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PUERPERAL FEVER.—A traumatic fever caused by poisonous bacteria which enter the wounds caused in the internal and external sexual parts during delivery. The disease was formerly erroneously called " milk-fever.' The bacteria find their way into the vagina during confinement through the medium of dirty fingers or other objects. They may, however, have existed in the pelvic organs (tubes, ovaries, womb, etc.) before pregnancy ; or they may have reached these parts during confinement by infection from other organs, as, for instance, in influenza.

The early recognition of the first symptoms of puerperal fever, and the overcoming of the disease at the beginning, are the most important factors in the treatment. Later on very little can be clone except to keep up the patient's strength, so that the body may be able to combat the poisons generated by the bacteria. The conspicuous and warning symptoms of the disease consist in a rise of the body temperature above too'? F., sleepless ness, headache, loss of appetite, diarrhoea, profuse perspiration or an abnormally dry skin, changes in the lochial discharge (causing it to resemble burnt raspberry-jelly), extraordinarily severe after-pains (especially in first births), swelling and soreness of the external wounds, and gaping of these wounds if they have been sutured. When such symptoms become noticeable, the patient should remain absolutely quiet on her back, and the physician summoned without delay in order to determine further treatment.

The proper measures for prevention are the prompt treatment of any occurring disorders and scrupulous cleanliness. In case of any abdominal disease, this must receive immediate and energetic treatment. This is particularly important in the case of catarrh of the womb (an affection which is often totally neglected), and especially when there is a mucus discharge. If pregnancy already exist, very little can be done without affecting its course. Should the condition become aggravated, operative interference may be necessary. The second point to be observed in the prevention of puerperal fever is the delivery. Here, as during the entire period of preg nancy, the most scrupulous cleanliness of the body is necessary. Also the body-linen, the clothes, the bedding, and all objects and persons with which the patient comes in direct or indirect contact must be absolutely clean. If cleanliness is lacking, the most powerful antiseptic remedies are useless. In such cases it is only sheer luck if fever does not appear. Bacteria coming from discharging wounds, from persons sick with puerperal fever, from erysipelas, diphtheria, scarlet fever, etc., or from decomposed meat or corpses, are very poisonous. Persons who have been exposed to such con tagion must, under no circumstances, ever enter the sick-room. Doctors and nurses who are careless about the cleanliness of their hands should be avoided.

Since the proper precautionary measures have been followed by the attendants at childbirth, there has been a considerable decrease in the number of cases of, and in the mortality from, puerperal fever. This wonderful progress, made within the last fifty years, is due solely to the successful efforts of scientific medicine. Oliver Wendell Holmes is to be credited with having been the first to announce the contagiousness of puerperal fever. The medical profession is, however, far from having attained its ideal of a confinement entirely free from fever. This is not the fault of the method, which, when compared with former times, has proved admirable ; but it is due to various factors which it is difficult to influence. Among these the patients and the lay attendants are the more important. The former need enlightenment, and the latter more supervision and better equipment for their work.

When childbirth begins the patient should be given a vaginal injection of about one pint of warm water. While this is being injected she should lie on her back or on the side, breathing deeply ; and the water should be allowed to flow in slowly. The nurse should also give the external sexual parts, as well as the thighs and abdomen, a preliminary cleaning with soap and warm water, whereupon the doctor should he notified of the approach ing childbirth. As to the nurse, the patient should make inquiries regarding her faithfulness, and especially as to whether she is scrupulously clean and conscientious in following the physician's directions, particularly with regard to disinfection. No nurse should be engaged who accepts new cases while caring for a confined woman suffering from fever, suppurating wounds, or other contagious diseases. She is violating the moral law if she does this ; and in some countries she even violates statutes. Hands that have been exposed to poisonous bacteria cannot be rendered absolutely free from germs by one disinfection, no matter how strong ; whereas the skin, in the course of a short time, cleans itself. In Germany there is a law commanding a midwife who has had charge of a patient suffering from puerperal fever to discontinue her services for a time, in the interest of subsequent cases.

For their own sake, patients should know that puerperal infection is most frequently communicated through dirty hands or instruments. An uncleanly physician or nurse is a menace in the treatment of childbirth. During the birth of the child, as well as afterwards, the internal parts must not be touched unless the physician deems it necessary. The external sexual parts, however, as well as the entire body, must be carefully washed every day, but only by a person who has properly disinfected her own hands. The bowel movements, as well as the evacuation of the bladder must receive careful attention.