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in those from kidneys and from the skin, generally in the vomitus,
but in the greatest amount in the sputum ; we should further in-
form them that drying only makes the germs more.readily diffused
through the atmosphere, that the ordinary process of washing
does not destroy their activity ; that burning or boiling is the only
means of rendering them innocuous, but that as long as they are
kept wet they are not disseminated through the air. Now, the
practical conclusions that are to be drawn from these scientific
facts are, that the underclothing and bedclothing of those suffering
from tuberculosis should be frequently changed and the soiled
elothing should be boiled for a half hour before being washed ;
that the excreta should all be passed into vessels containing water.



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8 ROCHESTER : THE PREVENTION OF DISEASE.

and that these vessels should be rinsed and thoroughly cleaned
with boiling water ; that the sputum should be expectorated into
a cup or other suitable vessel containing water, which is kept
covered when not in actual use (if the patient is walking about,
a wide-mouthed bottle, well corked, can be carried in the pocket);
that the sputum thus collected should be emptied from the vessel
three or four times in the twenty-four hours, and immedicUely
burned ; that the vessel should then be thoroughly cleaned in the
same manner as directed for the vessels used for excreta ; that the
mouth, nose and throat should be cleanpedat least twice daily with
a mildly alkaline wash ; that the table utensils of the patient,
including the napkin, should be thoroughly treated with boiling
water before being otherwise washed. The well members of the
family should not kiss the patient on the mouth ; and under no
circumstances should any one of them sleep in the same bed with
the patient. The patient's room should be thoroughly ventilated
and should never be tightly shut up ; it should also be as sunny
a room as possible. Whatever therapeutic measures may be adopted
for the treatment of the case, directions such as the above should
be given to the patient, or to some responsible member of the
family or to the attendant.

In addition to what is thus done by the physician in the way
of special directions to his patients, much — very much — may be
accomplished by the State or the municipality through the compe-
tent inspection of the food and milk supply. Though all cannot
be accomplished by either if the other does not cooperate, still, of
the two, more can be accomplished by the physician by such care-
ful directions to his private and dispensary cases, than can be by
the State if the physician neglects his duty.

Now, what can we do to prevent the occurrence of venereal
diseases and so aid in the strengthening and improvement of the race?

Laws may be passed by the State forbidding the existence of
brothel-houses, or licensing their existence and placing them under
medical and police surveillance ; appeals may be made to men and
women from a moral standpoint to avoid these places, and refrain
from unholy intercourse. These means have all been used, but
there is nearly, if not fully, as great prevalence of venereal diseases
in those communities where such regulations exist as in those
where they do not.

Now, it seems to me that the true way to prevent the occurrence
of these diseases is to give instruction to people of all classes as to



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ROCHESTER : THE PREVENTION OF DISEASE. 9"

the nature and serious character of these diseases. To make this
instruction effective, it must be given early enough in life to enable
young people to avoid exposure when first tempted. Therefore, it
seems to me that to boys of fourteen and upwards instruction
should be given in the physiology of reproduction, and, at the same
time, the sacredness of marriage should be impressed upon them.
Then it should be plainly stated to them that some men and women
put themselves on a level with, or even on a lower level than, the
beasts by indulging in indiscriminate sexual intercourse ; that
these women are known as whores, and that they and the men who
associate with them are despised by all decent people ; but that,
unfortunately for the cause of high morality, sometimes some such
people are tolerated by their fellows for the sake of other good
qualities which they may possess ; however, that, sooner or later,.
nearly all who indulge in such intercourse are afflicted with either
gonorrhea or syphilis, or both ; that rarely, if ever, is either of
these diseases completely cured. Then all the evil results of
syphilis should be vividly portrayed to them, illustrated by plates
taken from real life.

The same thing should be done in regard to gonorrhea.

A similar course of lectures should be given to the young girls
of all walks of life by some of the women physicians.

Finally, it should be impressed upon them that no one, who has
ever had syphilis, has any right ever to marry, for there are cases
on record, in which, after a lapse of twenty, thirty and even fifty
years from the time of the original lesion, tertiary symptoms
have developed, although no secondary symptoms had shown
themselves during the last three-quarters of the period, and the
patients had deemed themselves well ; for should such a one marry
and beget children, these children would have a syphilitic taint
that would show itself either in real syphilitic lesion or in an en-
feebled constitution. Nor should any one who has ever had
gonorrhea ever marry, if there remains the slightest trace of
the original disease or any of its sequelae — and it is very, very
rare that some such trace does not remain. The danger of such a
one's infecting his wife and the terrible results of gonorrhea in
women, should be plainly set forth.

Moreover, it is our duty as physicians and good citizens look-
ing to the welfare of humanity and the progress of true civiliza-
tion, to advise any, who may consult us as to the propriety of his
marrying, according to the principles just stated.



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10 POTTER : PCEBPEBAL SEPSIS.

Fellows of the Academy, let us be among the pioneers in patting
to practical use the results of the discoveries of the bacteriologists
and thus hastening the advent of the medicine of the future —
preventive medicine !

©riginaf (^ommunieationA.

PUERPERAL SEPSIS ; ITS PREVENTION AND CURE.*

Br WILLIAM WARREN POTTER, M. D., Buflfalo, N. Y.

Fellow of the American Association of Obstetricians and Gynecologists ; Examiner in

Obstetrics, New Yorlc State Medical Examining and Licensing Board.

I. INTRODUCTION.

Among the many serious questions urged upon the attention of
physicians at the present time, none have higher claims to their
thoughtful consideration than such as pertain to the prevention of
disease. If this be true in its larger sense when applied to the
entire field of preventive medicine, it is even more emphatically
true when we are called upon to consider those delicate and
serious questions that especially concern the lying-in chamber.
Here, if anywhere, a man is weighted with responsibilities of a
momentous nature, even such as he is called upon to sustain in no
other social, professional, or individual capacity. They are often
thrust upon him in the middle of the night, when he is least fitted
for clear thought or resolute action ; hence, he must, by frequent
discussion and much study, keep his mental armamentarium
always burnished and ready for use at a moment's notice. The
custom is, I fear, among some — I had almost said many — physi-
cians to assume these responsibilities in a ligh^hearted, easy-going
manner that occasionally approaches even to triviality. In my
view, there is no more solemn office to be performed by a human
being than in assisting at the delivery of one of his species. To
preside over such an event, and to conduct it to successful issue,
without permitting danger to mother or infant through neglect or
oversight, is to accomplish something that benefits humanity, pro-
longs life, and adds to the sum of human happiness.

II. OF PREVENTION (a) AS RELATES TO THE PHYSICIAN.

In order to perform this duty properly, that is, in a manner
to obtain its greatest results, it is essential, inter aliay that the

1. Read by title at the eighty-seventh annual meeting of the Medical Society of the
State of New York, February, 1893, and published in the Annah of Gynecology and
Pediatry, April, 1898.



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POTTER : PCTEBPEBAL SEPSIS. 1 1

obstetrician should be trained in habits of personal cleanliness
beyond those of the ordinary man ; and even, if I may be per-
mitted to say it, beyond those of the average physician. If a
man is not scrupulous with reference to the care of his person,
bow can he be expected to enforce a technical cleanliness in the
lying-in chamber ? A man who holds himself up to the com-
munity as an obstetrician should be a model in cleanliness of body
as well as in neatness of attire. He should take frequent baths,
wear clean underclothing and linen, but especially should he keep
his hair and beard closely trimmed and his finger-nails short and
clean. If the physician himself is careless of his personal
garb and cleanliness, he is placed at a disadvantage with
reference to enforcing the observance of these essentials in
others. He, then, is a commander-in-chief, who supervises every-
thing with reference to the parturient chamber, and enforces his
mandates with the discipline of a martinet in everything that
serves to prevent the approach of that stealthy, thieving, sneaking
but all-powerful enemy, dirt.

(b) AS RELATES TO THE CONFINEMENT ROOM AND NURSE.

The lying-in chamber should receive his personal supervision
in reference to its simplicity, cleanliness, and freedom from hang-
ings or draperies. If the room is a humble one, where luxuries
are absent and even necessities deficient, there still should be given
the same careful attention to cleanliness that prevails in the well-
appointed home. A free use of soap and water and the whitewash
brush will do much to provide against contamination and disease.
The nurse, too, who is to perform her offices in the lying-in
room, must be a woman of neatness in garb and cleanliness of
person beyond the average of womankind. She must be trained
in these habits until they become her second nature. She must
not be afraid to attack dirt wherever she sees it, nor unwilling to
act as a sentinel or detective with reference to that masterful foe
of the lying-in chamber.

(c) AS RELATES TO THE DELIVERY BED.

One of the important duties that a physician must perform in
arranging for the ordeal that awaits his patient is to look to the
proper preparation of the bed. If it is important that the cloth-
ing of the patient be clean, it is still more essential that her bed
should be the very quintessence of cleanliness. The mattress



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12 potter: puerperal sepsis.

should be inspected with reference to its freshness as well as its
former use, and all the linens and other dressings of the bed
should receive his most careful scrutiny in this regard. If the
station of the patient does not admit of more than the bare neces-
sities of the bed-chamber, then a clean bed-tick, filled with sweet,
clean straw, covered with a blanket and an impervious dressing of
some kind, over which is to be laid a folded sheet, furnishes all
that is necessary for the comfort, and even convenience, of any
patient. If I could have my own way, I would allow no woman,
whether of high or low degree, to be confined upon anything but
a straw bed which had been prepared especially for the occasion.
I lay great stress upon the preparation of the bed. Neglect in
this regard may be a source of bitter sorrow, whereas a little
timely and considerate attention to it beforehand may serve to
prevent disaster.

If, perchance, a woman has come to her old home to give birth
to her first child, it will not answer to allow her to occupy the
bed upon which, a few months ago, her sister lay grievously ill with
scarlet fever, or on which her brother died with diphtheria ; nor
will it be proper on this important occasion to permit her confine-
ment in the bed where her father was treated for a compound
fracture of the tibia and fibula ; or that on which her husband lay
during long and weary weeks while struggling with typhoid fever.
It may be the favorite family bed for all such trying occasions, but
there is a particular reason why we must discard it this time. I
have no doubt that many a case of puerperal sepsis is traceable to
the use of such a bed during delivery. Hence, I say, it would be
better to establish a hard and fast rule that every patient, no
matter how rich, no matter how poor, should be compelled to
occupy a new straw bed during her confinement. This ought to
be exchanged subsequently for a clean mattress, to be occupied
during puerperal convalescence.

(d) AS RELATES TO THE PARTURIENT.

The patient herself should be properly prepared for the ordeal
that awaits her. She should have a warm bath as near the onset
of labor as may be, and with the oncoming of pain should be
thoroughly bathed, antiseptically, over the abdomen, in the groins,
on the vulva, hips and thighs. After the bladder and rectum have
been emptied, this should be repeated, when the rectum and vagina
should receive warm lavements. Then, in a clean night-gown and



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potter: pusrpebal sepsis. 13

light woolen stockings, she may be considered ready to occupy the
delivery bed. The conduct of the labor should continue to its
«nd on the lines of absolute cleanliness, with few digital examina-
tions, and complete delivery of the secundines.

(e) AS RELATES TO THE REPAIR OF LESIONS.

Finally, I need scarcely remark that one available means of
great importance in preventing puerperal sepsis abides in the
prompt repair of all rents in the perineum. This removes an
important complication at once, as a large absorbent surface is
thus readily disposed 'of. There is no question in the mind of any
well-trained physician today that unrepaired perineal rents are a
septic menace, or that in many instances sepsis has invaded the
system through this channel. There is sufficient reason in this
danger alone to warrant immediate repair without discussing the
other important fact not germane to this paper, namely, that it is
essential to a woman's health and comfort, as well as to those of
her consort, to possess a sound perineum. In some instances,
likewise, it is advisable to repair cervical tears immediately,
especially when they are extensive enough to cause much hemor-
rhage, or threaten to prolong the puerperal period by delaying
involution or provoking other serious conditions.

III. OF CURE.

If thus far I have said little or nothing with reference to the
employment of antiseptics or chemical solutions, this has not been
an oversight on my part, but because I consider these of far less
importance in the prevention of puerperal sepsis than a strict
adherence to the principles of asepsis in the preparation for, as
well as in the management of, labor. I have an impression that
if we eould properly apply the rules of 'cleanliness in every case,
there would be no sepsis, and, hence, no puerperal septicemia or
^hild-bed fever, as it was called in the olden time. It is possible,
when every principle of mechanics known to science is properly
applied, and when human judgment is kept clear and free to apply
it, to prevent any and every form of railway accident that
threatens or destroys life or limb. When we come to consider
the great number of people who travel, we must admit that the
number killed is very small, but still it is yet far too great to satisfy
that tender regard for human life which should everywhere prevail
among mankind. So, too, do I believe that every case of puerperal



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14 potter: puebpbbal sepsis.

sepsis coald be prevented, provided human judgment was perfect
in its application of the principles of asepsis or cleanliness. Chemical
solutions are valuable, and must be resorted to by the obstetrician
to keep his hands and instruments clean, and also for the purpose of
rendering aseptic the linen and other cloths that are used around
and about the parturient woman. But, if the proper rule of clean-
liness is observed — in other words, if everything about her is
rendered aseptic — there will be no necessity for the employment of
antiseptics in an ordinary labor otherwise than as just indicated.

In operative midwifery, either manual or instrumental, there is
always danger that pathogenic germs may be carried into the
genital tract by the instruments or hands of the operator. Then
it is that antiseptics become necessary to clean out and wash away
the dirt, or to neutralize the effects of such as has been carried
into the absorbent, surgical uterine cavity.

Since, therefore, in spite of all known ways to prevent such
direful calamity, puerperal sepsis will now and then come — just
as in spite of all human precaution railway accidents will now
and then happen — we must be prepared to cure, if possible, the
former, just as railway corporations must be prepared to mitigate
the suffering and clean up the wreckage entailed by the latter. I
shall take but a few moments of your time in the consideration of this
part of my subject. If there is invasion of the genital tract for
the purpose of promoting delivery, either by hands or instru-
ments, then we must be wary lest secondary conditions follow,
that further complicate or hazard the patient's chances of recovery.
Intrauterine irrigation must be performed in every case where
such aids to delivery have been employed, and when done, it must
be carried out in the most complete modern surgical manner.
The woman must be placed upon a proper table, in a good light,
and the fluid — either Sterilized water, or water that has been
boiled and contains an adequate germicide — must be allowed to
flow into and out of the womb, in an unobstructed manner, until
it runs clear and is absolutely clean. There must be no detritus
left behind ; no nidus for the propagation of the germs of infection.
The mistake has been made of applying intrauterine irrigation
inadequately, either as to the method of employing it or as to the
material used. Either form of error is sufficient to bring failure,
or to render it useless or nugatory. I shall not here enter into
technical and minute details, for this has already amply been done
by Dr. L. S. McMurtry, of Louisville, honorary member of this



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pottee: pubrpeeal sepsis. 15

society,^ but I simply offer these general suggestions as to the
indispensabilities of the case, leaving the minutiae to be supplied by
the ingenuity of the physician when the occasion and necessity
are presented. There are certain things that must be done in such
an emergency. The woman must be made clean from the fungus
uteri to the ostium vaginse, and she must be kept so ; f uthermore,
it must be done in a manner and with a material that will do her no
harm. This is the whole sum and substance of the case, and we
may as well, first as last, settle down upon some fixed and deter-
mined principles in regard to this point.

But when, in spite of the prompt and persistent employment of
intrauterine irrigation, associated with the use of the curette when
indicated, as well as other concomitant preventive measures, puer-
peral sepsis continues to advance to a stage of suppuration and
aBscess, what shall be done ? Without entering into a full discus-
sion of this interesting subject, I shall content myself, on this
occasion, with the remark that, in such a case, and in the light of
our present knowledge, a prompt abdominal section, by a compe-
tent man, is not only entirely justifiable, but is the most intelli-
gent step to be taken in the treatment. All pus accumulations
should be cleaned out, irrigation thoroughly employed, and drain-
age used. In case the uterine body has itself become saturated
with sepsis, the propriety of its removal, together with its append-
ages, cannot be doubtful. The record of recoveries from such
desperate conditions is sufficient to justify its employment as a
necessary measure in such a direful class of cases. It needs no
argument to prove to this audience that a simple abdominal sec-
tion, with irrigation and drainage, would not be adequate to cure,
providing the uterus and its appendages were thoroughly satura-
ted with pus. It may be a more difficult question to decide as to
just what ought to be done in cases where sepsis still persists in
its manifestations after abdominal section, intraperitoneal irriga-
tion, and adequate drainage. But it would appear rational to re-
open the abdomen in such cases, and excise the putrescent uterus,
provided, of course, there is sufficient remaining strength in the
patient to warrant the procedure.

6ENEEAL BEMAEKS.

In the consideration of this subject, I have, designedly, only
here and there touched upon salient features for the purpose of

1. Trans. Am. Asso. Ob»t. and Gyneo., vol. iv., 1891, p. 26, et seq.



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16 POTTEB : PUERPERAL SEPSIS.

-covering as much ground as I coald in, the short time allowed
There is scarcely one of the subdivisions of this subject that would
not admit of an exhaustive paper. But, in order to command the
respect, not to say attention, of audiences in these days, writers
must evermore be brief. My purpose has been to make a plea
for cleaner and more considerate obstetrics. I would do awaj
with all haste, approach each case with due consideration for its
best interests, and a careful preparation to meet its complications.

A few years ago it was considered next to suicidal for a woman
to enter a maternity hospital for confinement. All this has
changed, and nowadays a maternity is regarded on all hands,
when properly conducted, as the safest and best place in which a
woman can be delivered. When these large institutions are pre-
senting a series of one thousand consecutive cases without a death,
embracing in many instances patients who have come within their
doors almost moribund, embracing also patients upon whom it has
been necessary to perform a Porro or other Cesarean section, I
say, in view of all this record, it becomes the obstetrician who
conducts a private practice to beware, lest the maternity physician
strips him of his laurels. The abdominal surgeon takes pride in
presenting a year's record of a hundred consecutive cases without
a death, but he is only enabled to do this by the utmost precision,
careful preparation of his patient, and a strict adherence to the
doctrines of the gospel of cleanliness. When the obstetrician
engaged in general practice can also present a record of a thousand
consecutive cases without a death, or without serious, prolonged
or grievous maiming to his patient, he will then stand in the front
rank and deserve to have his name enrolled alongside of the mater-
nity physician and the abdominal surgeon as having done, perhaps,
more than either to improve the condition of his fellow-men.

I have only suggested in this paper some of the simpler ways
through which this may be achieved. They are such as ought to
-commend themselves to every thinking man, and were known to
all of you just as well before their enumeration as afterward ; but,
as I have suggested, there are reasons which lead me to believe
that it is essential to review this subject now and again, for it is
only through the Grant plan of continual hammering that triumph-
ant victory can be wrung from a threatened humiliating defeat.
In justification of what I have just now said, permit me, in conclu-
sion, to remark that not long ago it was my privilege to read a
paper on a subject allied to this, which was published in the Phila-



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POTTEB : PUSBPEBAL SEPSIS. l7

delphia Medicdl Jtews. The editor of the Kansas City Medical
Hecordy in the Aagast issue of his joarnal, saw fit to comment
upon it as follows :

Dr. William Warren Potter, of Buffalo, appears in the Medical New8
with a paper with this caption, Asepsis and Antisepsis as Applied in
the Lying-in Chamber, in which the following paragraphs appear :

Here are a few simple propositions about which there can be, or at
least ought to be, no dispute : 1 . Let us begin by making the patient
as nearly clean as it is possible for soap and water to accomplish. 2.



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 2 of 78)