The Treatment 
(NOT PREVENTIVE) 
OF 
PUERPERAL FEVER. 
BY 
CHARLES WARRINGTON EARLE, 
PROFESSOR OF DISEASES OF CHILDREN AND OF 
CLINICAL MEDICINE, 
WOMAN'S MEDICAL COLLEGE. 
From The Chicago Medical Journal and 
Examiner. THE TREATMENT (NOT PREVENTIVE) 
OF PUERPERAL FEVER. 
By CHARLES WARRINGTON EARLE, 
PROFESSOR. OF DISEASES OF CHILDREN AND OF CLINICAL MEDICINE, WOMAN'S MEDICAL COLLEGE. 
The remark has been made that in con- 
sequence of the general use of antiseptics 
in Germany, there is no opportunity for 
studying septicsemia-that the disease in 
fact is vanished. To such an extent is this 
true that in some of the prominent journals 
devoted to obstetrics there is scarcely an 
allusion to the treatment of puerperal 
septicaemia during the past three years. 
But in a certain percentage of cases in- 
fection has taken place. The chill, in- 
creased temperature, and the pelvic distress 
are all, or partly, present. Some way, 
either from the doctor, the nurse, or the 
patient herself, the infectious element has 
gained lodgment in the parturient's system. 
Apart from these three sources from which 
the infectious material is usually furnished, 
a careful study of the subject leads me to 
believe that sometimes the condition which 
we have heard so ably discussed this even- 
ing, may arise from some old suppurating 
point hitherto not discovered, and in this 
way certain cases of puerperal fever, the 
origin of which it is extremely difficult to 
understand, is explained. 
For instance, supposing a woman has an 
old pyosalpinx, which has remained quiet 
for months, and possibly years, the traum- 
atism and pressure incidental to parturi- 
tion, may, it appears to me, relight this 
process, and be a cause for either local or 
general infection. But whatever the cause, 
the phenomena of puerperal fever are 
present. Dread it, as we all do, it will 
come to us, not that it may be in our own 
practice, but to those who seem to delight 
in rejecting methods which almost insure 
immunity against it. In hospitals, which 
in olden times were justly regarded the 
hot-beds for puerperal fever, we find but 
few cases. An epidemic of puerperal fever 
in a modern hospital would at once be re- 
garded as proof that some one had 
blundered. We must still be prepared to 
fight it in private practice. How shall we 
treat it? Mainly by the following pro- 
cesses and agents: 
(1.) The vaginal douche and antipyretics. 
(2.) The intra-uterine irrigation and anti- 
septics. 
(3.) Curettement and antiseptics. 
(4.) Drugs. 
(5.) Surgery. 
The following tissues and organs, accord- 
ing to the classification of Spiegelberg, 
must receive the local and general treat- 
ment. Not any two cases can be treated 
alike. Sometimes it must be a local 
remedy, at other times the removal of in- 
fective detritus. In other cases surgery, 
and in others nothing but drugs, from 
which we in many cases see absolutely no 
effect: 
1. Inflammation of the genital mucous 
membrane-endocolpitis, and endometritis. 
a. Superficial. 
b. Ulcerative (diphtheritic.) 
2. Inflammation of the uterine paren- 4 
chyma, and of the subserous and pelvic 
cellular tissue. 
a. Exudation, circumscribed. 
b. Phlegmonous, diffused; with lym- 
phangitis, and pyaemia (lymphatic form of 
peritonitis.) 
3. Inflammation of the peritoneum cover- 
ing the uterus and its appendages-pelvic 
peritonitis, and diffused peritonitis. 
4. Phlebitis uterina, and para-uterine, 
with formation of thrombi, embolism, and 
pyaemia. 
5. Pure septicaemia-putrid absorption. 
If we have the first condition, a super- 
ficial vaginitis or endometritis, we should 
use local disinfection, iodoform, boracic 
acid, and, possibly, for the endometritis, 
the intra uterine douche followed by the 
iodoform bacillus. The deep form of 
ulceration (and, possibly, diphtheritic) must 
be met with local cleanliness and applica- 
tions of some destructive agent, such as the 
chloride of zinc in proper solution, the 
bichloride of mercury, with applications of 
iodoform or boracic acid. Every diph- 
theritic patch must be touched with the 
local application, and the parts thoroughly 
washed out with an antiseptic fluid. Patches 
which can be reached should be packed 
with iodoform gauze. 
In the second condition, inflammation of 
uterine tissue proper, with circumscribed 
exudate, we should satisfy ourselves that 
no local point of infectious material re- 
mains, and treat the patient by insisting 
that she remain in bed till all pain sub- 
sides, meet all drug indications that follow, 
and follow with hot vaginal douches for a 
long period, to which should be added a 
generous diet and tonics. If the para- 
uterine tissues are involved (connective 
tissue immediately adjacent to the uterus) 
we must administer anodynes, use fomen- 
tations, and relieve the symptoms produced 
by exudates in the vicinity of the bladder 
and other pelvic organs. 
With the use of the above treatment, 
with hot douches, the mild and uncompli- 
cated cases disappear, and the formation 
of pus is the exception. Sometimes, how- 
ever, we have a hard tumor remaining for 
a long time, which is usually dissipated by 
counter-irritation, hot injections, good diet, 
and tonics. 
Pelvic peritonitis and general metro- 
pertitonitis are among the fatal forms of 
puerperal fever, although the first will 
usually recover if the source of infection 
is not too pronounced. General peritonitis 
is extremely dangerous, and in the majority 
of cases, under the old regime, absolutely 
fatal. In addition to the anodynes, which 
have for years been our sheet-anchor, and 
which in some cases are pushed in enor- 
mous doses, the question of drainage will 
certainly arise. It is an open question 
with me to-day whether such large doses of 
opium, producing constipation and reten- 
tion within the system of germs, is the best 
treatment. The abdominal cavity will be 
found filled with brownish or green fluid, 
and without its removal any treatment will 
be futile. It is in the first stage of this 
form of the disease that cocaine for vomit- 
ing, rectal injections of hot water for the 
extreme thirst, and saline laxatives as local 
depletants, should be used. 
The treatment by salines or laxatives is 
based upon actual observations and clinical 
experience. It has been known for a long 
time that some of the inferior animals 
poisoned by septic matter recover after a 
long and persistent diarrhoea, and the use- 
fulness of laxatives in puerperal fever has 
been strongly recommended by Latour 
Seyfert and Breslau (Schroeder). The 
best hope of eliminating the poison comes 
from this method, and not only this, but 
their administration reduces the fever, and 
the pain becomes less. Sometimes nature 
does better than the doctors, and a diar- 
rhoea is set up at the commencement, which 
persists until convalescence is established. 
If diarrhoea is present without laxatives, 
this is all that is needed. If not present, 
and the administration of salines does not 5 
produce it, the prognosis is bad. Eulenberg 
assures us that no fear need be entertained 
that the copious discharges from the in- 
testinal canal will weaken the patient, or that 
there will be any trouble in checking them 
at the proper time. The great weight of 
authority at this day is in favor of this 
treatment. 
Among the remedies to bring about and 
continue this method of cure may be men- 
tioned the bitter waters, caster oil, jalap and 
calomel, Hunyadi water, and perhaps best 
of all, magnesia sulph. These are to be 
given in such doses and at such times as 
will influence and keep up the depletant 
effect. 
The fourth form of puerperal fever in 
the classification I have chosen is uterine 
phlebitis, with or withour metastatic ab- 
scesses. It will not be necessary for me 
to trace for this audience the history of a 
phlebitis, sometimes making its appearance 
as a painful spot in the lower limb, with 
increased swelling and pain, the indurated 
blood-vessels, the irregular chills, and indi- 
cations of pus-points in different parts of 
the body. It is not new to class this as 
one form of puerperal fever, although there 
may be some who still believe in the old 
milk-leg theory of the ancient nurses and 
grandmothers. 
The treatment is simple and trifling in 
some cases, recovery is rapid; the infection 
is only slight and local. In others abso- 
lutely nothing seems to do our patients 
good, and we must be content with tonic 
and stimulant treatment, with a generous 
diet to sustain the strength of the patient 
until the infection is worn out, which, after 
all we can do, after long weeks of suffering, 
will in many cases cause the patient to 
succumb. This infection takes place at 
the placental site, and it comes on so 
slowly that the most experienced some- 
times will not detect it. The poison is dis- 
tributed to such remote parts of the body 
that we are disarmed at the very outset. 
We cannot reach with any known remedy 
the point of lodgment of emboli in distant 
organs; we can only destroy what remains 
of the infectious material at the original 
point of entrance, if we can happily dis- 
cover it, and try to sustain the strength of 
the patient till nature effects a cure. 
It is hardly -worth while for me to say 
anything in regard to a treatment for pure 
septicaemia. Sometimes the symptoms of 
blood-poisoning are so intense that the 
patient will die without any local lesions. 
What can be done has either been brought 
out in what has been said regarding general 
medication, or will be noted in the remarks 
on laparotony. 
In all of these different manifestations, 
however, there underlie certain general 
principles which we should be ready to 
adopt. The first is vaginal cleanliness and 
antipyretics. 
I know that in a few cases patients do 
not seem to do as well after even vaginal 
douches, but in the main it is because they 
are improperly given. Sometimes cleans- 
ing the vagina a single time will reduce 
temperature and alter the entire character 
of a threatened puerperal attack. If this 
does not reduce the temperature, then the 
next procedure should be an intra-uterine 
douche. This should be done with the 
utmost care and with a full realization of 
the dangers which sometimes take place. 
One about to give an intra-uterine douche 
should know that accidents sometimes hap- 
pen from entrance of air into the uterine 
sinuses, and that sometimes a hsemorrhage 
is produced. We should know, too, that the 
injecting-fluid may be introduced into the 
general circulation by the introduction of 
the injection-tube into the mouth of one of 
the large sinuses; that convulsions and 
pain may be produced, and that fluid may 
be forced into the peritoneal cavity through 
a Fallopian tube. If time permitted I 
could demonstrate that but little reason 
really exists for apprehending any of these 
accidents. Notwithstanding these dangers, 
however, it seems to me that the uterine 6 
douche is justifiable, and that in some condi- 
tions nothing will take its place. It is 
absolutely useless to administer drugs to a 
patient who is suffering from an infection 
from a retained placenta or from shreds of 
membrane, or from an old decomposing 
clot, or from retained lochial discharges. 
These must be removed, and the cavity 
must be kept clean. To be sure, we do 
not alter or change in any degree the in- 
fectious material which has been already 
absorbed into the system, but by washing 
away repeatedly these new sources of infec- 
tion, we prevent the system from being 
re-loaded time after time by this poisonous 
stuff. 
An intrauterine injection cannot be done 
with a half-ounce syringe and a goose- 
quill. One must realize the dangers, have 
the proper instruments, and know how to 
use them. The various steps are: 
1. Clean the outside of the patient 
around the vulvar orifice. 
2. Thoroughly cleanse the vagina. 
3. Give the intrauterine douche. 
4. Introduce iodoform bacillus. 
Always have the stream of water run- 
ning when the injection-tube is introduced 
into the uterine cavity. If the temperature 
does not fall in the course of a few hours, 
and there is a lochial discharge which is 
offensive, showing beyond a doubt that 
there is decomposing matter which has 
been infected in some way still remaining 
in the uterine cavity, it appears that now 
the time has come either for repeated in- 
trauterine douches or curettement. I am 
well aware that there are cases which 
neither the vaginal, nor the intrauterine 
douche, will effect. Not every parturient 
canal is a traumatic channel-the poison is 
often elsewhere. There are cases of puer- 
peral fever in which, it appears to me, it is 
impossible to discover the exact cause of 
the infection or its location. If the infec- 
tion has localized itself along the side of 
the uterus, and makes its appearance as a 
pelvic cellulitis, or as an inflammation in 
the broad ligaments, of course no good 
comes from repeated vaginal or intrauter- 
ine injections, but until we can demonstrate 
the localization of this poison the treat- 
ment by douches will give us the best re- 
sults. Whatever the cause, the first thing 
we should do is to properly cleanse the 
vaginal tract and search for some point of 
infection in this location. If a perineum 
has been restored and sutures of any kind 
been used, unless union is perfect, which 
will be rare indeed if infection has taken 
place, it appears to me that at this point 
very careful search should be made, and in 
addition to giving a vaginal douche, in my 
judgment the patient will be placed in a 
safer condition if these stitches are taken 
out and the old lacerations thoroughly 
cleansed. 
In regard to vaginal douches, I desire to 
say that I do not believe in doing anything 
to the parturient woman unless there are 
indications. But if a laceration has taken 
place, which has been closed by one, two 
or three stitches, at least a daily vaginal 
douche with either carbolized or bichloride 
water should be ordered. 
Among the drugs recommended in the 
treatment besides those I shall mention in- 
cidentally in connection with other methods 
of cure, I shall speak of quinine, antipyrin, 
veratrum viride, turpentine, opium, iodo- 
form. alcohol and hot baths. The use of 
the cold water coil and constant irrigation 
should also be mentioned. 
Quinine is undoubtedly an excellent 
remedy, and may be used either in anti- 
pyretic or tonic doses. Sometimes we can- 
not do better than to employ this remedy 
throughout the course of a puerperal fever. 
Antipyrin has been useful in reducing tem- 
perature, but its liability to produce shock 
makes me careful in its use in a disease 
which in itself severely taxes the strength 
of the patient. In the German Gyneco- 
logical Society of 188G antipyretics were 
discarded, while the advantages of hot 
baths and alcohol were reiterated. Pro- 7 
fessor Fordyce Barker will be remembered 
as the particular advocate of veratrum 
viride, a remedy most useful in some other 
diseases, but to me contra-indicated here as 
other depressants are. 
Turpentine has been useful externally, 
and has been administered by stomach- 
indeed, no one other remedy seems to do 
quite as well when the patient has a red 
tongue and some other symptoms simulat- 
ing a typhoid condition. It has been 
recommended recently by Thomas Madden 
in every form of puerperal fever. 
Iodoform has been given internally in 
one case with good results. 
The salicylates are also recommended, 
and theoretically they should do good in 
certain cases. 
I have said all regarding the opium- 
treatment that seems to be necessary. 
It appears to me that in the light of recent 
investigations, any remedy which persist- 
ently constipates, presenting local depletion, 
is contra-indicated. 
In the Transactions of the Ninth Inter- 
national Medical Congress, Dr. Nelson of 
this city speaks of the beneficial results 
from the sulpho-carbonic acid treatment. 
As far as I know, this remedy has not been 
used to a sufficient extent so that we can 
regard it as authoritative. 
The use of alcohol in all forms of septi- 
caemia is so well established that I need 
say nothing regarding its results. 
The reduction of the temperature by 
cold water, used by means of the coil 
placed over the abdomen, is one of the 
best agents to combat this symptom, which 
I have ever employed. Kibbee's cots, by 
which a large extent of coil through which 
cold water is introduced, has also been 
recommended by some. 
Say everything that we can in regard to 
drugs, there is nothing which has been 
brought prominently to the front during 
the past one or two years. Without other 
means than internal medicine to combat 
some forms of puerperal diseases, we are 
almost absolutely powerless, and we stand 
by the bedside of our patients watching 
them as they come under the influence of 
the infectious material, and gradually 
failing until death closes the scene. 
In the local treatment of puerperal 
septicaemia, says a recent author, "anti- 
septic intrauterine injections still hold their 
deserved preeminence. Bokelmann con- 
siders them indicated when forty-eight 
hours after birth the temperature rises to 
101.5° or 102.2° Fahr., with frequent pulse 
without a recognizable cause for it; (2) 
when fragments of placenta or membranes 
remain in the uterus as a cause for dis- 
turbance; and (3) when symptoms of infec- 
tion of the endometrium are present." 
After vaginal injections and disinfection, 
followed by the intrauterine douche with 
the iodoform bacillus, if evidence still 
remains that decomposing clots or intra- 
uterine debris of any kind are yet present, 
we should resort to curettement. I cannot 
see that the character of the pulse or any 
other symptoms can have much weight in 
causing us to decide in this manner. If 
there is evidence that any'extraneous sub- 
stance which has been infected is still left 
in the uterus, it appears to me it should 
come out. A stream of hot water cannot 
in some cases detach it. It still remains 
to again and again furnish infection, which 
is again and again to overpower the sys- 
tem. Take it away, not with a sharp 
instrument, not with manipulations which 
involve going through the uterine walls, 
but by first doing everything which has 
been suggested in the operation for the 
uterine douche, then curette, then give 
another douche, and follow with the iodo- 
form bacillus. Such an operation as this 
carried out carefully, and with all antisep- 
tic details, will sometimes change the 
prognosis of a puerperal fever with remark- 
able rapidity.* The fact that some one not 
skilled in the use of the instrument has 
perforated the walls of the uterus is no ar- 
gument against the operation. 8 
I have not time to enter into the treat- 
ment of all of the complications and 
sequelae which sometimes arise after a case 
of puerperal fever. It must suffice to say 
in regard to local abscesses, for instance, 
if they are within easy reach, it is perhaps 
as good practice as any to aspirate. We 
know that sometimes after aspiration the 
abscess disappears, does not refill, the 
temperature goes down, and the patient 
makes a good recovery. If, however, the 
abscess-cavity does refill, it must be found 
and properly drained. Sometimes this can 
be done through the cul-de-sac of Douglas, 
at other times by opening the abdomen 
and draining from this point. In some 
cases of doubt, I have seen the abdominal 
cavity opened, and the abscess found; the 
fact is demonstrated that the sac cannot 
be either extirpated or brought to the sur- 
face of the abdominal wound, and conse- 
quently drainage must take place through 
the vagina, the abdominal wall being closed. 
The relation of pyosalpinx to puerperal 
fever, and what shall be done with large 
collections of pus within the abdominal 
cavity, which sometimes follow in the 
course of puerperal peritonitis, is at this 
time receiving more than the usual amount 
of attention. Dr. Baldy, of Philadelphia, 
one month after labor has opened the abdo- 
men and removed the right tube, which 
was distended with pus, and the patient, 
although in a very critical condition when 
the Operation was done, rapidly recovered. 
The treatment of metroperitonitis, or 
purulent peritonitis, has also undergone a 
great change. These cases have been re- 
garded as almost hopeless. We have stood 
by the bedside of a woman with an abdomen 
enormously distended, and with all the 
symptoms of septicaemia, with undoubted 
evidences of pus in the cavity, and allowed 
her to die without opening the abdominal 
cavity. This in the future will not do. 
There is testimony, which is increasing 
every day, that if we allow such a condi- 
tion of things to remain without, at least, 
making an effort to save our patient by 
drainage we fall short of doing our duty. 
One of the most important advances in 
obstetric surgery during the past two or 
three years has been made by Tait, who 
for some time has been advocating abdomi- 
nal incisions, and cleansing of the peri- 
toneal cavity in such cases. During these 
years he has been making appeals to the 
practitioners in his neighborhood to be 
allowed to perform such operations, which 
at this time have been done in a few cases 
with excellent results. An abdominal in- 
cision is made, the foul fluids cleared out, 
a drainage-tube inserted, and the wound 
closed. 
Greig Smith makes the suggestion that 
in treating cases of suppurative inflamma- 
tion of the peritoneum the intestines should 
be kept floating in a hot antiseptic lotion. 
The fluid which he recommends is the hot 
boro-glycerine solution, which is repeatedly 
passed in through a drainage-tube and 
allowed to remain in the cavity for a short 
time. The fluid should be at least 102c 
Fahr. This operation with its technique is 
suggested by two of our greatest operators, 
and all details are not worked out. The 
absolute indications and the results must 
be decided by future research. The results 
cannot possibly be more discouraging than 
from our past treatment. 
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