Two months after delivery it has resumed its normal size provided involution has not been interfered with .3

The treatment in the cases of sepsis is the important part of the subject. The preventive treatment is that calling for active exercise of all the wisdom our profession has. It is my opinion that, notwithstanding the marvelous advancement in the practice of obstetrics, a large per cent. of the cases of puerperal infection during the last decade could have been prevented if diligent effort had been made along preventive lines. For an obstetrician to attain a maximum degree of success preventing puerperal infection, he must be willing to put himself to much effort and ill conveniences. He must be willing to turn the case over to some one else if there is doubt about asepsis. In the first place, he must be willing to change clothing through. out and bathe with antiseptic solutions before entering the room of a patient in labor, provided he has been in attendance upon or near any source of infection.

In other words, he must not be what most practitioners are very frequenlly, namely, the direct source of infection. Every instrument and article carried into the house should be clear of contaminating matter. If the medicine case has been in a room where erysipelas, septic infection, a septic wound, or any source of infection existed, that case had better have thorough attention, and another be substituted for awhile. How easy it is to take the hand from a septic source and grasp the handle of the case, leaving thereon deposits of infection that will cling to that same hand again in a perilous hour. After being sure that the physician himself and all that be carries can be depended upon as clean, it is necessary that the nurse and other attendants should be looked after with all the care that circumstances will permit. Here I would like to state that it is an easy matter to have too many attendants, for the greater the number the greater the danger of infection. When the sick room has been entered and symptoms of labor are present, it is necessary for the nurse to prepare the patient, thoroughly cleansing the external genitals with a solution of 1 to 4,000 bichloride of mercury after soap and water have been used. Just here it would not be out of place to mention a practice that has been adopted quite extensively, which at first glance seems rational, but which, in fact is not: I mean the practice of using antepartum vaginal douches as part of the antiseptic technique. Kronig and Bretschneider made investigation in 2,280 cases

by using the vaginal douche in every alternate case, and using none in the other half of the cases. In those in which the douche was used there was a febrile puerperium in 45.18 per cent. of the cases, while in those where no douche was used the percentage of febrile condition only reached 36.78 per cent.4 The reporter neglected to state whether the douche was an antiseptic solution, or merely sterile water. It is my opinion that the solution used would make very marked difference. My limited experience has taught me that the antiseptic solution has been followed by a more frequent rise in temperature than has the sterile solution. It is further believed by myself that the stronger solutions of bichloride of mercury and of carbolic acid are very powerful in contributing to infection. This is quite natural for the mucous membrane is stimulated and contracted by the strong solution and rendered non-elastic, so when it is put on the stretch in the second stage of labor, abrasions occur that would not otherwise exist. These abrasions absorb micro-organisms; hence the infection. The wearing apparel of the patient as well as the bed clothing should be clean. While all this is going on the physician could spend a very profitable fifteen minutes in removing the inhabitants from under his finger nails and from off the hands. Don't say they are not there, for we do not know and the one commendable way is the safe way. All this should be done before the first examination has been made. Making frequent examinations has been justly condemned so often until I will pass it. Be not anxious to hasten labor, for remember that rapid labors produce lacerations, and lacerations in turn open up avenues of infection.

Remember that the reasonably slow labors are the safe ones, provided a safe practitioner is in charge of the case. Be not hasty in using the forceps, for these mighty means for good have been abused quite frequently. I think too little stress has heretofore been placed upon the support of the perineum as the head and shoulders pass through. Proper support will certainly prevent lacerations that would otherwise happen. After the new-born has been removed from the bed, much care should be exercised in removing the placenta. Considerable time should be used in removing it. Most prac. titioners remove it fifteen minutes sooner than should be done. It should be removed, if possible, in toto without the introduction of the hand or instrument into the uterus. Now

is the time, however, to empty the uterus. Whatever blood clots or residue of placenta remain in the uterus should be removed now or forever left alone. All lacerations of the cervix and perineum should be repaired at once, so that these avenues of absorption may be closed. Daily vaginal washes of bichloride of mercury, 1 to 4,000, or normal salt solution, should be used. It has been said that the normal discharge from the uterus is aseptic and calculated to do no harm. This is probably true until the discharge has gained contact with the air, but then it is very liable to become quite a different substance. The discharge is nothing more nor less than decomposing human tissue, and that exposed to the air will soon become a mass loaded with living bacteria.

This is why it is extremely necessary to keep the external lacerations closed and the discharge constantly wasbed away. I know that there is a difference of opinion on this practice, as well as the uterine douche, but my contention is that if we keep the vagina washed out clean we burn the bridge, as it were, between the external genitals and the uterus, and it is a well-known fact that complete and continuous asepsis of the vulva and surrounding territory during the puerperium is an impossibility. I am of the opinion, however, that when a solution of mercury is used it should be a weak one, for ptyalism and poisoning are both possible. After all these precautions have been exercised, if a chill and fever comes on at any time within two weeks of confinement, showing that infection has taken place, the treatment to be employed is a question of debate. I admit that so limited an experience as can be had in seventeen years of private practice is too small from which to make a very reliable estimate. Notwithstanding this, I am somewhat influenced by what has taken place under the different modes of treatment, both in my own hands aud at the hands of others around me. I take the position that after the third stage of labor has passed, and the uterus bas thoroughly contracted, that this organ is a sacred chamber and should not be entered with either curette or douche until involution has been accomplished, or until the allotted time for that operation has been consumed by nature, stenosis excepted.

I would like to quote from the Atlanta Journal Record of Medicine: "Puerperal infection, as represented by an irregular temperature, usually preceded by a chill, with or

without a foul lochia, always calls for a careful and thorough curettage."5 "I never use anything as an intra-uterine douche except salt solution, for the reason that no one can tell, however careful you may be, when, without any pressure and seemingly without any provocation, the curette will at once be found to have slipped through the uterine wall and be within the abdominal cavity."6 The first one of these sentences I quote because the majority of the French and American authors most heartily endorse it. The other sentence, written by the same author, I quote to call your attention to a direful consequence of the curette. Think of this accident with a uterus filled with virulent micro-organisms. The more conservative obstetricians in America, and quite a large class in Germany, use the curette and uterine douche only in the putrid form of sepsis. They admit that in the streptococcus infection with a smooth endo-metrium and little or no dis. charge there is absolute harm in curetting and douching. Why not wake up to the real situation and say that while currettment and intra-uterine douching is harmful in the streptococcus infection, it is also harmful in the other forms that are less fatal, for the mode of infection and nature's mode of protection is practically the same in all cases except sapremia?

I have been very reluctant to take my present position publicly, for it is a well-known fact that many who oppose the aggressive mode of treatment have been called "old fogy" and "back numbers." There would never have been the great number of practitioners following up the aggressive mode of practice if each man had done his own thinking. If I were to suggest that physicians in their frightful rush for the front were like one canine family yelling after a leader who is himself following the trail of some phantom fox, some one might howl. I guess I had better not say it.7

Clinical history bears out the statement that the indis. criminate use of the curette is followed by more danger than if not used at all. One class of practitioners will tell us that if we have a rigor and a rise in temperature to 104° or 105°, circulation rising to 120 or 130, that we are having the absorption of one or more of the previously mentioned families of micro-organisms, and that it must be wiped out with an antiseptic uterine douche. Another class will say that the same thing is happening, but they do not stop at the use of the douche, but

introduce a curette and give the uterus a thorough scraping out. I condemn both these practices as almost criminal. The fact is, the poison has already gained entrance into the system and has produced these systemic manifestations, and probably the avenues of entrance have been closed by nature long before the physician reaches the patient.

The first class above mentioned will introduce the douche tube, and by filling the organ with his antiseptic or aseptic solution, put the contracting and involuting uterine walls on the stretch, and thereby open up some of the closed mouths of the veins and set up new absorption, and if there be any septic matter in the organ, or if the tube perchance carried along with it any matter unwholesome, the patient is very liable to be required to fight against a new supply of infection. Some say that the return flow prevents all this evil. I do not think that possible. The other class of operators make a further invasion and their curette tears down the protecting lining of the uterus, and with that instrument fairly vaccinate the organ in a number of places and the virus generally takes. It did so for me when I practiced that method of treatment, and soon another rigor would come on. At the first glance the douche method and the curette method both seem surgical and wise, but when we study the evolution of the womb and the involution of the same, we will see at once that we have a peculiar condition in which nature must not be hindered in her holy undertaking. The main object in these cases is to stimulate the patient and help her combat the evil already absorbed. Ergot aids contraction and hastens involution. Veratrum seems to answer a good purpose. I have thought that it was almost as potent in puerperal infection as it was in puerperal eclampsia. Veratrum, ergot, strychnine and supportive nourishment are the remedies to be relied upon.

A general collection of statistics is the only way to arrive at the truth. Statistics from every man's practice is what we need.

REFERENCES:

1. Playfair's System of Midwifery. Page 594.

2. Practice of Midwifery; second edition. Jewett. Page 605.

3. Science and Art of Midwifery. Lusk. Page 241.

6.

4. Practice of Midwifery; second edition. Jewett. Page 605. 5. Atlanta Journal Record of Medicine, January, 1903. Page 650. Atlanta Journal Record of Medicine, January, 1903. Page 652. 7. The Mobile Medical and Surgical Journal, October, 1902. Page 613.