PUERPERAL FEVER.
Propky/axis.—The obstetrician should realise that in every case of normal labour an attendant who does not understand or will not trouble to carry out the principles of antiseptic midwifery is a further element of danger added to the ordinary risks of childbirth. It may not be out of place to say here that this fact is already recognised by many of the laity, and is bound to be more and more as scientific education spreads. The midwife in England must now by law be at least possessed of the necessaries for carrying out her office under antiseptic conditions, and for the sake of his professional reputation, if for no higher reason, it is incumbent on the practitioner not to leave it in the power of anyone to say that in any case of confinement a single precaution which he ought to have taken was not taken. I am far from suggesting that every case of puerperal sepsis is to be laid at the door of the attendant. Infection is a matter not only of the seed, but of the soil where it is sown, and I grant at once that virulent septicemia or peritonitis may arise in a case where every possible precaution was observed. and that, on the other hand a patient exposed to all the dangers of examination or of instrumental delivery in the absence of any attempt at asepsis may never develop a bad symptom. But these cases are the exception, and not the rule. and it is as illogical to doubt the value of asepsis because of the one as it is dangerous to presume on account of the other. Experience shows that while it is impossible to conduct a confinement under absolutely sterile conditions, the precautions which can and should be taken reduce the number of pathogenic microbes in the field of operations to such a point that the resistance to infection of a normal woman is able to prevent them from obtaining either a local or a constitutional mastery over her tissues. An increased dose of microbes or a diminished resistance leads equally to infection, but this fact should only make us the more zealous to insure by antiseptic methods that the bacteria available for the attack shall he reduced to the numbers of a forlorn hope instead of being suffered to remain massed as an invading army on the patient's genitals and on the examining finger.
The precautions which should be observed have been already detailed at length under the heading of Labour (q.v.), and it is unnecessary to repeat them here. It will he sufficient to emphasise the following warnings:
Be sure to see that the patient's vulva and perineum have been thoroughly washed and disinfected before making a varinal examination or intro ducing instruments. Boiled india-rubber gloves must be worn for any vaginal examination or manipulation if the hands are chapped, rough or abraded, or have recently been exposed to contamination by septic material—e.g., pus or fxces—as under such circumstances it is impossible to sterilise the skin. No one, whether doctor or nurse, should have any thing to do with a woman in labour while suffering from an active infection on the hands, such as a pimple, suppurating wound or septic finger. Make as few vaginal examinations as possible. 1)o not hasten the third stage by kneading or massaging the uterus, and wait at least an hour before attempting manual removal of a placenta which has not left the uterus.
In regard to prophylactic douching, which is sometimes advocated, statistics do not show any very marked improvement from its use, and the opinion of the best authorities is that in normal cases it is unnecessary and probably harmful, except after such operations as manual removal of a placenta, or when the liq. amnii is stinking and probably infected in a prolonged labour.
In giving an intra-uterine douche the patient should be on her back across the bed, with the hips over the edge and a mackintosh below them to save the mattress from being soaked. A double-current uterine tube should he used—either Budin's, Bozemann's or, what I find best of all, Gibson's. The tube should be a large size, at least inch in diameter, and the douche receptacle should be raised only 2 or 3 feet above the patient, so that a plentiful stream of fluid is delivered without much force. At least 4 quarts at a temperature of io5° F. should be used, and the best solution is one of common salt (drachm to the pint). If an antiseptic is used it should be very dilute (f in f o,000 Perchloride or Biniodide, or drachm to the pint Lysol or Creolin). It is well to keep a hand on the fundus, lest the uterus should dilate suddenly, and after the douche has been given the uterus should be examined to make sure that it is well contracted and that no solution is retained in it; it should then be pushed down into the pelvis so as to expel the fluid from the vagina.