PREVENTION AND TREATMENT OF PUER

PERAL SEPSIS.

BY L. C. FISCHER, M.D., ATLANTA.

I do not feel that I should offer any apology to this assembly of men who are so vitally interested in the subject under discussion. Though it has been written about for ages and discussed by our most able men, we are constantly reminded of the need of more knowledge and more systematic work along this line every few weeks by seeing or hearing of some woman losing her life at time of confinement. The picture is typical: the woman is confined; on or about the second or third day we find that she has had a slight chill, that the temperature has risen as a result; then it is that we begin to make excuses to the family for her condition-that she is bilious, that her kidneys are out of order, etc. I know that there is not a man before me to-day who fully realizes his responsibility (and I hope we all do this), but that he watches his obstetrical cases with great care for the first few days after confinement, most of us with the constant fear that this one may be the case of infection that will cause us to feel much chagrined. I have no class of work that causes me more anxiety.

It was my misfortune to be called to a very severe case of infection in the first few months of my professional career. At that time I did not feel that I was sufficiently posted to treat the case, and so told the husband. At my suggestion two consultants were called; both of them

were men of ability and reputation. At the time they saw the woman, I remember now and have often since, that the posterior culdesac was as tight as it could well be not to rupture. I know now that that pelvis was full of pus. I had never done, nor had I seen done, a vaginal puncture to relieve this condition. In a few hours after seeing the woman, she developed general peritonitis, and died a few days later. This case was treated with salts, calomel and opium. While the results might have been the same, had other methods been pursued, I shall always feel that that woman's life was lost by not receiving the proper treatment at the first.

The statistics of pueperal infection can not be relied upon. Most of us know of cases of pueperal infection and death where they were reported as being due to typhoid or malarial fever, occlusion of the bile passages, to previous bad health, and other such like excuses.

In this day of advances in all sciences the death rate from puerperal sepsis is practically the same in private practice as it was years ago. Statistics of private work are unreliable in the South for several reasons. First, there are those in the profession who are afraid to report a cause of death as puerperal sepsis for fear of losing professional prestige in that locality, thereby losing fees. Then there are others who fail to report the true cause of death from ignorance of the real condition. Then the great amount of work done by midwives, especially among the very poor and negroes. Just here, I would like to say that there should be some law governing the practice of these midwives; they should be forced to stand an examination along the line of their work. Too many women are sent to the great Judgment Bar by their uncleanly, not to say, filthy work. The reports from the hospitals, while valuable, do not give us any idea of what

is occurring on the outside. In the hospitals and maternities the surroundings are the best. With the best physicians of the locality to conduct the case, with trained assistants, with nursing by competent hands, with time to prepare the patient, her bedding and clothing, with all instruments and dressings sterilized after the most improved methods; while, on the other hand, in private work, we have to contend with all kinds of cases in all stations of life, with all kinds of nurses, often a meddlesome negro nurse, who is a midwife as well as a nurse. While on a recent visit to New York I saw Dr. W. M. Polk operate upon two cases of infection in one day that were sent in to the Bellevue Hospital from the crowded. districts of New York. The same afternoon I saw Dr. Stewart operate for the same condition.

At a recent meeting of the Philadelphia Obstetrical Society Dr. Hirst said that he had to operate upon a large number of these cases every year. In the last three days three of the most desperate cases of puerperal sepsis were brought to the University Hospital in the ambulance. He had usually four to six cases under observation 'continually.

Go back a few years in obstetrical practice and you will see a great many patients who had "child-bed fever," phlegmasia alba dolens and their complications; they were considered unavoidable. Despite the great improvements in antiseptics, fever in the puerperal state is still seen. Strict asepsis in obstetrical work is practically impossible. First, due to the conditions that might have existed before we examined the woman, as the presence of gonococci, staphylococci, etc., and then the anatomical relations, close proximity of the anus, the excretions and the difficulty in making the vulva aseptic on account of the hairs and folds of the vulva.

It is admitted by all scientific workers that puerperal sepsis is due to the different streptococci to gonococci, to bacilli coli communis and staphylococci. Ther, witen we: admit the cause, we should use every effort to prevent the result; we should exercise the greatest care in our work in preparing the patient for confinement. We should see that she has had a general bath, with especial attention to the parts surrounding the vulva, that she should have on a clean gown, that bladder and bowels are emptied. The bed should be prepared so that all discharges can be removed when the woman is cleaned up after birth of child. A rubber sheet about four by six feet should be first placed on the bed, this to be covered over with a clean sheet; the use of a Kelly pad is advisable for two reasons: -the ease with which it can be made aseptic and cleanliness, it catching all discharges. If the rubber pad is not used, then an absorbent pad should be placed next to the rubber sheet and covered over with the draw sheet; the top sheet should likewise be clean. Where I can direct. the preparation of the bed, I like for these sheets to cometo the room fresh from the laundry.

The Kelly pad should be thoroughly soaked in bichlo-ride solution before being placed under the woman. Then, with the woman placed in dorsal position, I have the nurseor in the absence of a competent one do it myself, clip the long hairs from the mons veneris and labia majora, then sponge the external parts thoroughly with bichloridesolution, I to 2,000.

With the coat removed and a rubber apron on for twofold purpose, to protect the clothing and to protect the woman from any germs that may have accumulated on your clothes in everyday work; with the sleeves well above the elbows, scrub thoroughly with soap, brush and warm water from five to ten minutes, where time wilk

allow (this is the rule), then soak the hands thoroughly in bichloride solution, I to 2,000, for at least three to five minutes; careful attention should be given the nails. I prefer the use of gloves, soaking them in bichloride solution of the same strength. It is admitted that all cases of puerperal infection are caused from without, so we can not use too much care in our first preparation. When you have gotten to the case late, and have not time to make thorough preparation, the hands should at least be soaked in antiseptic solution, preferably bichloride, and gloves. worn, taking due care not to make any more examination than is positively necessary, and by no means in the vagina until you have time to cleanse the hands thoroughly. The parts should be cleansed hurriedly with bichloride solution before making any examination. After preparations have been made make a careful examination, donot allow the examining hand to come in contact with the bedding or unclean parts of the woman. If possible, make your diagnosis at your first examination; then watch the descent of the head by making external examinations; in normal cases one or two vaginal examinations is all that is necessary. One mistake that we make is examining the woman too often. It not only increases. the danger of infection, but increases the patient's anxiety as to her condition. Of course, there are cases where this rule will not apply. When it is necessary for version to be done, or forceps used, the hairs should all be shaved off from mons veneris and surrounding parts, then scrubbed thoroughly with soap, water and bichloride solution. A bichloride douche, I to 4,000, or lysol, I per cent, should be given before delivery. This cleanses the vagina and, where lysol is used, acts as a lubricant. In normal cases of labor the douche is not advisable by any means, especially after delivery. After the child is de-