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THE RELATION OF

MICRO-ORGANISMS TO THE PUERPERA

AMD

THE WAY TO MANAGE THEM.

X. JOHNSON -A.IjILiOAVA.Y, M.I>.,

(iryiueoolOKist to the Montreal Dispensary.

BeprirUed from the ** Canada Medical and SwrguxU Jotmuxl" for April

and August, 1886.

-"'^' v>^

Udontveat :

GAZETTE PRINTING CQM^AN.it

1886. "^' ;; '/■-:-iiii

(

REPRINTEI) FROM TUB "CANADA MEDICAL k SUROIOAL JOURNAL."

THE RELATION OF MICRO-ORGANISMS TO THE
PUERPERA AND THE WAY TO MANAGE THEM.

By T. JOHNSON ALLOWAY. M.D.,
GynsBcoIogist to the Montreal Dispensary.

(Read by title before the Canadian Medical Aaaociation, at Chatham, September, 1885.)

In speaking of the relation which micro-organisms bear to the
morbid conditions which the human puerpera is in danger of, it
is exceedingly difficult to avoid being to a certain extent prolix.
The vital importance of the subject becomes impressed upon us
more and more as we continue to devote our thoughts to it, and
as we become aware of deaths occurring in our midst frequently,
which we have every reason to believe should be preventable.
And it is this latter fact which is weightiest of all in urging us
on to investigate and add new ways of conducting the puerperium
towards attaining a low fractional mortality.

One of the great questions of the day is Iiow to obtain this
low mortality, and another — probably the more difficult of the
two — is how to make the yrowing-up members of the profession
convinced of facts tending toward this end ?

Up to a period of the world's history approaching the middle
of the present century, it was not an uncommon occurrence for
men to have had allotted to them during their individual lives a
number of wives varying from two to four. And we are told
that the wives of these men for the most part died in childbed
or from '"'' some obscure internal disease " presumably connected
with the organs of reproduction. On the other hand, it was well
established that *■*' old maids " never died. They became extinct
as individuals through a process of gradual desiccation experi-

enced in no other phase of nature. And I hold that until we
can reduce the mortality of '* wives " down to that of " maids *'
we will be wanting in our duty as faithful and determined investi-
gators. Let us turn our backs upon expectancy, redolent as it
is with the tenets of dark ages. I say this in much earnestness,
because infectious puerperal disease has still its friends at court
who are constantly disclaiming against such a wolf. They will
tell us in open council they have never, in many hundreds of
cases, seen one of septic fever ; that they do not believe in anti-
septic precautions ; that the lochia is a healthy-healing medium
(_sic')y and should not be interfered with ; that it is meddlesome
midwifery, and that the female genitals form a temple only for
the gods to behold. I have before me a copy of the Medical
Age (Aprir25th, 1884), in which there is an article on '' Com-
mon Sense in Obstetrics," by "An Old Practitioner." The
author says, " I never could muster courage enough to subject
a modest woman to the indignity of making an ocular examina-
tion for a rupture, and I have never found it necessary so to do.
Dr. Thomas to the contrary notwithstanding." The whole of
this article, from beginning to end, is a good sample of many
such as we see in medical journals of the present time. They are
simply harangues of vicious invective against modern advance
in gynaecic medicine, and are directed particularly against such
men as Gaillard Thomas and his followers in antiseptics. They
truly remind one of Bacon's definition of Fame — " A gilded
butt to be pierced by arrows of malignancy.''^

If these gentlemen of the pre-liberal age would only consider
that there are many circumstances connected with their indi-
vidual careers which would 9eem to justify them in leaving every-
thing to nature, and that there are possibly circumstances con-
nected with the lives of others not similarly situated which a like
procedure would be most fatal to their patients and their own
reputation, medical editors would be spared the publishing of
much matter which they cannot conscientiously endorse, and
Thomas, in his endeavor to save life and benefit our race, would
not sometimes feel with chagrin that he had been throwing pearls
to " inappreciative mortals.'

',-.

Between the years 1847 and 1880 no less than 164,446
deaths have been registered in England as the result of septic
puerperal disease. This number does not represent the true
facts of the case, as there must have been many such deaths
not registered under this term. It has been said by physicians
who lived at the beginning of the present century that they
would as soon be called to attend a case of hydrophobia as one
of puerperal fever. And, more recently, Dr. Stokes assured
the Dublin Obstetric Society that in his experience of over forty
years he had never seen a single instance of recovery from puer-
peral fever.

Fischel tells us that at Breisky's second clinic at Prague
during the three years from 1879 to 1882 the mortality varied
from 3.1 to .0 per cent, under various forms of prophylactic
precautions. And Fischel concludes that the prevention and
treatment of septic puerperal affections must be local and surgi-
cal in character.

Paul Bar, in his late work, tells us that prior to the year 1870
the percentage of deaths varied between 3.5 and 20.3 per cent.,
the rates being nearer the latter figure. After 1870, when
Tarnier began to practice and teach antiseptics, the mortality
began to decrease from 2.8 in 1871 to 1.1 in 1883. In Tar-
nier's pavilion, established in 1876, there was but one death in
88 cases. In 1877 and 1878, out of 204 and 23" deliveries
respectively, only two deaths; in 1879, out of 189 d -liveries,
only one death ; and since then up to middle of June, 1883,
out of a total number of 785 deliveries not a single death.

In the year 1875, Battlehner of Karlsruhe reports 530 puer-
peral deaths from all causes in the Grand Duchy of Baden.
Afker the introduction of antiseptic prophylaxis, the mortality
sank in 1880 to 450 ; in 1881 to 380 ; in 1882 to 225 ; and
in an average of 56,000 parturitions, from 0.95 per cent, to 0.4
per cent., or more than one-half.

In Dr. Macan's report of the Rotunda Hospital for 1883 there

. appears a most remarkably low mortality under strict antiseptic

precautions. The pupils and nurses are required to wash their

hands thoroughly in a solution of carbolic acid and then dip them

in a solution of corrosive sublimate (1 to 1,000) before making
a vaginal examination. The vagina is irrigated with an antiseptic
solution before any post-partum operation is performed, and the
uterus is irrigated afterwards with a solution of corrosive subli-
mate (1 to 2,000). The report states that under this practice,
of 1,090 women confined during the year, 6 died, a mortality of
0.55 per cent. And the most noticeable fact is that none of these
deaths were from septicaemia.

During the discussion on puerperal fever at the New York
Academy of Medicine (1884), very startling facts were brought
out by Dr. H. T. Hanks. He stated that he had obtained statis-
tics from the Board of Health of New York City showing that
during the past four years, out of 120,418 puerperal women,
1,005 deaths occurred from puerperal fever, or 1 death in 120
cases. And he expressed the opinion that, under such a state
of things, the profession should be ready to accept any judicious
change in the care of the puerpera which would promise better
results for the future.

From these few statistical quotations, it will be seen that the
mortality in childbed-fever has been gradually decreasing of late
years ; and as there must be a substantial cause for this improve-
ment, it is fairly attributed to the gradually increased shedding
of light upon the pathology of the puerperal state. From this
it became evident that child-bed fever, in its fatal forms, was
due to bacterial agency, and that a traumatic infective disease
was the imprint of its nature. It is true that there are eminent
writers, as Mund^ and some others, who maintain that all forms
of puerperal fever are not septic in nature. What this other
form or forms are, is not stated ; nor are we led to understand
that such forms of the disease have received any reasonable
proof which would militate against the fact that they are septic
all the same. When a rise of temperature occurs during engorge-
ment of the mammary glands, accompanied with some headache
and increase of pulse, and controlled by a little aconite and a
purgative, the condition should not be spoken of as *' puerperal
fever," although its identity with blood infection is more than
probable. I will but refer here, in a passing way, to the fruit-

■

less endeavors of the unhappy Semmelweiss to turn the stubborn
heads of his colleagues on this point. The history of the subject
in this respect is familiar to all. To Semmelweiss, the obstetrician,
is due the credit of having first shown that patients dead of
surgical blood-poisoning, died with the same symptoms as patients
dead of puerperal fever, and that the post-mortem examination
yielded similar morbid conditions in each. His strong conviction
of the truth of these facts led him to adopt antiseptic measures
with the well-known wonderful results. Some twenty years ago
it was established by Rindfleisch, Birch-Hirschfeld and others
that wounds, on becoming unhealthy, contained numbers of
spherical bacteria, and that the unhealthiness thereof stood in
direct relation to the number of these bacteria. The more abun-
dant these appeared, the worse became the state of the wound
and the general condition of the patient. The blood of patients
dead of puerperal fever was examined and found to contain bac<
teria in large numbers. In some of these cases it was also noted
that small metastatic deposits occurred in the organs and tissues
generally, aVid that these deposits were largely composed of
minute organisms. These were cases of true pyaemia, and in no
way differed from those dead of that disease undqr the care of
the surgeon. In these pysemic deposits bacteria generally appear
in colonies or zooglsea. The channel by which these passed from
the ori^nal source to form metastatic foci was shown by Klebs
to be through the interspaces of the cellular tissues, and that
this takes place either with or without the aid of wandering lymph
corpuscles. They also travelled by means of emboli from thrombi
situated in veins. Often in this manner septic organisms will
pass along the blood-current unharmed as regards their vitality
and power of settling in some distant organ or organs which have
suffered injury sufficient to weaken their power of bacterial re-
sistance. We know that micro-organisms cannot live in healthy
living blood. They may enter it by escaping from the original
wound-infection seat, but so long as the vitality of the blood is
high, and there is no diminished resistance, these organisms
become enfeebled aiid ultimately die outright. If, however, on
the other hand, the vitality of the individual is of a low grade,

•ad the resiitanoe to baoterlil life ii dimiDished, theie organiims
will gnduallj aooumulate in the blood and tiaiues. Thej will
increaie rapidly now, where thej found no footing before, and
the more prosperous and luxurious they became, the more will
the failing vital powers of the patient ^come evident. The
organisms will continue to multiply and form small groups that in-
crease in size until they are too large to pass through the capillary
network. In this way they are caught and detained in the lungs,
liver and other parts ; and, still continuing to grow, form dupli-
cates of the original wound-infection and supply the blood with
their ptomikine poison. These metastatic foci of infection find
the soil in which they become located suitable for their continued
existence and growth, and form a stage of the disease known
by the term pycemia.

Micro-organisms, however, do not always act in this way. We
know that much depends upon the dose, virulence of the organ-
ism, susceptibility of the patient, structure of the organ invaded,
and other circumstances. Koch has experimentally proved that
a very large dose of putrid blood will cause rapia death, with
symptoms like those accompanying death from a narcotic poison.
In these cases no organism whatever is found in the blood, and
very littie alteration of tissues is found at the seat of injection.
The animal, in fact, dies from the effects of an overdose of a
chemical poison before the infected micro-organisms had time to
enter the blood in any appreciable numbers. Moreover, the
blood from this animal so killed did not have any effect whatever
on another animal when injected under its skin. Here we have
a profound poisoning by ptomaines generated by the micro-or-
ganisms injected, and the animal dies showing no post-mortem
evidence of secondary metastatic deposits. If, however, a smaller
quantity of putrid blood be injected, the animal, say a mouse,
shows much less marked symptoms of poisoning, and, in fact,
they are quite absent when a very small quantity is used. If,
from those animals, however, which die after this small dose, a
small quantity of blood or subcutaneous fluid from seat of inocu-
lation be taken and injected into another animal, it will die of
precisely the same symptoms. This can be continued through

a series of any number of like animals, with the same results.
The post-mortem examination of these animals shows the blood
to contain larg€ numbers of very small bacilli. Koch, Davaine
and others called this disease Hepticcemia.

By this statement it is not meant that because the mice septi-
caemia of Koch is due to the presence in the blood of very minute
badlliy that these are also present in the blood of human beings
dead of that disease. In fact, the contrnry will be found to
exist, in so far that bacilli are not by any moans the predomi-
nating bacteria in man septicaemia, but that micrococci are the
pathogenic organisms here, as in the septicaemia of rabbits. The
question now comes before us — In what relation stand micro-
organisms to the septic process going on in the infected animal ?
Is the damage caused by their mechanical irritation, or by the
irritation and lethal effect of a material generated by their re-
production and growth ? Bearing upon this point, I remember
seeing, in consultation, a young woman, in the hot summer
weather of 1883, at the village of St. Honri. I found her
lying upon her back in an insensible condition. Narcosis was
as profound as if she was under chloroform. Temperature 105° ;
pulse 130. Her special senses wfe obliterated. She could not
be aroused. The stench of putrefying blood was simply horrible.
The windows were thrown open, and she was ordered to be
sponged with a carbolic solution until clean, and then removed
to another room for examination. During this operation I ob-
tained the history from her medical attendant as follows : She
was confined three weeks previous to my visit. On the tenth
day she left the house and walked to the next street corner and
back. She shortly afterwards felt considerable pain in the pelvis
and abdomen, which was followed by ? very profuse discharge
of blood. The pain ceased in a few days, but the discharge
continued free, and was not allowed to be interfered with lest the
patient should catch cold. The result was that days of accumu-
lated blood under the patient was allowed to remain and decom-
pose, and form a beautiful culture medium for the various micro-
organism deposited there. These followed the vaginal canal to

the cervix, which was extensively lacerated, and thence upwards

to the still unrepaired placental site. Here we had a terrible
state of things. I found the whole pelvic cellular tissue set in
one mass of inflammatory exudate. And it occurred to me that
here in this human subject was a case which bore a strange re-
lationship to Koch's experiments with chain-like micrococci upon
the field mouse. The lacerated cervix and unhealed placental
site were inoculated with decomposing blood containing masses
of micrococci. They invaded the blood and lymphatic vessels
of the parts, generated ptomHines, which set up an extensive
phlegmon of the whole cellular tissue of the pelvis. Constant
absorption of this poison was being carried on until the nervous
centres became so saturated, and their function interfered with
to such a degree, that impending ueath became apparent. The
only existing difference between the case of this woman and that
of Koch's field-mouse was, that in the woman's case the influence
of the organism was not sufficiently powerful to utterly destroy
the cellular elements of the tissues invaded ; in the case of the
mouse it was, and gangrene ensued. The organisms had, however,
the effect of forming a barrier to further extension of the disease
beyond the pelvic tissue. And although these micro-organisms
exert so baneful an effect upon animal life when they get a foot-
ing in injured tissues of a fitting soil, they also form a limiting
barrier to the spreading of inflammatory and suppurative disease,
which would otherwise become general and rapidly fatal. In
the case just related we had the inflammation set up by ptomaines
generated by the micrococci in the decomposing blood. The
organisms, in their turn, walled in the field of inflammation ;
but absorption of septic poison into the general circulation was
being rapidly pushed on to almost complete extinction of the
vital powers. This woman underwent treatment of which I shall
speak further on, and recovered. And I firmly believe if Koch's
animals had been experimentally treated on similar principles
shortly after their inoculation, death would not in these cases
have ensued.

In regard, then, to the role which micro-organisms play in the
septic phenomena, it would appear that they stand as the first
link in the chain of causation — in fact, it would be more correct

to say that that chain had but one link, and that the phenomena
arising therefrom were but expressions of malign influences com-
ing from this focus. Take away this focus and the septic phe-
nomena cease to exist. Ogston has pointed out to us that there
is no such condition as septicaemia or pyaemia per %e. We must
have a traumatism^ whether that be in the form of an inflamed
wound or an inflammation of seeming spontaneity, it matters
little. And it has always appeared to me that, next to the
mangled parts in a bad railway accident, there can be no more
fitting traumatism as a culture-ground for micro-organisms than
the mutilated passages of the puerpera.

Let us now take, in illustration, a puerperal patient with the
usual wounds in her parturient passages, and that it is under-
stood that there is a possibility of her becoming a subject of
infective disease ; that her wounds are the same as other trau-
matisms, and liable to the same dangers. What, now, are the
conditions leading to the infection of the ivounds in question ?
What are the most rational means, according to our present
knowledge of these dangers, to be adopted in prophylaxis ? It
is universally acknowledged that certain septic and pathogenic
micro-organisms surround our patient, and, if left undisturbed,
are capable of setting up putrefactive changes in wounds exposed
to their influence. It is also well known that when albuminous
fluids, such as blood, meat infusion, and such like products, are
exposed to the air for a certain time they become putrid, and that
on microscopic examination they are found to contain every variety
of micro-organism. That amongst the legion of different species
of micrococci and bacilli occurring in these fluids, the great
majority of them are quite harmless. When they are introduced
into the body of a healthy animal they are unable to grow or
multiply, and therefore are unable to produce any disturbance
whatsoever. But some few species there are which, although
growing and thriving in ordinary putrid substances, possess the
power, when introduced into the body of a suitable animal, to
set up a specific disease. Our best examples are the bacillus
of anthrax, the micrococcus of erysipelas (so much studied in
this respect by Fehleison), the tubercle bacillus of Koch, also

the bacillus of swine plague. Davaine's septicaemia of rabbits,
Koch's septicaemia of mice, and so on, cannot be produced by
every putrid blood or putrid organic fluid, only by some, only
now and then — i.e.^ when the particular micro-organism capable
of inducing the disease is present in those substances, and then
only when it finds access to a suitable animal. Davaine's sep-
ticaemia of rabbit!^ and Koch's of mice cannot be induced in
guineapigs. Anthrax cannot be induced in dogs, and so on with
other pathogenic organisms. These pathogenic or specific organ-
isms have the power of growing and thriving in the animal tissues
ab initio. Those which do not possess this power — the non-
pathogenic — cannot acquire it by any means whatever. Many
are familiar with Koch's and Klein's criticisms of Buchner's
experiments in endeavoring to prove the change of the non-
pathogenic hay bacillus into the pathogenic anthrax bacilhis, and
how Buchner's error occurred through accidental air contami-
nation. That Klein proved it was as imposible as to convc^rt the
bulb of the harmless onion into the bulb of the poisonous col-
chicum. There is also instanced the case of the so-called jequirity
bacillus, as proving the conversion of a common septic into a
pathogenic organism. This was proved to be more absurd than
the hay and anthrax bacillus story, as it was shewn that the
morbid condition set up in the eye by the introduction of an in-
fusion of jequirity bean was due to the fact that in this infusion
certain active principles existed, closely allied in nature to
albumen, in which the common septic organisms in the surround-
ing air formed a special nurture medium to grow and multiply
in. It is, however, with the common septic organism we have
to do chiefly in connection with the febrile condition met with
in the puerpera ; and it is to these I will draw attention.

Many observers have shown that by putrefaction of animal
substances a substance can be obtained — sepsin — which can be
isolated by a chemical process destructive of every living organ-
ism, and which, on injection into the vascular system of animals
in su£Bcient quantities, produce inarked febrile rise of tempera-
ture, and is capable of causing death with the symptoms of acute
poisoning. Lister has shown that under careful antiseptic dress-

ing of wounds, putrid intoxication, as well as septicsemic infec-
tion, does not at all occur. From experiments of this nature on
lower animals, we can easily find analogy in those rapidly fatal
cases of intense septicsemia occurring occasionally in the much-
neglected puerpera, and in some cases of death after abdominal
section. These septic organisms differ from pathogenic organ-
isms in some important respects. They require for their support
and thrift much less complex substances to live in — almost any
animal or vegetable fluid. They also differ from pathogenic
organisms in the very essential respect that they absolutely
refuse to grow in the living tissues of the living animal. During
the life of the patient should any part, such as the parturient
tract, become necrotic from severe injury, or so severely changed,
by inflammation or otherwise, that the part involved becomes
practically dead, then that part becomes packed with masses of
micrococci, and here these organisms find a suitable nidus for
growth and multiplication. They may, in extreme cases, also
be found in other organs distant from the orrginal seat of injury,
but it will be found that death has been so rapidly approaching,
and the general disorder has been so severe, that these tissues
have begun to lose their vitality, and therefore their power of
resistance to the invasion of these septic organisms. The ques-
tion may now be asked — Where do these organisms come from
which are thus capable of settling in remote tissue even during
the ebbing life of the patient ? In the case of the intestinal
wall and abdominal organs generally, there can be little doubt
but that they immigrate from the cavity of the bowel, where
they are normally present ; nor do I think there can be a doubt
in the case of a secondary pneumonia or inflammation of serous
membranes during a neglected case of septic metritis. It is not
difiGlcult to understand that when products which form a nidus
for these organisms become taken up by the general circulation,
they act as emboli, and thus set up secondary inflammations in
distant organs. These organisms, although unable to travel
through the living blood unprotected, can, under the protection
and cover of these emboli, be carried carefully to distant regions
and there deposited, retaining their full vigor and vitality. But

when found in these organs, it does not follow that they orignated
there, but are simply the result of transportation from parts which
have direct access to the outer world. We have this fact exempli-
fied in the puerpera ; the lochial discharge is charged with micro-
cocci from the very first day after delivery. This fact I have
demonstrated many times myself by examining the lochia micros-
copically at various periods during the puerperium, and have
never failed to find the specimen well filled with micrococci.
These organisms must, to some extent, find their way into the
blood, but being unable to resist the living healthy blood they
die at once and are no more heard of. But let these very
organisms reach, under protection, an organ in which the balance
between health and disease has been disturbed by excessive
functional activity or otherwise, and the result will be different.
It has been pointed out by Ogston that acute suppurative mas-
titis occurring in neglected puerperal patients was due to immi-
gration of micrococci, and that the reason they settle in the
breasts was on account of those organs being in a state of high
functional activity approaching congestion. This I have noticed
myself, and it has been evidenced to me by the fact that I have
never seen an acute suppurative mastitis since I began the prac-
tice of proper vaginal irrigation ; whereas prior to this, mammary
abscess was by no means an uncommon occurrence. As an ofi*-
set to these teachings, it may be said that the healthy blood has
been found to contain minute organisms normally, and that under
conditions they can be deposited in certain organs to set up mis-
chief. This theory has now been admitted to be utterly un-
founded, and it has been distinctly proved that the living blood
contains no organisms whatever ; and that the error in this
respect arose from accidental contamination. As we have now
seen somewhat ot the relation of micro-organisms to the puer-
pera, we will turn our attention to the means of managing them.

The part of the post-partum treatment of these patients which
treats of the prevention of septic phenomena is found in the his-
tory of antiseptics generally as applied to general surgery. Our
endeavor should be to inhibit the function of germs, and in this
way obtain a total extinction of the disease in question. To say

that we possess, according to our present knowledge, germicides
applicable to such cases is untrue.* Antiseptic measures we
can institute and carry out. Germs we will have settling in and
infesting parturient wounds, no matter under what circumstances
or how careful we are in endeavoring to exclude them. Ogston
proved that nine hours after delivery the lochial discharge con-
tained putrefactive organisms in abundance. This fact [ have
proved to my own satisfaction in every case, the discharges of
which I have examined. It only requires the necessary time
for these organisms, present from the beginning, to bring about
definite vital phenomena, characterized by the change of proteids
into soluble peptones, and these into leucin and tyrosin : these,
in their turn, into very low compounds, which ultimately yield
certain alkaloids having toxic effects when absorbed into the
blood. And it is interesting to know that these very changes
are brought about by abstraction of materials which are neces-
sary for the growth and multiplication of these organisms. We
constantly hear of the all-soothing and healing properties of this
perfectly harmless fluid, which nature in her great wisdom gave
woman as a sort of Balm of Gilead in their function of race-
production ; that it is, we are told, a crime to wash it away or
interfere with it in any way whatsoever ; that such- a course of
treatment is in direct contravention of the laws of nature, and
that woman in her wild state requires no such refinement of treat-
ment in labors. But it is here forgotten that woman in her wild
state is not surrounded by the conditions, too numerous to men-
tion, which her sister of the unhealthy and crowded city is, and
that it is not true thao they are altogether exempt from puerperal
fever. Dr. Engelmann has long since proved this, and I myself
have been informed by a trustworthy missionary's wife, many
years a resident with the Oka Indians of Canada, that the septic
micrococcus runs a high and mighty career amongst the lying-in
squaws of that settlement, occasionally sweeping many of them
away in the form of an epidemic. As regard the harmlessness
of the so-called healthy lochial fluid when at rest in the passages

* Vide Klein, Mioro-organisms and Disease, page 188. Cheyne, AntUeptio Treat-
ment of Wounds, page 25.

in contact with necrosed tissue, from what we have learned we
can only regard it as a veritable culture fluid of a fairly complex
nature ; that the passages in which this fluid rests form an ex-
cellent incubator, and that the necessary physical properties for
the incubation and growth of bacterial life — heat, moisture and
rest — are all here and constant. To me there is but one con-
clusion to be arrived at — namely, that we must break up these
conditions, and by changing that of rest into one of'motion or
running stream, we render the resident organisms harmless.
Upon this principal is based the whole value of the so-called
antiseptic irrigation, and in my experience it matters very
little, in uncomplicated cases, whether we use as a prophy-
lactic powerful antiseptics or boiled water. And that it is
not necessary to use irrigation to flush the bacterial stream
more often than once every twenty-four hours in simple cases,
and every twelve hours in more serious cases. The reason for
this is obvious. The organisms cannot make a start at growth
in their incubator under several hours of undisturbed existence,
and consequently no poison is generated in sufficient quantity
to produce a general systemic effect.

For the past five years, 1 have most strictly followed out the
plan of antiseptic irrigation in every case of parturition. I have
obtained, as is well known, the most gratifying results to my
patients and comfort to myself. I have also had some amuse-
ment in carrying out the treatment in the presence of those
women who have nursed patients for a quarter of a century, and
felt quite disturbed at innovations of this kind.

I remember attending a young married lady in her first con-
finement. About the sixth or seventh day she said to me,
" Doctor, when I left home my mother told me, if I should ever
be ill in this way, not to be alarmed if on the third day I would
feel very sick, have a bad headache, and feel feverish ; it would
be the * Weid,' and quite natural."

I remember a case which bears somewhat upon septic mid-
wifery, which was interesting to me at the time. The patient
was about 30 years of age, in her third confinement. I ordered
an irrigator as usual, but through some neglect on the part of

,^^..^-^

^:m"^^'

the nuree (I think intentional), it was always being forgotten.
On the morning of the fourth day I was sent for hurriedly. I
found this patient suffering from intense headache, high tem-
perature, and some pain in the pelvis. On close examination,
I found a small laceration, just within the posterior commissure
of the vulva, granulating. My finger went directly downwards
into a pouch full of very foetid discharge. The infective ma-
terial in this case may possibly have been absorbed from the
vulvar tear. It might also have been taken up by the slightly
lacerated cervix. Here was a case where the vagina was
converted into a most excellent incubator, and it only wanted
the necessary time for the organisms of putrefaction present to
establish the chemical changes before alluded to.

Another case of an interesting nature was a young married
lady in her first confinement. The husband had confided to me
the fact that he was suffering from an attack of gonorrhoea, and
that he felt sure he had conveyed the disease to his wife. I
used all precautions before the confinement. After the birth,
the irrigator was used twice daily up to the tenth day, and
thinking all was right, as far as the probability of specific infec-
tion was concerned, I omitted it from this date. All went well
until the fifteenth day, when she was seized with violent chills,
high fever, intense headache, and severe pain in pelvic region.
Uterus was irrigated morning and evening with subliioate solu-
tion, etc. On the twentieth day the symptoms abated. Here
was a case where the specific gonorrhoeal poison was being
washed away, and the action of the micro-organisms inhibited
for ten days. The discharge was then left with the coccus ; it
began to develop, and produced the poison in sufficient quantity
and virulence to induce, in four days, a violent toxaemia.

About a year ago I was asked to see in consultation a young
French primipara, who had been confined some six or seven
days previously. I found her intensely septicaemic. The air
of the room was very foetid, discharge extremely so, and matters
generally in a bad state. I noticed, also, that the husband of
this patient had his hand in a sling, as if wounded. On nearing
him I got a distinct odor of iodoform. The physician in charge

said this man had sustained a severe injury requiring ampu-
tation of two of his fingers ; that he had dressed the wounds
antiseptically, and that the injured parts were nearly well.
This was an excellent illustration of the strange views held in
regard to the treatment of puerperal wounds. If a man gets
his fingers injured, the wounds are carefully washed from all
foreign particles, edges nicely brought together with sutures
and iodoform and other antiseptic dressings carefully applied.
The wounds are re-dressed every day or so until recovery takes
place. When, however, an unfortunate young wife suffers
much more severe injury to her genital tract, the student is
told on no account to touch those parts, they are sacred,
nature will do everything ; should she fail, however, he is told
to do then what he should have done at the outset under the
principles of prophylaxis. In fact, to pursue the very course
the well-cultured surgeon had taught him in the case of the
injured husband. I cannot refrain here from commenting upon
the inconsistency of these expectant physicians. They recom-
mend for the cure of the disease that which they strongly de-
nounced for its prevention.

We will now pass on to the subject of antiseptics, and I will
only consider those which are applicable to the cases we have
under consideration. In using the terms antiseptic and germi-
cide we must be definite and clear upon the correctness of their
application. As used at present in current literature, their sig-
nification is somewhat misapplied. Their application would lead
us to suppose that in them we had substances which would kill
outright bacteric organisms, and that we need no longer fear
germinal activity on the part of these organisms. To be brief,
we have no such substance. Klein has shown us some very in-
teresting experimental results. By exposing micro-organisms in
nourishing media at proper temperatures, and adding carbolic
acid or corrosive sublimate in very strong solution, he found that
their growth was retarded or altogether inhibited, but on remov-
ing these organisms, and placing them in fresh nourishing media,
they grew and multiplied as if nothing had happened to them.
And, further, if the spores of anthrax, treated in this way, are

inoculated into guineapigs, the animals die of typical anthrax.
But be it understood that, although the spores of the bacilli
remain unaffected by such powerful agents, the bacilli are
killed, this being the cause in all probability of the inhibition
of their vital functions while in the antiseptic medium. Of all
the antiseptics with which Koch experimented, he found the
bichloride of mercury the most effectual ; 1 in 600,000 parts is
capable of impeding, and 1 in 300,000 of completely checking
the germination of spores. These spores can withstand, untwyured,
the effects of boiling water for a few minutes ; il, however, des-
troys them outright in a short time. Let us now consider in
detail the characteristics of a few of the favored so-called anti-
septics, or, more properly speaking, micro-bacterial inhibitors,
and the technique of their application.

Carbolic Acid. — Notwithstanding that carbolic acid has its
advocates, and that the most respected of surgeons. Dr. James
B. Hunter of New York, declares it to be superior, or equal, to
the mercuric perchloride, I think the majority of surgeons have
not found it by any means satisfactory. As a proof of this,
we find them using carbolic acid wherever instruments are in
danger of being injured by the bichloride, but directly the in-
struments are no longer required, the carbolic acid is put aside
and the bichloride substituted. I have found that carbolic acid
solution in obstetric cases requires frequent repetition of appli-
cation to obtain that action which insures safety. If we use five
per cent, solution frequently, it is likely to abrade the tissues,
and that in very weak solutions it has no material efiect what-
ever over boiled water. On account of the necessity for its
frequent repetition, it is doubtful whether the unavoidable dis-
turbance of the patient does not counterbalance in injury the
good intended to be obtained by its use. Also, it is left in care
of nurses, which has many times resulted in very disastrous con-
sequences. I have therefore given up its use entirely in obstetric
cases for some years past.

Iodoform — Is not generally used as a prophylactic in obstetric
cases. It does not, in small quantities, seem to have a very
powerful effect in inhibiting tl^e vital phenomena of micro-organ-

^tlJi^WAl aCi/L:'

itms. I have seen them, notably the bacterium termo, quite
active in a well-impregnated solution of beef on the third
day, the odor of the iodoform, however, covering up that of
putrid decomposition. Binz found that iodoform retarded the
migration of leucocytes through the vessel walls. Its odor is
peculiar, and has made it in the majority of cases objectionable
to the lying-in patient. As a slight digression from the subject
I might say here that I have used iodoform in the form of supposi-
tories in cases of puerperal metritis. These suppositories (gr. x
each combined with boric acid) are introduced into the enlarged
and oedematous uterus after each irrigation night and morning,
and the cavity was in this way rendered aseptic until the affection
had subsided. Its undoubted service in these cases is now, I
may say, universally acknowledged, and to such I think its appli-
cation in obstetrics will be limited.

Boradc Add is a good antiseptic in obstetric cases after the
sublimate solution has been discontinued. It is non-poisonous
and non-irritating. A large teaspoonful of the powder dissolved
in a quart of hot water can be used as an irrigation once or
twice daily, beginning on the eighth or tenth day and continued
for a period of two or three weeks. It removes any purulent
discharge which may have collected in the vagina at this period
of convalescence, and aids involution of the vaginal walls and
cervical glands, the latter of which are so enormously enlarged
during pregnancy. Boracic acid is also a much better antiseptic
than it usually gets credit for. I have at present a beef infusion
treated to saturation with boracic acid one month ago, and it is
still perfectly sweet and free from micro-organisms.

Naphthalin is not suitable for obstetric purposes, chiefly on
account of its insolubility in water. Placed in beef infusion, it
does not prevent the development of micro-organisms and putre-
|, faction taking place longer than eight days.

Eucalyptus Oil is a very good antiseptic. Bucholtz found
it to be three times as powerful as carbolic acid in this respect.

Bichloride of Mercury is the most recent and effectual in-
hibitor of bacterial growth. A solution of this salt so dilute as
1 in 300,000 will render the spores absolutely incapable of ger-

\<-

», r-

minating, and will, of course, kill the organisms outright. This
result is, however, not confined to mercuric solutions, as the
presence of carbolic acid, phenol, thymol, salicylic acid, and
even weak vinegar, if in sufficient quantity, will prevent the
spores germinating in any nourishing medium. But apart from
this, it is believed that the bichloride solutions has a specific
action on the injured and swollen tissues which no other so-called
antiseptic has in the same degree. I have seen most extensive
swelling of the walls of the vagina and vulva resulting from
prolonged forceps operations disappear, under irrigation night
and morning of a very hot bichloride solution, in 36 hours. Pain
and tenderness also disappear, leaving no further necessity for
the use of the catheter. In just such cases I have experienced
disappointment during the use of carbolic acid, Gondy's fluid,
and such like solutions, in being compelled to resort to the use
of the catheter for several days. Regarding this antiphlogistic
property of the bichloride, it is somewhat difficult to give a
definite opinion upon. Ogston however, has shown that acute
inflammation may be produced by micro-organisms. If corrosive
sublimate is here capable of destroying more effectually than
any other agent these resident micro-organisms, we can under-
stand this certainly very valuable clinical fact. It is not due to
astringency, as no other mineral astringent will act in the same
prompt way. A very remarkable relation obtains between vagi-
nal irrigation with the bichloride solution and the non-occurrence
of acute suppurative mastitis. Ogston has drawn our attention
to the occurrrence of mammary abscess at a puerperal period,
which coincides with the lowered vitality observed in unduly
stimulated and congested mammse and foetid poisonous lochia.
That cocci obtain an entrance into the circulation in some pro-
tected condition, and though powerless to effect a lodgment in
stronger organs, they become welcome guests and colonize in
the weakened and congested breasts. Be this as it may, I have
not seen, in a single instance, a mammary abscess occur in
practice since I began the mercuric irrigation ; and it was cer-
tainly not an uncommon occurrence to me when treating these
cases upon the expectant plan.

Kuestner (Jena) found that after carbolic irrigations of the
uterus, the prompt disappearance of the cocci could not be de-
monstrated, but they vanished very promptly after the sublimate
irrigation.

Freenkel (Breslau) found that during very extensive experi-
mental investigation with all known germicides, the cocci dis-
appeared from the uterine secretions most rapidly under the
sublimate treatment.

Hegar (Freiburg) uses the sublimate irrigation, and has
found it the most satisfactory of all germicides at the Freiburg
Clinic.

Kehrer (Heidelberg) believes that in the puerperium the
sublimate is indispensable. Only one-third of all parturients
under his care with the sublimate solution showed any signs of
fever, while before its introduction two-thirds of cases exhibited
severe fever-
Paul Bar's remarkable statistics of mortality in the Paris
Maternities before and after the introduction of antiseptics is
simply marvellous. In fact, they speak so emphatically in favor
of antiseptics that even the most obdurate of expectantists will
not in future have a leg to stand on.

Auvard (Paris), speaking of corrosive sublimate says : " It
is still the antiseptic to which preference is accorded in the
various obstetrical services of Paris. Its trifling cost, its power-
ful and certain action, and its almost entire harinlessness, gives
it supremacy over all other antiseptics in use at present."

At a recent meeting of the Obstetrical Society of London,
Dr. Mathews Duncan said that the subject of antiseptics was
the greatest in the obstetric department, but it received very
little attention. It was more important than the prevention of
epidemics, for they only came occasionally, while puerperal
deaths continually occurred. In the history of the subject, he
said all measures had failed to reduce mortality until antiseptics
were introduced. Dr. John Williams said : Taking the deaths
in childbed at one per cent., the lowest mortality after the de-
struction of puerperal fever would be a quarter of one per cent.
The object should be to reduce the mortality to this level, and

■

he believed it might be attained by antiseptics. He and Dr.
Champnoys had used in the GenerAl L)ring-in Hospital in suc-
cession carbolic acid, r^ondy's fluid, and 0(>rrosive sublimate as
antiseptic agents. Since the last named had been employed
there had been no deaths from puerperal fevrer, and scarcely
any illness.

Closely connected with this subject is Dr. Max Schede's con-
tribution to the literature of antiseptics in surgery and obstetrics
generally. (^Volkmanng Klinitiche Vortrdge,^l^o.2h\.") Pre-
vious to the time of Listerism by Schede*8 predecessor, the
number of septic accidents and cases of erysipelas was very
large. Under Listerism a marked improvement took place, but
it did not accomplish enough to satisfy the new director. He
Hrst began a systematic attempt to organize a surgical service,
and to teach all the attendants the need of absolute cleanliness
and asepsis. Coming to Hamburg at the time of the iodoform
era in surgery, Schede at once introduced the iodoform treat-
ment in all its details, but he was much disappointed in its
results. Although he had some brilliant successes, the iodoform
treatment often failed to prevent septic complications, while
erysipelas increased in the wards very rapidly. Schede does
not say that iodoform causes erysipelas, but he is decidedly of
opinion that it does not prevent it. The iodoform was therefore
abandoned as a failure, and the corrosive sublimate was intro-
duced in its stead. The results obtained, during now three
years, have been most brilliant and satisfactory, and Schede
comes forward as an enthusiastic advocate of the sublimate
treatment of wounds. The technique of his method is briefly
as follows : He has two sublimate solutions, one of the strength
of 1-1000 and the other 1-5000. The first is used to disinfect
hands, skin of patient, sponges, drainage-tubes, and all wounds
which are to be closed (in obstetrics, lacerated perineum). The
second is used for irrigating large wounds. The materials used
for dressing are sand, glass wool, sublimate gauze, sublimate
wadding, and sublimate catgut- Sublimate wadding and gauze
are prepared by soaking in a solution of the strength of 1-190,
with 10 parts of glycerine. They are wrung out and allowed

to dry. The glass wool, of which Schede speaks in the highest
terms, is prepared by soaking it in a one per cent, solution of
sublimate. Wounds are covered with this prepared glass-wool,
then with similarly prepared peat pads, and firmly compressed
with gauze bandages. Schede thus concludes : 1st, The subli-
mate solutions are more efficacious and less dangerous than ^^^
per cent, carbolic acid solutions. 2nd, In severe wound infec-
tion, diphtheria, and gangrene, the sublimate solution can be
used as strong as one per cent, with perfect safety.

Schede also discusses the dangers from sublimate absorption.
He refers to the report of Frankel, who found diphtheritic
entero-colitis post-mortem in a number of cases, and attributed
it to the mercury. To offset this, Schede reports four cases in
which the same lesions were found aftei death, but in which the
sublimate had not been used at all. He concludes that the
diarrhoea and enteritis may be caused by sepsis. His cases
certainly take away some of the force of Frankel's observations.
He believes that with proper precautions the sublimate wound-
treatment is safer than any other.

In connection with the subject of the dangers of sublimate
solutions in obstetric practice, it may be stated that Auvard, in
V Union Medieale, refers to two fatal cases from the intra-uterine
use of sublimate solution. Hofmeier also refers to two cases of
sublimate poisoning, one of which was fatal ; and similar cases
have been reported by Stadfeldt and Winter {N. Y. Med. Rec.^
March 14th, 1 885, pp. 291-2). One of the conclusions drawn
by Auvard is, that the condition of the kidneys is a most im-
portant one to bear in mind, as a nephritis renders the patient
more susceptible to the toxic effects of mercury.

It would be a very easy matter to continue producing clinical
evidence of the value of the bichloride in the prophylactic treat-
ment of the puerpera, but, at the same time, we must also look
to what is said of it on the dark side. It is well known to be a
powerful poison — first, in its therapeutic use as a lotion, and
second, in its accidental administration by the mouth. It has,
however, been evident to me that its ill effiects, when used in no
matter what way, have been brought about through want of care

and the proper knowledge of the technique in its application.
When these have been carefully observed I cannot but look
upon the drug as a perfectly safe one, and from a varied ex-
perience in its use, I think I always shall. For instance, it is
very horrifying to read of Stadtfeldt's case, where some one
had injected a post-partum uterus with a bichloridic solution
(1-1500) four hundred cubic centimetres in quantity. Sud-
denly, collapse set in, followed by diarrhoea, bloody stools and
death in ten days. An instructive accident of this nature occurred
to myself when giving a vaginal injection several days after an
accouchement. The tube, an ordinary glass one, attached to a
fountain irrigator, passed up through a large patulous cervix
into the uterus. She complained of the fluid passing higher
than usual into the abdomen, and before I could recognize what
had occurred, she turned pale and passed into a very violent
rigor and state of collapse. I withdrew the tube and rapidly
passed two fingers into the uterus, and with the aid of my right
hand over the uterus outside, allowed the fluid, to the quantity
of over half a pint, to gush out into the vagina between my
fingers. I satisfied myself that the uterus was completely emptied,
and then gave her a hypodermic injection of ergot. This patient
was a little restless the following night from disturbance of
her circulation, but was quite well next mornir\g, and continued
to be so afterwards as if nothing had happened. The collapse
here was simply shock produced by sudden over-distension of
the uterus by a fluid, and had I allowed that fluid to have re-
mained there, which, without interference it certainly would
have done, I would have had a subject for an essay upon the
death-dealing effects of the sublimate solution in obstetric prac-
tice. This accident was, of course, due to unpardonable care-
less on my part, and does not bear upon the general merits of
the principal.

The moral this lesson teaches is : Do not inject, even inten-
tionally^ a uterus with a tube which does not provide for a rapid
return of the stream. An interesting paper on this subject will
be found in the Obstetric Gazette^ August 1884, page 413, by
Dr. Palmer, urging the propriety of vaginal injections, used with

care, in every puerpera. An essay of this nature would not be
complete without alluding to Dr. Garrigues' well known method
of treating puerperal cases. It is briefly as follows : —

The patient is at first given a bath, then an enema. Her
abdomen, genitals, buttocks and thighs are carefully washed
with a warm solution of the bichloride, 1-2000. The vagina is
then irrigated by means of a fountain irrigator with the same
solution, two quarts in quantity being used. In protracted cases,
this irrigation is repeated every three hours. At the beginning
of labor the physicians and nurses wash their hands, using nail
brushes, in a solution of the same strength before touching the
patient. No lubricant is used in ordinary cases. If necessary,
glycerine with bichloride solution 1-2000 strength. As the head
appears it is received in a piece of lint saturated in same solu-
tion, and the genitals are kept covered with a similar compress.
The placenta is expressed by Credo's method and the vagina is
washed out with the bichloride solution. Intra-uterine injections
are only used when the hand or instruments have been intro-
duced into the interior of the uterus, or in case of birth of a
macerated foetus. Dr. Garrigues never allows any of the pla-
centa or membranes to remain in the womb. With careful anti-
sepsis the introduction of the hand into the uterus is in no way
compared with the danger of hemorrhage and septicaemia by
leaving any part of the secundines behind. In this case a large
(two to six quarts) sublimate injection, intra-uterine, is given
just as hot as the hand can bear it. After the expulsion of the
placenta, the patient is washed and the dressing applied. It is
(1) a piece of lint three inches wide, and double, saturated with
the bichloride solution, (2) outside of that a piece of oiled muslin
nine by four inches (3) outside of that a large pad of oakum,
and (4) the wholr; is fastened by means of a piece of muslin to
the binder, with pins, in front and behind. This dressing is put
on with the same care as a wound is dressed after a capital
operation, and renewed four times in the twenty-four hours.
At each removal the genitals are washed. No vaginal injections
are used unless the discharges become foetid. (This dressing
need not be so complicated. A good-sized solid pad of sublimate

jute made to fit well into the parts and secured to the binder in
front and behind, makes a very effective antiseptic dressing.)

Dr. Garrigues has proved the bichloride to be much superior
and more trustworthy than carbolic acid in such cases. His
cases occurred in the University Hospital, New York, and it may
have been not a difficult matter to carry out there under such
able nursing. But even in Dr. G.'s hands, it has not prevented
the lochia becoming offensive, which is evidence of putrefaction.
And under such circumstances, I am strongly inclined to think
that it was due more to the constant washing and changing of
dressing that his patients did not become septic than to any par-
ticular virtue in this complicated dressing. I have given it a
fair trial in private practice, and found that without irrigation
the lochia invariably became foetid just as without the dressing,
and I therefore combine it with irrigation.

For several years I have, with the exception of one case re-
lated of septic fever, used vaginal irrigation of corrosive subli-
mate solution of strength varying from 1-2000 to 1-5000 once
every morning at the usual visit. This was occasionally not
begun until the second day after the delivery, and I think it is
quite safe in private practice to begin irrigation at that time.
I have also combined with the irrigation treatment that of apply-
ing after the injection a pad of antiseptic sublimated jute to
the vulva and perineum, and pinning a strong napkin over this
to the binder in front and behind. This pad is renewed night
and morning only, and is chiefly intended to absorb discharge
and support the perineum and pelvic floor generally. The
patients have always expressed gratitude for the su^^port experi-
enced, and I am convinced of its benefit as a splint to the often
much over-strained pelvic floor. This method has never allowed
the discharge to become foetid, as the vagina is flushed with a
very Iwt irrigation of the sublimate solution every morning up to
the eighth or tenth day, and then I generally advise the patient
to have the nurse continue once every morning a very hot in-
jection of a solution of boric acid with the view of aiding involu-
tion of the parts. This may be continued for any length of time
up to a month. The benefit derived from this latter additional

advice to the patients will be seen in the properly involuted
vaginal walls, and every physician knows what that means.

As regards our an epartum procedure, my views are essen-
tially the same as those of Dr. Garrigues and other careful
observers. It is most unpardonable in the conduct of a physician
to examine his patient before he has washed his hands and arms
to the elbows in at least an additional relay of fresh water, using
nail-brush freely, and afterwards bathed them in a solution of
corrosive sublimate. This solution, in a pint bowl, he should
carry with him from the washstand to some convenient place near
the bed-side, and before each examination dip his hand freely
in the solution. Should it become necessary, during after events,
to introduce his hand into the cavity of the uterus, it may be
done so with safety.

In conclusion I would say :

1. Post-partum vaginal irrigation as described with weak
solutions of corrosive sublimate, is nothing more nor less than
antiseptic treatment of wounds ; and the surgeon who practises
the latter on other, and refuses to do so on puerperal wounds,
cannot endeavor to reconcile his action without appearing in-
consistent.

2. That this method of treatment is the one most reliable, by
which foetid decomposition, and therefore micrococcus poisoning,
can be prevented.

3. That the procedure is perfectly safe as regards mercurial
poisoning, provided ordinary care is recognized by the physician
himself, and that a nurse is never entrusted with the perform-
ance of the operation.*

4. That the water be as hot as can be borne, with the view
of aiding involution, and that the antiseptic pad should be applied
as described.

5. No solution should be used but that of the bichloride.

6. A perfectly new fountain irrigator should be used for each
private patient ; better none than a second-hand one, no matter
how apparently perfect.

*In hospitals trained nurses under a house physician can be relied upon.

7. See that the irrigator is playing before introduction of
nozzle, to prevent entrance of air.

8. It is well to remember that one drachm of the salt added
to one ounce of spirit, gives for each teaspoonful in one pint of
water, 1 part in 1000. From this solution one of any strength
can be prepared.

9. In a case where a macerated foetus has been born, the
uterus should be irrigated with a sublimate solution (1-5000)
once each day for from three to five days, according to circum-
stances. A macerated foetus need not of necessity be in a state
of putrid decomposition when expelled, but should it be so, it
will be sure to infect the cervix as it passes through. Evidence
of infection in such a case may not become manifest until the
second, third or fourth day afterwards, when it would be too
late to prevent serious damage, or perhaps to save life.

10. Napkins should not be placed against the vulva as a
dressing, under any circumstances. The same napkins are often
used at successive pregnancies throughout the whole child-bear-
ing life of one woman, and may, for aught we know, have done
service for neighbors as well. It is not difficult therefore to see
what a serious source of infection they may constitute. A piece
of unbleached cotton twenty-four inches long by six inches wide,
or better, a similar sized piece of washed gauze, will fix the
sublimated jute dressing firmly against the vulva and perineum
by being pinned to the binder behind and in front.

11. Lubricants of any kind should not be used ; I do not know
of any act more unnecessary at obstetric operations. The cervix
at this period of pregnancy is at its height of glandular function,
and secreting tenacious mucus in large quantities. I have seen
a physician deliberately anoint his forceps and hands with stink-
ing rancid lard and introduce them into the uterus. In cases
where we have reason to suspect venereal disease of the patient
we may use some clean unguent as a protection to the operator,
but under no other circumstance.

12. Be sure before leaving your patient that the uterus con-
tains no shreds of membrane adhering to the edge of placental
site. I believe a neglect of this precaution is responsible for

many of those cases of sepsis which puzzle us so much to account
for, and which has been hitherto placed under the head of auto-
infection. I regard the careful introduction of the purely
ASEPTIC hand into the vagina, and of the fore and middle fingers*
into the uterus, for exploration after expulsion of the placenta,
as a perfectly safe and justifiable procedure. And I am confi-
dent that as we gain in experience, we will come to admit on all
sides the truth of this teaching. And the procedure will be
proved to be much more harmless and rational than the intro-
duction of unwashed fingers within the rima vulvae of the puer-
pera for diagnostic purposes.

13. Lacerations of the perineum, oven to a slight degree,
should be repaired at once by the ^' single silk suture " method.

14. Never, under any circumstance, allow your sublimate
solution to leave your hands, nor prescribe the salt in the form
of powder, as recommended by Dr. Garrigues. As a neglect
of these precautions, I will briefly relate two instructive cases,
both of which show also the enormous doses of the salt which
can be taken by mouth with impunity :

A physician prescribed quinise sulph. gr. xx to be taken in a
spoonful of water ; also hydrg. bichl. gr. vii to be dissolved in a
quart of hot water and used as directed. There were several
of these latter powders to be compounded and sent to the patient.
The nurse, by some stupid error, gave one of the sublimate
powders in the spoonful of water instead of the quinine. The
patient shortly afterwards became violently ill, and continued
vomiting and purging for some time, but eventually recovered
without any apparent after ill effects. A notice of this case was
published in one of our daily papers at the time, and I took some
trouble to obtain a reliable history of the case, which satisfied
me regarding its correctness. Shortly after the occurrence of
the above case, I had occasion to irrigate a uterus after remov-
ing a decomposed decidua in a case of miscarriage. After
making the required solution, I put the bottle down un a dark
or shaded part of the table, and on leaving the house omitted
to take it away with me. Next morning I had a message to
say that my patient had taken spme poisonous medicine by mis-

take and was dying. I found she had taken a large teaspoonful
of the forgotten solution in some water, equal to about eight or
ten grains of corrosive sublimate. (It was thought to have been
some household remedy for neuralgic toothache.) The dose
was taken at 10 o'clock the night previous, fifteen hours prior to
my present visit. She had been vomiting nearly all night, and
was now suffering most intense abdominal pain and purging vio-
lently. Pulse and temperature were, however, undisturbed.
There was no history or appearance of collapse, simply an
expression indicative of suffering. I at once administered a
hypodermic of morphia, applied a sinapism, and after the pain
had abated left her. On calling next morning I found her, to
my surprise, perfectly well, there being only slight tenderness
on pressure over the hypogastrium. Cavendo Tutm,