failure of the pulse, irregularity of the respiration, and the blanched countenance, and, as beautifully expressed by an old. writer in reference to successful administration of anæsthetics, "Proceed steadily but cautiously to the end in view. He makes haste slowly, and with a boldness tempered by wisdom, carries his patient down into the dark valley which borders on death, drowns human agonies in the water of Lethe, and triumphs in the crowning glory of his art." ARTICLE XV. ON PREVENTION OF PUERPERAL FEVER IN PRIVATE PRACTICE. By CARL WALLISER, M. D., of Highland, Ill. More than twenty-five years have elapsed since Semmelweis. directed the attention of the medical profession to the etiology of puerperal fever. His assertions that the feverish diseases of the puerpera are for the most part due to blood infection resulting from resorption of decomposed putrid matter, have frequently been assailed. He made many enemies by putting the question, whether infection might not also be produced through the hands and instruments of midwives and physicians? In this decennium only scientific men examined these assumptions of Semmelweis, and finally adopted the theory: That most puerperal diseases are due to infection, which infection in the majority of cases comes from without. Since in the large lying-in hospitals antiseptic precautions for prevention of puerperal fever have been taken, since the patients have been treated in the same manner as those suffering from traumatic fever, septicamia, pyæmia, etc., morbidity and mortality of the puerpera have greatly diminished. Many private physicians and particularly country practitioners keep clear of the etiology of the puerperal diseases. Without examining the cause of infection and the spread of the epidemy, many "doctors" fill up the morbiditylist and mortality-tables with the handy entries, "milk fever," 9. I. C. R. Am. Jour. Med. Sci. 1867, p. 190. "puerperal peritonitis" or "self-infection." I know many cases where exitus letalis would have been avoided through an early rational prophylaxis. It should be, for every physician, a case of conscientiousness, a sacred duty, to avoid that death of a once healthy mother be occasioned by malpractice through ignorance or through neglect. As a pupil of Bishoff (of Basel), the pioneer of "obstetrical antiseptics," I have not only assisted at his first operations even, but I also, in the course of my practice, both here and in Switzerland, made it a point of modifying and simplifying Bishoff's antiseptic method for the use of private practitioners. I have performed under antiseptic auspices all kinds of manual and instrumental obstetrical operations, and I never have seen during the puerperium any symptoms of resorption fever. Before mentioning the most practical points of the prophydaxis of puerperal diseases, I shall give in the table (as an illustration) a brief report on a recent epidemy of puerperal fever, its probable origin and spread. All the cases registered in the table were attended to by the same midwife; they were all normal accouchments, taken care of by the midwife alone. Several women, who during the epidemy were delivered by physicians or other persons, escaped the danger of infection and remained free of disease in puerperio. Of the reported cases I saw one on the first, two on the second and all others between the third and eighth day; several of my patients have been seen and examined by my colleagues. I know that during the same time other physicians of this place had sick puerperas in treatment, and that death occurred in four of their cases. As far as I could ascertain the same midwife had also attended these women. Concerning the origin of the epidemy, I have made scrupulous investigations. Previous to October, 1876, diseases of lying-in women were not often met with in this town for some years. The first case noticed was an elderly multipara, who had been delivered of a dead, decomposed foetus; the midwife attended at the same time three women, who all fell ill. From October, 1876, to February, 1878, cases of puerperal fever came into treatment in long or short intervals. I do not remember one case of a then delivered (by the mentioned midwife) woman, where during the first week there were not more or less grave symptoms of the disease. It may be cited as an important etiological moment that during the winter of 1876 and 1877, scarlatina pre vailed in the neighborhood and it is proven that the midwife had been in contact with children suffering from diphtheria and scarlatina. Among the population of our district (about 3,000). morbidity and mortality rates of lying-in women were very high at that time; a "physiological" puerperium was an exception, a "pathological" one the rule. What country practitioner does not remember similar periods, when most of the obstetrical cases in his village expired under more or less grave symptomsof septic fever, when many well attended puerperal cases died. from peritonitis, septicemia and pyæmia? Most of the text-books on midwifery give etiological moments for origin of the puerperal fever, the artificial detachment of the placenta and the decomposition of such of its particles as remain behind in the womb. We accept this theory, though not to its full extent. How often does the medical attendant detach the placenta, and how seldom does resorbent fever occur, provided there is not a prevailing epidemy, a cause of infection? Every obstetrician knows, that those lying-in women have a greater liability to puerperal fever, as have undergone some manual or instrumental operation; particularly when protracted labors preceded or when the surgeon's hand worked under very difficult circumstances. Large lacerations. and contusions are very often the result of such operations of neglected cases. "Without wounds, (says Bishoff) and without infection of these wounds there is no puerperal fever." Small wounds: or rents of the parturient canal are an addition to almost every accouchment, the infection being only too often carried by the hand or instruments of the attendants, or by the foul air surrounding the patient. The principles of prophylaxis of puerperal fever are threefold: I. To avoid protracted labors and dangerous contusions by early and well performed manual and instrumental operations;, to prevent spontaneous perineal rents through lateral incisions.. II. Prevention of accumulation, decomposition and putrefaction of retained membranous or placenta rests; to facilitate the escape of discharges; to occasion a good contraction of the uterus. 111. The exclusion of unclean matter, foul air from the genitals ;: closing of rents (silk, catgut, silver wire sutures of superficial and deep lacerations of vagina, vulva and perineum); most scrupu lous cleanliness of the attendant physician, midwife and nurse; antiseptic treatment of all wounds, whether superficial or deep, large or small; to avoid any contact of undisinfected objects (fingers, sponges, instruments, linen, wadding, etc.,) with the vulva and vagina before, during or after delivery; in one word, prevention of all infection from without. In realizing practically the principles of obstetrical antisepsis, we shall detail this method, which strikes us as the simplest and surest, and which has led us to very satisfactory results. Before exploring a parturient woman, I wash both hands and arms in a warm water solution of two per cent carbolic acid. I require the same process of the midwife or any other person whose fingers come in contact with the parturient canal. As unclean, dirty (i. e. infectious) matter adheres very often to the sleeves, and is not so easily noticed there as on the fingers, the coat must be taken off and the shirt sleeves turned up. In many hospitals students are directed to put on taffety sleeves when attending lying-in women. This should be avoided, as these over-sleeves, when not thoroughly disinfected, rather spread than prevent the infection. I have often found expectorated matter on the inner and outer side of the coat sleeves and cuffs after attending children suffering from diphtheria. What physician, upon entering the room of a puerpera, remembers all the cases to which he has lately attended? Why do obstetricians so often speak of the coincidence of puerperal fever with scarlatina and diphtheria? In exploring the parturient canal the hand should be well anointed with carbol oil (ac. carbol 1, ol. oliv. 9). We never use the butter or grease offered us. All instruments are washed in the carbol water, and before the use anointed with carbol oil. The midwife is ordered to follow the same directions. From the beginning of the first labors to the birth of child and placenta, we practice every two hours a warm-water injection in the vagina; and when there are any signs of decomposed liquor amnii, or when the labors are protracted, we substitute for it a two and one-half or three per cent carbol. ac. solution, of which several pints are injected at short intervals. We have found that such injections clean perfectly the parturient eanal and prepare it for an easier passage of the child. Immediately after propulsion of the placenta, we inject into the cavum uteri the above-mentioned two to three per cent solution of the antiseptic (the water must be cold). We have found the best instruments for these intra |