of Rhodes. Spurious works Andronicus.

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and mortality of these grave complications of parturition.

The development of obstetric surgery has divided those who
practise obstetrics into licensed midwives, including general
practitioners of medicine, and obstetricians; the former com-
petent to attend normal labors, the latter skilled in the manage-
ment of the complications of pregnancy and labor.

The multiplication of hospitals makes it usually possible to
transfer operative cases. Should this resource fail the obstet-
rician will transport the essentials of surgical technic to the



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DAVIS: president's address. 867

patient's dwelling. The field of obstetric surgery, embracing
the complications of pregnancy, labor, the complete repair of
injuries, puerperal infection, the cure of conditions resulting
from and developing after labor, and injuries to the newborn,
is so large that especial skill and experience only can attempt
to do it justice. The double responsibility of maternal and
fetal life demands for this work special study and training.

In no other department of medical science has competent
specialization so lessened mortality and morbidity.

The mortality and morbidity from puerperal septic infection
outside of hospitals has been but little reduced by asepsis and
antisepsis, not because these methods are inefficient, but because
untrained midwives and incompetent general practitioners
undertake the management of complicated parturition. Nor
will this condition be improved until complicated delivery
receives that surgical attention which has so lessened death and
disease from other causes among women.

Obstetrics offers abundant work for the future. Toxemia and
eclampsia are but partly understood. It is still not proven that
vaginal delivery after opening the pelvic girdle is not accompanied
by such injuries that abdominal delivery is not better; and even
in the repair of lacerations, the final word has not yet been
spoken. It is still an open question whether in puerperal sepsis
we can do more than feed and stimulate the patient. The
effort to give the pregnant woman hospital care before labor, and
the study of what constitutes a rational puerperal period, promise
well and deserve attention.

If these things may be said of our work, what shall we say of
the workers? This Society is to be congratulated that during
the year past no death has occurred among our American
Fellows. But we cannot forget the striking loss of our German
colleagues, when within a few weeks Pfannenstiel, Runge, and
von Rosthorn, were taken from them. Pfannenstiel, our hono-
rary member, won our hearts during his visit in 1908. His
life promised much for science and for his colleagues. His loss
is indeed a deprivation.

This is the American Gynecological Society. While science
is our first love, we cannot forget our duty to our country. It is a
frequent boast that this nation, because of its situation, re-
sources, and numbers, is invincible.

There is no nation which cannot fall a victim to its own decay.
The rapid gain in Wealth, the amazing greed for luxury, the



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868 JOHNSON: POSTOPERATIVE CYSTITIS.

decrease of a sane and natural life, the lessened moral reflex
of the nation and increasing degeneracy, suggest a Roman
parallel for this Republic.

To us is entrusted the physical care of woman in her most
important function, the conservation of the American people.

Our supreme reliance in national crises is the moral sense of
the people. But how can this obtain unless children be bom
with sound brain in a healthy body, and trained from earliest
days to a natural life and prompt obedience. If this republic
is to endure, its women must bring to its altars not the paste
jewels of an artificial luxury, but those gems which made im-
mortal the mother of the Gracchi. Gynecology is an American
science, of which America may well be proud. Let us see to it
that it serves faithfully the land of its birth.

250 South T\\*enty-first Street.



POSTOPERATIVE CYSTITIS.*

BY

JOSEPH TABER JOHNSON,

Washington. D. C.

By postoperative or postpartem cystitis I mean an inflamma-
tion of the bladder which did not exist before the operation or
before the delivery and which followed the operation or child-
birth so closely as to make one reasonably certain that they bear
toward each other indirectly the relation of cause and effect.

While there may be a number of contributory and predis-
posing causes of cystitis, I desire to draw attention in this brief
paper to the too frequent bacterial infection of the bladder by
the bungling and painful use of the catheter by not sufficiently
trained nurses and hospital internes.

All recent writers on this subject with whom I am familiar
unite in ascribing the chief cause of this inflammation to " bacte-
rial infection," the germs being carried up, says Gilliam, by a dirty
instrument or gathered up by a clean instrument in the act of
passing a catheter. Cystitis arising from this cause is much less
frequent now than formerly, owing to the wide spread of knowl-
edge of the r51e played by bacteria in the inflammatory process.

** Despite all this, it is a fact, and a lamentable one, that many
if not almost all cases of cystitis in women are clearly traceable
to faulty methods of catheterization."

* Read before ihe American Gynecological Society, May 3, 4, 5, 191c.



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JOHNSON: POSTOPERATIVE CYSTITIS. 869

My chief object now is to draw your attention again to this
fact and to elicit a discussion which may emphasize the necessity
for a more strict prophylaxis and, when cystitis is diagnosed, a
more active and continuous treatment not only to bring about an
early cure, but to prevent the transition from an acute to a
chronic condition.

Cystitis seems to occur in women more frequently after ab-
dominal than after other operations where there are associated
the evil influences of both traumatism and bacterial infection.
Block found it to follow about lo per cent, of the cases he ob-
served. The traumatism consisted chiefly in the injuries in-
flicted on the bladder during the performance of radical cancer
operations or in supravaginal and panhysterectomies where the
bladder had been peeled ofiF from the anterior surface of the
uterus; I have found the bladder to resent the pressure of gauze
packing inserted into the abdomen to arrest hemorrhage or to
aid drainage from above or through an artificial opening into
the vagina. The overdistention of the bladder by retained
normal urine caused by the use of opium or other reasons will
lessen its resistance against infection from a less number or less
virulent germs than as if no such trauma existed.

Taussig mentions cases where cystitis followed catheterization
notwithstanding the most antiseptic precautions relating to the
hands, the instruments, the introitus vagina, the lubricant, etc.,
and came finally to the conclusion that the infecting germs
were picked up by the cathether in its passage through the
urethra and carried into the bladder. This he proved by finding
the same germs in the catheter-drawn urine, which he subsequently
found by a bacteriological examination in the secretions with-
drawn from the urethra. This same statement is confirmed by
Savor, Rovsing, Raymond, and others. While most observers
have found the staphylococcus to be the mosl frequently ofiFend-
ing germ in the causation of postoperative cystisis, the strepto-
coccus is not infrequently present, especially in puerperal cases,
and Raymond reports seven cases where the colon bacillus was
the cause of the cystitis.

It is probably true that many germs may be introduced into
the healthy bladder and that they may cause no infection or
inflammation in the entire absence of trauma.

My chief contention, however, is " that the ignorant or careless
use of the catheter by so-called trained nurses, overworked
hospital internes, or even by the operator himself" supply both



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870 JOHNSON: POSTOPERATIVE CYSTITIS.

the trauma and infection by their haste and neglect of the gentle
and aseptic use of this little instrument.

Many times have patients complained to me of the pain they
have suffered in the performance of this minor and so-called
insignificant operation, when I had promised that the withdrawal
of their urine would be a painless attention.

Where patients are catheterized several times daily for a
week or even longer, the conditions are present which easily
result in the production of a cystitis unless unusual care is prac-
tised to prevent trauma or infection.

The atrocious pain and nervous trepidation caused by the
very frequent and imperative desire to pass urine suffered by
patients with an acute postoperative cystitis presents a picture
not soon forgotten by them or their friends, the nurses, or the
attending staff. There is very little consolation to be derived
from the thought that this acquired condition might have been
avoided by the exercise of a little more skill, gentleness, and care.

There is a growing tendency among recent writers to class
postoperative cystitis among the preventable diseases and to
speak in severe terms of the "culpable neglect'* of those who
have introduced bacterial infection into the bladder by the un-
skillful or unclean use of catheters. Some of us have come to
regard the routine use of the catheter after our operations with
more dread than we do the routine use of opium. The irritating
effects of the use of one and the acquired and habitual use of
the other have sometimes created conditions which have out-
weighed the importance in the minds of the patients and their
friends of the disease for which they originally sought relief.

The main point in the management of these distressing cases
is their prevention. Perhaps enough has been said of prophy-
laxis when speaking of the etiology to intimate the steps neces-
sary to prevent trauma and the introduction of infection not
only the first time the catheter is used, but every time it is used.

Investigation shows that germs are found to be more numer-
ous and virulent in the genital tract and urethra of patients
confined to bed than in our ambulatory cases, showing that
greater care is necessary to prevent infection of the bladder by
the continuance rather than in the early uses of the catheter.

Rosenstein has suggested a double catheter or a catheter
within a catheter to avoid carrying infection germs into the
bladder; but Taussig and others think this rather bulky instru-
ment would do more harm than good by the painful stretching



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jacobson: the treatment of eclampsu. 871

of the urethra, and suggest that after the careful disinfecting of
the instrument and outside parts that the urethra might be
gently irrigated with a solution of boric acid and the glass
catheter followed by the immediate use of tablets of urotropin
by the mouth which would have for their object the liberation
of sufficient formaldehyde in the bladder to kill the few germs
introduced even after the carrying out of the strict antiseptic
precautions above mentioned.

We are deprived of the advantage, in these cases requiring
the use of the catheter, of the cleansing effect of the urine upon
the urethral mucous membrane, which is so valuable in pre-
venting an ascending infection in cases of urethral gonorrhea.

It is unnecessary to dwell upon the details of the treatment
of actual cases of cystitis, which are as familiar as their A B C*s
to every Fellow of the society.

The writer's object being to direct attention to the still too
frequent occurrence of this painful and embarrassing and un-
necessary complication of our otherwise successful gynecological
and abdominal operations, and to briefly discuss the etiology
and prophylaxis of this almost universally preventable condition.

926 Farragut Square.



THE TREATMENT OF ECLAMPSIA BY CONTINUOUS
SUGAR-WATER INSTILLATION*

BY
SIDNEY D. JACOBSON, M. D., M. R. C. S. (Eng.), L. R. C. P. (Lond.),

New York.

The term Eclampsia is derived from a Greek word meaning to

shine or suddenly appear. It is characterized by convulsive

seizures in which the patient becomes unconscious. It varies

in intensity from a very mild attack, in which there is only some

fibrillary twitching of the facial muscles, to one in which marked

opisthotonos, apnea, and deep cyanosis, with widely dilated

pupils and bloody froth upon the lips, bear witness that the end

is near. To the unobservant the attack appears to have come

on suddenly and without warning. Hence the name eclampsia.

The true physician, however, will rarely be surprised in this

manner. He will notice a slight edema of the eyelids, a puffiness

of the ankles, will know the significance of the complaint of

headache or dizziness, a tendency to vomiting in the latter half

of gestation, and above all will examine the patient's urine and

♦ Read before the New York Academy of Medicine, Section on Obstetrics and
Gynecology, May 26, 1910.



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872 jacobson: the treatment of eclampsia.

find the almost never failing signs of a nephritis — albumin and
perhaps casts.

I say almost never failing signs of nephritis in the urine,
because some authors (probably having copied from others)
claim that it is possible for eclampsia to appear without changes
in the urine. Personally, I have never seen such a case and have
always doubted its occurrence. *

The Clinical Picture. — ^The woman, usually young, very
likely a primipara in the second half of her pregnancy, is in con-
vulsion.

It is only with difficulty that the nurse can restrain her in bed.
Any set of muscles or apparently all muscles may be the subject
of tonic and clonic convulsions. She may be grinding her teeth
and biting her tongue, throwing her arms and legs about, stiffen-
ing her back and neck, or the muscles of respiration may remain
in a state of tonic spasm, preventing the act of breathing, until
deep cyanosis supervenes, the muscles relax, and with a deep sigh
she begins to breathe again.

The convulsion may last a minute or longer and it leaves the
patient greatly exhausted. Upon inspection she will probably
show a slight anasarca, her face will be bloated, her pupils
contracted to a pin-point, and a frothy mucus, perhaps tinged
with blood, exudes from her mouth. The tongue and lips are
swollen and perhaps badly bitten. Her sensorium is clouded:
she replies slowly to questions if they are shouted in her ear.
The pulse is accelerated, likewise the respiration. The tem-
perature may be raised. The most noticeable and important
thing about the pulse is its high tension. It feels like a cord
under the examining finger.

There may or may not be something out of the ordinary with
the uterus or the pregnancy. The patient may be approaching
labor, be in labor, or be delivered. Eclampsia may come on
several days after delivery of the child.

The convulsions recur after some minutes or hours, the
impairment of the senses deepens into coma, the loud snoring
gives place to tracheal "rattles" or r^les, and hypostatic con-
gestion or edema of the lungs ushers in the end. In some cases
the temperature rises considerably before death, 107*^ F. being
not unknown.

The diagnosis is not difficult.

The prognosis will be good if all the symptoms gradually
ameliorate, if the convulsions cease, if the clouded sensorium



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jacobson: the treatment of eclampsia. 873

clears so that the patient will answer readily when spoken to, if the
quantity of urine increases and the respiration becomes regular
and the pulse slow and soft. Memory is usually a blank as to
what occurred after the first convulsion.

The prognosis will be doubtful or grave if convulsions follow
each other in rapid succession, if the temperature is high, if the
very rapid and hard pulse becomes irregular and weak, if coma
is deep, if very little or no urine is secreted, if perspiration is
difficult to induce, and respiration shallow and signs of pul-
monary edema are present. Prognosis should be guarded in
nearly all cases, because experience proves that even after one
or two convulsions deep coma may set in, followed by death.
The amount of urine secreted will be a most important factor in
determining the prognosis. If the quantity of urine is very
small — only a few cubic centimeters — highly concentrated,
boiling solid in the test-tube, and containing large numbers of
granular and epithelial casts, fatty kidney epithelia, detritus,
and blood-cells, the outlook may be considered gloomy.

At autopsy the only constant changes found are degenerative
processes in the liver and kidney parenchyma, shown as cloudy
swelling, fatty degeneration, and necrosis of the secreting
glandular epithelium. The severity or degree of pathological
change found at autopsy varies considerably in different cases.
In some it may be noticed by the naked eye and in others
only careful microscopical investigation will reveal it. It is
remarkable that similar degenerative changes have been found
in the kidneys and liver of the children of eclamptics. Other
changes found are less constant, namely, embolic infarction
caused by liver cells, or by cellular elements of the placenta, fat
embolism, and hemorrhages into serous membranes. Lubarsch
and SchmoTl have given this subject much study and attention.
They maintain that the characteristic signs at autopsy in cases
dead of eclampsia are: anemic and hemorrhagic liver necrosis,
degenerative processes in the kidneys, hemorrhages into, and
softening of, the brain, and formation of multiple thrombi.

Its etiology is not yet satisfactorily determined. The following
theories have the greatest number of adherents: Frerichs states
that it is caused by decomposition of urea in the blood, liberating
ammonium carbonate. The latter if injected into the blood of
animals is known to cause convulsions. As against this view
it may be said that investigation has shown that the blood of
eclamptics does not contain an excessive amount of ammonium



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874 jacobson: the treatment of eclampsia.

carbonate. Lately the ammonia coefficient has been determined
by investigators, but nothing of definite value has accrued
therefrom. Traube believes that brain anemia due to edema
causes the convulsions because the edema compresses the brain
vessels. This theory has been abandoned. Spiegelberg believed
that a reflex contraction of the kidney vessels, which lowered
secretion from the kidneys or suppressed it entirely, was the
cause of eclampsia. Thus the poisons which were to be elimin-
ated by the urine were retained in the blood and poisoned the
system.

Bouchard claims that eclampsia is a form of uremia due to
autointoxication and that poisonous matter which should be
excreted in the urine is retained in the circulation. He went a
step further and sought to prove his theory by means of animal
experimentation. He injected the urine of human beings
intravenously into animals. It developed that the urine of
pregnant women thus injected was less poisonous than the urine
of the nonpregnant. From this he argued that pregnant women
show a tendency to retention of poisons in their system. Fur-
thermore, the urine of eclamptics was even less poisonous than
that of pregnant healthy women. The observations of Bouchard
and his disciples Riviere, Laulanie and Chamberlent revealed the
important fact that the blood-serum of eclamptics is very much
more toxic than the blood-serum of normal women. Ludwig and
Savor repeated these experiments and confirmed the results.
They also found that the urine of eclamptics after the disease
had abated was more toxic than the urine of normal individuals.

Finally came Schumacher, a pupil of Fehling, with proofs that
all the previous findings were wrong and showed conclusively
that the toxicity of the urine and blood-serum of eclamptics
does not depend upon some special poison, but is dependent
upon its concentration. If the concentration of the injected
urine was remedied by dilution, so that it approximated the nor-
mal specific gravity of urine, it made no difference whether the
urine injected was taken from a healthy person, a pregnant
woman, or one with eclampsia, the degree of toxicity of each
was about the same. He came to the same conclusion as regards
the poisonous quality of the blood-serum of eclamptics. Lastly
came the ubiquitous germ. An eclampsia bacillus was dis-
covered. However, it did not occupy the center of the stage very
long, because it was soon recognized to be a harmless micro-
organism which was often found in cadavers.



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jacobson: the treatment of eclampsia. 875

Of other theories supposed to explain the etiology of eclampsia,
only one will be mentioned here, namely, the theory that the
thrombi met with at autopsy are due to an agent causing coagu-
lation neciosis and which has its origin in the fetus (VoUhard).

The writer's belief as to the causation of eclampsia is that in
this disease we are dealing with uremia due to nephritis, and that
pregnancy, labor, or the puerperium are simply coincidents which
may also exert some deleterious influence upon the organism.

Some of the reasons for assuming this stand are :

Eclamptic seizures are common in uremia whether occurring
in man, woman, or child.

The clinical picture is very similar in these cases.

The urinary signs are the same.

The findings at autopsy are much the same.

The prognosis and treatment are the same, except that in
puerperal eclampsia, before delivery, the child has also to be
taken care of.

While it is admitted that during pregnancy, in the presence
of damaged kidneys, eclampsia is more likely to occur than in the
nonpregnant state, it is desirable to bear in mind that preg-
nancy of itself does not cause eclampsia, because in some cases
the convulsions do not appear until the child has been born for
hours or even days.

The writer is of opinion that uremia, or eclampsia, is caused
by the retention in the blood of the salts (principally sodium
chloride) which the damaged kidneys are unable to throw out,
in sufficient quantity, with the urine.

That it is principally this retention of salts which causes the
symptoms of eclampsia by raising the molecular concentration
of the blood and at the same time its specific gravity.

That when by some means — dilution of the blood, increase of
urinary excretion, increased perspiration — by throwing off the
excess of salts, the molecular concentration of the blood is
reduced to (somewhere) near normal, the patient will, at least
temporarily, recover. For reducing the molecular concentra-
tion of the blood in the patient only two methods seemed to be
available :

1. Starving the patient.

2. Diluting the patient's blood by adding water.

It has been the invariable practice of the writer to withhold
food from eclamptics for three days and to permit nothing to be
taken by mouth except water, plain or carbonated.



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876 jacobson: the treatment of eclampsia.

To dilute the patient's blood, administering water by the
mouth was inadequate, because comatose patients cannot drink,
and when awake they may refuse it. In any case water is not
absorbed by the stomach and to do good large quantities must
be administered.

After considering all the routes, the bowel was chosen as the
best absorbing surface.

It seemed to the writer that pure water created irritation of the
bowel. The usual physiological saline solution was rejected as
dangerous and illogical. If the patient is dying from a retention
of salts in the blood it would be worse than folly to administer
more salt in solution. After going over the field carefully, the
writer decided that a solution of sugar would meet all indica-
tions. The reasoning which led to this conclusion was as follows :

The desideratum was to find a substance which, mixed with
the water to be administered, shall be harmless and will not
increase the molecular concentration and specific gravity of the
blood, which are already too high.

Sugar was decided upon because of its high molecular weight.
The weight of a molecule of sugar is stated to be 342, while that
of salt is 58. It is clear that many more of the lighter or smaller
salt molecules will go into a given volume of water, than the
many times heavier or larger sugar molecule. So that the
molecular concentration of the blood would be speedily reduced
by diluting it with sugar water, whereas it would remain the same



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 90 of 109)