. While some recommend abstaining in
cases of abscess of the adnexa, believing that the curette only
spreads the infectious germs, others, far from abstaining, advise
curettement. Thus, Berlin of Nice is very categorical on this
point and says: '*! have for my part often curetted patients whose
adnexa were painful, and others who manifestly had foci of peri-
metritis; what I can say is that in these cases where there is a
preexisting lesion of the adnexa, I have never seen curettement
the cause of the slightest septic complication." Professor Rapin
believes that when there is inflammation of the adnexa, curette-
ment is not to be advised; it is only exceptionally that it is to be
employed, when, for example, there is a retention of the placenta,
and using it with extreme prudence. He has employed and has
seen it employed in several cases of inflammation of the adnexa,
and if in the majority of these cases the operation had no bad re-
sults it certainly did increase the intensity of some of the symp-

We have done it in two cases of puerperal parametritis, in one
of which an abscess had already formed, without remarking any
result, bad or good. In the first case, however, the temperature
dropped quite a little after the operation but went up again a few
days later. Consequently we believe that this operation, with-
out being dangerous, if performed in sufficient precaution, is use-
less as regards a cure, because if infection has started in the mu-
cosa of the uterus, it will have long ago passed the limits of the
organ and have become localized in the adnexa. This question
has for that matter been well studied recently by Mamey of Bor-

Some adversaries of curettement have based their aversion to
this manner of treatment, especially as concerns the operation in

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a woman recently delivered, on a pretended sterility which occurs
afterwards. Now, experience has shown that it is the contrary
result that takes place. How many women who have metritis
and who, from this fact, remained sterile or who, when pregnant,
always miscarried during the first few months of pregnancy, have
been able to conceive or go to term after one or several curette-
men ts! Consequently this operation has been advised at various
times for the cure of sterility.

The endometrium has the power of regenerating very rapidly,
and what is obtained by the curette, is nothing less than a process
occurring physiologically at each pregnancy and at each menstru-
ation, that is to say, a complete renovation of the mucosa.

And lastly, some few gentlemen have declared that curette-
ment of the puerperal uterus in these cases was done too late. Ac-
cording to them, it should be done at the very beginning, before
fever appears, because at this time they say that generalized in-
fection has already taken place. Now such a conclusion is false,
as Braim has shown ; infection is not generalized when fever be-
gins and is still localized to the endometrium.

The sooner cnrettement is done, as we have already said, the
more complete and rapid will be the result, but Fritsoh even up-
holds that all eases cured by this operation would have gotten well
without it.

From what has been said and the cases here reported, I may be
allowed to draw. the following conclusions: (1) Puerperal fever
being a disease whose origin is an infected wound , should he
treated by an antisepsis of the organ containing this wound, viz.,
the titerus. (2) The treatment should consist in the first place,
in antiseptic irrigations of the vagina and uterus, frequently re-
peated, (8) Tf in spite of the irrigations fei^er persists, curette-
ment is indicated, (4) Case VII demonstrates that curettement
is equally useful in puerperal fever, termed without localization,
(5) When there are acute lesions of the adnexa (parametritis), it
is better to abstain from curettement unless there be an absolute
indication for the operation.

Cask T. — B., multipara, delivered at. her home. Nothing aV
normal in the labor itself. During the delivery of the placenta
there was a hemorrhage necessitating artificial extraction of the
placenta, which had partly peeled oflF. All went well until the
fifth day, when the temperature went up to 38.° 8 C. in the even-

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^5 C); at the same time the lochia becan
d, and curettement was decided upon (i
had been given). On the next day tl
to 37.° 9 C, and in the evening it w
shia, which were abundant for two daj
lal in quantity. Recovery,
para, had a miscarriage at two month
elevation of the temperature (38.° 3 C. :
Dchia smelt rather strong. The next di
.°3 C. in spite of intra-uterine irrigation
to all symptoms.

tipara, had a miscarriage at the fourl

interference, but the placenta came awi

Up to the fifth day there were no sym

lochia were fetid and the temperature W!

57.° 2 (fetid lochia).

38.° 3 (intra-uterine irrigation, bichloric

g, 37.° 8 (intra-uterine irrigation, bichl

5, 37.° 6 (intra-uterine irrigation, bichl

3rsistent fetid lochia and the tendency <
re to remain above the normal, a curett
be next day the temperature did not g
hia became normal.

ufFered with loss of blood with clots f
n the anamnesis it is probable that the p
the second month. Hemostatics, vagin
rynter were all employed in vain and c
to. The curette brought out blood clo
The next day, hemorrhage was complet
me was there any rise of temperature,
his case, although there was no temper
B its importance in this sense that the c a puerperal uterus, immediat
B which had resisted all treatment for tv
is also reported because this operation i

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Btantly stopped a very severe pain in the uterus, following a mis-
carriage, although there was hardly any rise of temperature.

Case V. — On May 18, 1897, 1 was called to a young woman of
twenty-five years, multipara, who had miscarried two days previ-
ously, and who had had a severe hemorrhage on the next day.
When I arrived, the hemorrhage was nearl
was filled with clots so that the cervix couL
culty. The os was opened enough to allo\^
ter, but no laceration could be detected,
irrigation partly removed the clots and a:

The next day all bleeding had ceased,
plained of pains in the lower abdomen. 1
that there were some clots engaged in the c
the pains complained of were due to ut<
vaginal irrigations were ordered to be conti
nating with sublimate and tannin.

The clots had no odor and there was no
lasted five days and the bleeding had stopp
lower abdomen persisted and was localize
patient The vaginal culs-de-sac were peri
As the clots became slightly fetid, and aj
p. M. was 37.° 8 C, we decided to curett(
were scraped out and microscopically we :
By the next day all pain had disappeared a
menced its normal involution. Five days
well in every respect, was allowed to sit up

We report this case as an example whei
ployed only for fear of later complication
retention of clots and bits of placenta). 1
perature of any account nor marked odoi
rhage had ceased and the only suspicious sj
pain. As this disappeared at once after
that it was due to contractions of the uterui
of the cavity. Now the blood had been
rine cavity for several days, and there was i
might cause a locus minoris resistentiae fo:

(To be continued.)

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>, Vlpara, was delivered of a male child
9, 1898. The labor was easv and natural,
three previous labors, from all of which she
y without any complications. T was called
X to my own illness could not attend her, and
ces of a homtropathic physician, who has a
tice. November 18, he was dismissed and
hands. My first call was made at 10 a. m.,
lent very nervous and anjemic, face pale and
5 purple, pulse* 120, temperature 100.° 5 F.
ily coated, skin yellow, a little bile had been
g, and the patient complained of constant
On one finger on each hand were large
e caused by being hit with the edge of a but-
previous, and the other by a scratch about a
nement. Bowels were slightly tympanitic
e touch, especially in the right iliac region.
>ed voluntarily and caused much pain at in-
^as difficult but not painful, urine high col-
e uterus was very tender and congested, the
filled with exudate so that all the pelvic or-
\ as if they were encased in a plaster cast,
ion gave no evidence of any foreign matter
ucus discharge had no foul odor. T learned
instant pain since the birth of the child, in-
or 48 hours, when a large clot was passed.
1 relief, so the attending physician made a
■ the uterine cavity, but found no more clots,
^ere sterilized or not T did not learn. The
loved till the sixth day, when the patient in-
dose of castor oil. Douches were not or-
given by the nurse on her own responsibili-
led poultices to the bowels for a few hours
n was intense.

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I ordered Eff. Mag. Sulph. 3ii every four hours and tab. trit.
Hydrarg. Chlor. Mit. gr. 1-10, every half-hour till the bowek
moved, the action to be aided by an enema, if there was no result
after eight hours, DaCosta's Hpart TomV. ^Wv^th'sV Strvr»h.
Sulph. gr. 1-50 and Whiskey J
to be covered with a light flaxs
sible, copious hot sterile douche
nourishment. The dietarj'^ inc
as much milk, gruel, cocoa, bo
Food as the patient could be ii
the 19th I founpd the patient m\
freely with the aid of an enei
pulse was 108, temperature 100
tinned with the exception of the
every six hours, and pill of 2 gr.
Early that morning the patieni
physician from a neighboring t
small glass catheter. Mrs. M.
introduction of the catheter. 1
cystitis, a constant pain in the
other annoying symptoms comi
urine was thick, scanty, high col
strong odor. Pulse was 120 ai
very nervous, had slept little (
whiskey stopped and gave a mi
Silk, Collinsonia and Pereira I
half a glass of water, and from f
amus every three to six hours ti
21st, I found the patient had
since the day before, which was
with mucus and epithelium. 1
turition, but a constant ache in t
the right side; pulse 120, tem
weak, restless and sleepless, T g
the eflFeet of another sleepless
sulph. gr. ^ and atropia sulp. gi
repeated in half an hour if neces
of which she had taken ^ gr., ha
eight hours and felt much more
was still 104° F., and pulse

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Thinking that I must use some antiseptic for the bladder, and the
patient refusing to submit to lavage, I ordered Saliein in sohition,
in 2 gr. doses every four hours and dropped the Quinine. I gave
Saliein in preference to Salol because I feared the effect of Salol
on the stomach, and also because I wanted some bitter Ionic, and I
thought the Quinine might be irritating the bladder. To my
great delight, the next day there was no pus in the urine, and the
temperature had fallen to 102° F., pulse 112. I was allowed to
wash out the bladder, which I did with a solution of nitrate of
silver, 8 gr. to a pint of water. The pelvic organs were somewhat
less tender and the exudate partially absorbed. I continued the
treatment, and the next day the temperature was about 101.° 6
F., tongue was beginning to clear, and there was no pain any-
where; urine clear and abundant. I stopped the remedies for the
cystitis except one dose of the Potash mixture at night, and as I
had always relied on Quinine in fever following childbirth, I
dropped the Saliein solution and went back to Quin. 2 gr. everj
four hours. This was on Wednesday, the 23d. The pelvic exu-
date was so much less that I reduced the douches to one every 24
hours, followed by a boroglyceride and hydrastis suppository.
Thursday afternoon the temperature was again 104° F., and the
tongue more thickly coated. There was no increase of trouble
in the pelvis, and I was at a loss to account for the return of fever.
Since the first dose of morphia on Tuesday I had continued to
give about 1-12 gr. in solution once in from 12 to 16 hours, and
she kept this up for the stimulant effect, gradually increasing the
time between the doses and decreasing the dose, till Thursday she
was taking about 1-16 gr., which small amount could not be dis-
guising any very serious local condition. Every forenoon she
perspired freely, a cold, clammy sweat which did not materially
reduce the temperature. Friday and Saturday the conditions
remained unchanged, the temperature never being less than
103.° 6 F., and reaching 105° F. on Friday afternoon.

I felt that the high temperature must be caused by some septic
condition of the blood, for all the excretions were normal, and so
was the pelvic region with the exception of a slight metritis. Re-
membering the great improvement during the two days I had
used the Saliein, I stopped the Quinine and resumed Sal. 3 gr. ev-
ery four hours. Improvement was noticeable in every way in
24 hours, and by Tuesday, the 29th, the temperature had dropped

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302 J. H. PRESTON.

to normal in the morning and 99.^5 F. at night. Friday there
was no fever, the tongue was clean, the patient slept well and had
taken no morphia for three days. The appetite was returning
and T allowed some solid food. December 7, four weeks after
confinement, she was allowed to sit up and she dropped all medi-
cation except Strych. 1-60 gr., and Salicin 2 gr. t. i. d. I am
aware this one case proves very little for the use of Salicin in
puerperal fever, but the improvement seemed more than a coinci-
dence. The patient had no idiocyncracy against Quinine as she
had often taken it in 2 gr. doses every four hours for a cold, and
had received benefit from it. I was so convinced of the beneficial
result of the Salicin in Mrs. M.'s case that I used it with a patient
suffering from septic poisoning from necrosed placenta, which
had been retained five days after a miscarriage before I saw her.
In spite of intra-uterine douches and internal medication, after
four weeks' treatment I had been unable to reduce the tempera-
ture lower than 102^ each afternoon, with sweating and chills, in-
somnia, coated tongue and complete anorexia. T substituted the

Online LibraryErnest Watson CushingAnnals of medical practice → online text (page 27 of 77)