In case delivery calls for the application of instruments, these should first be dipped into a 1-20 phenic acid solution, and then rubbed with carbolized oil or vaseline. Interference with instruments, be it well understood, is only justifiable when absolutely called for. If labor is prolonged, if the membranes have ruptured prematurely, if the infant is dead, or the liquor amnii tinged with meconium, it is good practice to administer one or two injections of weak carbolized water, with the same precautions as those taken before labor.
The napkins, cloths, etc., should be frequently changed, and if the bowels move the faecal matter should at once be removed, and the genitals washed carefully with carbolized water. Sponges, if they are used, should first be soaked for several days in carbolic, 1-20, and should be employed but once. Tarnier rejects sponges and uses cotton dipped in carbolic. It goes without saying, that in maternitics entrance to the lying-in wards should be absolutely forbidden any student serving in the surgical wards, or in the autopsy room. The nurses should be required to take the same precautions as the accoucheur.
The woman once delivered, the toilette should be attended to with scrupulous care. The genitals should be washed with new carbolized sponges or with carbolized cotton. The 1 to 100 'carbolized solution should be employed for cleansing hor, it should be lukewarm, and it is prudent to administer a vaginal douche in case the woman has lost much blood, or the labor has been prolonged, or repeated examinations have been made, or the hand or instruments have been inserted into the vagina, or the infant is dead, or there are lesions of the fourchette or perineum, especially in primiparte, where fissures and abrasions of the mucous mem brane commonly occur. This precaution is all the more urgent in case it has been necessary to artificially extract the placenta, or in case the hand has been inserted into the uterus, for any purpose whatsoever, [in such instances a vaginal douche is not sufficient, but an intrauterine should be administered by the physician.—Ed.] Next, a carbolized compress is applied over the vulva and the patient is placed in a clean bed. In case the night dress is the least soiled, it should be changed before the patient is placed in her bed.
These precautions we believe are sufficient, and we do not think it necessary to deliver, as is recommended by Fehling and Schucking, under the carbolic spray.
[It will be noted that in the views above expressed, in regard to the pre cautionary measures necessary for the well-being of the patient, reference is purely made to phenic acid and none whatever to corrosive sublimate. This is because, at the time of writing, the latter antiseptic had not re placed the former. To-day, however, sublimate has replaced carbolic to a large extent, even as possibly something else may replace sublimate in the not distant future, for such is the history of antisepticism. What is found inimical to germs to-day, is found far inferior to something else to morrow. There can be no question, however, but that corrosive subli mate is superior in mild dilution to carbolic in fairly strong as an anti microbic agent, and further it is devoid of odor. It should be remembered, however, that corrosive sublimate is much more toxic in its effects than phenic acid, and therefore, where frequent irrigation is necessary, the latter had better be used in 3 per cent. solution. As for sublimate it has been amply proved that the strength of 1 to 4000 is strong enough for routine purposes.
The precautionary measures advocated by Charpentier, are eminently judicious as applicable to maternity hospitals. In somewhat the same direction are the views expressed by Garrigues, of New York, by means of whose teaching and writing it has been unquestionably demonstrated how puerperal infection may be kept out of maternity hospitals. Although
not as extreme an antisepticist as he pronounces himself to be, we are prepared to accept much of his teaching, and can testify that the excel lent results obtained in the New York Maternity Hospital are largely due to the system of prevention which he introduced there, and which his colleagues in its essentials practise with him. In a recently published pamphlet on antiseptic midwifery, Garrigues thus summarizes the pre ventive measures against puerperal infection: " If possible the patient should take a full warm bath at the beginning of labor. Give an enema of a quart of soap-suds. Have half an ounce of bichloride of mercury divided into sixteen powders. Pour one powder into a quart bottle, add a little hot water, shake, add alternately hot and cold water till the bottle is full; shake well. This is the standard solution of 1:1000. Scrub your hands, and for operative interference, your arms with soap and water, using a stiff nail-brush, and then scrub again with the above solution. Cleanse your nails with a pocket-knife. Place beside the patient's bed a basin with solution (1:2000), in which you hold your hand, and every thing that comes in contact with lin genitals, for at least one minute immediately before touching her. Wash the patient's abdomen, but tocks, thighs, and genitals with solution (1:2000), and if she is not clean, scrub the parts first with soap and water. Inject a quart of the same so lution into the vagina. Use no lubricant, except when the whole hand has to be introduced. Then use carbolized glycerine, three per cent. Examine rarely, and do not introduce your finger inside the os in com mon cases. When the presenting part begins to open the vulva, cover it with a compress wrung out in solution (1:2000). Likewise, after the child is born, express the placenta by Credt.'s method. • If after delivery it has been necessary to introduce your fingers into the vagina, or if dur ing delivery manipulations have been performed in this duct, inject from a pint to a quart of lukewarm solution (1:2000). If fingers, hands, or instruments, have been introduced into the cavity of the womb, or if the child is macerated, give an intrauterine injection of two to three pints of hot solution (1:2000). Wash the patient with solution (1:2000). Put on a belly binder and antiseptic occlusion bandage. Change the dressing every six hours in hospital practice, or three times daily in private prac tice. Let the patient at the time of dressing use the bed-pan, and after that run a stream of lukewarm solution over her genitals and neighboring parts. No vaginal injections in normal cases. Disinfect instruments with a solution of carbolic acid, 5 per cent. If any lubricant is called for, smear them with carbolized glycerine (3 per cent.)" Such are the rules in regard to antisepsis which have unquestionably had great influence in rendering the New York Maternity Hospital what it to-day approximates, an almost absolute safety refuge for the poor women confined there. Of course other factors have aided, such as a separate house-staff and nurses, and absolute prohibition of entrance into the wards of all who might in one way or another be the carriers of con tagion. We reproduce these rules in order that any of our readers in charge of maternity services desirous of testing a rigid antiseptic system may have one at their disposal, which has certainly borne marvellous fruit. In private practice. we do not deem any special set of rules necessary, provided we aim at scrupulous cleanliness and conduct the labor in accord ance with the principles elsewhere emphasized in this book.—Ed.] 3. After Delivery.—Now begins the true puerperal period, and here it is that the antiseptic method should be used with scrupulous care.