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PRIVATE

THE VALUE OF THE ANTISEPTIC SYSTEM IN OBSTETRIC PRACTICE; CONCLUSIONS BASED ON A STUDY OF THE PUERPERAL TEMPERATURE.

BY

HENRY D. FRY, M.D.,
Washington, D. C.

OBSTETRICS is the mother of antiseptic knowledge. Instead, however, of fulfilling her maternal duties and nurturing the offspring to full life and vigor, she neglected it, and but for surgery it might have been forgotten.

It is difficult to say why such was the case. The result of the adoption of antiseptic precautions in the hospitals of Germany was encouraging from the beginning, and, too, at a time when improvement was sadly needed. The mortality from child-bed fever at that period was something appalling.

Antiseptic delivery is not yet practised so universally as it should be in hospitals, and still less is it employed in private practice. During recent years, obstetricians are recognizing its merits and giving the subject more attention. Some idea may be formed of the neglect it had suffered at their hands, by making the following comparison. In volume I. of the Index Catalogue of the Library of the Surgeon-General's Office, a space

of about one-fifth of a column is occupied by references to articles on antiseptic midwifery, while antiseptic surgery takes up nearly nine columns of the same work.

I have said that the use of antiseptics in the delivery of women is even less employed in private practice than in that of hospitals, and the object of this paper is to consider the subject in the former aspect.

At a meeting of the Washington Obstetrical Society, held in April of last year, the subject for discussion was: "The Management of the Puerperium." I was at that time in full accord with the sentiments expressed by the majority of the members present in favor of antiseptic vaginal injections employed during the week or two succeeding parturition. So firm, indeed, was my conviction of their good effect, that I considered it a neglect of duty to fail to direct them in every case. Minor accidents in my own practice, and the reports of more serious troubles in that of others, had not deterred me from making use of them until, very soon after the meeting in question, I barely escaped having a death certificate to sign which would have read thus: First or primary cause, hot vaginal injection of a solution of carbolic acid; second or immediate cause, general peritonitis.

My patient had been confined of her third child, a girl, and had reached her eighth day safely and comfortably. Vaginal injections had been given by an experienced nurse, morning and evening, from the beginning of the lying-in; but, on the evening of the eighth day, its administration was followed by uterine pain, chill, fever, tympanites, and abdominal tenderness.

For several hours succeeding the injection, a watery fluid, tinged with blood, escaped freely from the patient's vagina. The next morning her temperature was 102°, the abdomen was still tender and tympanitic; bowels constipated.

By use of opium and hot applications, she recovered after twelve days of fever.

Dr. Chamberlain, of New York, has twice observed peritonitis quickly follow the use of vaginal injections of hot water. Although he says there was no evidence whatever, in either of these cases, that the fluid had been injected into the uterus, he nevertheless takes the precaution to avoid such an accident by having the injection administered while the patient is in a sitting posture; also to use a tube without a terminal opening. Dr. Frank P. Foster believes the injections dangerous, whether given hot or cold, and in any position; moreover, he has no

confidence in the theory that safety is secured by dispensing with the terminal opening in the tube. Mundé is of the opinion that the sitting posture favors the introduction of fluids into the uterine cavity, in parous women with probably lacerated and gaping cervices. In one of Dr. Chamberlain's cases, it was impossible to have injected the uterus because of stenosis of the cervical canal. He is of the opinion that the harm resulted from direct action of the hot water on the inflamed tissues. Dr. Foster attributes the pain following the injection to a spasmodic contraction of the muscular wall of the vagina around the nozzle of the syringe, in consequence of which the upper part of the canal is distended by fluid. To remedy this, Dr. F. designed a special nozzle to be attached to the syringe.

Dr. Mundé holds that this view is theoretical and not supported by facts, except when there are pelvic adhesions, as in chronic peritonitis and cellulitis. These gentlemen agree upon one point: that vaginal injections may produce pain and sometimes dangerous symptoms. Each holds entirely different views as to the manner in which the injurious effect is produced, and each suggests a remedy, while he places no confidence whatever in the remedies proposed by the other two. This discussion' is introduced here merely to call to mind some of the inconveniences which may attend the employment of these injections, and you can readily appreciate why, after the experience I have related with my own case, I determined to adopt some method that would obviate the necessity for using vaginal injections. The antiseptic plan so ably advocated by Paul Bar in France, and copied by Garrigues in this country, promised what I wished. The antiseptics are used externally.

It is evident that to arrive at any conclusion regarding the value of a certain line of treatment, some other method of investigation than that of mortality must be adopted, unless the opportunity exists to compare a large number of cases treated by different methods.

Playfair' has said: "The key to the management of women after labor, and to the proper understanding of the many important diseases which may then occur, is to be found in a study

1 "Treatment of Diseases of Women." C. H. Goodwin. Pp. 129-133. New York, 1884.

* "Science and Practice of Midwifery." 3d Am. Ed., 1880, p. 540.

of the phenomena following delivery, and of the changes going on in the mother's system during the puerperal period."

A careful study and record of these same phenomena, more particularly with reference to the range of temperature during the lying-in period, offered the only means of investigation I could command. The result furnishes the key to the management of women during labor as well as afterwards.

The number of cases upon which I have based the conclusions offered, although numerically small, is amply sufficient to convey to my mind the value of antiseptic delivery. Moreover, these conclusions confirm the results of others, who have employed and who advocate this system of treatment. If this were not the case, I should hesitate to present facts based upon such limited experience.

Before taking up the study of these cases, let us ascertain what is considered the physiological temperature of the first week of the puerperium.

Soon after childbirth the temperature begins to rise, and continues to increase until the maximum is reached about twelve hours afterwards. It declines during the second twelve hours, but does not quite reach the normal point for five or six days.

According to Schroeder,' "the highest temperature reached is, on an average, 38° C. (100.4° F.); it may be somewhat more, even over 39° C. (102.2° F.), without any actual disease being present."

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Lusk, following the teachings of Schroeder, allows a wide range within physiological limits of the temperature wave soon after delivery. If delivery is effected in the morning, he adds the usual rise of one or one and a half degrees following the act of parturition to the normal rise which takes place in the human body about 5 P.M., and, in this way, he witnesses an elevation to 102°, or even more, without uneasiness.

I cannot but think these conclusions were founded upon hospital experience. In private practice, at least, I have not been able to verify them. In cases observed by myself, the maximum point was usually between 99 and 100°, rarely beyond the latter figure unless instruments were employed.*

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1 "Manual of Midwifery." New York, Appleton & Co., 1873, p. 99. "Diseases of Women." Goodwin, New York, 1884, pp. 116 and 117.

Squire ("Puerperal Temperatures," Tr. London Obstet. Soc., vol. ix., p. 120) does not recognize the occurrence of this primary rise of tem

A few days after this primary rise of temperature, usually about the third or fourth day of the puerperium, it is customary for a second elevation to take place, preceded, perhaps, by chilly sensations, and accompanied with pain in the head, aching over the body, thirst, distention of the breasts, and secretion of milk.

The first rise of temperature is attributed to the "production of heat through rapid metamorphosis of the uterus" (Schroeder); the second, to the awakening of the functional activity of the mammary gland, and is consequently termed "milk-fever."

Accepting the temperature wave a shown in the accompanying chart as that which represents the physiological range during the first week of the lying-in, we will compare with it 6, which represents the average daily temperatures of twenty-six cases treated antiseptically during parturition.

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The cases from which this average is obtained are not selected, but, with the exception of four, constitute the entire number treated in this manner. Three of the four cases omitted were delivered with forceps, and, in the fourth, pneumonia developed. on the third day after labor.

The highest point reached by any of the forceps cases was 100.4° F. This occurred at 4.30 P.M. of the second day.

The average temperature of the cases delivered without antiseptic precautions during the same time is higher, but selected perature. He says a slight elevation occurs as a result of the efforts of parturition, but it commences to decline after childbirth, and reaches normal or subnormal by the end of twenty-four hours.

Barnes ("System of Obstetrics," Am. Ed., 1885) likewise states that a slight fall has been noticed, twelve or twenty-four hours after labor. Observations, he says, made in hospitals which show a rise of over .5° F. cannot be accepted as normal.

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