1896 Journal of the American Medical Association (JAMA)  
such a condition is a difficult task. None but an expert can do so, and they are frequently mistaken in diagnosis. Most gynecologists that favor hysterectomy advise to curette and tampon uterus, and if the patient does not improve or grows worse then remove the uterus. If this is a correct guide as to the indications for hysterectomy, then it is not a question of diagnosis, but failure in a certain line of treatment to give relief that demands the sacrifice of the uterus. In severe cases of
more » ... ic infection to curette and tampon the uterus, then perform hysterectomy, the death-rate would be so high as to condemn the operation and many lives would be lost that could be saved by less heroic means. To be more explicit, I will deviate from the title of this paper and enter briefly into the pathology and treatment of puerperal infection. It is of two general varieties, viz.: 1. Putrid infection or sapremia. 2. Septic infection or septicemia. The first is a local infection due to decomposition of the uterine contents by putrefactive bacteria only without migration of the bacilli, not contagious, nonprogressive by invasion, due to absorption of ptomaines not inoculable. In sapremia, putrid infection, remove the putrid material from the uterine cavity, irrigate, disinfect, drain, and 99 per cent, of cases will recover. Hysterectomy would relieve these cases, but it would be criminal to sacrifice the generative organs when such cases can be treated more successfully and with fewer deaths by less heroic measures. The second class is due to germ development, their rapid migration and invasion of new tissue even entering the general circulation; if at first local it soon becomes constitutional, highly infectious, and inoculable from case to case. The contagious principle is destroyed by boiling, putrefaction and germicides. In the treatment of septic infection we have a more difficult problem to solve. The septic germs soon extend beyond the endometrium, invading its muscular structures, the lypmphatics, the blood vessels, etc., and can not be removed by ordinary surgical measures, and it is very doubtful if hysterectomy could completely remove the infected tissues in severe cases. In putrid infection the curette and tampon might relieve the patient, but, in septic infection I do not believe such treatment is advisable, except it might be within one or two days after labor, where placental tissue, has been left in the uterine cavity. It is drainage and elimination we desire in these, cases, not obstruction. What surgeon of repute would tampon an abscess cavity through a very small opening without using a drainage-tube, letting the gauze remain tw7o, three or four days, especially when there is a broken down tissue, debris and septic germs present in abundance. After delivery nature establishes a process of elimination by a current flowing from the uterine cavity, the uterus and vagina being the main trunks of a sewer; the lymphatics, blood vessels, and uterine sinuses, its tributaries, obstruct the main channel, and what is the result? Who could think of filling the trunk sewer of a city with gauze and expect free drainage, even if done antiseptically after scraping out and flushing it? Yet we are advised to curette the uterus and fill it with gauze, damming up nature's channel of elimination, thus preventing the throwing off of effete material from the placental site, endometrium and lymphatics-obstructing the egress and retaining the phagocytes laden with germs and toxins, completely annulling phagocytosis, producing the very condition we should endeavor to prevent. Some will say only tampon after a thorough curetting: so much the worse, you have broken down and destroyed nature's barrier, opened up new surfaces for absorption, and favor that absorption by obstructing nature's method of elimination. I regret to say it, but it is my conviction that, the curette and tampon indiscriminately used kill more patients than they save in septic infection. Their indiscriminate usage manufactures cases for hysterectomy. In the treatment of these cases imitate nature as far as possible and establish a current of free drainage. If any foreign substance is in uterus remove it with the forceps, wounding endometrium as little as possible; irrigate the uterine cavity thoroughly with an antiseptic solution and introduce as large-sized rubber drainage-tube as the os will admit. Repeat irrigations and cleansing of the drainage-tube at least once or twice in twenty-four hours. Do not neglect occasional use of salines and calomel if needed, with systematic use of quinin, strychnin, tonics, and good nourishing diet. Quinin certainly has a specific action in these cases in checking germ development and controlling the chills which accompany these cases. I venture to say that where this line of treatment is properly carried out it will save more lives than the combined use of the curette, tampon, and hysterectomy. WThile I have in a great measure condemned hysterectomy in puerperal infection, I admit it has a limited field of usefulness in septic metritis, multiple abscesses in the uterine wall, thrombophlebitis, if it were possible, for us to be positive in our diagnosis, but if in doubt I prefer drainage. Unless future operative work gives better results, even this limited justification of hysterectomy may be abandoned. In the above collection of cases I am satisfied, if the operation be limited strictly to severe cases of septic infection, rapidly progressive and not in its secondary results, the death rate would be 80 or 90 per cent, of cases operated upon. Even a death rate of 50 per cent, is sufficient to condemn the operation. The proper use of the drainage-tube will not only save more lives, but the uterus, tubes and ovaries will be preserved for future usefulness and the surgeon's conscience left more at ease.
doi:10.1001/jama.1896.02430670022002e fatcat:dxzkmbzky5ezja245oupypajo4