Cases of Sporadic Septicemia 
in Gynecological 
Practice 
BY \ 
JAMES R. CHADWICK, M. D. 
bostOR, faAss. 
REPRINT FROM VOLUME IV. 
<&Dnctol0guaI Crans'acttontf 
1880 CASES OF SPORADIC SEPTICEMIA IN GYNE- 
COLOGICAL PRACTICE. 
BY JAMES R. CHADWICK, M. D., 
Boston, Mass. 
Burdon-Sanderson defines septicemia as “ the aggre- 
gate of effects which are produced in the animal organism 
when putrid matter is mixed with the blood-stream ; or, in 
other words, as a constitutional disorder of limited duration, 
caused by the entrance into the blood-stream of a certain 
quantity of septic matter.” 
This absorption of septic matter has long been recog- 
nized in surgery as liable to take place whenever putrid 
discharges come in contact with denuded surfaces. In ob- 
stetrics, this disease is now generally accepted as the path- 
ological condition pertaining to the gravest forms of puer- 
peral disease. The role which it plays in gynecological 
practice is scarcely less important, though less appreciated. 
The peculiar conditions which determine its genesis are 
not fully elucidated, yet the prime requisite is avowedly 
the contact of septic matter with a surface preternaturally 
endowed with the capacity of absorption. In the puerperal 
uterus there always exist, of necessity, extensive surfaces 
denuded of their natural covering, and hence prone to ab- 
sorption. Blood-clots, and the frequently retained pieces of 
placenta and membranes, supply the materies morbi. In 
the unimpregnated organ, tumors, polyps, and epithelial 
growths, disintegrating, either as a result of nature’s pro- 
cesses, or of instrumental interference, often give rise to 
septic matter, which may be taken up by the raw surfaces 
over which they needs must pass in escaping from the 
body. 2 
As the character and symptoms of septicemia, when it 
supervenes in this class of cases, lack full appreciation by 
general practitioners, and the necessity of immediate treat- 
ment by intra-uterine disinfectant injections is not univer- 
sally admitted even by specialists, I deem it wiser to pre- 
sent the subject pictorially by recounting the only cases 
which have come under my observation, than to discuss 
the topic systematically, especially as that task has been 
most ably done by Dr. Jenks in the paper to which you 
have just listened. 
Case I. — Septicemia from Retained Placenta after Abortion. 
Recovery} 
Mrs. R. came to me whep she was between four and five 
months along in her second pregnancy, with the story that she 
had had a sudden severe hemorrhage a week previously. Six 
days later she came to my dispensary, saying that she had miscar- 
ried in the preceding night. On examination the os admitted 
two fingers, which readily recognized the presence of the pla- 
centa. The patient was put to bed and plied with ergot; there 
was no loss of blood, but after thirty-six hours a dark, offensive 
discharge began to come away. On the third day the pulse went 
up to 96, the tongue was coated, the patient was feverish. The 
abdomen was not tympanitic, or distended ; neither was it the 
least tender, nor was the uterus. I concluded that there was ab- 
sorption of septic matter from the uterus, and deemed it impera- 
tive to remove the placenta without further delay. Accordingly, 
on March 5, with the assistance of Dr. Bixby, I sought to effect 
this object with only partial success, for, though the os was widely 
open, the placenta was so firmly adherent that no force could de- 
tach it. My forceps every time brought out their fill of placental 
tissues, but the mass of the placenta remained. Having by this 
means removed one half to three fourths of the mass, I was 
forced to desist, from the failure of the patient’s pulse owing 
to loss of blood. To check further oozing, I injected liquor 
ferri perchloridi, one part to four of water. This was effectual. 
On the next day the patient was quite easy till night, when she 
CASES OF SPORADIC SEPTICEMIA. 
1 This was reported to the Suffolk District Medical Society nearly 
three years ago, and was published in the Boston Medical and Sur- 
gical Journal, September 7, 1876, xcv., p. 295. suddenly had a well-marked chill, followed by headache, malaise, 
and a pulse of 140. There was still no tenderness or distention 
of the abdominal walls, or other symptoms of peritonitis or me- 
tritis. 
I consequently diagnosticated incipient septicemia, due to ab- 
sorption of the blood-clots formed by the iron, and of the pla- 
cental fragments. I immediately washed out the cavity of the 
uterus with a solution of permanganate of potash. This was re- 
peated every night and morning for a week, when the discharges 
ceased to be offensive. On the day following that on which she 
had the first chill, the patient experienced at one time a sensation 
of chilliness. On the following days the pulse gradually fell, the 
headache slowly subsided, and the retained fragments of the pla- 
centa were ultimately discharged. A perfect recovery was ulti- 
mately secured. 
Case II. — Slow Septicemia, following Abortion. Recovery. 
On July 24, 1877, I was summoned by Dr. C. W. Stevens, of 
Charlestown, in consultation about Mrs. H., a multipara, twenty- 
eight years of age. He had first been consulted by her two 
months before on account of a fetid uterine discharge. Discov- 
ering that she was three months pregnant, Dr. Stevens diagnosti- 
cated the death of the fetus, dilated the cervix with sponge-tents, 
and withdrew pieces of a decomposed ovum. Considerable 
hemorrhage persisting, other portions of the placenta were sought 
and extracted. A slow fever then set in, with rigors and evening 
exacerbations. As this state continued, with gradually increasing 
prostration, in spite of vaginal injections of hot water, I was sum- 
moned three weeks after the last operation. In the absence of 
all evidence of inflammatory action in the pelvis, I attributed the 
condition to septic absorption from the uterine cavity, and rec- 
ommended intra-uterine injections of a solution of permanganate 
of potash. This treatment was carried out twice by Dr. Stevens, 
the second injection being followed by an alarming but harmless 
uterine colic. The fetid discharge was at once arrested, the fever 
subsided, and the patient made a slow but perfect recovery. 
Case III. — Normal Labor at Term, with Perineal Rupture, fol- 
lowed by Septicemia. Recovery. 
Mrs. X. was delivered by Dr. B. F. Davenport, on December 
27, 1877. The forceps were applied when the head began to 
JAMES R. CHADWICK. 
3 4 
CASES OF SPORADIC SEPTICEMIA. 
press upon the perineum, owing to the feebleness of the pains, 
but, after a few tractions, were removed before the head emerged 
from the vulva. The placenta and membranes were expelled 
soon after entire. Examination showed a superficial laceration 
of the perineum down to the external sphincter ani. On being 
summoned to operate, I had doubts of its necessity, but finally 
united the torn edges by two deep wire sutures. 
Half a drachm of the fluid extract of ergot was given twice a 
day, and the vagina washed out thrice daily with a half per cent, 
solution of carbolic acid, as prophylactic measures. On the 
morning of the fourth day the lochia was pale, inoffensive, nor- 
mal. Her condition was in every way satisfactory. During the 
vaginal injection at 9 a. m., she was seized with a sudden sharp 
pain in the abdomen, immediately succeeded by a most severe 
rigor, from which neither hot alcoholic stimulants internally nor 
the external application of heat to the body and limbs seemed to 
bring on reaction. 
Dr. C. W. Swan, who was hastily summoned in consultation, 
administered a drachm of tincture of capsicum, after which the 
rigor slowly subsided, having lasted a full hour. Fifteen grains 
of quinine were given in a dose. Temperature 105° just after the 
rigor. Vomiting took place, and caused the expulsion of a blood- 
clot as large as an orange from the vagina. Much hemorrhage 
followed. 
On reaching the house at 4 p. m. I found the patient unnat- 
urally free from pain or discomfort, considering the severe chill 
of the morning. There was no tenderness of the abdomen, or in 
the course of the crural veins ; no abdominal distention or pain ; 
no evidence of inflammation of any kind; yet the pulse and tem- 
perature indicated systemic disturbance. The perineal wound 
was clean and united. I ventured the opinion that septic matter 
had been and was probably still being absorbed and poisoning 
the blood; further, that the process could be arrested by washing 
out the cavity of the uterus by a disinfectant solution. 
With the assent of Dr. Davenport and Dr. Swan, who had just 
joined us, I carried a silver male catheter to the fundus of the 
uterus and injected a solution of permanganate of potash until it 
issued from the vulva unchanged in color. 
At 6 p. m., just after the injection. Temperature 101.80. 
Pulse 100. 
At 10 p. m. Temperature 99.8°. Pulse 96. LAMES A. CHADWICK. 
5 
Fifth day, 8 a. m. Temperature 98.4°. Pulse 84. 
From this time until she left her bed on the 20th day the tem- 
perature ranged from 98.4° to 102.20, and the pulse from 72 to 100. 
There were no subsequent chills or other symptoms calling for a 
repetition of the intra-uterine injections. As a substitute for these, 
and as probably equally efficient, I suggested a method of admin- 
istering vaginal injections of the same disinfectant solution, which 
seems to me deserving of exact description. 
With the patient lying upon her side, the solution was ordered 
to be injected into the vagina with an ordinary syringe and noz- 
zle until the fluid began to ooze from the vulva, the patient was 
then gradually turned upon her face, while the injection into the 
vagina was continued. By this plan I believe that the vagina 
was distended to its utmost, as in the knee-elbow position, while 
the uterus gravitated into the abdominal cavity and allowed the 
fluid to flow through the patulous cervical canal into the cavity 
of the organ with the force of pneumatic pressure and no more. 
Any air that might thus be forced into the vagina by the syringe 
would remain in the vagina, and thus the possible danger of its 
passage into the uterine sinuses be avoided. This method was 
carried out by Dr. Davenport for several days, during which no 
further symptoms of septic infection were manifested. 
The vaginal injections brought away offensive discharges for 
two weeks. On the eighth day the perineal sutures were removed 
and union found to be perfect. The patient left her bed at the 
end of three weeks, and is now in perfect health. 
Case IV. — Normal Labor followed by Septicemia with Erysip- 
elas as One Manifestation, and Malaria as a Complication. Recov- 
ery. 
Mrs. B. was delivered on September 14, 1878, by a prominent 
homeopath of this city, after a normal labor of nine hours. The 
placenta was expelled soon after entire with the membranes. 
The childbed for seven days was normal, although the patient 
was much disturbed during this time by an unruly child. On 
the seventh day she had a severe rigor followed by high fever; 
the lochia was arrested, as was the milk, which latter had been 
secreted in moderate amount since the third day. During the 
ensuing week the temperature ranged from 103° to over 106°, as 
affirmed by the skilled nurse. There were at no time symptoms 
of inflammatory action. After a slight remission the fever be- 6 
CASES OF SPORADIC SEPTICEMIA. 
came exacerbated on the fifteenth day, when erysipelas appeared 
in the gluteal region. On the twenty-first day there was some 
tympanites, and so great prostration that the attending homeo- 
path admitted that the patient could not live a week “ unless 
there was a change.” 
At the suggestion of Dr. H. I. Bowditch, who was consulted, 
the case was placed in my charge. On October 6 (twenty-sec- 
ond day) I found the patient, aged twenty-three, primipara, ex- 
tremely pallid, with impaired hearing, freedom from pain, except 
for tenderness at the parts affected with erysipelas, with temper- 
ature 104.6°, pulse 130 feeble, respiration 34 ; tongue dry and 
somewhat coated, mind clear. The uterus was well involuted 
but in dextro-version. There was no evidence of pelvic inflam- 
mation. I learned that in the previous treatment no stimulants, 
special nourishment, or other than homeopathic doses of medi- 
cine, had been administered. 
This chart shows the range of the temperature, pulse, and 
respiration until complete recovery on the forty-seventh day after 
delivery. The treatment consisted chiefly in large doses of 
quinine, stimulants, beef-tea, etc. The marked remission on the 
morning of the twenty-third day is probably attributable to the 
sudden change of treatment, but the system was still too heavily 
loaded with septic matter to sustain so sudden a rebound from 
its depressed state. From the twenty-fifth to the twenty-eighth 
days, however, a marked improvement is made manifest by the 
chart. This may have been to some extent due to an intra- 
uterine injection of permanganate of potash, made on the twenty- 
fifth day because of a sero-sanguineous discharge, there having 
previously been no lochia for some days, but was chiefly owing 
to large doses of quinine given through the morning to avert the 
midday exacerbations of the fever, which were attributed chiefly 
to malaria, contracted three years since in New York State. 
On the evening of the twenty-ninth day a fresh exacerbation 
manifested itself without apparent cause, and induced me to re- 
sort on the next day to disinfectant intra-uterine injections morn- 
ing and evening, in order to arrest any septic absorption that 
might be taking place without giving signs. On that day she 
had a slight chill at five p. m. On the thirty-first day the intra- 
uterine injection was repeated and again on the evening of the 
thirty-second day, yet on the three following days the fever 
ranged higher, despite the continuance of the injections. No 
intra-uterine injections were given after the thirty-fifth day. JAMES R. CHADWICK. 
On the thirty-eighth day the temperature was taken immedi- 
ately after a chill attributed to malarial origin, as were the chills 
and fever on the fortieth and forty-first and forty-second days ; 
they were treated by increasing the doses of quinine and the 
stimulants. 
On the forty-first day the erysipelas finally disappeared from 
the left foot, it having gradually spread downwards from the 
gluteal regions, where it was located when I took charge of the 
case. 
I have purposely abstained from a wearisome recital of the 
day to day details of treatment, and will simply say in conclusion 
that reliance was chiefly placed in quinine, which was given in 
large amounts throughout, on the forty-second and forty-third 
days between forty and fifty grains having been administered in 
the twenty-four hours. Stimulants were given frequently and in 
large quantities. Beef-tea was given both by the mouth and by 
the rectum. 
Although the erysipelas may be regarded as an effect of the 
elimination of septic matter through the skin, that inflammatory 
process may in itself account for some degree of the fever. 
With ordinary tonic treatment the patient has since been 
slowly regaining her strength and is now, a year later, in perfect 
health, and four months pregnant. 
Case V. — Submucous Fibroid Tumor of the Uterus. Attempt at 
Enucleation. Septicemia. Recovery. 
On March 28, 1877, Mrs- B., of South Boston, aged forty-two 
years, applied to me for the relief of menorrhagia. She had had 
two children and one miscarriage. For five years the menstrual 
flow had been profuse, and been succeeded by a serous discharge 
which lasted for a week. 
The uterus was found to be uniformly enlarged by a fibroid tu- 
mor, so that the fundus rose to the navel. The cervix was hard 
and prominent. The uterine sound passed six inches, its end 
then being felt through the fundus and abdominal walls to the 
right of the tumor. 
I diagnosticated a fibroid, either submucous and presenting by 
a large extent of its surface to the uterine cavity, or polypoid. 
Twenty-four drops of the fluid extract of ergot, three times a 
day, were prescribed, 
On April 20, the patient reported that the loss of blood had 
been greater than before ; the tumor seemed smaller. 
7 8 
CASES OF SPORADIC SEPTICEMIA. 
On May 13, as the hemorrhage was increasing, and the pa- 
tient’s strength beginning to fail, I dilated the cervix with sponge- 
tents, and, with the assistance of Dr. G. H. Lyman, satisfied my- 
self that the tumor was of the submucous variety. The capsule 
was accordingly incised, and an attempt made to enucleate the 
mass. This proved not to be feasible, but its tissues were exten- 
sively lacerated and disintegrated, in the hope that nature would 
continue to complete the process. The hemorrhage became so 
great as to necessitate the injection of a strong solution of liquor 
ferri perchloridi fortior. 
The patient rallied from the operation speedily, and had no 
bad symptoms until the third day. 
On May 16, at 12 m., her pulse and condition were normal; 
there was no occasion for taking the temperature. 
At 4 p. m. she had a sudden severe rigor. At 9 p. M. I found 
the pulse no and the temperature 105.6°. The abdomen was 
very little distended with tympanites, but not tender, although the 
womb was slightly so. There was headache and precordial dis- 
tress. Recognizing the supervention of septicemia, and the 
gravity of her condition, I immediately carried a silver catheter 
into the uterine cavity and washed it out repeatedly with a solu- 
tion of permanganate of potash, until the brilliant color of the 
returning fluid announced the complete disinfection of all parts 
of the cavity reached by the fluid. 
On the following morning she had a slight chill; pulse, 125 ; 
temperature, 103.50 ; the intra-uterine injection was repeated. In 
the evening, pulse, 100 ; temperature, ioo° ; injection. 
I will not weary you with the day to day records of the case. 
There was much offensive discharge, containing shreds of tissue, 
for several weeks. The temperature rose and fell for several 
weeks, being steadily combatted by intra-uterine disinfectant in- 
jections, quinine, stimulants, etc., and did not return permanently 
to the normal until the sixth week. 
The patient made a good recovery, and has had no further 
hemorrhages or bad symptoms, but I have been unable to detect 
any diminution in the size of the tumor in consequence of the 
sloughing. 
These cases have certain characteristic features in com- 
mon. In all it was known that the uterine cavity presented 
extensive denuded or wounded surfaces, in direct contact JAMES R. CHADWICK. 
9 
with which were, or might have been, tissues presumably 
undergoing decomposition. The first symptom in all was a 
severe chill, supervening suddenly upon a state of apparent 
perfect health, not attended or followed by pain, vomiting, 
or other sign of inflammation ; yet in all, a most critical con- 
dition of the general system was indicated by high fever. 
To me, the most characteristic feature of septicemia is the 
abnormal insensibility to pain, taken in conjunction with 
a very high fever. This was manifested in all of my cases. 
Evidence of the presence of septic matter in the uterine 
cavity from offensive lochia is valuable when existing, but 
its absence has repeatedly been shown to be delusive if al- 
lowed diagnostic weight. 
Reviewing the above cases seriatim, we recognize cer- 
tain conditions. In Case I., there was evidence of incipient 
septicemia from decomposition of an adherent placenta be- 
fore the attempt at its removal; the injection of perchloride 
of iron to arrest hemorrhage at the time of the operation ; 
an absence of ominous symptoms for twenty-four hours 
when the patient had a second chill, followed by fever; the 
only therapeutic measure adopted was that of repeatedly 
rendering inert, by disinfection, the only source of septic 
matter, namely, the sloughing remains of the placenta, and 
the blood-clots formed by the iron. The success of the 
treatment fully substantiates the correctness of the diag- 
nosis. 
In Case II., we see that the greater portion of an 
ovum, only three months advanced, was removed by two 
operations ; hence that probably the amount of septic mat- 
ter present was small, and the extent of the absorbent sur- 
faces limited, for which reasons the system was less rapidly 
charged with septic matter, so that a less acute form of sep- 
ticemia ensued ; yet the persistent absorption of septic mat- 
ter tended to undermine the system and threaten a fatal 
result, until disinfection arrested the process and saved the 
patient’s life. 
In Case III., there was no reason to apprehend the 
development of septicemia, yet the symptoms pointed so 10 
CASES OF SPORADIC SEPTICEMIA. 
clearly to that disease, that the appropriate treatment was 
adopted and proved successful. 
In Case IV., the diagnosis is less clear, owing to the 
imperfect data obtained as to the course of the disease dur- 
ing the first fourteen days of its presence, and to its compli- 
cation with malaria. There was no reason to suppose the 
presence in the womb of disintegrating tissues or clots as a 
viateries morbi, yet one of the accepted predisposing causes 
of septicemia — namely, mental worry — existed to an ex- 
treme degree ; moreover, had the initial chill been of mala- 
rial origin, I think it would have been followed by others 
periodically, whereas there was no such recurrence until the 
thirtieth day — a period of twenty-one days. In addition, I 
should not expect so complete prostration to result from 
malarial fever, even in the puerperal period. Finally, the ap- 
pearance of erysipelas on the fifteenth day, post partum, a 
well known effect of the elimination of septic matter through 
the skin, gives further testimony in support of this diagno- 
sis. As there was every reason to suppose that the uterine 
cavity no longer contained decomposing matter on the 
twenty-second day, when I took charge of the case, there 
seemed no reason for the use of disinfectant injections, the 
only indication being to sustain the forces of nature in their 
effort to eliminate the poison already absorbed. Although 
the recurrence of the high fever, later, induced me to in- 
sure the patient by disinfection of the uterine cavity and 
its contents against the possibility of fresh blood poisoning, 
yet I doubt whether that measure had much influence in 
determining the favorable result. I am, however, convinced 
that the long and nearly fatal illness might have been 
checked at the outset by intra-uterine disinfectant injec- 
tions. 
In Case V., a large fibroid tumor had been lacerated 
and blood-clots formed in the uterine cavity by perchloride 
of iron, so that septic absorption was a process greatly to 
be feared, the symptoms were characteristic, and the indica- 
tions for treatment unequivocal. The amount and firm 
structure of the sloughing tissues protracted the septic ab- JAMES R. CHADWICK. 
11 
sorptions for six weeks, yet a persistence in the use of dis- 
infectants was unfailing in its curative effects. At one time 
in the course of the disease, my attention was drawn to the 
fact that a chill for several successive days occurred imme- 
diately after the intra-uterine injection. I suspected that 
the irritation of that procedure was sufficient to evoke a 
chill in a system so thoroughly charged with pyretic mate- 
rial, which view seemed to be corroborated by the absence 
of chills for three days upon intermission of the injections. 
The subsequent recurrence of the chills and other symp- 
toms of septicemia, however, necessitated a fresh resort to 
disinfection by the old method without again, however, 
evoking the chills. 
A few words with regard to the disinfectant. I give 
preference to permanganate of potash, and always carry a 
small bottle of the crystals in my bag. A few crystals are 
simply sprinkled into a basin or cup of hot water and stirred 
until the solution is of deep claret color, no more exact es- 
timate of its strength being required. It is equally efficient 
with any known disinfectant, and has one great advantage 
over all others, in that it gives evidence by a change in the 
color of the solution from a deep claret to a dirty yellow, so 
long as there is putrid matter to be rendered inert; in other 
words, we are thus informed when we may safely desist 
from the operation. I have, moreover, noticed a marked 
astringent effect upon the vaginal walls which has led me 
to infer that besides rendering the putrescent matter inof- 
fensive, it might also so astringe the denuded surfaces in 
the uterine cavity as to deprive them, for a time, of ab- 
sorbent properties. Carbolic acid in solution is objection- 
able, because, in several instances, it has been shown to 
have been absorbed from the uterine cavity with the effect 
of acting as a virulent poison upon the general system and 
causing death. The potash has one disadvantage, that of 
staining the linen ; this I deem a small matter in so critical 
an emergency, and may be specially guarded against. 
The lesson that I wish to inculcate by these cases is this: 
(i) that after all processes — whether natural or artificial 12 
CASES OF SPORADIC SEPTICEMIA. 
— which leave denuded surfaces in the cavity of the womb, 
there is danger of blood poisoning; (2) that if this poison- 
ing be by septic matter the source of the infection may be 
reached by intra-uterine injections and rendered inert by 
disinfectants; (3) that if this be done early in the disease, 
the system will not have been charged with more morbific 
matters than it can eliminate, and consequently that the 
fatal result may be thus averted.