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Six cases of puerperal infection
SIX
C14SES
OF PUERPERAL
BY JOSHUA RONSHEIM,
INFECTION”
M.D., BROOKLYN,
N. Y.
N reporting the following cases of postpartum pelvic infection it is my intention to show that these infections are of various distinct types and may be classified as follows : I
1. Endometritis,-the infection remains limited to the’mucosa of the genital tract. 2. Bacteremia,--the infective organism invades the blood stream. This may be (a) directly from the placental site, or (b) secondarily from a thrombophlebitis of the pelvic veins. 3. Parametritis,-the infection spreads through the lymphatics into the parametrial tissues. A less common variety of this type is the lymphatic peritonitis. 4. Pelvic thrombophleb,itis,--the infection spreads through the pelvic veins. 5. Pyosalpinx and its associa.ted conditions, in which the infection spreads through the tubes. This type is almost invariably gonorrheal. 6. Phlegmasia alba dolens. Whether this cond.ition is produced by an exudate in the pelvis compressing the lymphatics or whether the lymphatics forming a network around the pelvic veins are compressed by an endophlebitis of these veins is not definitely understood. Nevertheless, the diffuse white swelling of the thigh resulting from lymph stasis is a definite clinical picture. CASE I.-Bosteremio by direct invasion from the p7acedd site. Mrs. K., a primipara, twenty-three years of age, entered my service at the Jewish Hospital on January 24, 1918, in labor. Labor terminated normally in about nine hours. A About 36 hours nick in the fourchette wa.s closed with one plain catgut stitch. morning, 45 hours after after delivery her temperature rose Co 101”, and, the following delivery, she had a chill with e’evation of temperature to 103.6”. Her only complaint examination showed nothing was of slight pain in the middle of the lower abd.omen; For the next 72 hours there was a gradual but a tender uterus. Lochia was scant. lowering of her temperature, then an elevation to 104” and a fern hours later, following a severe chill, to 106”. Blood culture sh,owed a streptococcus hemolyticus. Death occurred on February 4. This is a case of septic endometritis, then invasion of the placental site as shown by the first chill, then an incubation period, tInally overwhelming invasion of the blood stream.
CASE 2.-Baotercnzia following tluomboph?ebitls. Mrs. S., twenty-eight years of age was admitted to my service at the Jewish Hospital at 3:45 A. %I., January 31, 1923, in the third stage of her first labor. She had had a spontaneous delivery three *Abstract Williamsburg
of paper on “ Pelvic Medical Society, Oct.
Infections :X6, 1923.
359
in
the
Puerperiunn,”
read
before
the
tile rnein~brauea i1aJ xp""'"‘! ~yontaneaa~l~ Jereral &yr !XLLL~ px3viously; and a.t vwious times there2~33 onset of labor. Twenty niinutcv after dclirery, ~.‘tcr, unsuccessful a.ttempts were made to express and extract the placenta. During On admission the vulva vas Eli~‘1 this time the patient wa.5 steadily b!eeding. ..:a~& and the cord vas protruding; ute~~~s flabby with the fundus in the right ‘r,:~pochondrium; no external hlcecling at this time. Hieae sounds mu2 feeble, p&e rcqiratious s!on and sjmllom. Skin and mucous apid and of wxy poor quality, ~rwmhrams showed a marked pallor and the patient constantly begged for water. 3hc was p’aced in the Trende!enburg position and covered vith warm blankets. The .:r!va was shaved and under careful asepsis the placenta was extracted manuaiI~-. ‘3e cc. of pituitrin was given Irypndermica.11 J’ and this, tonl)M with manipulation -4s the husband’s b!ood did not 2. ” the fundus, p~odncecl contraction of the uterus. ~aM-i and as no other donor was arailab!c at that tome she was giren a h~poAt IO:00 .I. x. her condition xl-as much .ie~moclpsis of 1000 cc. saline soiution. 2 her temperature rwc to :Itrproved,-TPR 99--98--20. At 2 :OO I’. u., Febn~ary ‘33” and she comp!aiired of pain in the sacia! icgion and occipital headache. Pulse 53, heart action good, !ungs negative. The abdomen was soft, uterus well tonLrlcted and not tender; no tcndeincss in the flanks or iliac qions, thi~gha, 01 ba?asts. Lochie moderate red. On February 3 Itw condition wa,s the xame, her ,:ily complaint being the sactal pain; her tompcrature .rnw lower. At 1 :OO A. IN.. ‘cbruary 4 she had her first chill with cleration of tempwature to 104.X”. R’ontl : -1lture was taken. Careful examination failed to wvca! an-tihing abnor,mal. RBC :\b.S 2,400,‘300; hi, 45 per cent ; WXC ‘J,2OO with polys 78 par ecnt. R!ood cultul~c~ :.:0x3 a streptococens non-hemolytious. Her condition continued the sanv with xdated ehil~s a:H temperatux ranging from normal to 106” until February 11 ~b%en her chills crawl, he:. temperature vemaincd ~&.eadi!y high and simultaneously FM laboratory reported that t!7e bIood now sliowet! a strcptococcns henro!pticus. 5nc did on the morning of February 15. :hii:.Y
&s13 3.---Pa~anfct~*iii,~. &s. R. S.? twenty-one years of age, a pYimipa.~a vas ~:,*ii in conru!tation on May 3 I, 193O. Hhe had been in labor 40 lIoL7ls. She hat1 c dystocia due 70 diqxoport:on the pelvis bcinp noln~al but the baby o\-ersjzc~l. ‘i’ltc eervis was three lingws d&cd I the inembrancs intact, and a wrtes riding at ix brim. The baby was dead. On admission to the hospital at a:00 P. AL she ‘Ivas ~.q3hinized, my intention being to await full dilatation and then pwforate tlic \~ltCX. The following afternoon she had increased t,he di!atation somewhat and, ‘I~ spite of my expressed desire to let her aione, one of my staff delivered her 1-i:: ,I:-called manual diia.tation and high forceps. The cervix was laCCI’dtcd considerably .::la the perineum nuts lacerated to the Spbilicte~ ani. There x-as an imnwcliate TLR~’ _; Z temperature to 104.4” with pain in the lo-iricr abdomen anil a gradual dewlop :wnlt of a mass in the pwamctrial t,iesucs of the left side. on Augwt 17, the -Lawrty-seventh day postpartum the mass shnmt~d a finftraing and bn’ging in the ,rift anterior fornis and the followinq 7noiGig d this absecss was opened and drained. “UT a few days hc~ temperatwe ~~homd a tendency towar~3 normal but oh August :_), following the rCm0oal of the paeliillg strips in tiie ea\&y the temper,aturc agail] ~CX From this time on her condition remained stationaq and on Septc7nber 1 she .ras sent home, vhcre her treatme~~t was continued. On September 29 another pus ;a.vity was drained just in front of the cervix. ‘This rexltcd in a httle improvt~ :dnt, her temperature showing 8 tendency to remain lower than pre\:iously, althouch 7. still showed the decided rcmisrion~:. 011 OctOhW IS, I::9 days after dciiyeyy 1~1 ..mdition was better than at ally tinw pl cvionsly, but- it ~vas fo,.rnd that her ur+llc,
The diagnosis. mas evident, namely rupture of a pus was no-w practically pure pus. cavity into the b:addcr. She gradually improved, gaining in weight and strength. Every n.ow and then she would have an attack of pain in the pelvis with a rise, of pulse and. temperature coincident with the disappearance from the urine of praetically all signs of pus; this would be followed by a sudden gushing of pus from the bladder, the disappearance of all pain and return of temperature to normal. Cystoscopie examination sho\vcd enormous edema of the mucosa of the fundus with As the treatment produced no innumerable small streams of pus coming through. satisfactory results the patient ma.s persuaded to undergo operation, especially as a mars had again developed in the left side of the abdomen ,with a discharge of pus from the umbilicus. Accordingly, on April 5, 1921, she was re-admitted to tile hospital and operation performed on April 7. On opening the abdomen the mass in the left side was found to be in the abdominal mall, being an exudate The uterus was adherent to the bladder around a sinus leading to the umbilicus. and anterior abdominal wall; the left tube and ovary were buried in dense adhesions with marked thickening of the left broad ligament; adhesions of the right tube and ovary also but less marked. A supracervical hysterectomy was done including both tubes and ovaries; the umbilicus and its granulating sinus were excised. A rubber drain was placed in the euldesae and out through the lower angle of the wound. AI1 the urine now drained throu& tho abdominal wound until ApriI 10 when, following the removal of the drain, a permanent catheter was @aced in the b-adder. The wound healed rapidly; the catheter Tvas removed six days later and the patient was discharged from the hoFpita1 on May 7 in excellent condition and urine normal. She has been seen on several occasions since, her only complaint being her weight. This is a, case of infection in the lymphatics of the parametrial tissues of the left broad ligament, the point of entrance probably being the la.ceration of the cervix, with formation of a pelvic exudate, subsequent pus formation in this exudate, and final rupture of a pus pocket into the bladder. CASE 4.-ThrolnFophle7,itis. E. R., tTventy-two years of age, a primipara, Iv-as admitted to the Jev&h Hospital December 3, 1932. She leas pregnant six months with a complicating hyperthyroidism. Because of her condition it was decided to interrupt her pregnancy. It is, and was then, the writer’s opinion that the only way to empty a uterus at six months of pregnancy is to perform an anterior vaginal hysterotomy, but in this case the patient’s phy+ian put forth an eloquent appeal in favor of nonoperative induction of labor. Accordingly, on the morning of Deeember 7, the cervix being tight!y cl.osed, a strip of gauze was packed into the OS and the vaginal canal tightly packed, December 8 the packing was removed and It was found that it was just possible to slip the smallest Voorhees bag through. December 9 the bag was removed, having produced little, if any, advancement in the dilatation. The uterus and vagina were now tightly packed lvith gauze. The following morning this packing was removed and the uterus completely emptied. Instead of a clean-cut operative procedure of thirty minutes’ duration the patient was subjected to repeated intrauterine manipulation over a period of four days, the natural result of which is her subsequent course. On the afternoon before the final emptying of the uterus her temperature rose to 101.4”, but dropped with the complete evacuation of the uterine contentonly to rise the next day. Her temperature now continued irregu’arly between 102” and 105’ for ten days, during which time she complained of some pain in the lower abdomen. Elxamination revealed a tender, boggy uterus, otherTvise the pelvis was negative. On the afternoon of December 20 she had a severe chill lvith e’evation of temperature to ~1116.2” ; e*e,ry day thereafter until December 29 she had a severe chill with varying elevations and remissions of temperature. Following her chill on December 29 she complained
_A 3xemc~latlng pala 1n -he Y left. knee nil1ca socn ‘became the seat of a mar8w insion j the next day an alveo!ar abscess developed which was handled by the ,dd surgeon. Her condition now began to improve. On January 7, after two .s.ys of normal temperature she was thou&tIessly allowed out of bed; there was Lci almost immediate recurrence of temperature. During the next ten days the ,&tient was desperately ill and on January i7 in an attempt to bolster up her failILL vitality she was given a transfusion of 300 e.e. of uumodified blood. There ,a~ no reactian but on the morning of January 19 her temperature suddenly droppea 0 subnormal followed by a severe &ill, elevation of temperature to 106.4” and ecere pain in the right hip. Pollowing this attack there was decided general im:cvement and her temperature slowly approached normal until January 25 When .Im again appeared ill, aithough she had no complaints; this period lasted eight lags. Her temperature reached normal on February 2, and, excepting one fortyI,gl~t-hour rise about the middle of February, her recovery was rapid and uneventful. 3ilk3 was discharged March 3. Cultures of the blood and urine were repeatedly %i>gative. Pelvic examination on December 14 and again on January 14 was nega.-Ye. This imdc
is a typical processes.
case
of
thrombophlebitis
of
the
pelvic
veins
with
scattered
B. B., age thirty-nine, para iii, was ad323~ 5.-TWegmasio alba &lens. 2, 1921. The vagina was .l,;~~ed to my service at the Jewish Hospital on April ,&eked with gauze; this had been plaeed there by her physician foIlawing a severe She was immediately prepared and under aseptic precautions the ~wmorrliage. +nze was removed and a careful vaginal examination made. A central placenta ;,:.evia was found with eufseient dilatation of the cervix to permit of a Brarto* ,lIicks version being done. Two hours later she expelled the baby stillborn. Four &ays postpartum she complained of severe pain in the vulva and left side Of the &vi% She continued to complain of this pain intermittently, alPNo of an occasional nothing unusual was found Qntil April 23 when +I in the left thigh. However, The left thigh was now distinctly warmer than the :le pain became unbearable. .ght, although no swelling could be made out. By the 26 of April the thigh was Gradual im:~ormously swollen, glossy white, and extremely painfcl and tender. rovement. Blood transfusion April 30. Qn May 6 she eomplained of severe pain -:I the vulva; the right labium mas swollen and extremely tender; two days later :.:ie right thigh was involved.. The pain was so inten@e 5s to require morphinization ‘.or days at a time. By the I1 of May her pain and swelling were markedly iessened ,: ~~ii she was discharged on May 27. Pelvic examination early in July showed a pro,h::unced thickening in the left broad ligament. ‘?ASE 6.---Q. T.) age twenty-two, was delivered by me on June 11, 1912. ExaminaAUU an July 12 showed a normal pelvis. During the latter part of her pregnancy .I.ZP husband contracted a gonorrhea1 urethritis. On August 7, three days after :;heir first indulgence in sexual relations, she came to the office suffering severe -;olicky pain in the left side of the lower abdomen with temperature of 102.8”. Cite night before she had had a slight amount of vaginal b’eeding. Examination &owed a typical tumor in the left side of the pelvis and smears from the cervix ‘vere reported positive. Under appropriate treatment she improved until August 27 >4!~en the attack was repeated on the right side. Her subsequent course was uni,entful and she was discharged September 9. Examination six man tha later snowed a normal pelvis.
Me
A ease of gonorrhea1 infection with apparently :no untoward
involving results.
Arst
the
left
tube
and
then
the
right
R~QNSHEIM:
SIX CASES OF PUERPERAL
INI$EOTION
363
In septic endomeThe differential diagnosis is usually not difficult. tritis, a chill and moderate elevation of temperature and pain in the region of the fundus ; a large, boggy and tender uterus ; profuse, bloody, and distinctly malodorous lochia (unless there be retention) ; and rapid improvement under appropriate treatment make the diagnosis clear. The bacteremias are ushered in with a severe chill and rapid elevation of temperature. No further chills occur; the temperature remains uniformly high. The pulse is rapid and thready. Headache, extreme weakness, inability to sleep, euphoria, and mental confusion make up the picture and the laborat.ory confirms the diagnosis. In the parametritis the onset is usually late, no distinct chill, moderate elevation of temperature, pain and tenderness on. one side of the pelvis. Examination revea1.s a mass of varying size, usually limited to one side of the uterus, cervix and vagina in the pelvic connective t.issues,the region of the bladder and culdesac are free. The mass is immobile, hard, somewhat tender, and is continuous with the uterus ; the exudate broadens toward the pelvic wall in contradistinction to intraperitoneal tumors. Blood culture is sterile. Thrombophlebitis is characterized by its violent onset, the chill being severe and lasting up to thirty minutes or even longer. The repeated chills, extreme variations in temperature, and the profuse sweats are characteristic. Pain is low down in the back. The pelvic e,xamination is negative, as the condition is entirely within the veins. Later the embolic processes are typical. Blood cultures will usually give posil-ive results if specimens of blood are taken at t.he time of the chill. The. gonorrhea1 tube is characterized by absence of chill, moderate temperature with rem&ions suggestive of pus, pain is of a colicky, sticking type. Vaginal examination reveals the typica, tender sausageshaped tumor. If pelvic abscess,occurs the culdesac bulges, there may be retention of urine and feces, and t.he mass cannot be palpated above the pelvic brim. Phlegmasia alba, dolens is characterized by severe pain beginning in the labium of the affected side and spreading to the thigh. The edema of the thigh is pronounced, while edema of the leg is ,entirely absent or occurs later than in the thigh. It is a lymph stasis without transudation. 205 HICKS STREET.
C14SES
OF PUERPERAL
BY JOSHUA RONSHEIM,
INFECTION”
M.D., BROOKLYN,
N. Y.
N reporting the following cases of postpartum pelvic infection it is my intention to show that these infections are of various distinct types and may be classified as follows : I
1. Endometritis,-the infection remains limited to the’mucosa of the genital tract. 2. Bacteremia,--the infective organism invades the blood stream. This may be (a) directly from the placental site, or (b) secondarily from a thrombophlebitis of the pelvic veins. 3. Parametritis,-the infection spreads through the lymphatics into the parametrial tissues. A less common variety of this type is the lymphatic peritonitis. 4. Pelvic thrombophleb,itis,--the infection spreads through the pelvic veins. 5. Pyosalpinx and its associa.ted conditions, in which the infection spreads through the tubes. This type is almost invariably gonorrheal. 6. Phlegmasia alba dolens. Whether this cond.ition is produced by an exudate in the pelvis compressing the lymphatics or whether the lymphatics forming a network around the pelvic veins are compressed by an endophlebitis of these veins is not definitely understood. Nevertheless, the diffuse white swelling of the thigh resulting from lymph stasis is a definite clinical picture. CASE I.-Bosteremio by direct invasion from the p7acedd site. Mrs. K., a primipara, twenty-three years of age, entered my service at the Jewish Hospital on January 24, 1918, in labor. Labor terminated normally in about nine hours. A About 36 hours nick in the fourchette wa.s closed with one plain catgut stitch. morning, 45 hours after after delivery her temperature rose Co 101”, and, the following delivery, she had a chill with e’evation of temperature to 103.6”. Her only complaint examination showed nothing was of slight pain in the middle of the lower abd.omen; For the next 72 hours there was a gradual but a tender uterus. Lochia was scant. lowering of her temperature, then an elevation to 104” and a fern hours later, following a severe chill, to 106”. Blood culture sh,owed a streptococcus hemolyticus. Death occurred on February 4. This is a case of septic endometritis, then invasion of the placental site as shown by the first chill, then an incubation period, tInally overwhelming invasion of the blood stream.
CASE 2.-Baotercnzia following tluomboph?ebitls. Mrs. S., twenty-eight years of age was admitted to my service at the Jewish Hospital at 3:45 A. %I., January 31, 1923, in the third stage of her first labor. She had had a spontaneous delivery three *Abstract Williamsburg
of paper on “ Pelvic Medical Society, Oct.
Infections :X6, 1923.
359
in
the
Puerperiunn,”
read
before
the
tile rnein~brauea i1aJ xp""'"‘! ~yontaneaa~l~ Jereral &yr !XLLL~ px3viously; and a.t vwious times there2~33 onset of labor. Twenty niinutcv after dclirery, ~.‘tcr, unsuccessful a.ttempts were made to express and extract the placenta. During On admission the vulva vas Eli~‘1 this time the patient wa.5 steadily b!eeding. ..:a~& and the cord vas protruding; ute~~~s flabby with the fundus in the right ‘r,:~pochondrium; no external hlcecling at this time. Hieae sounds mu2 feeble, p&e rcqiratious s!on and sjmllom. Skin and mucous apid and of wxy poor quality, ~rwmhrams showed a marked pallor and the patient constantly begged for water. 3hc was p’aced in the Trende!enburg position and covered vith warm blankets. The .:r!va was shaved and under careful asepsis the placenta was extracted manuaiI~-. ‘3e cc. of pituitrin was given Irypndermica.11 J’ and this, tonl)M with manipulation -4s the husband’s b!ood did not 2. ” the fundus, p~odncecl contraction of the uterus. ~aM-i and as no other donor was arailab!c at that tome she was giren a h~poAt IO:00 .I. x. her condition xl-as much .ie~moclpsis of 1000 cc. saline soiution. 2 her temperature rwc to :Itrproved,-TPR 99--98--20. At 2 :OO I’. u., Febn~ary ‘33” and she comp!aiired of pain in the sacia! icgion and occipital headache. Pulse 53, heart action good, !ungs negative. The abdomen was soft, uterus well tonLrlcted and not tender; no tcndeincss in the flanks or iliac qions, thi~gha, 01 ba?asts. Lochie moderate red. On February 3 Itw condition wa,s the xame, her ,:ily complaint being the sactal pain; her tompcrature .rnw lower. At 1 :OO A. IN.. ‘cbruary 4 she had her first chill with cleration of tempwature to 104.X”. R’ontl : -1lture was taken. Careful examination failed to wvca! an-tihing abnor,mal. RBC :\b.S 2,400,‘300; hi, 45 per cent ; WXC ‘J,2OO with polys 78 par ecnt. R!ood cultul~c~ :.:0x3 a streptococens non-hemolytious. Her condition continued the sanv with xdated ehil~s a:H temperatux ranging from normal to 106” until February 11 ~b%en her chills crawl, he:. temperature vemaincd ~&.eadi!y high and simultaneously FM laboratory reported that t!7e bIood now sliowet! a strcptococcns henro!pticus. 5nc did on the morning of February 15. :hii:.Y
&s13 3.---Pa~anfct~*iii,~. &s. R. S.? twenty-one years of age, a pYimipa.~a vas ~:,*ii in conru!tation on May 3 I, 193O. Hhe had been in labor 40 lIoL7ls. She hat1 c dystocia due 70 diqxoport:on the pelvis bcinp noln~al but the baby o\-ersjzc~l. ‘i’ltc eervis was three lingws d&cd I the inembrancs intact, and a wrtes riding at ix brim. The baby was dead. On admission to the hospital at a:00 P. AL she ‘Ivas ~.q3hinized, my intention being to await full dilatation and then pwforate tlic \~ltCX. The following afternoon she had increased t,he di!atation somewhat and, ‘I~ spite of my expressed desire to let her aione, one of my staff delivered her 1-i:: ,I:-called manual diia.tation and high forceps. The cervix was laCCI’dtcd considerably .::la the perineum nuts lacerated to the Spbilicte~ ani. There x-as an imnwcliate TLR~’ _; Z temperature to 104.4” with pain in the lo-iricr abdomen anil a gradual dewlop :wnlt of a mass in the pwamctrial t,iesucs of the left side. on Augwt 17, the -Lawrty-seventh day postpartum the mass shnmt~d a finftraing and bn’ging in the ,rift anterior fornis and the followinq 7noiGig d this absecss was opened and drained. “UT a few days hc~ temperatwe ~~homd a tendency towar~3 normal but oh August :_), following the rCm0oal of the paeliillg strips in tiie ea\&y the temper,aturc agail] ~CX From this time on her condition remained stationaq and on Septc7nber 1 she .ras sent home, vhcre her treatme~~t was continued. On September 29 another pus ;a.vity was drained just in front of the cervix. ‘This rexltcd in a httle improvt~ :dnt, her temperature showing 8 tendency to remain lower than pre\:iously, althouch 7. still showed the decided rcmisrion~:. 011 OctOhW IS, I::9 days after dciiyeyy 1~1 ..mdition was better than at ally tinw pl cvionsly, but- it ~vas fo,.rnd that her ur+llc,
The diagnosis. mas evident, namely rupture of a pus was no-w practically pure pus. cavity into the b:addcr. She gradually improved, gaining in weight and strength. Every n.ow and then she would have an attack of pain in the pelvis with a rise, of pulse and. temperature coincident with the disappearance from the urine of praetically all signs of pus; this would be followed by a sudden gushing of pus from the bladder, the disappearance of all pain and return of temperature to normal. Cystoscopie examination sho\vcd enormous edema of the mucosa of the fundus with As the treatment produced no innumerable small streams of pus coming through. satisfactory results the patient ma.s persuaded to undergo operation, especially as a mars had again developed in the left side of the abdomen ,with a discharge of pus from the umbilicus. Accordingly, on April 5, 1921, she was re-admitted to tile hospital and operation performed on April 7. On opening the abdomen the mass in the left side was found to be in the abdominal mall, being an exudate The uterus was adherent to the bladder around a sinus leading to the umbilicus. and anterior abdominal wall; the left tube and ovary were buried in dense adhesions with marked thickening of the left broad ligament; adhesions of the right tube and ovary also but less marked. A supracervical hysterectomy was done including both tubes and ovaries; the umbilicus and its granulating sinus were excised. A rubber drain was placed in the euldesae and out through the lower angle of the wound. AI1 the urine now drained throu& tho abdominal wound until ApriI 10 when, following the removal of the drain, a permanent catheter was @aced in the b-adder. The wound healed rapidly; the catheter Tvas removed six days later and the patient was discharged from the hoFpita1 on May 7 in excellent condition and urine normal. She has been seen on several occasions since, her only complaint being her weight. This is a, case of infection in the lymphatics of the parametrial tissues of the left broad ligament, the point of entrance probably being the la.ceration of the cervix, with formation of a pelvic exudate, subsequent pus formation in this exudate, and final rupture of a pus pocket into the bladder. CASE 4.-ThrolnFophle7,itis. E. R., tTventy-two years of age, a primipara, Iv-as admitted to the Jev&h Hospital December 3, 1932. She leas pregnant six months with a complicating hyperthyroidism. Because of her condition it was decided to interrupt her pregnancy. It is, and was then, the writer’s opinion that the only way to empty a uterus at six months of pregnancy is to perform an anterior vaginal hysterotomy, but in this case the patient’s phy+ian put forth an eloquent appeal in favor of nonoperative induction of labor. Accordingly, on the morning of Deeember 7, the cervix being tight!y cl.osed, a strip of gauze was packed into the OS and the vaginal canal tightly packed, December 8 the packing was removed and It was found that it was just possible to slip the smallest Voorhees bag through. December 9 the bag was removed, having produced little, if any, advancement in the dilatation. The uterus and vagina were now tightly packed lvith gauze. The following morning this packing was removed and the uterus completely emptied. Instead of a clean-cut operative procedure of thirty minutes’ duration the patient was subjected to repeated intrauterine manipulation over a period of four days, the natural result of which is her subsequent course. On the afternoon before the final emptying of the uterus her temperature rose to 101.4”, but dropped with the complete evacuation of the uterine contentonly to rise the next day. Her temperature now continued irregu’arly between 102” and 105’ for ten days, during which time she complained of some pain in the lower abdomen. Elxamination revealed a tender, boggy uterus, otherTvise the pelvis was negative. On the afternoon of December 20 she had a severe chill lvith e’evation of temperature to ~1116.2” ; e*e,ry day thereafter until December 29 she had a severe chill with varying elevations and remissions of temperature. Following her chill on December 29 she complained
_A 3xemc~latlng pala 1n -he Y left. knee nil1ca socn ‘became the seat of a mar8w insion j the next day an alveo!ar abscess developed which was handled by the ,dd surgeon. Her condition now began to improve. On January 7, after two .s.ys of normal temperature she was thou&tIessly allowed out of bed; there was Lci almost immediate recurrence of temperature. During the next ten days the ,&tient was desperately ill and on January i7 in an attempt to bolster up her failILL vitality she was given a transfusion of 300 e.e. of uumodified blood. There ,a~ no reactian but on the morning of January 19 her temperature suddenly droppea 0 subnormal followed by a severe &ill, elevation of temperature to 106.4” and ecere pain in the right hip. Pollowing this attack there was decided general im:cvement and her temperature slowly approached normal until January 25 When .Im again appeared ill, aithough she had no complaints; this period lasted eight lags. Her temperature reached normal on February 2, and, excepting one fortyI,gl~t-hour rise about the middle of February, her recovery was rapid and uneventful. 3ilk3 was discharged March 3. Cultures of the blood and urine were repeatedly %i>gative. Pelvic examination on December 14 and again on January 14 was nega.-Ye. This imdc
is a typical processes.
case
of
thrombophlebitis
of
the
pelvic
veins
with
scattered
B. B., age thirty-nine, para iii, was ad323~ 5.-TWegmasio alba &lens. 2, 1921. The vagina was .l,;~~ed to my service at the Jewish Hospital on April ,&eked with gauze; this had been plaeed there by her physician foIlawing a severe She was immediately prepared and under aseptic precautions the ~wmorrliage. +nze was removed and a careful vaginal examination made. A central placenta ;,:.evia was found with eufseient dilatation of the cervix to permit of a Brarto* ,lIicks version being done. Two hours later she expelled the baby stillborn. Four &ays postpartum she complained of severe pain in the vulva and left side Of the &vi% She continued to complain of this pain intermittently, alPNo of an occasional nothing unusual was found Qntil April 23 when +I in the left thigh. However, The left thigh was now distinctly warmer than the :le pain became unbearable. .ght, although no swelling could be made out. By the 26 of April the thigh was Gradual im:~ormously swollen, glossy white, and extremely painfcl and tender. rovement. Blood transfusion April 30. Qn May 6 she eomplained of severe pain -:I the vulva; the right labium mas swollen and extremely tender; two days later :.:ie right thigh was involved.. The pain was so inten@e 5s to require morphinization ‘.or days at a time. By the I1 of May her pain and swelling were markedly iessened ,: ~~ii she was discharged on May 27. Pelvic examination early in July showed a pro,h::unced thickening in the left broad ligament. ‘?ASE 6.---Q. T.) age twenty-two, was delivered by me on June 11, 1912. ExaminaAUU an July 12 showed a normal pelvis. During the latter part of her pregnancy .I.ZP husband contracted a gonorrhea1 urethritis. On August 7, three days after :;heir first indulgence in sexual relations, she came to the office suffering severe -;olicky pain in the left side of the lower abdomen with temperature of 102.8”. Cite night before she had had a slight amount of vaginal b’eeding. Examination &owed a typical tumor in the left side of the pelvis and smears from the cervix ‘vere reported positive. Under appropriate treatment she improved until August 27 >4!~en the attack was repeated on the right side. Her subsequent course was uni,entful and she was discharged September 9. Examination six man tha later snowed a normal pelvis.
Me
A ease of gonorrhea1 infection with apparently :no untoward
involving results.
Arst
the
left
tube
and
then
the
right
R~QNSHEIM:
SIX CASES OF PUERPERAL
INI$EOTION
363
In septic endomeThe differential diagnosis is usually not difficult. tritis, a chill and moderate elevation of temperature and pain in the region of the fundus ; a large, boggy and tender uterus ; profuse, bloody, and distinctly malodorous lochia (unless there be retention) ; and rapid improvement under appropriate treatment make the diagnosis clear. The bacteremias are ushered in with a severe chill and rapid elevation of temperature. No further chills occur; the temperature remains uniformly high. The pulse is rapid and thready. Headache, extreme weakness, inability to sleep, euphoria, and mental confusion make up the picture and the laborat.ory confirms the diagnosis. In the parametritis the onset is usually late, no distinct chill, moderate elevation of temperature, pain and tenderness on. one side of the pelvis. Examination revea1.s a mass of varying size, usually limited to one side of the uterus, cervix and vagina in the pelvic connective t.issues,the region of the bladder and culdesac are free. The mass is immobile, hard, somewhat tender, and is continuous with the uterus ; the exudate broadens toward the pelvic wall in contradistinction to intraperitoneal tumors. Blood culture is sterile. Thrombophlebitis is characterized by its violent onset, the chill being severe and lasting up to thirty minutes or even longer. The repeated chills, extreme variations in temperature, and the profuse sweats are characteristic. Pain is low down in the back. The pelvic e,xamination is negative, as the condition is entirely within the veins. Later the embolic processes are typical. Blood cultures will usually give posil-ive results if specimens of blood are taken at t.he time of the chill. The. gonorrhea1 tube is characterized by absence of chill, moderate temperature with rem&ions suggestive of pus, pain is of a colicky, sticking type. Vaginal examination reveals the typica, tender sausageshaped tumor. If pelvic abscess,occurs the culdesac bulges, there may be retention of urine and feces, and t.he mass cannot be palpated above the pelvic brim. Phlegmasia alba, dolens is characterized by severe pain beginning in the labium of the affected side and spreading to the thigh. The edema of the thigh is pronounced, while edema of the leg is ,entirely absent or occurs later than in the thigh. It is a lymph stasis without transudation. 205 HICKS STREET.