Part 156

But the early experiences of the Hôpital Cochin and the Hôpital Lariboisière, costly, palace-like structures, with every appliance of art, prove that fresh air alone does not protect patients from the consequences of inoculation.

The great improvement in the condition of maternity patients in recent years has been due to the application of Lister's principles to obstetric practice. Complete antisepsis in the surgical sense is, of course, impracticable. Adequate antisepsis has, however, been proved to result from the observance of a variety of precautions which have been the slow outcome of experience. These, in brief, in hospitals, consist in protecting the patient from every known form of contamination, and in the prompt removal and isolation of every puerperal woman who manifests febrile symptoms.

In citing the examples of the Hôpital Cochin and the Hôpital Lariboisière, I was led to the selection because these hospitals most strikingly illustrate the extent of the triumph of the new doctrines. Whereas at the Lariboisière the mortality in 1854, the year of its opening, exceeded 10 per cent., as a result of the prophylactic measures adopted by M. Siredey the mortality was 1 to 145 in 1877, and 1 to 199 in 1878. And at the Hôpital Cochin, in 1878, Lucas-Champonnière, with 770 confinements, was able to report but 2 deaths from puerperal causes.

{1025} As regards details, the bedsteads should be of iron and should be frequently scrubbed with a carbolic solution; after each confinement the palliasse upon which the woman lay should be washed in boiling water and the straw should be burned; in place of the usual rubber covering to the bed, Tarnier recommends tarred paper, which is antiseptic, and costs so little that it need be used in but a single case; all soiled linen should be instantly removed from the ward, either to be burned or disinfected by prolonged boiling; sponges should be banished, as, when they have once been soaked with blood, not even carbolic acid can make them safe; nurses employed in the puerperal wards ought not to have access to cases of labor, as D'Espine and Karewski have shown that the lochia of even a healthy person on the third day will poison a rabbit; a patient attacked with fever should be immediately removed, and the nurse in attendance should go with her. At the Emergency Hospital, with the first appearance of catarrhal affection of the genital organs or of so-called milk fever, the wards are immediately emptied and fumigated with sulphurous acid. In spite of recent scepticism regarding the value of the fumes of sulphurous acid as a germicide and disinfectant, I do not hesitate to express, after long experience, my firm conviction as to their efficacy.

Doléris formulates the indications for effective prophylaxis as follows: 1, prevent the introduction of germs (antisepsis before confinement); 2, paralyze their action (antisepsis after confinement); 3, shut up the doors--veins, lymphatics, and Fallopian tubes (employment of means which promote uterine contraction).

The first duty of the physician is to refrain from attending a case of labor when fresh from the presence of contagious diseases or from contact with septic materials, whether derived from the dissecting-room or the clinic. Scepticism regarding these sources of danger is sure in the long run to be severely punished. In a doubtful case the least concession should consist in a full bath and a complete change of clothing. A special coat for confinement purposes, stained with blood and amniotic fluid, is liable to convey infection. In every case of labor, whether in hospital or private practice, the hands and forearms should be freely bathed in a carbolic solution before making a vaginal examination. A nail-brush should form a part of the ordinary obstetric equipment. Frequent examinations during labor should be avoided. All instruments employed during or subsequent to confinement should be carefully disinfected. In prolonged labors, after operation, in cases of dystocia, or where the membranes have ruptured prematurely and the foetus is dead, it is a useful precaution after delivery to wash both uterus and vagina with warm carbolized water or solution of corrosive sublimate (1:2000). In Vienna both Spaeth and Braun after difficult labors introduce a suppository of iodoform, 2 to 2-1/2 inches in length, into the uterine cavity. The formula recommended consists of--

Rx. Iodoformi, 20 grammes; Gummi Arabici, Glycerinæ, Amyli puri, aa. 2 grammes; Ft. Bacilli, No. iij.

{1026} In their introduction the half-hand (left) should be passed to the cervix; the iodoform bacillus should be seized by a pair of polypus forceps and pushed into the cervical canal. The hand in the vagina should then be used to shove the suppository upward past the internal os. No symptoms of poisoning from the iodoform have been observed. The disinfection is complete and prolonged. In hospitals the woman should be bathed before entering the lying-in ward, and the vagina should in all cases be disinfected with carbolic acid or corrosive sublimate both before and immediately after labor. The conduct of labor under carbolic acid spray is commended by Fancourt Barnes. Doléris advises the application of a compress soaked in carbolic fluid to the external genitals during the progress of labor. Tarnier advises dressing the vulva, so soon as the head begins to emerge, with a pledget soaked in carbolized oil (1:10). With the recession of the head during the interval between pains a portion of the oil is carried upward into the vagina.

In the puerperal period the warm carbolized douche stimulates uterine retraction and promotes the rapid healing of wounds in the vaginal canal; in hospital practice it possesses the additional advantage of preventing the accumulation of putrid albuminoid matters in the air. In private practice the patient should employ a new syringe; in hospitals every woman should be supplied with a glass tube to be attached to the irrigator. When not in use these tubes should be immersed in carbolic acid. The stream injected into the vagina should be continuous, like that furnished by the fountain syringe. With my hospital patients, in place of cloths to the vulva I have been in the habit of using oakum. By soaking the latter in a solution of carbolic acid the vulva is surrounded by an antiseptic atmosphere.

Pedantic as these directions may seem, they are justified by experience, and the carrying out of the details given easily becomes a matter of habit. That by such precautions puerperal fever is destined to be erased from the list of dangerous diseases attacking the woman in childbed is saying more than is warranted. Nevertheless, it is true that a physician ought never to lose the sense of personal responsibility for its occurrence. Indeed, puerperal fever ought to be regarded as a preventable disease, and an attack as the evidence that some source of danger has been overlooked, though, owing to the imperfection of our knowledge, it may easily happen that even with the keenest scrutiny the precise cause in an individual case may escape detection.

When the details of this treatment were first published by Garrigues, many took a humorous view of it, but mark the result: In the following 162 confinements there were no deaths, and from October to July, inclusive, of the present year, of 409 patients confined, though many operations were performed, 5 died; but of these, 3 only were from septic causes, and they, Garrigues believes, were the result of the neglect of certain of the prescribed details.]

{1027} Before terminating this section upon the prophylaxis of puerperal fever, I take great satisfaction in furnishing from Tarnier's recent treatise the following description, by Pinard, of the ingenious pavilion designed by Tarnier to make it possible to secure for hospital patients, at the minimum expense, the benefits of isolation, and to provide for each room in the pavilion all the conditions favorable to rapid and complete disinfection.

The pavilions are two-storied and of a rectangular shape, twenty-four feet in width by forty-six feet in length. The front and rear face to the north and south, the ends to the east and west. Two main partitions divide the interior into three divisions. Each end division is subdivided by a central partition into two chambers, so that each story has five compartments--a central one for the attendants, and four at the four corners destined for the reception of patients. On the ground floor the central compartment consists of a vestibule facing to the north, and an office facing to the south. On the former are placed the staircase, the water-closet, and a reception-closet. In addition to the main entrance there are three interior doors--one leading to the water-closet, one to the closet, and one to the office. The latter, for the occupation of the person on duty, contains a heater, a portable bath, a table, chairs, and wardrobe. Two windows face the south. The office has two doors, one opening into the vestibule, and the other, in the opposite side, opens directly outward. The four corner rooms for patients have each a door and a window, the latter looking from the end of the partition and reaching to the floor, and the former opening out from the façade. These four rooms are therefore not only independent of one another, but have no communication with the vestibule or the central office. On the second floor the arrangement is similar, except that the rooms open upon a balcony, by means of which communication from the outside is rendered possible. Upon each façade a glazed screen furnishes shelter in rainy weather. The screen extends to the roof, but is not in direct contact with the walls, a space being left for a current of air. The eight rooms for patients, four on each story, are severally fourteen feet long, eleven and a half feet wide, and ten feet high. Below, the floors are of asphaltum; above, of flags or slates. The walls and ceilings are stuccoed and covered with oil paint. The corners are rounded to prevent the accumulation of dust. To facilitate {1028} washing, the floors slant toward a gutter communicating by means of a pipe with the sewer. In each room panes of glass enable patients and the office attendant to see one another, so that surveillance is secured without sacrificing the principle of isolation. The furniture of the rooms consists of an iron bedstead with metallic springs. The pillow, bolster, and palliasse are stuffed with straw. In addition, each room is provided with a night table, a round table, a chair, a stool, and a crib--all of iron. A bell-rope at the bedside, the wire of which passes to the office by the outside of the building, enables the patient to summon assistance. Each room likewise contains a washstand, with faucets for hot and cold water, the latter supplied from a cistern on the roof, the former from the office heater. The patients remain in the rooms where they are confined until they are discharged. When this takes place the chamber is aired, the furniture is removed and washed with care, the straw is burned, and the walls are washed with an abundant supply of water. If a patient is taken ill, she is carefully isolated, and has assigned to her her own especial attendant and physician, who do not come into contact with other puerperal patients.

That the plans of construction in the Tarnier pavilions would require some modification to adapt them to the rigor of our winters seems probable, but the principles which they illustrate are sufficiently vindicated by the results so far reported--viz. 6 deaths in 1062 confinements, whereas in the old Maternity the death-rate, formerly amounting to 5 per cent., still aggregates 2 to the 100.

TREATMENT.--When the septic germs characteristic of putrid infection have once entered the blood, they are beyond the reach of the physician. Except, however, in cases of acute septicæmia, where the quantity of poison introduced at the outset is excessive, the patient rallies from the immediate shock, and, provided no fresh pyrogenic material finds its way into the system, recovery is to be anticipated. The indications for treatment are, therefore, to neutralize the puerperal poison at the point of production, in order to prevent its causing further mischief, and to adopt measures calculated to enable the patient to tolerate its presence, when once absorbed, until it is either eliminated or loses its harmful properties.

Toward the fulfilment of the first indication it is to be recommended that in every case of fever of puerperal origin the vagina be cleansed with a 2 to 3 per cent. solution of carbolic acid or corrosive sublimate (1:3000) every four to six hours. The douche in itself is absolutely harmless. In most cases the infection starts from the wounds of the vagina and of the cervix. Then, too, the tendency of the secretions to stagnate in the vaginal cul-de-sac, bathing as they do the cervical portion, is a prolific source of septic trouble. In all but the mildest cases the vaginal orifice should be examined with reference to the existence of puerperal ulcers. All necrotic patches should be touched with hydrochloric acid, with a 10 per cent. solution of carbolic acid, with iodoform, or, what I personally prefer, a mixture composed of equal parts of the solution of the persulphate of iron and the compound tincture of iodine. The latter acts as a powerful antiseptic, while the former, by corrugating the tissues, closes the lymphatics and shuts up the portals through which the septic germs penetrate into the system.

{1029} Intra-uterine injections should be resorted to with extreme circumspection. They are not indicated by a simple rise of temperature. A very large proportion of the febrile attacks which occur in childbed run an absolutely favorable course. Unless the infection--and this is not the rule, but the exception--proceeds from the uterine cavity, they are unnecessary. In circumscribed inflammations, where the morbific poison loses its virulence at a short distance from the puerperal lesion, they are often injurious. It is difficult, if not impossible, to so conduct them as to avoid opening up afresh recent granulating wounds. Yet the practice of local disinfection is warmly advocated by Fritsch, Schüller, Langenbuch, and Schroeder as a prophylactic against puerperal affections. On the other hand, Braun von Fernwald, with his vast opportunities for judging obstetrical questions, writes with reference to this: "We must protest against injections made by physicians into the uterine cavity. Such meddlesomeness is more likely to do harm than good." This corresponds with my own experience. In theory, the proposition to treat the uterus as one would any other pus-secreting cavity seems rational, but I have found that every attempt to carry the theory to its logical conclusion in hospital practice has been followed by a rise in the puerperal death-rate. Runge reports an epidemic of puerperal fever in Gusserrow's clinic brought about by the employment of intra-uterine irrigations, during which the mortality rose to 3.8 per cent. With the abolition of the irrigations the mortality sank to .39 per cent. In 1880, Fischel introduced the so-called permanent irrigations into the Prague maternity. Of 880 patients, 9 died of sepsis. The irrigations were then prohibited. The following year, of 933 patients, only 2 died from the same cause, and in 1882, of 521 patients, there were no deaths from sepsis. Fehling, who limited the use of intra-uterine injections to special momentary indications, reported, in 1880, 415 confinements without a single death.

Among the accidents which have been referred to the use of injections are convulsions, shock, and carbolic-acid or corrosive-sublimate poisoning; but the chief danger lies in the possibility of conveying the infectious materials from the vagina to the previously normal uterus. There seems to be no question as to the superior effectiveness of corrosive sublimate as a germicide. It not only acts more rapidly than carbolic acid, but its action is more permanent. In the usual proportion of 1:2000 it is apt, when repeated frequently as a vaginal douche, to corrugate the vagina and cervix. When used for intra-uterine irrigation great pains should be taken that no portion of the fluid remain behind in the uterine cavity. Since its introduction into the Emergency Hospital there has been one death from ulceration in the colon, which possibly was attributable to its use. It is to be hoped the claim that corrosive sublimate is an efficient antiseptic in the proportion of 1:10,000 may prove well founded.

In pressing the necessity of caution and discrimination, I have not, however, intended to discourage the employment of intra-uterine antisepsis in cases where it is strictly indicated. Thus, it would be folly, in a fever due to the decomposition of placental débris, of shreds of decidua, of strips of membrane, or of retained coagula, or in diphtheritis of the mucous membrane, to treat the general symptoms and neglect {1030} the local cause of difficulty. In a specific case it may prove difficult to decide as to the correct course to pursue. In general it may be stated that it is proper to wash out the entire length of the genital canal when fever follows prolonged operations conducted within the uterine cavity or the birth of a dead foetus, and in cases of fever associated with a fetid discharge which persists in spite of the vaginal douche, with the presence of recognizable portions of the ovum or its dependencies in the lochia, with the repeated discharge of decomposed coagula, or with a large, flabby uterus. It will, however, be seen that with proper disinfection during and immediately after labor, the occasions for late intra-uterine injections are extremely rare.

The operation of cleansing the uterus should be conducted with the most scrupulous care. The syringe employed should produce a continuous and not an interrupted stream, and all air should be expelled from the pipe. The tube to be passed through the cervix should be of glass, of the size of the little finger, and bent somewhat to conform to the pelvic curve. The vagina should first be subjected to a thorough disinfection, by way of precaution against conveying septic materials into the uterus. The introduction of the tube should be made with the guidance of two fingers passed through the external os. But slight force is requisite to reach the internal os. It is neither necessary nor desirable to push the tube to the fundus. The fluid injected should be tepid, and, if carbolic acid is used, of the strength of two or three drachms to the pint; if corrosive sublimate is employed, the strength should not exceed 1:3000. It should be introduced very slowly, and pains should be taken to ensure its unimpeded escape, which can usually be accomplished by pressing the anterior wall of the cervix forward by means of the glass tube. Langenbuch recommends securing permanent drainage by leaving a bit of rubber tubing in the cervical canal--a plan concerning the merits of which I am not able to speak from experience. The tube is said to be well tolerated, and to possess the advantage of enabling subsequent injections to be performed without disturbing the patient.

In many cases the results of intra-uterine treatment are very striking. Often the temperature falls notably within an hour or two of the operation. This result is, however, rarely permanent. Usually the fever recurs, and the operation has to be repeated. The patient should be carefully watched, and with the first sign of returning danger the injection should be repeated. Two or three injections may thus be called for in twenty-four hours, and they may require to be continued for a week. Still, by the means indicated a certain pretty large proportion of women seemingly destined to destruction in the end make favorable recoveries.

Ehrendorfer relates a case of septic endometritis and erysipelas {1031} starting from the genital organs, in Spaeth's Clinic, where, after seven days of ineffective uterine irrigations, two bacilli, containing together ten grains of iodoform, were introduced into the uterus. The washings with carbolic acid were then stopped. On the next day the discharge was diminished and the odor was less marked. On the fourth day two new iodoform bacilli were introduced. The patient, in spite of the fact that the erysipelas spread over nearly the entire body, eventually recovered.

Of the symptoms, the first in order which calls for treatment is usually the peritoneal pain. It is, as we have seen, commonly of a lancinating character, and is associated with hurried breathing and extreme frequency of the pulse. So soon as the pain is once fairly under control the violence of the onset begins to abate. It should be met, therefore, by the hypodermic injection of from one-sixth to one-third grain of morphia in solution. The anodyne action should be maintained by doses administered by the mouth in quantities and at intervals suited to the severity of the case. The most important object to be secured is freedom from spontaneous pain. It is, moreover, good practice to push the opiate until pain elicited by pressure is likewise controlled, provided it can be accomplished without producing narcosis. In susceptible patients and in localized inflammations the quantity required may not be very great, while in acute general peritonitis the tolerance of the drug exhibited by puerperal women is sometimes extraordinary. Thus, a patient of Alonzo Clark took the equivalent of 934 grains of opium in four days; a patient of Fordyce Barker 13,969 drops of Magendie's solution in eleven days; and one of my own, at the Maternity, the equivalent of over 1700 grains of opium in seven days. In this latter instance the patient was to all appearance moribund when the treatment was begun. Thus, the features were pinched, the face was drawn, the pupils were dilated, the finger-tips were blue and cold, the respirations were rapid, and the pulse was scarcely perceptible. In this condition the large doses of opium did not produce narcosis, but were followed by restoration of the circulation, by normal breathing, and by the disappearance of the symptoms of shock. Any attempt to relax the treatment was at once succeeded by a recurrence of the alarming symptoms. At the expiration of the disease the opium was discontinued abruptly without detriment to the patient.

In contrast to cases of acute peritonitis an extreme susceptibility to opium is often observed in the pyæmic variety. Here opiates seem to me rarely to do good. They do not hinder the migrations of the round bacteria, there is rarely pain to relieve, and I have sometimes thought that their administration was simply the addition of a second poison to the one which already was overwhelming the nervous system.

In pelvic peritonitis, in the course of forty-eight hours plastic exudation is thrown out and the pain to a great extent subsides. From this time very moderate doses of opium, as a rule, are needed to make the patient comfortable.

In France leeches applied to the abdomen are much used as a means of relieving peritoneal sensitiveness. That they do this is beyond question. {1032} Their disuse in this country is due probably more to popular prejudice than to their inefficacy.

In the beginning of an attack a turpentine stupe to the abdomen is a source of comfort to many women, while the sharp counter-irritation exercises possibly a favorable influence upon the course of the disease. At a later period I commonly employ flannels wrung out in water and covered with oil-silk to prevent speedy evaporation. It is an old experience that in the beginning of a puerperal fever the provocation of loose stools by purgatives is frequently followed by a fall in the temperature and a great improvement in the patient's condition. The result, however, is far from uniform, as in other cases these artificial diarrhoeas have a tendency to aggravate the peritoneal symptoms. Owing to this uncertainty in their action, purgative remedies should be administered with caution, not from any theory as to their eliminative powers, but because of the ascertained existence of fecal accumulation. In pelvic inflammations castor oil in two- or three-tablespoonful doses, or five to ten grains of calomel rubbed up with twenty grains of bicarbonate of sodium, as recommended by Barker, may be given when thus indicated. After the bowels have once been freed, however, the purgative should not be repeated. In cases of intense local inflammation and in general peritonitis enemata should alone be employed for the removal of constipation.

Every increase of body-heat is associated with rapid tissue-waste, with enfeebled heart-action and with exhaustion of the nerve-centres. Since the modern recognition of the deleterious effects of high temperatures per se, antipyretic remedies in place of the old-time cardiac sedatives have come to play the leading rôle in the treatment of fevers.