ON 
THE MEANS EMPLOYED 
AT THE 
PRESTON RETREAT 
FOR THE 
Prevention and Treatment 
OF 
PUERPERAL DISEASES. 
BY 
WILLIAM GOODELL, M.D., 
Physician-in-Charge of the Preston Retreat, Clinical Professor of Diseases of 
Women and Children in the Hospital of the University of 
Pennsylvania, etc. 
Extracted from the American Supplement to the “Obstetrical Journal of Great 
Britain and Ireland”!®* July and August, 1871. 
PHILADELPHIA: 
COLLINS, PRINTER. 
1874. PREVENTION AND TREATMENT 
OF 
PUERPERAL DISEASES. 
It was not my purpose to publish the statistics of the Preston 
Retreat until one thousand cases of delivery had been reached. 
But, in view of the fatal epidemic of puerperal fever now pre- 
vailing in Philadelphia and in the city of New York, I have so 
far yielded to the wishes of my friend, the editor of this journal, 
as to give a short account of the precautions taken in this insti- 
tution to guard against the occurrence of puerperal diseases. 
This I am the more emboldened to do, because the peculiar mea- 
sures adopted have apparently made the statistics of this 
institution compare very favorably, not only with those of like 
charities, but also with those of private practice. They have 
also kept its wards free from any epidemic of puerperal fever; 
although, during the past three years there has been more or less 
of this disease in this city, and, within the past two months, a 
number of deaths from this cause have occurred in the immediate 
neighborhood of the building. 
The Preston Retreat is a small lying-in hospital for reputable 
married women. The yearly average has thus far been about 
one hundred labors, but it is now rapidly increasing. It contains 
four wards, each with a capacity of 9153 cubic feet, and each 
furnished with five beds, of which not more than four are gene- 
rally occupied at one time. The ventilation in winter is obtained 
by the escape of the cold and foul air through an old-fashioned 
fireplace, in which a jet of gas is kept constantly burning, and 
by the free admission of pure air, which has been heated in the 
basement bypassing around steam-chests, with large radiating sur- 
faces. In summer, the admission of pure air depends exclusively 4 
Prevention and Treatment of 
upon open doors and windows, and the ventilation is, consequently, 
less perfect than in winter. In the spring and autumn months, 
there are many days in which the temperature is too warm for 
the free admission of heated air, and yet too cold for open win- 
dows. These are, therefore, the two seasons of the year which 
I dread the most, and in which I avoid, as much as possible, 
crowding the wards. 
The wards are used invariably in rotation. By close manage- 
ment, and by crowding walking patients together, one of these 
wards in its turn stands idle for two or three weeks. During this 
time the doors and windows are kept open. Before it is again 
occupied by patients, the walls, floor, wood-work, and furniture— 
all of which are painted—are thoroughly scrubbed with carbolic 
acid soap, and then mopped over with a solution of half a pint of 
carbolic acid (Calvert’s No. 4), to one pail of water. From this 
time until the ward is again vacated, no portion of it, not even 
the floor—unless accidentally soiled—is touched with water. 
The nurses wear such clothing only as can be washed. As 
soon as the inmates of a ward are well enough to take care of 
themselves or of one another, their nurse is relieved from duty. 
She now takes a soap bath, puts on an entirely clean suit of 
clothes, and goes into a ward which has been thoroughly venti- 
lated and cleansed. Before a new batch of patients falls to her 
care, she has had one week or more of rest. I visit the wards 
thrice daily, beginning always with the ward last occupied, and 
with the patient last delivered. Whenever a vaginal examina- 
tion is needed, it is put off until all the other patients have been 
seen. The examining finger is then anointed with an ointment 
containing carbolic acid, and the hands are afterwards washed 
with carbolic acid soap. Post-mortem examinations I never per- 
form. Whenever one is needed, an expert is called in, and re- 
munerated for his services. 
The beds consist of a tick filled with fresh straw and covered 
with an army blanket. After the discharge of a patient, her bed 
is emptied, and the tick, blanket, and bedclothes are boiled in 
water to which a little carbolic acid has been added. Each bed 
is furnished with a feather bolster and pillow, which are exposed 
on slats to the air when not in use. Once a year every bolster 
and pillow-tick in the house is washed, and the feathers baked Puerperal Diseases. 
5 
and “renovated,” as it is technically termed. They also pass 
through the same process whenever soiled, or whenever used by 
a patient whose convalescence has been delayed. 
The patients come chiefly from the poorest classes; but many 
in more comfortable circumstances, with the hope of getting bet- 
ter care, seek admission on account of some difficulty attending 
their former labors. On this account, the proportion of difficult 
labors is much above the average. Those patients who have 
families often put off coming in until labor has actually begun, 
and then leave at the earliest possible moment. Notwithstand- 
ing this, since patients have the privilege of remaining four weeks 
after their delivery, the average stay of each one is sixteen days 
before delivery, and eighteen days after. Every patient, upon 
admission, takes a warm bath, and at least one a week thereafter 
before her delivery. If she exhibits signs of feeble health, she 
is at once put upon the use of quinia, and of the house mixture, 
consisting of two parts of the muriated tincture of iron, with 
three of dilute phosphoric acid. The habitual constipation of 
pregnancy is met by the administration, either in the morning 
of a teaspoonful of pulv. glycyrrhizae comp, of the Prussian phar- 
macopeia; or, at bedtime, of four Lady Webster’s pills (pil. sto- 
machicae). When a more active purge is needed, the pulv. 
jalapse comp., or the pil. cathartic, comp. (U. S. P.) is given. 
Headache and sleeplessness are treated by warm baths, by full 
doses of potassic bromide, and by the above-named medicines, 
when indicated; albuminuria is dealt with in pretty much the 
same way, but always with iron and phosphoric acid. The regu- 
lar diet is plain and wholesome, yet more liberal than is usual in 
charitable institutions. Apart from the frequent use of aperients, 
a relaxed condition of the bowels is promoted by serving table 
syrups at every meal, by fruits—-fresh or dried, according to the 
season—and by all such vegetables as can be eaten raw, viz., 
lettuce, cress, radishes, leeks, onions, tomatoes, cucumbers, and 
cabbages. Of these, in this latitude, an ample supply is obtain- 
able during nine months of the year. 
When a patient falls into labor, she first has her bowels moved 
by an injection, and then takes a warm bath. The bag of waters 
is usually ruptured artificially, and the liquor amnii collected in 
a grocer’s scoop. The second stage of labor is never allowed to 6 
Prevention and Treatment of 
linger; any delay is met by the use, either of the vectis or of 
the forceps. As soon as possible after the birth and the removal 
of the child, the placenta is delivered by Crede’s method. I may 
here remark that the still pulsating cord is first cut, then “ strip- 
ped” of its blood, and as much as possible of its gelatin, and 
finally tied, when it has ceased to bleed, and has become flaccid. 
Neither belly-band nor any kind of dressing is afterwards ap- 
plied, but the cord freely dangles about from the navel. Treated 
in this manner, it dries up without any bad smell, and falls off 
like a ripe fruit, without leaving a raw stump. Out of more than 
five hundred infants treated thus, not one has had a pouting or 
sore navel requiring treatment, and not one has had an umbilical 
hernia. I am also well satisfied that, by dispensing with the 
belly-band, I have had fewer cases of inguinal hernia. Those of 
my readers wdio wish a more detailed account of this method of 
dealing with the cord, can consult the American Journal of Ob- 
stetrics, vol. iii. p. 327. 
Ergot is hardly ever resorted to as an oxytocic; but one tea- 
spoonful of the fluid extract is invariably given as soon as the 
head presses upon the perineum. When the labor is over, the 
perineum is examined, and, if torn, is at once sewed up with 
silver sutures. The patient is now washed clean, and a binder 
and cylindrical compress applied, the latter in the hollow just 
beyond the fundus of the womb. The bedstead on which she 
has been delivered is next wheeled from the Delivery Room to 
a ward and placed along the side of a bed, to which the woman 
now hitches herself over. Contrary to the generally held opin- 
ion that absolute rest after labor is indispensable, in no single 
instance has this muscular exertion apparently brought about a 
flooding. It seems rather to condense still further the uterine 
globe. Very rarely, indeed, has a flooding happened outside of 
the. Delivery Room. However warm the weather, a blanket 
is thrown over the patient, and a foot warmer put to her feet. 
These remain until reaction sets in, and she asks to have them 
removed. A mug of beef-tea made from Liebig’s extract is now 
given, and the child put to the breast as soon as it will take it. 
Thereafter, in a natural convalescence, the woman gets tea, boiled 
eggs, bread and butter, for breakfast; potatoes, and some kind 
of meat for dinner; stewed or fresh fruits, tea, bread and butter, Puerperal Diseases. 
7 
for supper. On the morning following the day of her labor, the 
binder is removed for good, and she slips into a chair while her 
bed is making. This is repeated once or twice a day until the 
fourth or fifth day, when she, if so disposed, gets up and dresses 
herself. No patient quits her bed against her will; yet the force 
of example is so great, that very few care to stay in bed, when 
they see their companions up and about. 
No woman is allowed to suffer from after-pains. Whenever 
these are complained of, one-quarter grain doses of morphia are 
administered every hour until relief is obtained. In stubborn 
cases of after-pains I have found nothing act so promptly as the 
exhibition of ten grains of quinia every six hours, until the ears 
ring. For this valuable suggestion I am indebted to my friend 
Dr. Fordyce Barker. Bed-pans are not employed, except in 
cases of illness, or in cases requiring vaginal injections ; but each 
woman has her own chamber-pot which she uses indifferently, 
either in the sitting or the knee-elbow posture. Every woman 
is required to wash her own person at least once a day, and that 
with carbolic acid soap and a wad of fine oakum, which is at 
once thrown away. Only under very exceptional circumstances 
does the nurse cleanse the patient. Should the lochia become 
offensive, the woman is made to get out of bed and slip into a 
chair three or four times a day. This usually corrects the fetor; 
but if it does not, then and only then is a solution of potassic per- 
manganate thrown up into the vagina. Firmly believing the noz- 
zle of a syringe to be the medium of virus communication from 
patient to patient, I avoid the use of vaginal injections as much as 
possible. For a like reason, the temperature thermometer is not 
habitually used, but only in single cases as an aid to diagnosis. 
Whenever the lochia are offensive, or the pulse is over 90, or 
the thermometer indicates a temperature higher than natural, or 
pelvic pains are complained of, or, in short, whenever any un- 
toward symptom appears, quinia is given in from six to ten-grain 
doses every four hours, until the ears ring. In addition, for ab- 
dominal pains large doses of morphia are given, and the whole 
belly is painted with iodine, and covered with a mush poultice. 
The canonical purge on the third day is dispensed with. A 
patient has usually a movement of the bowels either before, or 
on the day in which she gets up for good. If this does not hap- 8 
Prevention and Treatment of 
pen, she takes four Lady Webster’s pills at bedtime, which then 
act on the morning of the sixth day. As soon after getting up 
as she feels strong enough, she takes a warm bath. 
Thus far I have stated the means adopted at the Preston 
Retreat for the prevention and the treatment of puerperal dis- 
eases. I now purpose to give my reasons for such of them as 
need some explanation. 
But few words are needed to explain why the ordinary cham- 
ber-pots are used, and why patients are made, once or twice a 
day after the first, to get out of bed and slip into a chair. The 
presence of putrescent fluids in the utero-vaginal tract is recog- 
nized by all writers as the great cause of the autogenetic variety 
of puerperal disorders. But the recumbent posture of itself 
fiecessarily tends to detain these poisonous discharges in contact 
with the traumatic lesions of labor. These discharges may also 
be partly imprisoned in the vagina through the swollen condition 
of the more external soft parts, or partly corked up in the uterine 
cavity by the presence in the cervical canal of a putrid clot. In 
such cases detergent vaginal injections are highly recommended. 
But clinically they will be found of limited value; for they cannot 
reach high enough, and do not ordinarily dislodge a large clot 
even when situated low down. True, intra-uterine injections are 
not open to one of these objections; but, apart from their being 
attended at best with some degree of hazard to the patient, the 
operation is too delicate a one to be entrusted to a nurse. Be- 
sides, in hospital practice the nozzle of a syringe—to say nothing 
of the fingers of a nurse—is, I fear,, so often one of the vehicles 
for the transmission of virus, as to make this means of disinfection 
of doubtful propriety. In a local outbreak of fever, especially of 
the diphtheritic form, I should, however, suggest the use, imme- 
diately after labor, of vaginal injections containing the nitrate of 
silver or the persulphate of iron, in quantities large enough to 
sear over the traumatic lesions of labor. Such injections I have 
had no occasion to try, but they ought to inhibit active absorption 
and promote healthy granulation. 
While seeking a substitute for the syringe, my attention was 
directed to the fact that the act of sitting on the ordinary cham- 
ber-pot often forced out putrid shreds or fetid clots, which had 
not been washed away by vaginal injections. This led me to Puerperal Diseases. 
9 
discard, except in cases of positive illness, the use of bed-pans 
or of any other utensil—such as urinals—which can be used by 
a woman when lying on her back. Shortly after making this 
change, I found that, for like reasons, some shrewd and very 
practical writers of the last and the present century, urged an 
early departure from the recumbent posture. Further; a resi- 
dence of some years in the East had taught me that oriental 
women, at least, can with impunity get up and be about a few 
hours after delivery. Influenced by these facts, I decided, cau- 
tiously at first, to introduce into the wards of the Retreat a sys- 
tem of puerperal gymnastics, consisting in no restraint whatever 
as regards the position in bed, and in the daily release from an 
irksome confinement. I was much pleased to find that the mus- 
cular exertion needed for these movements, so far from inducing 
hemorrhage, excited the womb to contraction, and emptied it 
and the vagina of their putrid contents. I can testify that when- 
ever the lochia are offensive, these upright positions, repeated 
several times a day, are excellent deodorants, better in fact than 
any detergent vaginal injections. There is yet another advan- 
tage gained by this plan: it affords, in hospital practice, an ex- 
cellent opportunity for bundling the bed and bedding out of the 
ward, and giving them a much needed airing. In a crowded 
hospital ward the hygienic importance of such repeated disin- 
fection can, hardly be overestimated. At the risk of being called 
an enthusiast, I will go a step further, and hazard the assertion 
that there is a form of puerperal septicemia not necessarily ac- 
companied by putrid lochia—at least not appreciably so—but 
indicated by high temperature, rapid pulse, complete anorexia, 
heavy sweats, and, later, by herpes labialis, which stubbornly 
resists treatment until the patient is made to get out of bed. 
This I have seen often enough, after keeping a woman on her 
back for some pelvic disturbance, to prevent any mistake as to 
the relation of cause and effect. 
Lying-in women are encouraged to get up for good when they 
feel so disposed, because there are, to my mind, strong objections 
to the rigorous maintenance of the recumbent posture. Labor 
is, in general, a strictly physiological process, and there can be no 
sound reason why it should be made to wear the livery of disease. 
Nature teaches this very plainly, for most women wish to get up 10 
Prevention and Treatment of 
long before-their physicians are willing to let them. The fact of 
a woman’s wishing to get up is to me a very good reason why 
she should get up. In the second place: few physicians will 
deny that nothing so relaxes the tone of muscular fibre as a close 
confinement in bed. In my experience a woman ordinarily feels 
stronger on the fifth day than she does on the ninth, if rigor- 
ously kept under quilts and blankets. Once more : the upright 
position not only excites the womb to contract, but, by distribu- 
ting the blood and equalizing the circulation, it actually lessens 
the amount of the lochia and shortens their duration. On the 
other hand, the dorsal decubitus keeps up a passive congestion 
of the womb as a whole, the engorgement of the greatly hyper- 
trophied placental site, and a blood-stasis in the now thickened 
posterior wall—all important factors in hindering the process of 
involution. Again: uterine diseases are hardly known among 
those nations whose women early leave their beds. From pas- 
sages in the writings of the classics, it is evident that among the 
ancient Greeks and Romans, those models of physical strength 
and beauty, the women arose and even bathed in a running 
stream, very shortly after delivery; in some cases on the very 
day. Finally: what is sounder than all theory, a sufficiently 
long and well-sifted experience has proved to me that, by such 
a treatment, convalescence is rendered far more prompt and sure. 
At this result, very unexpected to the multiparous patients of 
the Retreat, they are constantly expressing their surprise. 
The arguments against the customary purge on the second or 
the third day are to my mind very sound. lam well satisfied 
that the “milk fever,” for which it was originally introduced into 
practice, is essentially a myth. Genuine “milk fever” as such 
is a rare complication, and, when present, of no significance what- 
ever. Unless the nipples are chapped or abraded, the engorge- 
ment of the breasts hardly ever leads to abscesses. In proof of 
this assertion; how rarely does mastitis follow stillbirths! In 
the vast majority of cases, the occasional constitutional disturb- 
ance, the chill-and-fever on the third or fourth day—the so-called 
“milk-fever”—is owing to a septic cause, and not to a mammary 
one. True, the breasts are by this time swollen and painful, but 
it is a mere coincidence, and coincidence is here mistaken for 
causation. Purges are, therefore, not only wholly unnecessary, Puerperal Diseases. 
11 
but they disturb the equilibrium, and, what is worse, promote 
the absorption of septic matter. Partly from increasing the 
activity of the absorbents, the hemorrhages of labor are very 
liable to be followed by blood-poisoning. Now, the same result 
may be logically predicated of a depletion in the shape of a 
purge. Were my readers to go over their cases of puerperal 
fever or of other puerperal diseases, I think that they will find 
some of them dating from the day on which a purge had begun 
to act. Is it not more than a mere coincidence that these dis- 
eases attack a woman usually on the third or the fourth day, 
viz., the day of or following the administration of the customary 
purge? Three instances of puerperal peritonitis, two of them 
ending in death, have come to my knowledge, which were refer- 
able as plainly as could be to purgation. In one, the lady was 
slowly but surely mending from the effects of a severe instru- 
mental delivery. For some reason or other she took, in the third 
week, an ordinary dose of citrate of magnesia. This violently 
purged her, and at once brought on a fatal attack of fever. In 
the other two the patients could not have been doing better, 
until they got a dose of castor oil, which was given for no other 
reason than that the authors of our text-books were haunted by 
the bugbear of “milk-fever.” Did space permit, I should like 
to show that this opinion is not shared by myself alone; that 
cases of phlegmasia dolens have been traced to the effects of a 
purge, and that the use of aperients during an epidemic of puer- 
peral fever has been strongly condemned. 
Quinia is given without stint, because, apart from its well- 
known tonic and antiperiodic properties, it possesses others which 
make it, above all remedies, the one best suited for puerperal 
disorders. By lowering high temperature it retards the oxida- 
tion of tissue, and hinders the formation of fibrinous concretions. 
By shortening the excursions of uterine fibres in their alternate 
contractions and expansions, it lessens the diastolic engorgement 
of the womb, diminishes the calibre of uterine bloodvessels, and 
thereby tends to keep their protective coagula from becoming 
loose and soluble. By contracting the placental site it propor- 
tionally limits that area of absorption. By constringing the 
coats of the capillaries, and by its inhibitory power over the 
migration of colorless blood-corpuscles, it either arrests suppu- 12 
Prevention and Treatment of 
rative inflammation or restrains its violence. Finally, it seems 
to exert a positive curative action on the blood in cases of putrid 
or purulent absorption. Clinically, I have found nothing com- 
parable to quinia as well as a prophylactic against puerperal dis- 
orders, as a remedy for them. But it must be given early, fre- 
quently, in large doses, and pushed to a high grade of cinchonism. 
Ergot is a very untrustworthy oxytocic. One never can tell 
beforehand whether it will behave kindly, or run a muck. It is, 
therefore, no favorite with me. The vectis and the forceps being 
under perfect control, are far better oxytocics; their aid is there- 
fore often invoked, in order to save a woman’s strength, and to 
avoid that laxness of uterine fibre following a long and weary 
labor. Ergot is, however, given as the head is about to emerge, 
in order to lessen the chances of a flooding or of unruly after- 
pains, and to aid the process of involution by condensing the 
uterine globe to its minimum size. For an analogous reason I 
feel persuaded that Credo’s method of placental delivery pro- 
vokes to a more complete involution. It certainly empties the 
womb of all clots, and squeezes it down to its smallest capacity. 
The prolonged use of the binder is given up for reasons which 
have been published in this Journal (April, 1874, p. 8). I shall 
therefore not repeat them. I wish, however, here to state that 
even its brief use during the first few hours after labor, is not 
held by me as a cardinal point. I begin to have grave doubts 
whether it is of any value whatever in the prevention of hemor- 
rhage. On the score of utterly abandoning it lam quite open 
to conviction. 
So much for the reasons on which the foregoing measures are 
based. Let me now give the results. Up to date there have 
been 756 cases of delivery, with six deaths. The following are 
the order and the numbers of the fatal cases, as copied from the 
Case-Book: 
No. 22. Concealed accidental hemorrhage from the gravid womb. 
“ 203. Puerperal peritonitis. 
“ 289. Acute chorea. 
“ 360. Caries of petrous portion of the temporal bone. 
“ 398. Chronic pelvic abscess. 
“ 647. Septic pneumonia. 
The case of puerperal peritonitis was an isolated one. The Puerperal Diseases. 
woman had been abandoned by her husband, to whom she was 
devotedly attached. She fretted and brooded over this desertion 
in so despairing a manner as to make me apprehensive of mania. 
Three other patients occupied the same ward with her, but they 
escaped from contagion,. 
Cases 22, 289, and 360 were deemed by me so exceptional 
that their histories were reported to the Obstetrical Society of 
Philadelphia, and afterwards embodied in its Transactions (Am. 
Journal of Obstetrics, vol. ii. p. 286; vol. iii. p. 140; vol. iv. p. 
126). Case 398 was that of an old pelvic abscess following a 
previous labor, viz., an abortion produced by the kick of a 
drunken husband. During the last week of utero-gestation this 
abscess began to inflame and to cause her so much suffering 
that very large doses of morphia were needed to control it. 
Labor very greatly intensified this distress. When the womb 
was emptied a tumor was found in left broad ligament, and all 
the symptoms of localized peritonitis were present. Under ap- 
propriate treatment she soon began to mend; but on the four- 
teenth day she was suddenly seized with violent abdominal pain 
and fell into a collapse, from which she never rallied. An au- 
topsy, made by my friend the editor of this Journal, revealed an 
old pelvic abscess, which had burst into the cavity of the abdo- 
men. This case, it seems to me, cannot fairly be attributed to a 
septic cause, but to the ante-partum recrudescence of an old lesion. 
Case 647 is one of doubt in my mind. There were no appre- 
ciable pelvic or abdominal lesions; and yet, in default of an au- 
topsy, which was not permitted by her friends, I think it fairer 
to attribute the pneumonia to blood-poisoning rather than to a 
non-septic cause. 
To sum up, then: out of 756 cases of labor there have been 
2 deaths from septic causes, 
i death from the bursting of an old abscess. 
1 death from hemorrhage. 
2 deaths from non-puerperal diseases. 
Apart from the above record the Case-Book exhibits no case 
of phlegmasia dolens, and none of pelvic abscess. One woman, 
however, had, I am told, a pelvic abscess at home. Through 
fright at an outbreak of measles in the building, she insisted on 
rising from her bed and on being discharged on a wet winter Prevention and Treatment of 
night. Although a large proportion of the inmates were primi- 
parae, and two of them confirmed epileptics, but two cases of 
eclampsia took place, and these in women who had not been 
subjected to any prophylactic treatment. The one, while labor- 
ing under violent convulsive attacks, was brought in a hack by 
her friends. The other was seized the day after admission. 
Both recovered under repeated rectal injections of drachm doses 
of the hydrate of chloral, and a final delivery under ether with 
the forceps. 
Since nothing is so fallacious as statistics, even when based 
on large averages, it is with much diffidence that I offer the 
above meagre data. They may not sustain my views; but they 
will, I hope, show that lying-in women can be gainfully treated 
in a manner less artificial than is customary, and more in accord- 
ance with the maxim naturd duce. 
One word more: For many reasons the statistics of a lying-in 
hospital can never compete with those of private practice. Of 
these I shall adduce but two. In the first place, the former 
are more trustworthy, for physicians very naturally shrink from 
reporting their fatal midwifery cases as such. I have known a 
death from post-partum hemorrhage returned as one from “ ane- 
mia,” and another from puerperal albuminuria as a case of “pneu- 
monia”—edema of the lungs being present; whilst fatal cases 
of puerperal septicemia are constantly being certified to under 
the heading of some prominent symptom which tells no tale, 
such as “peritonitis,” “pleuritis,” or “pneumonia.” For instance, 
during a period of eight weeks of this year I was asked to see 
eight cases of puerperal fever—four of them from one Sunday 
to another. Of these all but one proved fatal. During the same 
time I casually became cognizant of seven other fatal cases. 
Now, during these eight weeks I studied with much interest the 
weekly returns of the Board of Health, and found there reported 
just twelve deaths from “puerperal fever.” There were, how- 
ever, also reported, eleven deaths from “ inflammation of the 
peritoneum,” one death from “child-bed,” and one each from 
“septicemia” and “pyemia.” Comment on the above is unne- 
cessary ; the figures speak for themselves. 
In the second place, physicians naturally shirk the worry and 
anxiety, the delay and trouble incident to difficult labors in their Puerperal Diseases. 
15 
private practice, especially when such occur in a class from which 
they can expect no adequate remuneration. A hospital thus 
becomes the Cave of Adullam for all these abandoned cases. 
For instance; out of the six fatal cases which I have reported 
from the Case-Book of the Retreat, the one of chorea and that 
of hemorrhage were sent to the institution by the family phy- 
sician—the former on account of her being unmanageable at 
home; the latter because her labors were growing more and 
more difficult from an exostosis. The two epileptics1 adverted 
to, two distressing cases of phthisis and valvular disease of the 
heart, and many of difficult labor in multiparas come under the 
same category. There are at present in the building two women 
not yet delivered, who were sent there by their respective medi- 
cal attendants. The one is an epileptic primipara; the other a 
secundipara with a vesico-vaginal fistula—the result of cranio- 
tomy in her previous delivery. It is thus that the death-rates of 
lying-in hospitals show to disadvantage beside those of private 
practice. 
1 I am not aware that epilepsy predisposes to puerperal eclampsia—at least I 
have not found it to do so. But many physicians look upon it as a dangerous 
complication in labor.