Measures have also been adopted with the view of fostering leucocytosis, in the hope that increase in the number of leucocytes will be followed by increase in the amount of phagocytosis. Quinine is credited with the power of calling forth a leucocytosis, and part of its reputation in cases of infection may have been earned by this quality. A more direct effect is produced by the administration of Collargol, either by inunction of a drachm of Crecle's ointment (Collargol 5j., adipis prparat. into the skin of the thigh or axilla daily, or by the injection into a vein of io c.c. of a i or 2 per cent. solution. Nuclein or Nucleinic Acid has been given by hypodermic injection (i to 2 drs. of a 2 per cent. solution) for the same purpose. It must be confessed that, though both these drugs produce a leucocytosis, the effect upon the infection is very doubtful. Another method is the " abscess of fixation " produced by the injection of a drachm of Spirit of Turpentine under the skin of the abdomen. It is said that if an abscess forms the effect on the general condition is favourable, but if no tissue reaction results a very bad prognosis may be given.
Good results have been reported after the intravenous injection of Eusol solution in normal saline (i 20 c.c.) and also of Chloramine-T solution, but sufficient data are not in hand to be certain whether this method will prove to be an advance in the treatment of puerperal infection or not.
When the case has passed the acute stage, open-air treatment, tonics and judicious feeding will be required. Any inflammation persisting will be localised, and may be treated as described under Pelvic Inflammation (q.v.). In some cases a chronic pymic condition becomes established, and abscesses form in different parts of the body. These should be opened as they form. It is in these conditions that vaccine treatment is likely to prove of much service.
Operative Treatment.—This line of treatment is not incompatible with that just described. The same measures as to feeding, drugs, etc., are just as applicable and as necessary even if operative measures have been taken or are contemplated. The advocates of the expectant method rely, however, entirely on the patient's powers of resistance, reinforced it may be by appropriate treatment, to deal with the invading microbes; the advocates of operation hope by their interference either to diminish the number of invaders or to seal against them the port of entry. As every breach of surface, including even the abrasions caused by a blunt curette or the point of an intra-uterine douche-tube, opens up a fresh avenue of infection, interference to be rational must be so thorough as to do away with all or all but a feeble remnant of the invading cocci at the same time that the door is so widely opened to them. It is true that the
inoculation of fresh raw surfaces made by surgical means may be taken to represent a vaccination, but it is with a vaccine of which we do not know the strength and in a patient of whose resistance we have no precise information, and therefore the chances of good being done on the lines of a vaccine are infinitely less than the probability of harm. We have to consider further that no surgical intervention can touch the cocci whichhave already invaded the circulating blood or lodged deep in the tissues, and that the power of these to multiply is still present. Lastly, we must remember that septic patients arc notoriously bad subjects for amesthesia and for prolonged operations.
To my mind, the lessons to be drawn from these considerations are, first, that if operation is contemplated it should be done in the initial stages of the attack, if possible while the infection is localised, and certainly not when the patient is already exhausted by fever, pain and want of sleep. Whatever operation is done—and this especially applies to curetting--it should be as thorough as possible, for the fire is not to be stirred, but to be raked out. When the patient is already in a dangerous condition, with rapid pulse, looking very ill, with tympanites or vomiting, operation is a desperate resource, and is more likely to shorten her life than to save it. Other things being equal, the shorter and less severe the operation the better.
I shall briefly describe the more important operations recommended for cases of sepsis. I shall not consider those adapted to the relief of Pelvic Inflammations and their sequelic, which the practitioner will find fully discussed under that heading, further than to say that where there is evidence that a collection of infective fluid, serum, sero-pus or pus is present, nothing but good can follow its free evacuation, always provided that good drainage can be established.
The most common form of surgical interference is the curetting el the uterus with the object of removing the infected endometrium. This can only be done with a sharp curette, and as the uterine muscle is friable and easily perforated in many of these cases, the practitioner will do wisely to avail himself of the services of a specialist unless he has had a good deal of experience of the curette. The curetted uterus should be douched with abundant warm saline fluid, and a gauze drain should be carried up to the fundus or an india-ruhher drain-tube may he introduced through the cervix if there is likely to be any hindrance to the free flow of discharges.