Etiology and treatment of puerperal sepsis.
GEORGE C. PORTER, M.D., LINTON, IND.
Puerperal sepsis, as the name implies, is an infected condition of a lying-in patient, incident to the delivery of a child. The sepsis must be transmitted from without to the inside. The requisites for this infection must include an open or absorbing surface through which the infection passes. This will include lacerations of the cervix or perineum, or the forceful separation of some part of the secundines from the wall of the uterus. Retained placenta is a fruitful source of such conditions.
Introduction of the sepsis from the without must come from improper sterilization of the hands or instruments of the accoucher or attendant, along with improper preparation and sterilization of the parts involved. It should be regarded as negligent on the part of the attendants to have the development of sepsis in any given case of parturition. The infection may be introduced by the use of unsterile napkins, gowns or bed clothing or not infrequently has it been brought about by the use of an unsterile syringe nozzle in giving cleansing douche. The infection is streptococcic.
Treatment.—The treatment is antiseptic throughout. I should divide the treatment of puerperal sepsis into three distinct phases, viz., hygienic, surgical, and medical.
Hygiene.—The patient should be placed in a light, well-ventilated room cleared of all unnecessary furniture, curtains, etc. All clothing should be removed, followed by a cleansing sponge bath; patient provided with a short, white slip for gown. The hair of the pudendi should be removed and a sterilization of vaginal vault made with Lysol solution, strength 1 to 1,000 parts of sterile water. Patient should be placed between two laundered sheets. Diet should be liquid to soft, depending upon severity of lesion, giving abundance of hot water, as nearly all these cases are dehydrated. Attention should be given to free action of both kidneys and bowels. A saline laxative is preferred.
Surgical.—After proper preparation of patient and physician and sterilization of instruments, a careful survey of the womb should be made, examining for retained placenta and lacerations. An intra-uterine wash of Lysol solution, strength as of above, at the temperature of 105 degrees. This will dislodge all fold debris and cleanse the uterine cavity, thus arresting absorption of septic material.
If there is found to be any retained placenta, forceps should be applied, inviting its removal. Care should be exercised to not opening any more surface for absorption.
The curette is not to be used, and perhaps never in a case of puerperal sepsis, lest a disturbance of the endometrium will allow free absorption of the offending material, and in this manner create more harm than is possible to do good.
All lacerated or abraded surface should be touched with silver nitrate solution 10 per cent, to close and prevent farther absorption at these points. Intra-uterine wash should be used once in twenty-four hours for two or three days, when it can be withheld, unless further emergency exists for its continuance.
Sterile pads should be provided and precaution taken against the continuance of the infection. If the case is bad, with low resistance of patient, 500 cc. or normal saline solution should be given intra-venously or by hypodermoclysis, to be repeated as indications may call for.
Medical.—Internal medicine should be directed against the septicemia and for support of the patient. With high and intermittent fever, 5 to 10 grains of quinine should be given at intervals of four to six hours, when temperature is down. If peritonitis be present, it should be met with aconite and bryonia in suitable doses. If inflammation of the uterus, aconite and macrotys, or phytolacca and macrotys, should be given in suitable doses every two hours. Echinacea is of prime importance in combatting the internal sepsis and should be given throughout.
The heart and circulation must be supported with cactus and strophanthus, as indicated.
The bowels and kidneys should be kept working abundantly. In extreme cases of septicemia, I have had wonderful results from the intravenous use of sodium iodide, 10 cc. doses, at intervals of twenty-four to forty-eight hours until the sepsis was controlled.
Attention should be directed in the convalescing stage to the upbuilding of the general strength and blood of the patient. To this end, iron in some form, along with arsenic, is splendid. Lloyd's iron answers admirably at this stage of care, as it supplies an assimiable form of iron with phosphorus and does not disturb the stomach or mouth.
Do not overlook the action of veratrum viride. In hepatitis, nephritis, engorgement of the viscera, it proves to be a very dependable antiseptic as well as an alterative of no mean ability. In puerperal convulsions we have used it time and again with great success. Lack of space here prevents us from lauding this drug in erysipelas. Use it. It will help you.
National Eclectic Medical Association Quarterly, Vol. 26, 1934-35, was edited by Theodore Davis Adlerman, M.D.