15omplimonts of C. Frank Lydston. TZEECIE] Prophylaxis#Treatment of Puerperal Septaemia -AND THE- puerperal inflammations. BY G. FRANK LYDSTON, M.D., Late Resident Surgeon Charity Hospital and State Emigration Refuge and Hospital, New York City; Lecturer on Genito-Urinary and Venereal Diseases, College of Physicians and Surgeons, Chicago, III. Read before the Chicago Medical Society, May 12, 1884. Chicago, III.: A. M. Wood & Co., Book and Job Printers, 1884. EEEATA. Page 23—Fourth line from top of the second column: for 1 to 5,000, read 1 to 500. Page 25—Third line from bottom of second column: for irritation, read irrigation. The Prophylaxis & Treatment of Puerperal Septaemia and the Puerperal Inflammations. By G. FRANK LYDSTON, M.D., Late Resident Surgeon Charity and State Emigrant Hospitals, N. Y., Lecturer on Surgical Diseases of the Genito-Urinary Organs, College of Physicians and Surgeons, Chicago. Among the most recent topics which have excited the interest of the medical profession in the east, and especially in New York city, is the prevention and treatment of puerperal fever. In the New York Academy of Medicine, and the New York County Medical Society in particular, the subject has been discussed with great vigor, the question of antiseptic midwifery receiv- ing unusual attention. The admirably written essays upon the subject pre- sented by Drs. Thomas and Garrigues, the one at the Academy and the other ai me County Society, are familiar to all who have watched the columns of the New York Medical Record for the past few weeks, and have ere this become incorporated with the medi- cal knowledge of a large number of the profession, who naturally enough are inclined to follow the guid- ance of those so well qualified to speak as the gentlemen mentioned. In the discussions following the reading of the papers the authors were ably seconded by some of the physicians present, but as stoutly opposed by others. Now while agreeing in the main with those gentlemen who en- dorse the conclusions offered. by Thomas and Garrigues, there are some points in which I am inclined to differ with them decidedly, and against which I feel it incumbent upon me to raise the humble voice of a general practitioner in protest. I am encour- aged in this opposition chiefly because I am personally familiar with the data from which many of the conclusions arrived at by the essayists and their supporters were drawn, more particu- larly in the case of the views expressed by Dr. Garrigues. In presenting the subject of puer- peral fever, I shall endeavor to dem- onstrate the apparent sources of fal- lacy in the paper read by Garrigues especially, while at the same time en- deavoring to present the deductions drawn from a moderate amount of personal experience and observation. As an introduction to the discussion of a disease it is always well to con- sider its nature; hence it might be advisable to ask, ‘ ‘ What is puerperal fever ? ” Now if I were asked what in my estimation is the most difficult problem in medicine, I should be dis- posed to answer “to define puerperal fever. ” One would but need to glance at the descriptions of the disease given by some of our eminent obstetrical authorities to be convinced of the truth of such a statement. Leish- man’s description of the affection 2 LYDSTON—PUERPERAL PROPHYLAXIS, ETC. would perhaps be a fair sample of these.* Hervieux defined puerperal fever as a multiplicity of affections produced by puerperal poison. Lusk in his recent work upon midwifery, de- fines it as “an infectious disease, due as a rule to the septic inoculation of the wounds which result from the sep- aration of the decidua and the pas- sage of the child through the genital canal. ”f How widely differ- ent are these definitions! The puerperal fever of Hervieux is “a multiplicity of affections; ” that of Lusk described ten years later, is “ an infectious dis- ease.” Both of these authorities, how- ever, ascribe the disease or diseases to essentially the same cause, i. e., the absorption of a poison into the blood; but with one it is a “septic” and the other a “puerperal” poison. It would seem that although the more recent of these definitions is the more accur- ate as to the materies morbi which gives rise to such serious results in the puerpera, it is far behind the earlier definition in the matter of classification. The idea of a specific cause of puerperal fever is fast losing ground, and will doubtless some day disappear entirely. It is to be hoped that with it there will also disappear the belief in a febrile disease peculiar to puerperal women, which is prevalent in some quarters. As Barker has said, “the gist of the matter stripped of its superfluous and obscuring elements lies in the inquiry whether there be a disease which attacks puerperal women, and only puerperal women.”* He believes that there is such a disease, due to a specific puer- peral poison, f But in spite of the opinion of so eminent an author- ity, I venture to make the assertion that puerperal fever as an entity does not, and never did, exist; and be- ing so firmly convinced of its truth, I can see no reason for retaining the obstetrical nomenclature which admits its existence. ✓ Such modern terms as “metria” and “septa?mia” are no better, however, if applied to the puerperal febrile conditions taken col- lectively. ' '' To ascribe the low asthenic fever, the various inflammatory affections of the important organs of the pelvis and their various tissue investments, and the general peritonitis which follow labor in different cases, to a common cause, is, in my estimation, unwise and far from being the true explana- tion of their etiology. I make this assertion irrespective of whether “septic” or specific “puerperal” in- fection be the assumed common cause. When we began to understand that the poison which is operative in the causation of certain morbid puerperal conditions might be ordinary septic products of organic decomposition in- stead of specific “puerperal” poison, wTe made a great stride in the proper direction ; but when we ascribe all of the puerperal febrile states to this as a common cause we make a mis- * Leishraan’s System of Midwifery. Ed. by Parry, t Lusk—Science and Art of Midwifery. * Medical Kecord, Feb. 16, 1884. t Ibid. LYDSTOX—PUERPERAL PROPHYLAXIS, ETC. 3 take which nearly nullifies the advance- ment gained. To assume that diseases which may occur from numerous and most di- verse causes in the non-puerperal female become suddenly specific in the puerpera, and traceable to one common cause, viz.: “septic” or “puerperal” infection would appear very illogical. Inflammations for ex- ample, which may occur in healthy women from very slight exciting causes involving exposure or traumatism, are not likely to be deterred from attack- ing the puerperal female whose con- stitution and local conditions both invite their occurrence. In making this statement, it is not denied that these same general and local condi- tions favor the production and absorp- tion of septic materials ; but on the contrary, it is admitted that they are peculiarly favorable to such absorp- tion. To enumerate them all would be but to repeat many facts which have been insisted upon so often and by so many who are much better qualified to speak upon the subject than my- self, that it would be an act of super- erogation upon my part to attempt it. The result of the discovery of the fact that septic absorption is a promi- nent element in certain puerperal dis- orders has been a powerful tendency to ascribe every little disturbance to it, and as I have already intimated, to overlook certain of the ordinary causes of disease. This is indeed fallacious reasoning, for, as Barker has said, “ no one has yet maintained that the process of parturition and the puer- peral state exempt a woman from those causes which induce local in- flammations in the non-puerperal, or will deny that the process of parturi- tion and other attendant conditions besides the absorption of septic poison, may he the efficient cause of local in- flammation.” He also states it as his opinion that in private practice where there is no epidemic influence, twenty cases of local inflammation due to such causes will be met with where one will be found due to septic absorption. * Per- haps this latter statement is a slight exaggeration, but it is certainly ap- proximately borne out in practice, which is, perhaps, peculiar when all the circumstances favorable to septte- mia are taken into consideration. Now, while inclined to accept Barker’s statements in the main, I do not wish to be understood as advanc- ing any arguments in favor of ignor- ing the danger of septemia, but simply as offering a protest against what for convenience sake might be termed the septophobia, prevalent in some quar- ters. Having defined my position as mid- way between the two extremes of practice, I may venture to allude to a few of the points predisposing to puer- peral septemia, which so far as I am aware, have not been very strongly emphasized. During intra-uterine life the circu- lation of the mother and that of the child are in most intimate relation, the nutritive functions of the latter * N. Y. Medical Record, Feb. 16tli, 1884. 4 L YDSTOX—PUERPERAL PROPHYLAXIS, ETC. being entirely dependent upon ma- terials derived from the blood of the former. As a necessary consequence of this arrangement, there is a constant in- terchange of nutritive and waste materials between the two vascular systems through the medium of the placenta. The nutritive material tak- en to the placenta is far in excess of the waste materials returned there- from, this being a physiological ne- cessity. In the process of osmosis, therefore, which governs this interchange of material, the direction of the fluids is chiefly toward the child. At birth, however, all this is changed, and there is no longer osmosis in the< di- rection of the uterine cavity, but on the contrary, a decided tendency of the fluids contained therein, and the nutritive juices of the uterine tissue, toward the maternal circulation. The afferent current is checked, but the lymphatics and veins are now more active than ever, as it is mainly through them that the retrograde metamorphosis of tissue, which is the essence of physiological uterine involution, is accomplished ; or in other words, their function is to remove those nutritive materials, which, by the removal of the foetus, have been rendered unnecessary. That a large amount of waste ma- terial is thus removed is evidenced by the peculiar characters of the colos- trum. This, rather than the patulous con- dition of the uterine sinuses per se, is the most important physiological circumstance favoring septic absorp- tion, tor with the products of retrograde metamorphosis of tissue, we are likely to have absorbed the products of putrefactive changes, should such by any mischance occur. The probability of a small amount of morbid but not necessarily injuri- ous material becoming absorbed in a large proportion of cases is very great, and indeed some of our most experienced obstetricians have lately ascribed the so-called “milk-fever” to this cause. This would agree very well with the views of those who believe with Lusk* that round micrococci are the necessary causal element of true sep- tic fever. For my own part I incline to the belief that the ‘ ‘ milk-fever ” is simply due to the hyper-activity of the nutri- tive functions resulting from the sudden introduction of an excessive amount of nutritive material into the circulation. It will lie observed that the fever lasts only until the excess of material has had time for elimination, chiefly through the selective action of the mammary glands. Of course it must lie admitted that if products of putrefaction be also introduced, the rise of temperature and danger of eventuation in septi- cemia will be proportionately in- creased. “ Milk-fever ” is a usual concomi- tant of child-bed, but varies in prominence in different cases. When- * Op Cit. L YDS TON—PUERPERAL PROPHYLAXIS, ETC. 5 ever the temperature rises much above 101° or 102° F., especially if the lochia be abnormal, septic com- plications should be suspected, and in general too much dependence must not be placed upon the state of the mammary gland as an explanation of the febrile phenomena. It may be observed by anyone who has given the subject much attention that pale, weak, amende women are most liable to develop septaemia, while more robust women will quite likely resist septic absorption, and if sick at all are most likely to be attacked by local inflammation of some variety. It needs but a glance at the clinical characters of a typical case of each to determine a wide difference between them, a difference too which is due to the fact that the two forms depend upon widely different causes, in spite of the efforts of some authorities to throw the responsibility of both upon one common cause, viz, “septic” absorption. Surely the origo mail in the flrst case cannot be that of the second. Here we have, on the one hand, a puerperal woman w ho on the third day after conflnement has been taken with fever, with or without rigor, the fever becoming continuous, with more or less marked remissions, unattended with any discomfort whatever, unless perhaps a feeling of exhaustion, and finally merging into a typhoid condi- tion, with perhaps diarrhea, terminat- ing in death; and upon the other hand, an affection arising sometimes within a few’ hours after labor, char- acterized by abdominal or pelvic pain of frequently great intensity, great tenderness over the region involved, sthenic fever of perhaps moderate in- tensity, with local manifestations of an inflammation, and perhaps fol- lowed by suppuration, but the case on the whole warranting a moderately favorable prognosis. Quite a decided difference between the two, yet they are both included by many under the head of “ puerperal fever.” Cases are of course frequently seen in which both affections are blended, so that it is hard to say whether the sephemia is primary and the inflam- mation secondary, or the reverse, or whether they are simultaneous in their onset, though independent of one another in their pathological re- lations. For my own part, I believe any of these sequences to be possible. It might* be said in explanation of the occurrence of septaemia in one woman, while another, more robust, escapes that disease but falls a victim to pelvic inflammation, that the former is of feeble resisting power and incapable of withstanding toxic infection, while the latter, being plethoric, is not so susceptible to toxic influences, but is markedly pre- disposed to inflammation. There is, however, another marked difference between these women, for while one is well nourished and her tissues do not want for an abundance of nutritive pabulum, the other is de- bilitated and her tissues fairly crave for supplies of new material, she be- ing practically a huge sponge, ready 6 LYDSTOX—PUERPERAL PROPHYLAXIS, ETC. for the absorption of any materials of an organic nature which may be brought in contact with absorptive surfaces, providing such materials be in a condition suitable for absorption. Now this is precisely the process which takes place in the uterine cavity, the osmotic current being especially strong, and containing not only ma- terial which is nutritive, but also that which is toxic. Conditions of debility favor un- healthy and readily putrescible secre- tions, which is another strong causal element of septamiia in women whose health is below par. We will accept the statement that quite a large number of cases of fe- brile disturbance following labor, are septic in their origin, and inquire as to the influence of bacteria in their causation. I am inclined to believe that septamiia may occur from the ab- sorption of fluid from which bacteria are absent, but I am nevertheless of the opinion that bacteria are the origin of such cases of septamiia, for in the absence of such organisms no putre- faction is possible. Sepsin, the principle isolated by Bergman and Smeideberg from putre- fying fluids from which bacteria have been removed by filtration, will, when introduced into the blood, pro- duce septemia, but bacteria were originally essential to the production of the sepsin. Sepsin, in its results, differs not at all from snake virus, and operates precisely like the latter in that its de- structiveness depends in a great measure upon local and constitutional conditions in the affected individual. In the production of that phase of septic intoxication known as pyaemia, and which is but one grade of septi- cemia, bacteria must necessarily be present. In certain instances of fe- brile attacks following childbirth, it would seem probable that we have simply a traumatic fever. As the latest theories regard- ing traumatic fever assume that it is septic in origin, it might nat- urally seem to be included under septsemia, but I hold the opinion that traumatic fever, while often due to septic absorption, may be due to nervous influences. It is a well-known fact that shock is often followed by fever from excessive re- action, and this is, in my estimation, precisely what we have in certain im- pressible females following childbirth, i.e., traumatic fever resulting from nutritive disturbances, due to excess- ive reaction following nervous de- pression, particularly of the sympa- thetic system, from shock'. Many of the cases of fever following instru- mental labors might perhaps be ex- plained in this way. Obviously, septamiia might follow the traumatic fever quite readily, in- asmuch as any febrile disorder in the puerpera renders her peculiarly liable to septremia. This will be found true in cases affected by malaria, in hospi- tal practice especially, and may explain the confusion that sometimes arises in the differentiation of malarial fever in the puerpera from septic infection. LYDSTOX—PUERPERAL PROPHYLAXIS, ETC. 7 In certain cases of septic infection following labor, we have abscesses and diffuse suppurations resulting in va- rious situations, and sometimes the characteristic curve which with other phenomena, constitute the symptoms of the disease termed ‘ ‘pyaemia, ” and dif- fering little, if any, from the pyaemia following surgical operations or inju- ries. (1 have noticed, however, in the few cases I have seen, that the char- acteristic temperature curve is excep- tional. This probably arises from the fact that the peculiar physiologi- cal condition of the woman, particu- larly as regards the secretion of milk, interferes to a certain extent with the typical curve of the “ pyaemic ” fever.) This form of puerperal septaemia is sometimes very chronic. I recall an instance occurring in the New York State Emigration Hospi- tal, in which a woman developed sep- tamiia with resultant gluteal abscess that lasted for over two months. Upon autopsy secondary suppurative processes were found in the liver and kidneys. I wish to say in this con- nection that I am unable to see any valid reason for our adherence to the term “pyaemia” under any circum- stances, as it is a misnomer, and as such should not be retained, unless perhaps with the qualification that it is but a phase of septaemia. The causal element of the phases of dis- ease usually termed respectively pyae- mia and septicaemia is the same, viz., the absorption of septic matter. The essential difference between the two lies in the fact that in one we have the formation of thrombi which contain micrococci, and which become de- tached, enter the circulation, and pass along until they become lodged in some tissue or organ, where they form new foci for suppurative inflam- mation, while in the other no thrombi are formed, or if formed, become so rapidly and thoroughly disintegrated that secondary suppurations do not result. Virchow believes that a se- vere case of septaemia implies a con- tinued formation and absorption of septic poison, but this is obviously not always the case, for in certain in- stances the septin acts like the venom of serpents—a very small quantity apparently sufficing to cause fatal dis- organization of the blood. This is illustrated in certain cases of septae- mia following dissection wounds. In such instances the rapid disorganiza- tion of the blood prevents the forma- tion of thrombi, and consequently metastatic abscesses cannot occur. In a general way it may be said that the formation or non-formation of thrombi depend upon the intensity of the in- fection and the local and constitu- tional conditions present. The pecu- liar condition of the blood of the pu- erperal woman probably has much to do with the non-formation of metas- tatic abscesses which, as we all know, are quite exceptionally seen in the puerpera. Such abscesses might more often occur, however, were not the patients so speedily destroyed by the intense infection characteristic of pu- erperal septaemia. As for the symp- toms which are generally assumed to 8 LYDSTOX—PUERPERAL PROPHYLAXIS, ETC. be characteristic of “pyeemia,” they are simply those which we might nat- urally expect from the formation of pus under other circumstances; viz., chills, febrile movement, and perhaps sweating, or practically hectic fever, the severity of which depends mainly upon the constitutional condition of the patient, the extent of the suppu- rative process, and the importance of the organ involved.* From what has been said I think it may be seen that I recognize the im- portant bearing of septic absorption upon the production of puerperal fever, preferring however to omit the latter term from our classification. Thomas is among those who go to the extreme of attributing all puerperal disorders to the absorption of septic poison. According to him, “it mat- ters not whether the disease be a phlebitis, cellulitis, lymphangitis, or peritonitis—the essence of the disor- der is the absorption of poison into the blood of the puerperal woman through some solution of continuity in the genital tract. ”f Such an asser- tion is certainly too sweeping; for who of any experience but will admit that exposure and the effects of tram matism per se will account for many cases of inflammatory trouble follow- ing labor? It hardly seems possible that so thorough a practitioner as Thomas would make such a state- ment. Such however is the liberty ac- corded to great men, who never want for followers wherever they may lead. Phlebitis following labor and giving rise to the disease known as phlegmasia dolens, may result from trauma, especially if exposure be su- peradded, or it may arise from simple thrombosis occurring independently of bacteria or septic processes. In the same manner cellulitis may arise. There is necessarily, especially in pro- tracted labors, more or less bruising and disturbance of the circulation of the tissues and organs of the pelvis, and a “locus minoris resistientiee ” being thus afforded; and the woman being especially susceptible to cold and de- pressing influences of all kinds, it re- mains but for an exposure to a draught of air to light up an inflammation ot the uterus constituting a metritis, or more probably of the surrounding se- rous or cellular tissues constituting a pelvi peritonitis or cellulitis. That causes, much slighter than labor, will produce pelvic inflammation will be readily appreciated by any one who has had an experience similar to my own, in lighting up a severe cellulitis by the simple passage of a sound into the non-pregnant uterus. In the event of the pelvic peritoneum becoming in- volved, simple extension may result in a rapidly fatal general peritonitis. In these instances of puerperal in- flammation, septsemia, if it occurs at all, is secondary to, or a complication of, the inflammatory affection. In the same way, septamiia may precede the local inflammation, which occurs as a complication, but may be due *In an article upon the relations of pyaemia to sep- ticaemia in the Westebn Medical Repoktbk for July, 1883, I have fully presented my views upon this subject. tPaper read before the New York Academy of Med- icine Nov. 6,1883. LYDSTON—PUERPERAL PROPHYLAXIS, ETC. 9 either to the septic affection per se, or to other causes. I will not undertake to give a de- tailed description of all the diseases to which the puerpera is liable, but in order to direct attention to what Her- vieux terms their “multiplicity,” and to illustrate the probably fallacious reasoning of those who affirm that septicaemia is the term by which they should collectively be designated, I will present Parry’s excellent classi- fication of those puerperal disor- ders whose principal feature consists in fever with its various concomi- tants.* Three classes are given, as follows : I “Local inflamma tony diseases.— a. Metritis, b. Pelvic cellulitis, c. Pelvic peritonitis, d. General peri- tonitis. II. “Septic diseases.—a. Pyaemia and septicaemia, b. Diphtheria of wounds, c. Erysipelas of the geni- tals and internal organs. III. “Idiopathic fevers in the pu- erperal female.” The author of this classification frankly admits that it is open to criti- cism, being rather too dogmatic in the present state of our knowledge of the subject. While willing to acknowl- edge that in a large proportion of cases such an arbitrary division is impossible, I still entertain the belief that it is practicable sufficiently often to enable us to recognize the existence in different cases, of each and every one of the affections named. The exr planation of the confusion surround- ing’ the classification of the puerperal diseases lies in the simple fact that in any given case septic absorption may occur either primarily or secondarily, being on the one hand the essence of the disease, and upon the other merely a complication. There are a few modifications of Parry’s classification which might be suggested as enhancing its accuracy. To the first class, or local inflamma- tions, may be added the “dissecting metritis,” so thoroughly studied by Garrigues,* and phlegmasia dolens. Class II should be qualified by the statement that in certain instances the local inflammations are septic in character, and diphtheria of puerperal wounds and erysipelas should be classed as specific; indeed these two affections, with the idiopathic fevers, are the only puerperal disorders that can be properly called specific. Pyaemia should be omitted al- together from the classification as a distinct affection, as it is simply a septamiia with secondary suppura- tions. Parry has himself, ascribed the difficulty of classifying the puerperal affections to the fact that ‘4 all may be attended by or produce the symptoms of purulent or septic infection.” He also recognizes a marked difference between the septic and simple forms of puerperal peritonitis. There is a simple explanation of the marked clinical difference in the two forms ♦American Journal of Medical Sciences, Jan., 1875, and Leishman’s System of Midwifery. ♦American Journal of Obstetrics. 1883. 10 L YDS TON—PUERPERAL PROPHYLAXIS, ETC. of inflammation, and which does not imply any pathological difference be- tween them, which Parry does not give, and that is, that the exhaustion of the vital powers by a complicating septic infection is amply sufficient to account for the asthenic character of so-called septic peritonitis. The origin of the disease may be precisely the same as in simple peritonitis, and in no sense septic, excepting that sephe- mia occurs as a complication, and in proportion to its severity modifies the serous inflammation. I will not deny that puerperal per- itonitis may be, and undoubtedly often is, septic in origin, but I do most emphatically insist that it is not always so, and that there is not a characteristic “septic” peritonitis. In regard to the belief in the conver- sion of the poisons of the exanthemata into a specific puerperal poison enter- tained by many, I consider it abso- lutely untenable, apparent evidence to the contrary notwithstanding. The idiopathic fevers are, of course, more severe, and necessarily of great gravity in the puerperal female, but this is due to the fact that the genital canal is in a condition which invites inflammation. We all know the danger of exciting intestinal inflammation by the admin- istration of cathartics in the exanthe- mata, and it is easy to appreciate the far greater liability to local inflamma- tion which exists when the genital tract is so profoundly disturbed as after labor, particularly if it be at all difficult. The idiopathic fevers, too, vitiate all the secretions, rendering them readily putrescible, and the uterine cavity is consequently a very favorable soil for bacteria and the pro- duction of sepsin. There are, of course, many facts which tend to bear out the belief in the conversion of the poison of one specific disease into that of another, and one writer in particular, has stren- uously advocated the “ unity” of the materies morbi of various diseases.* For my own part I will admit that I have been quite forcibly impressed by the apparent interdependence of the poisons of different diseases. Numer- ous cases might be cited of persons contracting diseases, the most diverse apparently, from exposure to the same atmospheric influences, f One source of confusion doubtless arises from the fact that in many specific diseases septic conditions arise, and such septic conditions present essentially the same phenomena in whatever disease they may exist as a complication Then, too, the type of specific disease of any particular kind may vary greatly, being chiefly dependent upon the constitutional condition and sanitary surroundings of the individual. While discussing the nature of the puerperal diseases in a general way, I wish to make especial mention of diphtheria of puerperal wounds and puerperal erysipelas. Diphtheria of * Dr. G. De Gorrequer Griffith, reprint from Midland Medical Miscellany, and from Glasgow MedicalJournal, 1882. + Vide account of such a case by Dr. L. J. W. Lee in the N. Y. Medical Record, Vol. XXV, No. V, page 84. LYDSTON—PUERPERAL PROPHYLAXIS, ETC. 11 puerperal wounds was first described by Fordyce Barker in 1860. It had not been regarded as a distinct dis- ease prior to that time, Martin, of Berlin, for example, having taught that diphtheritic deposit was the only essential element of puerperal fever, a view which in the light of our more recent observations is, of course, untenable. The disease has received marked attention only within the last fifteen years, and where observed has usually been of the nature of a hospital epide- mic. Parry has described about one hundred cases, with a mortality of twenty-five per cent., which occurred in the Philadelphia hospital between 1870 and 1874, * and this description is about as thorough as any with which I am familiar. Garrigues has given the matter considerable atten- tion within the last two or three years. The disease is not of very great frequency, and in a quite considerable experience, as well as observation of the cases of my friends in hospital and dispensary practice, I do not re- member to have seen more than two or three well marked cases of the dis- ease. Garrigues, however, asserts that nineteen cases of the disease occurred in the Charity hospital, New York, between October 1st, 1882, to April 1st, 1883. f As contrasted with the six months from October, 1880, to April, 1881, this number of cases is certainly astonishing, as during that time we did not have a sinjrle case of puerperal diphtheria. If Garrigues be correct, the prognosis of the dis- ease must have improved wonderfully since Parry’s excellent description was written, for certainly the statis- tics of the Charity hospital from April. 1882, to April, 1883, do not indicate the occurrence of any epide- mic of so fatal a disease during the year. Parry is rather non-committal as to the nature of the disease, leaning rather toward the theory that it is pri- marily a local septic inflammation, but adds “that there is some reason for believing it to be parasitic in origin.” Now this latter is rather more than a possibility, it is to my mind a strong probability; for there would seem to be very good grounds for the belief that diphtheria of puerperal wounds is pre- cisely what its name implies, viz.: true diphtheritic infection, the local mani- festations of which are restricted to wounds of the genital tract. There is surely very little in the clinical history and morbid appearance of the disease to refute this assumption. There is, to be sure, a far greater liability to secondary sepsis than in ordinary diphtheria, but that might nat- urally be expected from the local and constitutional conditions pres- ent. Erysipelas in the puerpera seems to be characterized by its especial tend- ency to invade the peritoneum, and to be attended by septfemia. The “puer- peral fever” resulting from infection with erysipelatous poison, is simply i an erysipelas attacking the genital *Phila. Med. Times, Jan., 1875. IN. Y. Medical Record, Dec. 20, 1883, page 704. 12 LYDSTON—PUERPERAL PROPHYLAXIS, ETC. lesions resulting from parturition, with frequently an internal erysipelas involving the peritoneum. The disease, however, does not necessarily attack the parturient tract, but may make itself manifest in the face or other locality remote from the genitals. I have seen cutaneous facial erysipelas and phlegmonous erysipelas of the leg occur in the puerpera and run their course as in the non-puerperal subject, the con- stitutional symptoms, however, being more profoundly asthenic than in the latter. Of two cases observed in which labor came on during an attack of erysipelas, one died and the other re- covered. The first case was one which was sent up to Charity hospital from Bellevue by boat, upon a cold February day, four hours after an in- strumental delivery. She was put into one of the erysipelas wards with her baby, and as I was not notified I did not see her until several hours after her admission. No binder had been applied by the surgeon who con- fined her, nor had she received any attention which was proper in such a case. She developed the most acute case of peritonitis I have ever seen, and died in twenty-four hours, a martyr to obstetrical carelessness. The second case was one which I saw within a few weeks past, for my friend, Dr. Landis, of this city. In spite of unusual obstacles, this woman recovered, although upon the third day she developed tympanites; the lochia became fetid, and the tempera- ture rose nearly to 104° F. A full dose of calomel and soda with fre- quent hot carbolized vaginal injections brought the temperature down to 101° by the next morning, and after that recovery was rapid. Septicaemia has occurred in puer- peral erysipelas in my experience, be- ing apparently superinduced by the peculiar condition of the blood and secretions resulting from the ery- sipelas, but aside from this pecu- liar predisposition to toxaemia, there is nothing peculiar about the dis- ease. The causation of puerperal erysip- elas is usually alleged to be infection with the specific poison of the disease, and most generally through the me- dium of unclean instruments, dress- ings, or the hands of nurses and physicians. The possibility of the disease being transmitted by miasmatic contagion is also entertained by some. Now, while admitting that contagion by either of these methods is possible, and believing that I have seen in- stances of it, I still think that it is rarely possible to trace the source of contagion. Cases of erysipelas are prone to spring up in hospital wards, or for that matter in private practice, under the most diverse circumstances, and in such a manner as seems almost inexplicable in the light of the modern germ theory of disease. Very often we can trace the disease to no other cause than cold and ex- posure. There seems in hospitals to be an atmospheric influence constantly LYDSTON—PUERPERAL PROPHYLAXIS, ETC. 13 present which may develop erysipelas in certain patients, while others, ap- parently equally exposed, escape it. There is some mysterious element in the way of constitutional tendencies, which remains to be explained. As for direct contagion, if my own ob- servations are any criterion, it must be quite exceptional. During my term of service at the New York Charity Hospital, I had at one time for several months, an ob- stetrical ward, simultaneously with a general surgical service in which numerous operative cases occurred, and two ophthalmic wards in which there were from time to time quite a number of cases of purulent oph- thalmia. Nothing more than ordinary caution and cleanliness were observed, yet at no time did an out! weak of erysipelas occur in the midwifery ward, which, to make matters more favorable for contagion, was situated in the very center of the main hospital building. Cases of erysipelas were plentiful in the hospital pavilions at the time, and occasionally appeared in the gen- eral wards, although such cases rarely arose in the hospital, most of them being sent from the city. The special maternity wards, half a mile away from the main building, gave no more favorable showing than that in the hospital proper. On the other hand, I have noticed outbreaks of erysipelas from simple exposure to cold and dampness, ap- parently independent of possible con- tagion. Thus, at the New York State Emigration Hospital, I noted periodical outbreaks of erysipelas and acute rheumatism, which attacked both women and children in the con- valescent ward, and which, upon careful investigation, proved to be co- incident with careless scrubbing of the floors. Dr. E. G. Maupin, at that time physician-in-chief of the institution, informed me that he had noticed the same circumstance. Upon substituting dry cleaning the out- breaks ceased. In view of the modern antiseptic system of midwifery in vogue, espe- cially in hospital practice, it may seem rather a bold move on the part of one who is willing to admit the im- portance of sepsis as a causal element of puerperal disease, to advocate the non-interference plan of management of labor, and to suggest other and more simple means of preventing septamiia and allied diseases than those advocated by such eminent authorities as Thomas and Garrigues; but as careful observation tends to sustain me in my position, I shall not hesitate to affirm that the bichloride of mercury, antiseptic pads and injec- tions, with bare walls, floors, and other surroundings, characteristic of small pox and typhus fever wards, are not a necessity in the lying-in chamber. Before entering upon the details of the prophylaxis of the puerperal dis- eases, I wish to define my position in regard to antiseptic midwifery. I am not opposed to antisepsis in the true sense of the word, but I wish to place 14 LYDSTOX—PUERPERAL PROPHYLAXIS, ETC. myself among those who protest against the views of such obstetricians as believe in dressing the genitals after labor ‘ ‘ with the same care as in dressing a wound after a capital op- eration,” a procedure advocated by Garrigues.* Antiseptics are well enough in their way, but I think that it will be found that any application of them which is attended by compli- cated manipulations, or even frequent disturbance of the patient, is not pro- ductive of the best results in the lying-in room. I am perfectly willing to admit that non-interference can rarely be so absolute in hospitals as in private practice, at least under the present system of hospital construc- tion and management. This is to be deplored as a necessary evil. In a recent article, Dr. Garriguesf has described a very elaborate system of antisepsis now used at the New York Maternity hospital, which im- plies all the details that could possibly be devised, including prophylactic in- jections before, during, and after labor, with an antiseptic pad over the* vulva. A series of ninety-seven cases is cited, without a death, and with but six cases of illness, comprising pelvic inflammations, metritis, and eclampsia, without a single case of septaania.(Y) Before passing upon the merits of this report, I will quote verbatim Dr. Garrigues’ accurate de- scription of the New York Maternity service, in the wards of which he has so thoroughly tested (?) his system of rigid antisepsis : “ A hospital is the true place in which to try the value of an antiseptic, and I doubt there are many places which present the condi- tions for a more crucial test than our New York Maternity hospital, an in- stitution which, properly speaking, does not exist at all, except in so far that it has a medical board of its own, while in every other respect it is only a department of Charity hospital — a large general hospital in which all diseases, medical and surgical, are treated. Seventy women or more, expecting to be confined within a pe- riod varying from four months to a few days, occupy two ‘waiting wards. ’ When labor-pains set in, they are transferred to the ‘pavilions,’ two small wooden buildings, each of which contains two large and two small wards, but one of the large and two of the small being used as dormi- tories for the pupils of the Training School for Nurses. As soon as feas- ible, the patients are therefore returned to the main building, and placed in the so-called £ convalescent ward,’ which accommodates twenty- four patients. When at times there reigned much disease in the pavilions, the whole service was transferred to a ward in the main building, where the results became still worse, (?) until the pavilions had been disinfected, and could be occupied again.”* The ar- rangement thus described by Gar- rigues, has existed since December, 18S0, prior to which date the regular maternity service was located in sev- *N. Y. Medical Record, Dec. 29th, 1883. flbid. *N. Y. Medical Record, Dec. 29th, ’83, page 703. LYDSTOX—PUERPERAL PROPHYLAXIS, ETC. 15 eral cottages situated about half a mile north of the hospital. In Octo- ber and November of 1880, I was in charge of the waiting wards, in which all the women awaiting confinement were kept, irrespective of their phys- ical condition. (Cases of severe syphilis and certain incurables ex- cepted.) In order to improve the records of the maternity service proper, all cases in which complica- tions were apprehended, were retained in the waiting wards ; thus, cases suffering with syphilis, Bright’s dis- ease, malaria, phthisis, etc., were delivered by the physicians in charge of the waiting wards, who always had in addition a large general service. During the months in question, I had the largest venereal service in the hospital, in which surgical operations were frequent, and two large ophthal- mic wards, in which cases of purulent ophthalmia existed almost constantly. When I took the service, there was one case of puerperal septsemia in one of the waiting wards, the only one which had occurred in the service of Dr. Harrison, who preceded me, and this case died in a few days, being mori- bund when I first saw her. The rules of the hospital required that the women be sent by the ambulance to the maternity proper as soon as labor set in, but curiously enough, I found that the women strenuously objected to transference to maternity,preferring to remain at the hospital rather than incur the risk of dying with u the fever''’ at modernity. How frequently they would conceal their pains until the head was on the perinseum and it was too late to send them up the island, can be answered by any of the physicians or nurses who were ever employed in the waiting wards. This fact alone should be sufficient evidence to prove that the record of the cases delivered at the main hos- pital, was at least as clean as that of maternity, but I can demonstrate that it was even better, especially when it is taken into consideration that the cases in the waiting wards were se- lected because complications were anticipated. I must state at this point, however, that the visiting staff seldom entered the waiting wards, hence the statements made by some of them relative to the comparative statistics of the two services might quite naturally be expected to be in- accurate. Thus the statement was made by one gentleman, some time ago, that the improved mortality rate consequent upon removal of the mid- wifery service and waiting wards to the pavilions was due to the fact that before such removal, the women had been kept in the waiting wards of the main hospital, prior to their transfer- ence to maternity, until seeds of dis- ease had been sown in their systems, which developed puerperal fever as soon as labor had occurred. This looked very pretty upon paper, but as I have elsewhere shown,* the fact of the matter was that the mortality rate of the cases actually confined in the main hospital, had always been *Vide Letter to the New York Medical Record Dec. ‘23, 1882. 16 L YDS TON—PUERPERAL PROPHYLAXIS\ ETC. better than those of maternity. This fact alone is sufficient to settle such an argument, and as I will endeavor to show, there were other and very much more logical reasons for the change for the better. The maternity service was conduct- ed by a staff of resident and assistant physicians who served for six months continuously to obviate frequent changes and the consequent great danger (?) of importation of “germs.” Prior to assuming charge of the ser- vice, each physician was required to “disinfect” by means of a carbolized bath and several days’ absence from the hospital, and during the term of service was compelled to keep out of the hospital wards, and as nearly out of sight of the dead-house and surgi- cal wards as possible. The nurses were required to go through the same routine. The patients were syringed and antisepticised from morning till night, from the time labor set in until they were transferred to the conval- escent ward. Should the merest sus- picion exist of a piece of placenta or shred of membrane having been left in the womb at the termination of labor, a tour of exploration and vig- orous scraping was immediately insti- tuted. The placenta was usually ex- pressed by Crede’s method, and alto- gether dame Nature had about as much chance as a feather in a cyclone. At the main hospital the physician could not by any possibility prepare for his duties in the elaborate manner above described, for he invariably had in addition a large general ser- vice; and even should such a course have been practicable, its benefits (?) would have been neutralized by his constant exposure to contamination in the general wards. The nurses were quite frequently changed and lived in the main hospital. The cases were selected because of their sup- posed liability to puerperal complica tions (excepting those who voluntarily remained with us), and when confined were let alone as far as possible under the rules of the hospital; (and for my own part I wished they might have been disturbed even less.) According to the views of Garrigues, as implied in his article on antisepsis, already mentioned, we lesser lights in charge of the waiting wards, ought to have lost all of our cases; but unfortu- nately for theory we not only did not lose them all, but our records were better than those of maternity, and we were always ready to deliver all the women whenever, as was fre- quently the case, our septophobic friends had their hands so full of sep- temia that to be delivered at maternity meant death in the eyes of the anxious women in the waiting wards. Two such instances occurred during Octo- ber and November, 1880, the service on the last occasion remaining at the hospital permanently. Statistics are often of advantage, and it behooves one of positive opin- ions to have a few figures on hand. 1 have a few which I may ask to be allowed to present. They do not cor- respond exactly with those given by Dr. Garrigues, but I am prepared L YDS TON—PUERPERAL PROPHYLAXIS, ETC. 17 to substantiate their correctness. From August, 1880, to December, 1880, there were confined in mater- nity proper, titty selected cases. Of these five, or ten per cent., died of puerperal metritis, septemia or peri- tonitis. In the waiting wards during the same months, there were confined seventy-two cases, also selected; but for their peculiar liability to compli- cations, the exceptions being those who dreaded the perils of maternity, and concealed their pains until too late for transference. Of these six died, only three of which, or about I per cent., died of septic infection, the remainder dying respectively of ne- phritis, cardiac disease, and meningi- tis (the latter cases showing conclu- sively the unfavorable character of our cases as a class). During October and November I delivered in the waiting wards alone twenty-five women, of whom but one died, and she of extensive heart le- sions and pulmonary oedema. An- other death occurred, but that was the case of septemia before mentioned as having been left over from the pre- ceding service. During these same months, thirty out of the fifty cases cited from the maternity records, were delivered at maternity proper, and of tin ise the five fatal cases mentioned formed a part, making a mortality for the two months of 16$ per cent, from septicemia at the maternity, and only four per cent., and that from cardiac disease, in the main hospital. The statistics published by Garrigues include all cases confined at Charity hospital during the years from 1875 to 1882, and include cases confined in the general and venereal wards, which should not he included at all, as such cases could hardly be a fair criterion of our obstetrical success, being the most unfavorable that could be imag- ined. I will not undertake to