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The American journal of obstetrics and diseases of women and children online

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have used with very gratifying results when the temperature
of the air will permit of its use. I have in a number of instances



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408 RAKESTRAW: OPERATIVE TECHNIC IN ITS RELATION TO SHOCK.

relieved a patient of restlessness (so-called nervousness) by this
open-air and sunlight treatment when drugs under other circum-
stances would have been indicated.

Immediately upon recovery of the patient from anesthesia
I begin giving water by mouth in quantities sufl&cient to assuage
thirst when a patient is not suffering nausea from peritoneal
irritation. Ice and ice-water are objectionable for various
reasons and I never permit their use. Cool water, cool enough
to be palatable, when it does not cause painful peristalsis is
preferable, but if, for any reason, it causes discomfort or pain I
resort to water heated to the temperature of hot tea or coffee.
Tepid water I have always found nauseating. When a patient
is vomiting, water by mouth washes out the stomach, frees it
of the irritating ether and decomposing mucus, and soothes the
gastric mucous membrane. Some of it getting into the intestine
produces a peristalsis that is gentle and drains the gastro-
intestinal contents toward the exit. Ileus is consequent in
part on the excessive irritation of the toxic substances in the
intestinal canal. Water dilutes these irritants rendering them
less effective locally and preventing their absorption.

The introduction of water into the system is the most impor-
tant measure in postoperative treatment and when it is absorbed
by the tissues, it raises the blood-pressure, acts on the skin and
kidneys, dilutes the urine, and hastens the elimination of the anes-
thetic and toxins. In the vomiting of peritoneal irritation
water by mouth is contraindicated, for it produces painful peris-
talsis and, in case of infection of the peritoneum, spreads the
infection and prevents localization of the process. When water
is contraindicated by mouth for the above reason, we should
resort to its administration per rectum. For effecting this
successfully the best procedure is that advised by Murphy.
An ordinary fountain containing warm saline solution at ioo° F.
is fixed at an elevation sufficient to cause a gentle pressure that
is not uncomfortable to the patient. To the fountain is attached
a tube long enough to reach the patient, but not of such a length
as to permit chilling of the solution. To this is attached a nozzle
that is so curved that it will fit comfortably in the rectum and
be retained there. On either side of the tube next the patient's
body two hot-water bottles are placed to keep the solution warm.
This constant flow under gentle pressure forces the solution
up into the' bowel and the reverse peristalsis carries it upward
into the colon where absorption is most active.



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RAKESTRAW: OPERATIVE TECHNIC IN ITS RELATION TO SHOCK. 409

It is a serious mistake to give food too soon after operation ; for
if it is not readily digested, it decomposes, adding toxins to the
already surcharged system. The digestive system is not, as a
rule, ready for work until the bowels have moved. If hunger
causes the patient very much annoyance simple broths will
answer.

To prevent ileus and prepare the stomach and bowels for
food, castor oil and calomel are the most used. Calomel given
immediately after operation will at times relieve nausea and by
its antiseptic action will stop fermentation and its consequent
gases from distending the bowel. Usually a dose of a quarter
of a grain is all that is required to do this. To relieve abdominal
distention, the insertion of the long rectal tube or the use of hot,
high enemas are of great benefit, keeping always in mind no
measure is to be employed that causes severe or prolonged
suffering.

The bowels cannot be moved until a certain amount of reaction
has set in, and it is always best to let a patient rest during this
period. The best results are at times secured by first moving
the bowels with oil and enemas, and then if calomel is indicated
it can be given with less discomfort.

The improved methods of suturing enable our patients to
assume various postures for the relief of aching and restlessness.
At times nausea can readily be relieved by placing the patient on
a backrest. Any position that does not interfere with drainage
nor cause pain can be assumed by a patient without harm.

Drugs, — From Dr. Crile's findings strychnine is decidedly
harmful in shock and, when given on the operating-table, is con-
ducive to it. If shock is due to an overstimulation nothing
but harm can accrue from adding to that stimulation. At times
strychnine will appear to be of benefit, but that is when the
shock has passed away and the pendulum has swung from
excessive irritation to an overrest, but just when this condition
is present it is impossible to determine. Strychnine is not a
heart stimulant, but it is a vasomotor excitant: it renders the
tissues and cells more excitable. I have seen patients in shock
given strychnine until they had convulsive moven^ents without
the heart being stimulated. Such patients usually die. During
shock Roger tells us the cells are inactive, benumbed by their
own toxins, then how can they absorb and utilize a drug injected
under the skin? When such practice is employed, the drug
usually lies in the tissues for dose after dose until the normal



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410 RAKESTRAW: OPERATIVE TECHNIC £N ITS RELATION TO SHOCK.

reaction begins to take place, and then it is all absorbed at once.
This proves what folly it is, how unscientific, for a drug to
be ordered given at regular intervals, so much every hour,
irrespective of its action or indication. Every dose of any drug,
however simple, should be given according to indications and
never so much every hour or two until seen again. For we can
never prophesy just how much of it will be beneficial; and when
we give more than enough to be of good, we are doing harm.

Phillippen established the fact that in shock there was present
an autointoxication, the result of disorders occurring in cellular
nutrition. This is positively the strongest argument against the
use of morphine that can be advanced. We know that morphine
blocks the organs of elimination — the skin, the kidneys, and the
bowels. It also stops the processes of digestion encouraging
gastrointestinal fermentation and interferes with leukocytosis.
Now, if shock is a toxic condition, of what benefit can a drug
be that stops or interferes with the elimination of toxins from
the body? If the dose could be regulated to a nicety and just
enough given to overcome the excessive irritation and not para-
lyze the eliminative functions it would be of great benefit, but
as this cannot be done we must always use morphine with the
greatest caution. There are times, of course, when we must use
it, but experience teaches that we can often relieve pain without
its use by the employment of measures that reach more directly
the cause of the pain. And this is the more scientific, for mor-
phine merely masks symptoms and never reaches the source of
irritation. I have had cases that complained bitterly of pain
to the nurse and on going to see them have simply sat beside the
bed and with a few words of assurance relieved their anxiety,
and they realized that the pain was not as severe as they imagined.
Mental suggestion is a wonderful force at times in these cases and
every nurse should be taught its use and value. A patient
coming out of an anesthetic is undergoing a relaxation from a
nervous strain that dates to a period long before the time of
operation. After it is all over, the primary excitement swings
back to the other extreme of depression and he needs an encour-
aging intellect to splint his shattered will. To receive a call
over the phone from a nurse that the patient is suffering pain
and then simply order morphine is against the very principles of
scientific interest in a case. Morphine never fails to increase
intestinal inactivity and it always prolongs the elimination of
the anesthetic.



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RAKESTRAW: OPERATIVE TECHNTC IN ITS RELATION TO SHOCK. 411

The introduction of water into the system, elevation of the
feet to permit the gravitation of the blood to the head, warmth
to the body and extremities, and enemas to relieve gaseous
distention are the measures to be first employed. Then oxygen
given by inhalation, or exposure to the open air and all measures
that encourage the elimination of the toxic products in the blood
and tissues is the best procedure.

Intravenous infusion is not indicated because the lowered
blood-pressure is not due to hemorrhage; the vasomotor system
is relaxed and the vessels flaccid. To force solutions into the
blood under these circumstances is to overcrowd the circulation
and flood the tissues.

Hypodermoclysis is at times of great benefit, for it forces the
absorption of liquids, acts on the kidneys and skin, and washes
the blood and lymph systems. A small quantity administered
with a gravity apparatus is better than the use of a Davidson
syringe. The tissues will take the water by gradual gentle
pressure without injury, while forcing water into the tissues
often bruises them and adds to the shock.

But, after all is said and done, the more we improve our
operative technic the less after-treatment we will be called upon
to employ. When we have been gentle and effected our purpose
with the least possible traumatism, when we have used only
that haste that is consistent with thorough work and kept our
patients well protected against exposure, they get well by being
let alone.

The points of this paper that I wish to emphasize are the
following :

By completing all preparations of the operative field before
an anesthetic is administered the time of anesthesia is reduced.

In preparing the patient for operation the sheets and blankets
on which he is to lie during the operation should be kept per-
fectly dry. At the same time he should be kept warm and
guarded from exposure.

Placing a patient on a veranda in the open air facilitates his
recovery from the anesthetic and prevents the prolongation of
nausea from the odor and reinhalation of the anesthetic.

Sunlight is a sedative and will relieve nervousness.

Change of posture will relieve backache and restlessness.

To irritate the skin with a scrubbing brush is harmful and not
necessary.



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412 RAKESTRAW: OPERATIVE TECHNIC IN ITS RELATION TO SHOCK.

Tight Stitching of wounds causes pain in the wound, tissue
necrosis from pressure, and invites infection.

Cold or dry gauze applied to the peritoneum causes irritation
and shock. It abrades the peritoneal surfaces and invites
adhesions.

Stimulation should always be supplemented by nutrition.
Stimulation without nutrition disappoints the organism and
tends to produce a serious reaction.

Strychnine is not indicated in shock because it adds to the
condition by stimulating the already excessively irritated nerve
centers.

Morphine confines the toxins in the tissues by interfering
with the organs of elimination. As shock is largely a toxic con-
dition, the relief of which is dependent on the elimination of the
toxins in the organism, morphine aggravates the condition.

By giving water by mouth immediately after operation it is
rapidly absorbed, or if vomited it washes the irritating sub-
stances out of the stomach and relieves the nausea. When
absorbed it induces intestinal, renal, and sudoriferous excretion
much more rapidly than any other agent by raising the blood-
pressure in a normal way. When it cannot be taken by mouth
or when such would do harm, we should resort to proctoclysis.

Forcible packing of gauze in the abdominal cavity irritates
the intraabdominal structures by pressure and shocks the
organism.

The practice of giving drugs regularly at intervals irrespective
of indications is harmful. In shock no treatment should be
given unless indicated at the moment of its administration.

An anxious patient will magnify his pain and anticipate
its increase until he is on the verge of panic at times. In such
a case a few words of assurance that all is well will work wonders.

Lastly, shock cannot be treated intelligently until that which
caused it is understood. The treatment then consists in re-
moving the cause.

In an article on "Diffuse Peritonitis" in the last Annals Dr.
Deaver says: "The use of morphine in the treatment of perit-
onitis cannot be too strongly condemned. Before operation
it deceives both patient and surgeon and may be the cause of
operative delay. It retards peristalsis, but the- good effect in
this respect is overcome by the increase in intestinal retention,
in this manner adding another factor of toxic absorption to that
which is already great enough. Moreover, opium has been



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pinkham: the treatment of septic abortion. 413

found to dimmish leukocytosis and thus in another way to act
against the protective forces of the body.*'

Dr. R. H. Harte says that *'The routine dose of morphine
before a patient is etherized is in time liable to lead to serious
results, numerous cases being reported where this dose has been
fatal."

1 2 East Liberty Street.



THE TREATMENT OF SEPTIC ABORTION,
With a Few Remarks on the Ethics of Criminal Abortion.*

BY
EDWARD W. pinkham, M. D.,

New York.

The occurrence of sepsis following abortion is so extremely
common that a consideration of its pathological character and
of its proper treatment becomes of great importance. In the
brief space of time allowed me for reading this paper, it will be
possible to consider the subject only in outline. The remarks
upon certain ethical features of criminal abortion are added at
the suggestion of our President.

Although an infection following abortion may be due to any
one of a great number of pathogenic organisms, the most common
are the staphylococcus and the streptococcus. The same organ-
ism may exhibit different degrees of virulence at different times
and under different conditions. To me it seems that the mode of
entrance into the system, together with the resistance encoun-
tered, may account for the varying degrees of severity observed in
the symptoms of most of the cases. If a germ enters the system
through a wound, its pathological progress will be more rapid and
violent than if it were deposited on a mucous surface. People
of apparently robust constitution, who have a hereditary or
acquired deficiency caused by syphilitic, tubercular, or other
taint, as well as those who have been weakened by disease, over-
work, or excesses, have in their cellular economy less power of
resistance to bacterial invasion than others in better condition
and are not so well prepared to fight infection or to respond to
the action of therapeutic agencies. Hence, in some cases the
same organism seems very virulent, in others less so. The extent
of the infected area and the duration of the process of absorp-

♦ Read before the New York Obstetrical Society, December 14, 1909.



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414 pinkham: the treatment of septic abortion.

tion also have a great deal to do with the severity of the symptoms
and with the outcome of treatment.

The most common organism found in cases of criminal or,
more properly, of unscientifically induced abortion is the
streptococcus haemolyticus. If the organism is deposited on a
mucous membrane, it produces a catarrhal condition which ex-
tends over the surface and spreads to contiguous structures. If
planted in the connective tissue of the submucosa, an inflamma-
tion which is phlegmonous, more or less quickly spreading, and
becoming seropurulent, fibrinopurulent, or purulent, is the re-
sult. In the exudate surrounding the focus, the cocci may be
found free or partly imbedded in cells (Ziegler). If muscle
becomes involved, the cocci increase rapidly and spread quickly,
chiefly into the connective tissue, and are taken up by the lym-
phatics. The phlegmons run a rapid course, and usually lead to
tissue necrosis and suppuration. The appearance of the cavity
of the uterus varies with the presence or absence of placental
formation, but in every case there is the phlegmon from which
the infection may be spread. Usually, in septic abortions, the
method of introducing the organism is by instrumentation.
This means that in most cases the abortion has been induced
either by the woman herself or by some professional abortionist.
It may happen that the infection is deposited on the surface, but
usually it is introduced under the mucosa or deeper, into the
muscle, through a wound. This condition is practically the same
if the wound has been made at the placental site or in the placenta
itself. The infection may be carried from the original focus to
the peritoneum by the lymphatics or by means of the Fallopian
tubes. In some cases, especially those which occur toward the
latter end of gestation, the cocci enter the blood current, produc-
ing a septic thrombosis, or the condition termed bacteremia.
Nature's physiological guard, generally speaking, against the
spread of infection within the body, is the lymphatic system.
The lymph thrown out in the presence of the cocci, however,
seems to form an excellent medium for their multiplication.
The exudate around the phlegmon is made up largely of phago-
cytes sent to the locality to destroy the organism, a work which,
to a greater or less extent, they accomplish. But microscopical
examination of foci of infection thus surrounded, has demon-
strated cocci, some of which have been shown to possess viability,
thus proving that the phagocytes cannot always complete the
work which they were sent out to perform. In all cases of sepsis,



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pinkham: the treatment of septic abortion. 415

toxins are produced by the infecting organisms, and these carried
into the blood cause the most notable symptoms of the condition.

The treatment of septic abortion, it seems to me, should have
a purely surgical foundation or beginning. With that idea in
view, the first thing to do is to remove, as far as possible, the
focus or foci of infection. When the pregnancy is far enough
advanced for placental formation, the dull curette may be of
service in removing the secundines. But lying deeper is the
phlegmon with its active cocci, which still remains the focus.
The dull curette will make no impression on this, only the sharp
curette can perform the necessary service. Great care must be
used, of course, to avoid perforation or too much mutilation of
the musculature. One of the strongest objections brought
forward to the use of the sharp curette is that it removes nature's
barrier to the spreading of the infection. This I believe to be a
fallacy, for the pathological reasons which have been stated.
The question of Goffe, If nature walls ofif the uterus, why do pa-
tients die ? is very pertinent. It is customary to speak of empty-
ing the uterus in these cases. Of course it is proper to do this
when there are retained secundines, but even then the removal
of the more deeply seated focus is as necessary as before the
placenta is formed.

I have seen on autopsy the lining of the uterine cavity a mass
of necrotic tissue in cases where either the dull curette had been
used or no curretting done, the cavity having been packed with
gauze or irrigated. In these cases — three in number — a laparot-
omy had been performed with both posterior and abdominal
drainage. What chance have the vital forces of the patient in a
contest with these nests of constantly multiplying bacteria?

If the work in the uterine cavity had been more thoroughly
done in the first place, there might have been more chance of
saving the patient's life by the major operation that was re-
sorted to.

Applications to the uterine cavity, after curettage, of the
various antiseptics, iodine, iodoform, carbolic acid, etc., may
perhaps be of benefit. Gordon {Brit. Med. Journ., April, 1908),
strongly recommends the application and subsequent employ-
ment of undiluted Izal following the use of the sharp curette
in puerperal sepsis. The intrauterine douche, so commonly
employed, is strongly condemned by Gordon and other writers
as of no value, and possibly in some cases harmful.

Drainage is, of course, positively indicated. Packing the



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416 pinkham: the treatment of septic abortion.

uterus and pelvic cavity does not always give satisfactory drain-
age. The gauze soon becomes clogged and is a menace instead
of an aid. Most surgeons favor the cigarette or gutta-percha
drain, while some adhere to the tube, glass, or rubber. The
upright, or Fowler, position, greatly aids in carrying off the
discharges. If a laparotomy is done, it may be necessary, in
addition to the drainage of the pelvic cavity, to remove the
adnexa or even the uterus. It is my belief that every case of
septic abortion, whether there are signs of peritonitis or not,
should have a posterior section and insertion of a drain, for there
is no way of determining beforehand, the extent or severity of
the infection. Goffe, Vineberg, Lantas, and others, may be
referred to as supporting the surgical principles thus far outlined,
with perhaps the exception of the last.

Scarcely second in importance to the surgical procedures
which have been mentioned, are those measures of treatment
which have for their object the neutralization or destruction
of the poisons which have become absorbed into the blood.
Of these measures, I mention first the use of the so-called salt
solution by hypodermoclysis, intravenous transfusion, or by
seepage into the rectum. In whatever way this remedy acts,
whether by diluting the toxins and thus rendering them less
harmful, or by increasing the volume of blood — in this help-
ing the action of the heart and promoting elimination — its
worth has been proved in many cases and is generally recog-
nized by the profession. Prompt and frequent administration
of the remedy is to be recommended in all serious cases.

For antagonizing the germs and their toxins directly, various
specific remedies have been proposed. Some of these have
had their enthusiastic supporters for a while, only to be dis-
carded at last because they did not prove to be the expected
panaceas. That they have been of service and are still valuable
is attested by many competent observers. Perhaps the most
familiar treatment of this kind is that by the sera and the prepa-
rations of dead bacteria called bacterins or vaccines. I have
had some experience with these agents, but so far the result
has been negative. The failure may have been due to some
fault in the technic of administration, or to a lack of persist-
ence in the use of the remedies. With further and more careful
trial, a different showing may be made. Nozzi (Italy), Mayer,
Miiller, Atonson, and Henkel write in favor of these methods
of treatment. Von Miculicz proposed an artificial leukocytosis,



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pinkham: the treatment of septic abortion. 417

produced by the use of nucleogen. The best results with all
these remedies have been obtained in early cases. Henkel and
Miiller claim that these antidotes are efficacious only as pro-
phylactics or in early cases. French writers, especially, advo-
cate the use of colloidal silver, coUargol. Herring reports ex-
cellent results, and advises intravenous injections in doses of
from five to fifty centigrammes. Doyen, Le Calv^, Maroken,
and others speak favorably of the remedy thus administered,
but say they have had the best results in early cases. Brindreau,
in Bull, Soc. d'Ohsiet. de Paris, 1908, advocates the use of Metch-
nikojff's preparation of lactic acid bacilli, introduced into the
cavity of the uterus, on the theory of the natural antagonism
of that bacillus for the streptococcus.

More important, perhaps, than anything which has so far been
mentioned is that line of treatment which may be called support-
ive. We must not lose sight of the fact that in all successful
cases the real cure is wrought by nature herself, and that what-
ever we may do is only an aid to her eflForts. When attacked in
her citadel by her foes, the death-bearing microbes of infection,
she sends out her armies of protection, the phagocytes, to de-
stroy the germs, and, to neutralize the toxins that they pro-
duce, she manufactures an antitoxin which,* being autogenous,
is always more or less effective. In scores of mild cases, and
even in some which are severe, she is equal to the task of cure



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 42 of 109)