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combat the infecting germs, and removal of the ordinary channels
of infection, such as adenoids and decayed teeth, are indicated.
Class III includes the grave cases, so-called chorea major, which
are really cases of septic or malignant endocarditis. Class IV, or
Huntington's chorea, may be regarded as due to arteriosclerosis
of the vessels of the motor cells. Class V, chorea graividarum,
is due to a toxic state or to nervous depression in a pregnant
woman, and the movements are only symptomatic. Other
conditions showing incoordinated movements doubtless occur.
The cause of such movements should always be sought, so that
treatment may be directed toward the causative element.

The Artificial Nursling. — V. Wallich (Ann. de Gyn, et d'ObsL,
September, 1909) describes a new device for removal of
the milk from the breasts when the infant is unable to nurse.
The apparatus, called the succipump, is so arranged that there
is a return current of air into the aspirator at each stroke of the
piston. Thus it simulates the action of the infant in suckling.
In five or six minutes a considerable amount of milk may be
obtained which may be fed to the infant with a spoon or through
a nursing bottle. The aspiration must be made slowly and with
intervals of rest such as the child gives in nursing. The pump
may be so arranged that the mother may empty her own breast
by placing her foot in a stirrup which fixes the pump, and pump-
ing with one hand while she holds the reservoir with the other.
The author gives examples of successful use of the pump in his
own experience. Its value is seen in bad shaped nipples, cracks,
lymphangitis, and abscess of the breast, in debility of the new-
bom child, in diseases like convulsions, and in harelip. This
method allows of mixed feeding with cow's milk and mother's
milk at the same time. Its use may avoid syphilitic contamina-
tion of wet-nurses by suspected infants.
Use of Steiilized Linen for Nurslings. — Edmond Weill (Lyon



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BRIEF OF CURRENT LITERATURE. 183

Mid., September 26, 1909) believes that he has demonstrated
the value of sterilized clothing against the infections that are
liable to occur in an old and unhygienic institution, which, by
long occupation, has become infected with various microorgan-
isms. Such buildings have to be used in the Children's clinic
at the University of Lyon. Before the use of sterilized linen
many of the little patients contracted streptococcus infections of
the skin, and some died of them. Since he has made use of
only sterilized clothing, these infections have become rare. The
infections consisted of pemphigus and pyodermatitis of various
forms. Children with varicella would be severely sick from a
mixed infection. Sterilized linen has a curative as well as prophy-
lactic effect in these infants. Trial of series of children side by
side in the same rooms was made, one series being arrayed in
sterilized, another in simply washed garments. Those whose
garments were merely laundered had dermatitis, while the others
escaped. If the sterilized linen ceased to be used the previously
healthy infants would be seized with dermatitis. In those
cases already affected the use of sterilized clothing would bring
about relief of the dermatitis in twenty-four hours. Bacterio-
logical examination of linen that was simply laundered showed
many colonies of streptococci and staphylococci. Since these
experiences the author has all the clothing sterilized in bags in
which it remains until it is to be used.

Joint Tuberculosis with Special Reference to its Pathology. —
Leonard W. Ely {Med, Rec, October 2, 1909) presents some
interesting deductions based upon the clinical histories and
laboratory examination of forty-eight specimens from forty-five
patients. Of these, forty-five were joints, one a specimen of
bone alone, and two of tendon sheaths. The specimens were
furnished by 12 operators, some of them men of great ability.
Of the ten joints in which no tuberculosis was found, nine sent
to the laboratory with a diagnosis of tuberculosis. On the other
hand, four joints were sent in as nontuberculous, in which tuber-
culosis could be demonstrated by the microscope. It may be
argued of the former class that tuberculosis may have been pres-
ent in the specimen and may not have been discovered in the
laboratory, br may have died out. This is, of course, possible,
but the number of such cases must be very small, for any tuber-
culous process capable of giving symptoms justifying a resection
or amputation would almost invariably produce changes in the
joint so marked that they could be recognized by a careful patho-
logical examination. These observations show that no pains
should be spared in arriving at a correct diagnosis before proceed-
ing to a radical operation on a supposed tuberculous joint; and
that we should accept with great reserve any statistics of tubercu-
lous joints cured by conservative means, when these statistics
are based upon the unsupported clinical opinion of the man who
has compiled them. The writer gives an outline of the pathology
of joint tuberculosis of the primary bony type and of the primary



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184 BRIEF OF CURRENT LITERATURE.

synovial type and emphasizes the large percentage of cases appar-
ently of the latter class among his own specimens. It has
become the custom to regard all cases of joint tuberculosis as due
to a bony focus. In opposition to the arguments advanced to
support this opinion, he says that if all the articular ends of the
bones, sawn across near the joint, present no evidence of any
involvement, and if the synovial membrane in its entire extent
and in its entire thickness is filled with tuberculosis, the possibility
of primary synovial tuberculosis must be seriously considered.
Again, it seems unlikely that a tuberculous process, starting in the
bone, would make its way directly to a joint and involve the
entire synovial membrane without spreading at all in the Bone.
Often in the cases known to be primarily bony, the superficial
layers alone of the synovial membrane have been involved, as
would naturally happen if the disease broke through into the joint
from outside, while in the primary synovial type the membrane is
involved in its entire thickness. Considering the very evident
effort of nature to immobilize a joint as soon as tuberculosis
appears in or near it, and the uncertainty that resection will
remove the entire process, the writer says that possibly hereafter,
in treating tuberculous joints, less effort will be expended in pre-
serving motion, and more in obtaining ankylosis. We shall not
dread the wearing away of the joint cartilages, but shall rather
encourage it. We have thought for a long time that the crowd-
ing of the bone ends together by muscular spasm tended to the
same thing, and have expended all our efforts to overcome it,
instead of regarding it as one of nature's efforts at cure. The
conservative treatment by weight-bearing and immobilization —
that is, by plaster of Paris — in disease of the knee and hip seems
more in line with this theory than the older method of stilting
and traction. The writer feels that a most cursory examination
of these joints will convince anyone of the futility of the opera-
tion of curetting as usually practised. A tuberculous process
involving a synovial membrane in its various folds and ramifica-
tions, and running up under the joint cartilage into bone, per-
haps with a distinct bony focus, is not to be eradicated by blindly
thrusting a sharp spoon into the joint and scraping away at ran-
dom. It is also better to take long chances of life and death than
to resect a joint of a child.

Typhoid Bacilli in Breast-milk. — As an explanation of the mode
by which nursing infants may contract typhoid fever, C. H.
Lawrence (BosL Med, and Surg, Jour,, July 29, 1909) reports a
case of typhoid fever in which the typhoid bacillus was
isolated from the breast-milk during the course of the disease
though no signs of local inflammation were present.



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THE AMEBIO.AJN"

JOURNAL OF OBSTETRICS

AND

DISEASES OF WOMEN AND CHILDREN.

VOL LXI. FEBRUARY, 1910. NO. 2

ORIGINAL COMMUNICATIONS.



INJURIES TO THE PUERPERAL UTERUS.

BY
EDWIN B. CRAGIN, M. D.,

New York.

The goal sought in every parturition is the delivery of a
living, uninjured child without such lesion or infection of the
parturient canal as will cause either morbidity during the
puerperium or subsequent discomfort to the patient.

It is well known that any lesion of the parturient canal pre-
disposes to infection and so long as the uterus is the most im-
portant portion of this canal as far as infection is concerned, the
importance of the subject before us is clearly seen. For purposes
of discussion injuries to the puerperal uterus will be considered
tmder two heads.

(a) INTRAPARTUM INJURIES AND (b) POSTPARTUM INJURIES.

Furthermore, for completeness of the study, some license will
be taken and the term "puerperal" made retroactive so as to
include the emptying of the pregnant uterus during the early
months of gestation, whether this abortion was intentional for
good medical reasons, or whether the intent was criminal.
Although injuries to the uterus at term are of chief importance
and will receive the most of our attention, injuries during an
induced abortion are common enough to deserve our consider-
ation. The writer will only incidently refer to perforations of
the pregnant uterus in the early months by long stiff instruments
as sounds, catheters, knitting needles, umbrella wires, etc., in



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186 cragin: injuries to the puerperal uterus.

the hands of the abortionist, or the patient herself driven to
desperation in the desire to empty the uterus of the products of
her conception.

Instances of these injuries are too familiar in the experience
of members of this society who are connected with large hospital
services. While the treatment of these injuries might well lead
to fruitful discussion, lack of time compels the writer to pass on
with the mere statement that the danger resulting from these
injuries depends chiefly upon three factors;

1. The amount of infection carried to the uterus and peri-
toneum by the instrument.

2. The question of intestinal injury.

3. The amount of laceration and hemorrhage.

While many cases of uterine perforation with clean instruments
have recovered without operation or other treatment save rest,
the list of those who have lost their lives from infection of the
peritoneum either from the dirty perforating instrument or from
the escape of the contents of the perforated intestine, is far too
large in spite of skilled surgical intervention. Of more interest
to the conscientious obstetrician and gynecologist are the
injuries which sometimes occur in the hands of men as skilled
as we are, when emptying a uterus in the early months of preg-
nancy in order to save the life of the would-be mother. The
two injuries most common under these circumstances are i.
extensive laceration of the cervix during instrumental dilatation,
and ::. perforation of the uterus by curette or ovum forceps in
cases where the cervix is too rigid to allow of sufficient dilatation
for the introduction of the finger and the use of it as the extract-
ing instrument. Those who have seen the nonpregnant cervix
which was being gradually and carefully dilated with a glove-
stretcher dilator suddenly split to, or above the vaginal junction
without apparent excuse, can understand how such an accident
may occasionally occur in a case of rigid or cicatricial cervix
associated with early pregnancy. The writer knows of only one
way to avoid this accident and that is to prepare the cervix for
dilatation by a preliminary softening. This may be accom-
plished by an intracervical and vaginal gauze tamponade, or by
the introduction into the cervical canal of a small elastic bag.

The perforation of the clean pregnant uterine wall by the
curette or ovum forceps is thought by some men the result of
carelessness and impossible in their hands. Yet this injury has
occurred in the hands of so many good men that its possibility



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cragin: injuries to the puerperal uterus. 187

must always be considered. The uterine wall in pregnancy is
softened; it may be thin and relaxed and in these conditions,
without extreme care, perforation is easy. The procedure which
seems to me most likely to avoid this accident is to have the
fundus of the uterus steadied by the hand of an assistant or
nurse while the operator introduces his curette or ovum forceps
(the writer prefers for this purpose a fenestrated sponge holder)
as carefully as he would use a delicate probe until the fundus is
reached and identified, applying what little force is used solely
in the outward stroke. This same rule of delicate introduction
should be followed in each application of the instrument.

One other possible injury to the uterus at this period is the
continuance of the curettage beyond the limit set by nature in her
discharge of the products of conception. It must be remembered
that the ovum and decidua are all that should be removed and
that deeper scraping, going through the endometrium and
removing portions of the muscular structure is likely to lead to
subsequent trouble, perhaps hyperin volution, amenorrhea and
sterility. The surest way of avoiding this fault in technic is
for the operator, especially one of limited experience, to use
instruments which although stiff, are blunt.

Advancing now to the completion of gestation, intrapartum
injuries will once more be first considered, and again lacerations
of the cervix during artificial dilatation stand out predominantly.
It is unusual before the birth of the child to have serious hemor-
rhage resulting from laceration in manual dilatation of a rigid
cervix, yet the writer has seen such a case in consultation where
a most skillful obstetrician had simply stretched with the fingers
of one hand a cervix which had long resisted nature's efforts at
dilatation. The hemorrhage had almost exsanguinated the
patient and her life was saved with difficulty.

The hemorrhage in this case occurred many hours before the
birth of the head and may well impress the lesson of care needed
in dilatation even when the cervix is thinned by labor and the
canal tamponed from above by the vertex. The two conditions
which are most often associated with intrapartum injury of the
uterus, are eclampsia and placenta previa with the accouche-
ment forc6 which is so often employed in their treatment.

In eclampsia emptying of the uterus has been so uniformly
followed by improvement in the condition of the woman, that the
dictum is generally accepted, given an eclamptic seizure proceed
to empty the uterus.



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188 cragin: injuries to the puerperal uterus.

The writer believes that this dictum should be modified by the
additional clause "as soon as is consistent with the condition of
the cervix."

If the cervix is short, soft and in the condition usually called
dilatable, it can generally be dilated by accouchement forc6 with
relatively little laceration, if the dilatation is done carefully,
gradually, and without too much haste. On the other hand, if
the accouchement forc6 and delivery are performed in a case
with long rigid cervix without previous preparation, the cervix
after delivery will often show deep lacerations extending to the
vaginal junction, perhaps even into the lower uterine segment.
The writer remembers at least one case in which in the hands of a
member of the Interne Staff this laceration extended completely
through the lower uterine segment into the peritoneal cavity,
and this in spite of the constant advice of the attending obstet-
rician who was standing by his side and supervising each step
of the operation.

Considering the frequency of extensive lacerations of the cervix
in accouchement forc6 when performed in the case of a long
rigid cervix, the question naturally arises, Is the eclamptic
patient with uterus emptied but with extensive cervical lacer-
ations and considerable shock better off than she would have been
with uterus emptied a few hours later, after preliminary soften-
ing of the cervix with an elastic bag which had made dilatation
easier and extensive laceration less probable? In general, the
writer believes this question can be answered in the negative,
and in his own work both in his service at the Sloane Maternity
and in his private practice he makes it a rule in cases with long
rigid cervix to soften and prepare the cervix for dilatation by the
introduction of an elastic bag before resorting to accouchement
forc6. In the rare cases where the cervix is so long and rigid
that the elastic bag either cannot be introduced or does not
accomplish its purpose, the so-called vaginal Cesarean section
has its limited field.

There is one other condition in which accouchement forc6 is
sometimes resorted to and in which, to avoid extensive uterine
injury, a word of caution may not be out of place, i.e., placenta
previa. With the low implantation of the placenta and the
accompanying inroads of the chorionic villi, the cervix and
lower uterine segment, although perhaps rigid at the ring of the
external os, are often more friable than usual and in the endeavor
to speedily reach a foot and by drawing it down make the thigh



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cragin: injuries to the puerpesal uterus. 189

and half breech serve as a uterine tampon, extensive laceration
even amounting to uterine rupture, has too frequently occurred.

This accident can best be avoided by considering the possi-
bility of its occurrence; by preliminary softening and dilatation
of the cervix by the elastic bag, or gauze tamponade, and by
gentleness of manipulation striving, in the endeavor to avoid
the Scilla of hemorrhage from the placental site, not to run on to
the Charybdis of hemorrhage from uterine rupture.

No discussion of intrapartum uterine injury is complete without
a consideration of that most serious injury known as uterine
rupture.

Reference has already been made to extension of cervical
lacerations into the lower uterine segment resulting from me-
chanical dilatation of the cervix. The form of uterine rupture
however which deserves chief consideration, because in most
instances avoidable, is that resulting from version in cases in
which version should be considered contraindicated. Some idea
of the frequency of uterine rupture and of its high mortality
can be gained from the following statistics:

In a series of 20,000 consecutive deliveries at the Sloane
Maternity Hospital there were thirty cases of ruptured uterus,
i.e., one in 666 2/3 deliveries. Of these thirty ruptures, fifteen
occurred before the patient was brought to the hospital and
fifteen after admission. Twenty-three were in multigravidae,
and seven in primigravidae. Sixteen were of the complete and
fourteen of the incomplete variety. Of these thirty ruptures,
one occurred spontaneously. The maternal mortality was 86 2/3
per cent. The fetal mortality 80 per cent. Of the fifteen sub-
jected to abdominal operation two recovered and thirteen died.

Of the twenty-three treated by gauze tamponade three
recovered and twenty died.

Of these twenty-three cases fourteen were of the incomplete
variety.

Of the twenty-six maternal deaths fifteen were due to shock
and hemorrhage, nine from infection; two from eclampsia
independent of the rupture.

Until practitioners realize that a uterus working too long
against an unsurmountable obstacle, especially if that uterus is
weakened by previous cicatrices, may spontaneously rupture
and until they realize that a case with membranes ruptured,
liquor amnii drained away and uterus contracted upon the child
is unsuited for version, uterine rupture is likely to occur.



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190 cragin: injuries to the puerperal uterus.

With the wider diffusion of knowledge concerning the etiology
of uterine rupture, this accident is becoming less frequent.
This may be seen from the fact that in the last 6,000
deliveries at the Sloane Maternity no case of uterine rupture has
occurred either among those admitted as waiting women, or
among those in whom delivery had been attempted before
admission.

One cause of uterine rupture which seemed to me unique was
presented by a patient brought to my hospital service by a well-
known member of our profession. Her history was as follows:
After a long tedious labor with little progress and with fetal
heart showing evidences of weakening, her physician, a very
able obstetrician, decided to deliver her with forceps. The
administration of chloroform was intrusted to a monthly nurse
who soon after the application of the forceps had the misfortune
to spill a portion of the bottle of chloroform upon the face of the
patient. She had received but little of the anesthetic by
inhalation and now coming out of its influence and feeling the
burning from the chloroform on her face and eyes she became
almost frantic. With one kick (she was a powerful woman) she
deposited her obstetrician on the other side of the room and in
the next moment threw herself forceps and all against the wall
beside her bed. Her next move was to raise herself and fall
on the handles of the forceps. By this time her physician was
by her side and slipped off the forceps. The head which was
previously engaged was now found receded and freely movable,
version was performed and the child easily extracted. It
lived about two hours but seemed injured about the neck.
Examination of the patient on admission to my service showed a
rent through the anterior uterine wall extending from cervix to
within about an inch of the fundus but not opening the peritoneal
cavity, i,e.y an incomplete rupture. This rent and the sub-
peritoneal space in front of it were packed with iodoform gauze
and the patient recovered giving birth to another child two
years later.

Postpartum Injuries. — ^The most important and most frequent
postpartum uterine injuries are those associated with attempts
to empty and cleanse the uterine cavity. This applies especially
to cases in which the uterine contents or the uterine wall itself
is more or less infected and this holds equally true whether the
pregnancy has ended in abortion or in full-term labor. Of
these injuries perforation will be first considered. If a clean



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cragin: injuries to the puerperal uterus. 191

uterus recently pregnant is easily perforated just because its
wall has been softened by the pregnancy, much more easily is a
uterus perforated which has been both pregnant and infected.

Many of us have seen these infected uteri after removal,
through which the curette or sponge holder could be passed with
almost as much ease as through dough. Hence the importance
in cleansing these septic uteri of secundines, blood clots, etc.,
of using the instrument which will do the least harm. This in
the opinion of the writer is the sterilized finger wherever the
dilatation of the cervix will allow of its introduction.

In cases where the cervical canal will not admit the finger or
fingers, some substitute must be employed, such as the blunt
firm curette, sponge holder, etc., and here with the same precau-
tions as recommended when discussing the cleansing of the uterus
after abortion, namely, counter-pressure upon the fundus;
the very gentle introduction of the instrument, and limiting
whatever force is employed to the outward stroke.

The injury to the postpartum septic uterus which is frequently
inflicted and its importance too little recognized, is a traumatism
opening up new avenues of infection in attempts to cleanse the
uterine cavity. The impression that because a woman shows a
rise of temperature a few days after her delivery, her uterus
should be vigorously curetted and frequently douched has
undoubtedly been the cause of many a death.

A single intrauterine douche carefully given by a competent
man will occasionally, in the presence of septic material in the
uterine cavity, so injure the wall of the uterus as to open a new
avenue for absorption of toxins at least, as is shown by a rigor and
marked rise of temperature within an hour or two following
the douche. If by this procedure the uterus has been cleansed
of septic material and the temperature after its rise falls to normal
and remains so, the result is considered as justifying the means
in spite of the penalty of a rigor and rise of temperature.



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 20 of 109)