pEPRINT from MEDICAL MIRROR, 
% St. Louis, July, 1891. 
SO7VVE REMARKS 
ON ONE PHASE OF 
PUERPERAIs SEPSIS. 
B Y 
EDWIN WALKER, M. D., PH. D., 
. President Indiana State Medical Society, Evansville, Ind. SOME REMARKS 
ON ONE PHASE OF 
Puerperal Sepsis. 
BY 
EDWIN WALKER, M. D., Ph. D., 
President Indiana State Medical Society, Evansville, Ind. 
It is not my purpose in this brief re- 
port to say any thing on the subject of 
the prevention of puerperal sepsis. 
This has been fully set forth in the 
numerous communications on the sub- 
ject in the last few years. 
So fully have the profession mas- 
tered the prophylaxis of this dreaded 
malady, that a competent physician 
rarely ever has a case in his practice. 
The midwives give us most fre- 
quently the opportunity of studying the 
treatment of " puerperal fever." 
Nor do I propose to discuss the 
etiology of this disease. Suffice it to 
say that, in my opinion, it is fully set- 
tled that puerperal fever or septi- 
caemia is caused by the introduction of 
specific poison into the genitals, where 
it grows and is absorbed or extends. 
The morbific agent may enter the 
circulation from laceration of the peri- 
neum, vagina or cervix, or it may find 
its way to the cavity of the uterus, or 
tube, or peritoneum. 
It may infect the entire organism, 
or be localized and fo*rm a focus of 
suppuration. 
It seems, therefore, that, given a case 
of infection following labor, the indica- 
tion is to ascertain, if possible, the lo- 
cation of the septic material and to 
remove it. 
One condition in which this may be 
accomplished by early laparatomy is il- 
lustrated by the following cases which 1 
will briefly report. 
Case 1. Mrs. B. age 17, primipara. 
Was delivered Oct. 21st, 1890. 
Three days latei' had rigor followed 
by fever, the latter continued until I 
saw her five weeks later. She was at 
that time thoroughly septic, temperature 
ranged from 103 to 104, pulse 100 to 
120. 
Examination revealed a tumor as large 
as a lemon to the left of the uterus. 
Section was recommended and with the 
consent of the family was done the next 
day, November 25th. The tumor proved 
to be an enlarged and thickened Fallo- 
pian tube, a coil of small intestine and 2 
part of the sigmoid flexure of the colon, 
all firmly bound together by heavy 
exudate. In the center was about two 
ounces of pus. The adhesions were 
broken up and the tube removed. It 
was so friable that all ligatures tore out 
and the hemorrhage was stopped by the 
actual cautery. 
The abdomen was washed out with 
boiled water, the incision closed with 
silk worm gut and a glass drain intro- 
duced. 
Fever continued about two weeks. 
After that recovery was uninterrupted. 
She is now entirely well. 
Case 2. Mrs. M., age 25, also primi- 
para. Saw her first five weeks after 
confinement. Was attended by a mid- 
wife. She had fever all the time, but 
never very high. She suffered constant 
pain in the right iliac region. To the 
right of the uterus a tumor as large as 
the first was found. Operation Decem- 
cember lltb, 1890. 
The condition was almost exactly as 
the last case, large tube, ovary and coil 
of small intestine bound by adhesions, 
and in the midst an ounce or two of 
pus. The same difficulty with ligatures 
as in case 1 was experienced. Wound 
was closed and drained the same as 
case 1. 
Recovery rapid and uninterrupted. 
Highest temperature second day 102. 
The next case is somewhat different, 
but illustrates, I think, what might have 
occurred in the other cases, if they had 
been allowed to run their course without 
operative interference. 
Case 3. The history is much the same 
as the others except that the septic con- 
dition was more pronounced. The 
fever ranged from 104 to 105, - there 
were rigors, sweats, and diarrhoea and 
great pain. The tumor was on the right 
side and reached as high as the umbilicus. 
An incision was first made in the me- 
dian line, in order, if possible, to re- 
move the entire mass, but the adhesions 
were too extensive. 
An opening was then made in the 
groin and a pint or more of pus was 
evacuated. Rubber drain was intro- 
duced. Recovery was very tedious. 
I would not in another case, where 
the tumor was so large, attempt to re- 
move it at all. The median incision 
gave us very little trouble, but it is 
quite difficult to prevent the infection 
of the wound in such a case. 
I do not know how frequent such 
cases are. 
We should, however, bear them in 
mind and not wash out the uterus to re- 
move what is not in it. 
Parrish says (Gaillard's Journal, 
October, 1890) that he has seldom in 
post-mortems found cases in which lap- 
arotomy would have been of service, 
but there are undoubtedly some such 
cases, but adds that it requires more 
skill to determine which cases should 
be subjected to section than to do the 
operation. 
Baldy, Price, Woodward, Tait and 
others have reported cases in which 
they have done laparotomy for septic 
infection of the tubes and peritoneum. 
I have no doubt that many of the 
cases of pelvic abscess which run such 
a slow and tedious course could be 
entirely and quickly relieved by early 
laparotomy. 
Where it is feasible we should always 
try to remove the diseased part since 
recovery is so much more rapid and 
probably more complete. 
Ido not feel justified from my very 
limited experience or what I have 
found in current literature, to lay down 
any positive indications for laparotomy 
in puerperal sepsis. 
There are many cases in which the 
tubes are inflamed, or perhaps a tumor 
of the character found in my cases ex- 
ists, which recover without operation or 3 
the formation of an abscess which 
comes later to the surface. 
These cases, however, usually make a 
tedious recovery and many of them are 
of the kind which were formerly diag- 
nosed cellulitis. While some Of them 
improve and perhaps eventually re- 
cover, the greater number remain more 
or less invalids. I remember well a 
case I had some five years ago. 
The symptons, fever, rigors, sweats 
all pointed to suppuration. The tumor 
was distinguishable. 
She lay ten or twelve weeks in this con- 
dition. I thought pus had formed, but 
hesitated about operating. Eventually 
the fever and septic symptoms subsided 
without a discharge of pus in any way. 
The patient slowly improved, - the 
mass has now nearly disappeared, but 
she has never been entirelv well since. 
I believe an operation would have saved 
her much suffering and she would now 
be in better health. 
In closing I would repeat what I said 
in beginning, that puerperal fever or 
better sepsis is the result of an infection 
by a specific virus, and we are to seek 
out its lodging place. If we can find 
the location of the poisonous ma- 
terial, be it in the vagina, uterus, 
tubes or peritoneum, it should be re- 
moved. 
Cases like those reported, in which 
the products of the infection are local- 
ized in the tubes, or in the peritoneum 
by adhesions, and the system kept in 
a septic state, the safer procedure is 
removal by laparotomy. 
With proper precautions the mortal- 
ity should be very small. w-ffluuMl? 
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