The relationship between toxemia of pregnancy and uterine sepsis from a study of 400 toxemic cases

Abstract 1.“Eclampsia” is not a “self-limited disease” except in the sense that “all things end in death” and so are self-limited. If 25 per cent of our eclampties die, these usually coming to us moribund with the head on the perineum, the limit is somewhat too early for the patient's good. Whether treatment is active medical, or active surgical, or active both, it is always active and the term self-limited as applied to “eclampsia” should be dropped, for psychologically it leads to too much watchful waiting on the part of the general practitioner. Toxemic symptoms call for something to be done when discovered, be it medical or surgical. Some cases of everything get well if watched and let alone, but this should be forgotten in toxemia of pregnancy. 2. The mortality of toxemia with convulsions in hospital practice is 25 per cent; 90 per cent of these die within thirty-six hours of eclampsia,—whatever that is. It is, therefore, one of the most dangerous diseases from which people recover. 3. The mortality in hospital practice of toxemia without convulsions is 2.5 per cent which shows that best hospital care for these cases is none too good. 4. Uterine sepsis is responsible for 9 per cent of deaths of toxemias with convulsions that survive. 5. Uterine sepsis in toxemics without convulsions and in the nonseptic control show the same percentage mortality—0.5 per cent, but uterine sepsis is responsible for more deaths in toxemics than in nontoxemics because it is more frequent. 6. Two and five-tenths per cent of nontoxemics unselected become septic, 14.0 per cent of toxemics without convulsions become septic, 25.0 per cent of toxemics with convulsions become septic, {ce:italic}irrespective of method of delivery{/ce:italic}. 7. Toxemics are about four times as likely to become septic {ce:italic}under similar methods of delivery{/ce:italic} as nontoxemics, unselected. If they have convulsions, more; if without, slightly less. They are more likely to have difficult operative deliveries with a higher septic rate. 8. That these figures establish that toxemics are very prone to sepsis; that the quotation from De Lee regarding withholding salts until after delivery, or closing off the rectum if the patient has been under medical treatment and delivery is forced in the midst of it, is worthy of more attention than in general is given it. 9. That though we must be very cautious in applying these figures to methods of delivery, since sepsis is only one element in the situation, and the series of vaginal and abdominal cesareans studied here is very small, it speaks for normal labor or low forceps, and the Voorhees bag, and delivery from below after full dilatation, as against baginal or abdominal cesarean. But certain cases are only deliverable by these methods. I, personally, believe at the present time that no toxemic with or without convulsions {ce:italic}making progress in dilatation{/ce:italic}, either by her own pains, or with a Voorhees bag, should be operated to hasten the delivery, even in the presence of impending convulsions, or increasing symptoms, because of the increased danger of sepsis. I also personally believe now that a cutting operation, vaginal or abdominal cesarean, as the case may call for, should be done only in cases in which preliminary observations show an unwillingness of that cervix to dilate readily enough to take a large bag. With this exception, I think that bag induction—failing to start labor with catharsis—and allowing the patient if possible to deliver herself, or at least dilate herself fully and come to low forceps, is the choice of procedure in all toxemics with and without convulsions, controlling the convulsions as much as possible with morphia, and in selected cases in which repetition of convulsions is more to be feared than excessive hemorrhage afterwards, with blood letting. I do not believe that the amount of time saved by hurried, difficult operating through the undilated cervix is worth the risk of immediate shock and subsequent sepsis. This conclusion should be qualified by stating emphatically that when an introduced bag fails to work, it should be removed and delivery completed in the most appropriate way, which may be either vaginal cesarean section, or completing dilatation manually. 10. We frequently hear that hospital figures do not apply in private practice; but in the relationship of toxemia to uterine sepsis, nothing in my own work or in what I know of the work of others leads me to believe that these hospital figures are worse than private and consultation figures. That they are worse than the careful specialist's own private work is not on account of any difference in the relationship of toxemia and uterine sepsis; but because he has learned the real danger of toxemia of pregnancy, and dallies not at all with these cases. It is this point of view which all practitioners of obstetrics should get, namely, that symptoms of toxemia of pregnancy call for quick action and good judgment.