THE ROUTINE TREATMENT OF PUERPERAL SEPSIS
Journal of the American Medical Association
should have been done, but the patient refused ampu¬ tation and died on the fourth day from acute sepsis. The other case was one of prolonged septicemia from a mixed infection in a man who had a compound fracture of both bones of the leg, for which no direct fixation was done. The mortality was 4.16 per cent. One patient with compound comminuted fracture of the bones of the leg with dislocation of the ankle-joint had a mixed infection; destruction of the joint and tarsus followed and an
... on became necessary. All but one of the forty-six patients who left the hos¬ pital had useful limbs, that is, the one previously noted on whom amputation was done. Of these patients, 40.32 per cent, have returned to their former work and report that they notice no disability. Roentgenograms which were taken show the con¬ ditions of the bones during and after recovery. Roent¬ genograms in cases of compound fractures are taken (1) after the first permanent dressing; (2) after the fixation plates have been removed ; (3) when the union seems complete; (4) after the patient has returned to his occupation. The number of cases is too small for any set con¬ clusion with regard to the treatment of compound fractures, but certainly in this small series direct fixa¬ tion has produced much quicker recoveries and far better results than the former conservative methods. It will be noted that not one of the thirty-five patients in whom direct fixation was applied to the fragments died. They all made good recoveries. In the smaller number of cases (thirteen) in which the fragments were not fixed by direct splints on the bones (three hopeless cases are not considered in this reckoning), two patients died of sepsis. Roentgenograms show that fragments which have been plated together remain in better adjustment than those which have been wired, and the anatomic results are better, except in cases of fracture of the patella. There is less pain after the use of plates than when wire is used, and union results more quickly. It seems, therefore, that compound fractures of the long bones are best treated by rigid splints applied directly to the bones. I believe that the Lane plates are not the best for these cases, however. Experience of other surgeons has shown that in cases of compound fractures the Lane plate must nearly always be removed. Usually it is difficult to get at the screws and then it becomes necessary to use a general anesthetic and to make a considerable additional wound in order tó remove this plate; whereas a plate fastened by pegs which proiect through the skin may be released simply by with¬ drawing the pegs, and if it is necessary to remove the plate this may be done simply by utilizing one or two of the punctures remaining after the peg has been removed, which requires no anesthesia. A further consideration is the time of disability. My cases show that the average time of disability for compound fractures below the knee was six months and for those above the knee, namely, fractures of the femur, thirteen months. The use of plates thus shortens the time of disability in leg cases by about four months and of the thigh cases, five months. Of the patients, 40.32 per cent, are known to have been able to resume their former occupations. No doubt a number of others were likewise able to do this, but I could find only this number after a year or more from the time their treatment was ended. Medicine PHILADELPHIA It is obvious that not every case of fever in the puerperium is of septic origin. Engorgement of the breasts, constipation, nervous perturbation, malaria, syphilis, typhoid and other adynamic fevers are some of the many causes of fever entirely separate and distinct from sepsis due to bacterial invasion. It must also be remembered that there are two distinct varieties of sepsis: sapremia due to saprophytic infection and putrefaction of pieces of placenta, membranes, decidua or blood-clot in the uterine cavity, and septicemia due to actual bacterial invasion, most often streptococcic, of the endometrium and adjacent structures, frequently invading directly the blood-current and by far the most dangerous variety. Sapremia answers promptly to a single evacuation of the uterus and disinfection of the genital canal, with possibly a few supplementary daily intra-uterine douches. Septicemia means a long, hard fight, not infrequently a losing one, against many complications. It is not my purpose to discuss the various means by which bacteria can be introduced into the genital canal of a parturient patient, except in one particular. One of the causes spoken of is auto-infection, in which the germs are already present, and no one, except the patient herself, is responsible. This is a comforting thought, but merely means that she is suf¬ fering from one infection (gonorrheal, for instance) which reduces her resisting power to a supplementaryinfection by any pathogenic micro-organisms which may be in the lochia, and is really not auto-infection at all. PIAGNOSIS The diagnosis of sapremia is easy. There is a mod¬ erate fever, considerable subin volution of the uterus and a foul brown or brownish-red discharge. A single evacuation and disinfection of the uterine cavity is usually sufficient. The diagnosis of septicemia is not so easy, in its early stages. The general symptoms are chills, rap¬ idly rising temperature, rising pulse-rate and a physi¬ cal depression often out of all proportion to the other symptoms.