In mild cases of septicemia there may be no visible local lesions; there is a febrile rise for a day or two, with headache and malaise, then restitutio ad integrum, rapidly takes place. In severe cases, local inflammations-diphtheritic, purulent, gangrenous-predominate; the fever is excessive, there is disturbed involution of the uterus, with sensitiveness and pain over that organ, the constitutional disturbances are intense. Steurer's observations* are of the greatest interest in this connection.

His cases, which occurred during the epidemic of puerperal fever at Bellevue Hospital, New York, in 1874, "all presented diphtheritic patches about the vulva, or upon the mucous membrane of the vagina and uterus. . . . From the patches the bacteria could be traced between the muscular fibres and deep down into the canalicular spaces of the connective tissue, where their presence gave rise to cellulitis. From the canalicular spaces they entered the lymphatics, with resulting lymphangitis. In many cases the lymphatics could be traced along the broad ligaments to the ovaries (puerperal oöphoritis), and into the subperitoneal tissue of the lumbar region. By perforation of the walls of the lymphatics which directly underlie the peritoneum, they made their way into the peritoneal cavity, and excited pyæmic peritonitis. . . . The wide stomata upon the abdominal surface of the diaphragm allowed the facile entrance of the organisms into the lymphatics. Waldeyer found in diaphragmitis the lymphatics of the diaphragm filled with bacteria. And thus, following the lym phatic system, if we only admit that the round bacteria are the carriers of sepsis, a fact which hardly admits of dispute, the frequency in severe types of puerperal fever of inflammations of the serous membranes-of the peritoneum, the pleura, the pericardium, and the joints-finds an easy explanation. . . . Sometimes the bacteria pass directly into the veins, and give rise to phlebitis. When the bacteria enter directly into the circulation, they sometimes, in passing through the heart, adhere to the endocardium and valves, causing exudation, ulceration, and decomposition, and thus give rise to the socalled endocarditis ulcerosa puerperalis."

peral fever? I have seen patients die by the extension and gravity of a carbuncle. Now, as far as microbiology can tell us, anthrax is caused by the same streptococcus that causes septicemia.

*Cited by Lusk in his "Science and Art of Midwifery."

PROPHYLACTIC TREATMENT.

A knowledge of the causes of puerperal infection irresistibly suggests the proper prophylactic treatment.

The indication is to exclude all bacteria; no bacteria-no infection, no putrefaction, no suppuration. The same general principles of asepsis, which have given such uniformly good results in surgery, must be applied in all their rigor to obstetrics.

Semmelweiss may be regarded as the father of modern antiseptic midwifery. His work, in which he shows that puerperal fever owes its origin to the absorption of decomposing organic matter and is only a form of pyæmia, was published in 1847. He afterwards added that this disease might also arise from the decomposition of the lochia, blood clots, necrosed or placental tissue. Hence if obstetricians would prevent puerperal fever in their patients, the maintenance of absolute cleanliness, and sometimes disinfectant ablutions and irrigations, become necessary.†

It would take too much time to go fully into the history of antisepsis in midwifery. Such treatises as that of Paul Bar, "On Antiseptic Methods in Obstetrics;" H. J. Garrigues, "On Antiseptic Midwifery;" Dr. Robert Kucher, "On Puerperal Convalescence and the Diseases of the Puerperal Period ;" and the recent expositions of Lusk, Charpentier, Winckel, Playfair, Leishman, Barnes, Parvin, etc., in their respective text-books, are, or ought to be, in the hands of all practitioners. Especial interest in this country has been directed to the subject since the publication of the important paper read by Dr. T. Gaillard Thomas before the New York Academy of Medicine in 1844, in which rather extreme measures of prophylaxis were advocated; since the discussion which followed the reading of that paper in 1884 and in 1885; since the promulgation of the results obtained by Dr. Garrigues from antiseptic midwifery in the lying-in wards of Maternity Hospital, New York; by Dr. W. T. Lusk, in the Bellevue Hospital; by Dr. W. L. Richardson, in the Boston Lying-in Hospital; by Dr. B. C. Hirst, at the Maternity Hospital, Philadelphia; by Tarnier, at the Paris Maternity; by the chiefs of the obstetric departments in the hospitals of Vienna, Berlin, and other foreign cities. These results are

† See a valuable paper in the Boston Medical and Surgical Journal, January 27, 1887, by Dr. W. L. Richardson, "On the Use of Antiseptics in Midwifery Practice."

well summed up by Dr. Lusk in a paper read before the Association of American Physicians, May 13, 1890. Only one expressive sentence will be here quoted: "Hospitals which were formerly the seat of violent outbreaks of puerperal fever are now the safest places for women in labor."

The order of events in the history of antiseptic midwifery are as follows:* 1. The institution of antiseptic prophylaxis (by means of chlorine water), by Semmelweiss, in 1847. 2. The creation of antiseptic surgery, by Lister, in 1866 3. The application of antisepsis to midwifery, by Stadfeldt, of Copenhagen, in 1870, and the use of carbolic acid as the best antiseptic. 4. The introduction of bichloride of mercury into obstetric practice as a better antiseptic than carbolic acid, by Tarnier, about 1880. Since the beginning of the last decade the leading hospitals of this country and the old world have adopted the essentials of what is now known as antiseptic midwifery.

Technique. The accoucheur of to-day has a responsibility resting upon him from which the accoucheur of a former age was free. He feels, in a sense which he never felt before, the greater knowledge of the present day dawned upon him, that the life of his patient is in his hands. If he do not carry infection to the patient, and if he employ the proper means to make the patient and her environment aseptic, there is a fair certainty that restoration will take place normally. Knowing that in the great majority of cases of puerperal septicemia the patient is infected by the hands or instruments of the accoucheur, he will take the utmost pains that both hands and instruments are both clean and aseptic. Before making an examination, the sleeves are rolled up above the elbows, and the hands and forearms are thoroughly scrubbed with soap and water; the nails and the spaces under them and the creases about the skin are cleaned with a stiff brush. Then the same parts are soaked one or two minutes in a sublimate solution, I to 1000. Paul Reynier adds that the hands and forearms thus disinfected should not be wiped, unless one is sure of the aseptic condition of the towel. The examining finger may then be greased with carbolized vaseline, or with an ointment composed of 1 part eucalyptus and 7 parts vaseline; whenever afterwards an examination is made, these antiseptic precautions must be repeated.

* Garrigues, loc. cit.

+"Recent Conference on Asepsis," Bull. et Mém. de la Soc. de Méd. pratique.

Instruments (when used) must first be cleansed in soap and water, then dipped in boiling water, which is a sufficiently good antiseptic, and kept till needed in a 1 to 20 carbolic solution. Before applying forceps they should be greased with eucalyptus vaseline. Garrigues recommends carbolized glycerin.

During the first stage of labor, the patient should be disinfected by a vaginal injection of corrosive sublimate, I to 3000, about a quart being used for this purpose; the external genitals, hips, nates, and lower abdomen. should be washed with a somewhat stronger solution,-1 to 1000. For convenience, the physician may carry in his satchel little packages, each containing fifteen grains of corrosive sublimate; one of these to a quart of water makes a solution of the strength of I to 1000. Or the antiseptic tablets of the pharmacists may be employed; each tablet contains seven and a half grains of the sublimate. A basin containing the stronger (1 to 1000) solution should be kept in a convenient place in the lying-in room; into this the physician should dip his hand before making an examination. It is needless to say that vaginal or uterine injections should be made with syringes that have glass or rubber suction-tubes and canulæ, as metal corrodes when in contact with corrosive sublimate. Moreover, only the weaker solutions (1 to 3000 or 1 to 4000) should be used for such injections. The injection may be given with the patient lying on a bed-pan, or (in the absence of this) on a thick folded blanket, and she should be turned upon one side, or be made to sit up for a minute after the injection, that the solution, after distending the vaginal pouch, may all run out, as cases of poisoning from absorption of sublimate solutions are on record.

This one injection before delivery is generally sufficient. Some authorities recommend a carbolized or sublimate douche immediately after labor, and if this be used hot, it has a favorable effect in stimulating uterine contractions and stopping flowing.

In the paper read by Dr. T. G. Thomas before the New York Academy of Medicine, December 6, 1883,† that eminent authority advised to repeat the vaginal injections every three hours before, and every eight hours. after, labor. The voice of the medical profession has very generally been against interference to this extent with what may be called a natural physiological process, and most ob

N. Y. Med. Journ., December 15, 1883.

stetricians now content themselves with one antiseptic injection before labor (unless the first stage be unusually long and tedious), and none after labor.* If, however, the lochia should become at all offensive, and especially if any febrile symptoms should arise, the vagina and uterus should at once be washed out with a carbolized solution (two and a half per cent.), or with a sublimate solution,-1 to

4000.

This injection should be repeated every six or eight hours, till the lochia lose their fetor, and till all febrile symptoms disappear. Dr. W. L. Richardson speaks favorably of iodoform pencils (crayons of cocoabutter incorporating ten grains of iodoform), which may be carried up into the uterus night and morning and left there.

The placenta, if it does not speedily follow the foetus, should be delivered in as antiseptic a manner as possible. Credé's method is recommended by Richardson and Grandin. Then the external genitals should be thoroughly cleansed, soap and water and the sublimate solution being employed, any perineal lacerations closed with antiseptic catgut, and an aseptic pad applied. These pads may be prepared by soaking common napkins in a sublimate solution (1 to 3000), and allowing them to dry. The nurse should be instructed to have a quantity of these napkins ready. The object of these pads is to seal the entrance to the vagina and uterus by a germ-proof protective against the attacks of septic bacteria from the air and other external objects."† Oakum has been used by some obstetricians, and seems to answer a very good purpose.

The pad recommended by Dr. W. L. Richardson resembles Liston's "protective," and as much stress is laid on this part of the dressings, especially by those that omit the douches after the third stage of labor, I will describe Dr. Richardson's method of preparing this pad :

* It may, however, be affirmed that physicians in private practice only exceptionally employ the vaginal douche as a routine practice, and that the intrauterine douche is now never used except when there is especial

reason to fear that infection has entered the uterus. "The douche repeated at short intervals," says Lusk,* "is not unattended with drawbacks. It interferes with the localizing processes by which most of the pelvic inflammations become self-limited; it helps to extend the morbid condition of the uterus to the tubes, and, if continued long enough, paralyzes the uterine walls."

† Dr. H. F. Adams, Boston Med. and Surg. Journ., March 1, 1888.

* Lusk, "Antisepsis in Midwifery," Medical News, May 31, 1890.

A strip of Canton flannel (nineteen by four and a half inches) is placed upon a table, with the soft side uppermost. On the centre of this is laid a piece of carbolized cotton (eleven by four and a half inches), about half an inch in thickness when not compressed. Over the centre of this is a piece of oiled muslin (nine by four inches). On this is placed the pad itself, which is made of what is known as absorbent scrap or waste closed up in cheese-cloth, and of a size sufficient to cover the oiled muslin, and about half an inch in thickness before it is wet or compressed. This pad, before using, is dipped in a solution of corrosive sublimate (1 to 3000) and dried. Whenever a pad with its binder is removed and a fresh one substituted, the old pad, including the Canton flannel, etc., is burned up.

In the discussion which followed Dr. H. F. Adams's paper before the Essex North District Society, one of the speakers (Dr. R. C. Huse) stated that he had been in the habit of using two towels. One of these he dips into a 1 to 1000 solution, and after wringing it out with his hands, he folds it into a square pad, and places it over the vulva. The second towel he likewise wrings out of the antiseptic, and folding it once likewise, passes it between the legs, and pins it to the binder at front and back.

A Word about the Environment of the Patient. The room occupied by the puerpera should be clean and well ventilated, and pig sties, or stables. In hospitals it is quite should not be in propinquity to cess-pools, possible to carry out Dr. Thomas's requirement that the room in which the confinement is to take place should have the floor, walls, and furniture thoroughly washed with a ten per cent. solution of carbolic acid or mercuric chloride, 1 to 1000, and the bedstead and mattresses should be sponged with the same solution. Curtains, carpets, and upholstered furniture should be dispensed with as far as possible.‡

Ought the Physician when attending Contagious Diseases to undertake Confinement Cases? -This is a question which, before the days of antiseptic midwifery, would have been answered unqualifiedly in the negative. And now, without the most rigid attention to personal cleanliness, and an entire change of clothing, it would not be right for the physician to go from a case of scarlet fever, diphtheria, especially erysipelas, or from a post-mortem, to a case of labor. I believe, however, that such thorough disinfection of the person can be obtained that it will be safe for the physician who is attending such diseases to enter the lying-in room. Every article of clothing

Dr. T. G. Thomas, in N. Y. Med. Journ., December 15, 1883.

must be changed, the whole body, including the hair and whiskers, must be washed, then bathed with a strong boric acid solution, as Thomas recommends; then especial attention must be given to the disinfection of the hands, fingers, and finger-nails in the manner before indicated.

Among the prophylactic means should be. included a suitable tonic and fortifying regimen, especially needful when the patient has been exhausted by protracted labor or by hemorrhage. Quinine, wine, and even brandy may be indicated, with such nutrients as the stomach can bear; the vital forces are thus rallied, and the reparative processes favored. Ergot, given at the completion of the second stage of labor, will promote uterine contraction and vascular tonicity. Some obstetrical authorities advise giving ergot through the entire puerperium.

Many physicians may think antiseptic midwifery encumbered with too great fussiness of details, but there is not one of these details but is important, and it is quite possible that valuable lives may now and then, in the lifetime of even a country physician, be saved by rigid attention to such minutiæ as have been above set forth.

CURATIVE TREATMENT.

In sapræmia, irrigation and cleansing of the utero-vaginal cavity may be about all that is needed; the headache and fever may demand a saline draught of acetate of ammonium or nitrate of potassium, and an acetanilid tablet. Quite often I have seen the fever rapidly subside after the administration of a hot carbolized uterine douche. Sapræmia is kept up by a continuous supply of the poison. To stop the supply is the problem of cure.

Of course, it may not be possible to wash out the peccant debris—which may be a blood clot, a shred of membrane, a small bit of placenta-by deodorizing irrigations, and it may be necessary to introduce the finger, or even the whole hand, well disinfected, into the uterus, and remove the offending cause. Then the washings must be repeated three or four times a day, till all fetor of the discharges has disappeared and the temperature has become normal. Intrauterine injections, when needed, must be made by the physician, and not trusted to the nurse.

I think that cases of sapræmia in connection with abortion are more common than with labor at full term, for the reason, probably, that abortions are frequently neglected, often lacking the ministrations of a physi

cian, till some septic complication arises. It has been my lot continually to see cases of sapræmia from retention and decomposition. of the placenta. I have seen pyæmic complications follow such cases, and have found reason to doubt whether any hard and fast line exists between sapræmia and septicemia. A case may begin as sapræmia and end as pyæmia. The following case, from my notebook, is in point:

Mrs. F., Hampton, N. H., aged 30 years, was delivered of a dead foetus at the end of the fourth month, May 1, 1889.

seen by Dr. Fellows, of Seabrook, on the 7th, who found a marked febrile condition, tender abdomen, considerable prostration, but regarded it as a case of sapræmia. He removed a putrid placenta. This patient was living in a retired country place; the surroundings were as healthy as could be imagined; all ordinary causes of infection were excluded; the sister of the patient was alone with her during her miscarriage.

On the 15th I saw Mrs. F. along with Dr. Fellows. She had had a series of chills; there was fever of marked hectic or remittent character; great nervous prostration; pulse 140 per minute. I opened a large abscess on the back of the arm above the left elbow, giving vent to a pint or more of foul pus. There seemed to be another abscess forming in the left thigh; left knee swollen and painful. There was an offensive ichorous discharge from vagina. I recommended a hot sublimate douche-1 to 2000-every morning, and the application after the douche of a crayon of iodoform, 20 grains, to be passed up to the fundus and left there. Gave the douche and applied the crayon before leaving the house. Prognosis unfa

vorable.

May 20.-Again visited Mrs. F. with Dr. Fellows. Condition not improved. Opened an immense abscess at the upper part of the thigh, giving issue to most fetid pus. Put in a rubber drainage-tube. There seemed to be an abscess forming in the vagina. Temperature still high, ranging from 101° to 104° F. Pulse 140 per minute. Nervousness and pain required sulph. morph., 4-grain, every six hours. Patient was taking large doses of tinct. ferri chloridi with sulph. quinine, 20 drops of the iron tincture, and 5 grains quinine, every four hours. This treatment was continued by Dr. Fellows for nearly four weeks. Eggs and milk, brandy, beef peptonoids, meat juice, and other nutrients were freely administered.

The abscess in the thigh kept discharging for several weeks.

The swelling in the left knee subsided without suppuration.

The abscess in the vagina was in due time opened by Dr. Fellows. The condition of this patient long continued critical, but she eventually made a perfect recovery.

An important indication is to relieve pain and nervous disturbance. For this object there is nothing better than a hypodermic injection of morphine. The grain tablet triturates of the manufacturing pharmacists are convenient for this purpose; or Magendie's solution may be used, which contains 16 grains sulphate morphine to an ounce of distilled water-10 drops of this solution is

1. To prevent any further absorption of poison by the lymphatics and veins of the genital passages.

The hypodermic may have to be repeated twice or three times a day. Where there is a complication of peritonitis, the pain is a formidable symptom, and must be kept in

3. To aid the natural forces in the contest with the enemy.

4. To combat fever, and meet other symptoms and complications that may arise.

When the disease is declared, douches and ablutions cannot, of course, do the good that is expected of them in simple sapræmia, and may not be needed at all. If, however, there is any fetor in the discharges, and any reason to believe that the uterus and vagina are still the breedingplaces of septic organisms, the irrigations should still be practised twice a day. A vaginal injection is always harmless, and if the lochia are suppressed, the hot douche may favor their return. Intrauterine douches may do serious harm, and should not be resorted to unless there is decomposing debris to be removed. All danger may be avoided by using (as Dr. T. G. Thomas advises) a large injecting-tube, which cannot enter an open-mouthed sinus (and, I may add, that, if there be no orifice on the end of the tube, and the fluid be made to issue from minute orifices on the sides, all the better); by using water warmed to 105° F.; by injecting the fluid through the tube so as to exclude air before passing this up to the os uteri; and by making the injection cautiously and with great gentleness. The os uteri ought to be patulous, so as to allow the injected fluid speedily to flow back; in the event of its being contracted and closely hugging the canula, it should previously be dilated by some mechanical means. A fountain syringe, which gives a continuous stream, is preferable to a Davidson syringe.

Cases of pyæmia and septicæmia, says Matthews Duncan, are to be managed rather than treated. We cannot arrest or even moderate the storm, but we may guide the bark through it.

My own custom has been to begin with a subcutaneous morphine injection, and to keep up the effect by grain doses of solid opium given by mouth. I have seen cases where 2 grains every hour were barely sufficient to control the pain, but quantities much larger than this have been given with impunity.*

In the pyæmic variety there is rarely severe pain, and opiates are of little use, and may often be omitted altogether.

The third indication is to aid the natural forces in the contest with the enemy.

The puerperal fever patient is a person whose constitutional powers have been impaired by various causes which have rendered her susceptible to septic agencies. She is, moreover, still further depressed by the multiplying virus in her system, and an "antiphlogistic" or spoliative treatment would be eminently improper. While blood-letting is not to be thought of, active purging, with a view to elimination, is not justifiable. It is only where there is constipation and fæcal accumulation that purgatives are required, and then mild laxatives should be chosen,— cascara sagrada, castor oil, castor oil and calomel (an ounce of the former to five grains of the latter, rubbed up with twenty grains of bicarbonate of sodium). † The occurrence of a diarrhoea (whether accidental or provoked), where there is peritoneal inflammation, is injurious rather than salutary, and is not to be encouraged. Milk, beef tea, beef peptones, wine, and other alcoholic stimulants are to be regularly administered. Quinine in pretty