woman to be confined in a street-gutter than to enter the portals of a
lying-in asylum. Goodell's experience shows that a hospital for
respectable married women may be so conducted that its inmates may
enjoy absolutely a greater degree of safety than do women in their
homes surrounded by all the aids that wealth can command. Equally good
results are not to be obtained in hospitals which are open to
unfortunates of every class. But there is much misapprehension and
confusion of ideas respecting the fate of these women when no
charitable provision is made for them. In Copenhagen the Maternity
Hospital is closed for from six to eight weeks in the summer-time.
During this period unmarried parturient women receive pecuniary
assistance from the hospital to enable them to obtain a place in which
to be confined. Now, Stadfeldt reports a larger mortality among this
class than among those delivered in the hospital. Yet they are
confined at a favorable season of the year, without any communication
with the furniture, the sage-femmes, or the {1023} physicians of the
hospital. As they fortunately receive nothing but money, that can
hardly be suspected of communicating contagion. What their fate would
be in New York City perhaps may be judged from the following facts:
Excluding cases confined in hospitals, nearly one-thirtieth of all the
deaths and one-twenty-fourth of the cases of metria between 1867 and
1875 are reported by four practitioners. Ten practitioners out of
twelve hundred signed the death-certificates of one-fifteenth of the
women dying from puerperal causes, and one-tenth of the cases of
metria. But it is not to be supposed that these deaths were all the
result of malpractice and incompetence. The true history of most of
them probably was that the doctor was engaged to attend the case of
confinement for a small fee, with the understanding that he should
make no calls subsequently, unless specially summoned by the friends
of the patient. The latter, left to ignorant care or perhaps without
any assistance whatever, and exposed to all the pernicious influences
bred by poverty, when illness supervened probably did not call the
physician to her aid until the time for help had passed, so that in
the end his professional functions were confined to procuring the
requisite permit for burial.
Humanity demands that charity should furnish places of refuge in which
poor outcasts can receive assistance during the perils of
child-bearing. If we must, then, have maternities, we should make them
safe, and this can be in great measure accomplished by remembering the
twofold source of danger arising from a poisoned atmosphere and direct
inoculation. A hospital must be clean, spacious, and well-ventilated,
or its atmosphere will become charged with the spores of septic fungi
and produce nosocomial malaria. The most rigid sanitary precautions
observed by the attendants will not prevent a badly-ventilated ward
from becoming unwholesome, unless unoccupied wards are kept to which
patients can be transferred upon the first admonition of danger.
Goodell states that at the Preston Retreat the wards are used
invariably in rotation. In connection with the Maternity at Copenhagen
there are a number of small supplementary hospitals scattered through
the city, which serve as safety-valves for the central institution.
Artificial methods of ventilation render the task of keeping the wards
wholesome comparatively easy. They do not need, however, to be
complicated and expensive. The good repute of the Rotunda Hospital, it
seems to me, is in large measure due to the natural ventilation
afforded by open fireplaces.
In the Vienna Clinic, according to C. Braun, the mortality between
1834 and 1862 averaged 6 per cent., and in 1842 the enormous total of
521 deaths to 3067 confinements was reached. With the introduction in
1862 of what is known as Böhm's heating and ventilation system an
immediate improvement was experienced. In the sixteen years from 1863
to 1878, inclusive, the total mortality has been 1.6 per cent., though
in that time 5464 practitioners have received an obstetrical training
in its wards. In commenting upon this change, Braun says: "I have now
from practical experience arrived at the knowledge of the fact that
the rapid and thorough prevention of putridity by adequate ventilation
is to be regarded as a good preventive measure against puerperal
fever; that it is not the number of patients in a lying-in hospital,
nor yet the number of patients in a single room, but the deficient
circulation of air--a fault {1024} which may inhere to separate
compartments in the smallest maternities--which is the important
feature in the spread of puerperal fever; that puerperal women are to
be protected from childbed diseases not by isolated buildings and
gardens, nor by walls, but by the permanent introduction of great
quantities of pure, warm air." He then adds, what is in thorough
accord with my own experience, "Before new institutions are built
greater attention than heretofore should be paid to the ventilation of
the old structures, and, where this is found defective, a system
should be substituted corresponding to the scientific requirements."
In the year 1872 puerperal fever destroyed 28 women of 156 who were
confined in the Bellevue Hospital. The service was then broken up, and
a great outcry arose against "tainted hospitals." Wooden pavilions
were accordingly erected on Blackwell's Island for the reception of
lying-in women. These buildings were constructed upon what is known as
the cottage plan. They were favorably situated in an airy location
remote from the general hospital. They were, however, heated by large
iron stoves, and no means of ventilating the wards was provided,
except by lowering the windows. In less than three months from their
occupancy an epidemic of puerperal fever made it necessary to remove
the service for a time to the Charity Hospital. The same result
followed every subsequent attempt to utilize them for maternity
purposes, until, after three years' trial, it was found necessary to
abandon them altogether.
In private practice it is likewise important that the lying-in room
should be provided with plenty of light and air. The physician should
insist upon the value of ventilation as a means of contributing to the
speedy recovery of childbed women. By hermetically sealing the
windows, through false fears of his patient's taking cold, he exposes
her to the risk of becoming poisoned with her own exhalations.
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[66] 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.
[Footnote 66: D'Espine, _"Contributions à l'étude de la septicémie
puerpérale,"_ p. 18; Karewski, _loc. cit._]
Doléris[67] 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).
[Footnote 67: _La fièvre puerpérale_, 1880, p. 303.]
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.[68]
[Footnote 68: I know that of late there has been a strong reaction
against the use of vaginal injections in normal childbed, but
personally I have experienced none of the disagreeable effects
ascribed to them. Indeed, both my hospital and private patients alike
speak of them as soothing and grateful. I therefore have had no ground
to discontinue them. That they are indispensable I do not claim. They
are no longer used in Vienna, in Prague, nor in the New York
Maternity, and yet, none the less, their results have since been in
the highest degree satisfactory. At these institutions, however,
vaginal disinfection is vigorously resorted to during and immediately
subsequent to labor, and during childbed some form of antiseptic pad
over the vulva is employed.]
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.[69]
[Footnote 69: Since the above was written Dr. Garrigues has furnished
a most extraordinary example of the efficacy of the antiseptic
treatment at the New York Maternity Hospital. From the years 1875 to
1882, inclusive, the number of confinements was 2827; the deaths 116,
or a little over 4 per cent. The highest percentage was reached in
1877--viz. 6.67; the lowest in 1881, when it fell to 2.36. In 1883, of
345 women confined, 30 died. In September of that year there were 9
deaths, and of 5 puerperæ who were seriously ill, 1 died later. At
this time he introduced a series of reforms of which the following,
omitting details, gives the essentials: Wards fumigated with
sulphurous acid fumes, and the floors and furniture washed with a
solution of corrosive sublimate (1:1000). Every patient, on entering
the lying-in ward after the bath, had her abdomen, buttocks, genitals,
and thighs washed with sublimate solution (1:2000). During labor
vagina irrigated with latter solution. In prolonged labors irrigation
repeated every three hours. Great care of hands on part of doctor and
nurses. Glycerine and corrosive sublimate (1:1000) used for
lubricating fingers before making internal examinations. Antiseptic
pad applied to the head during its egress, and to the vulva until the
secondines had been expelled. Absorbent cotton covered with netting
soaked in corrosive sublimate solution applied to external genitals
during childbed period. This latter applied and removed with the same
care as in dressing a wound after a capital operation. Irrigation,
first of the vagina and afterward of the uterus, immediately after
labor in cases where the hand or instruments had been passed into the
uterine cavity.
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.