is transpiring, and we can derive consolation therefrom, you will know that over your bier will be shed the tears of many men and women; that among the mourners there will be Jew and Gentile; there will be Catholic and Protestant; there will be black and white; there will be those of different political opinions; there will be the old whom you have assisted in the time of their trav ail; there will be the young with whom you were present when they came into the world. In short, there will be all classes and conditions of mankind, and they will be each shedding an honest tear, as they realize the fact that their benefactor and the benefactor of mankind has passed away.

PUERPERAL SEPSIS, IS IT ALWAYS PREVENTABLE?* By A. H. GARNETT, M.D.,

Colorado Springs, Colo.

Mr. President and Gentlemen of the Society: Apropos to the discussion going on in the medical press as to the prevention of puerperal sepsis, and the radical position taken by some, that its occurrence should be regarded in the light of criminal negligence on the part of the attending physician, I purpose this evening to briefly take up the subject in opposition to the more pronounced position in support of its prevention under any and all circumstances, dealing with the subject as far as I am able from a purely practical standpoint. It will be remembered by some of you, that several years ago in the early craze, I may say, of antisepsis, I read a paper before this body, titled "Puerperal Fever—Are Antiseptics a Positive Prophylaxis?" My position then was that the method was not only not a certain prophylaxis, but that the extreme to which the treatment was carried was one of questionable propriety, and if carried out in all its details, to my mind, hurtful; and although my views as to the etiology of the disease have undergone some modification since then, I am still not prepared to-night to depart wholly from the position then assumed as to the antiseptic methods of treatment. Now, let us glance for a moment at the generally accepted tenets of faith as held and practiced to-day regarding the cause and treament of puerperal sepsis. 1. Puerperal fever, so called, is not a specific disease peculiar to women in the lying in condition, but is allied to and identically similar to any other of the septicemic or pyemic con

Read before the El Paso Medical Society.

ditions which arise more commonly in connection with surgical affections. 2. The disease is not in any sense a specific, but due to the activity of the lower forms of life included under the general head of micro-organisms, which, when introduced into the body under favorable conditions, develop symptoms to be classed under the head we are now considering. 3. That the normal course of parturition being to recovery, any variation from this tendency must be ascribed to the introduction of some disturbing influence from without. 4. That if the morbific principle be kept out of the body, no disturbing action will occur; finally, that the channel of entrance is most generally through the genital tract and that the carrying agent is unquestionably, very commonly the infected hands of the attendant or instruments introduced of necessity into the vagina or uterus at a most receptive stage for the culture of bacterial agents; in short, that a partur ient woman is essentially in the condition of a wounded woman, with more or less solutions of continuity in the genital tract, offering a possible chance for the entrance of microbes. Such, I say, briefly considered, may be taken as correctly reflecting the position of the profession to-day upon the subject under discussion.

In this connection it is interesting to relate some of the singular phases of sepsis occurring in the face of strict antiseptic precautions, practiced along the lines of modern teachings. Whilst they may not serve as irrefutable evidences in support of an opposite view, they are none the less worthy of explanation in substantiation of the present position. The celebrated case of Dr. Rubber of Philadelphia, with which the profession at large is familiar, who, in the year 1843, before the days of antiseptics, it is true had forty-five cases of puerperal sepsis, is unique to say the least of it. It is recorded that the doctor went to the veriest extremes in personal cleanliness; bathed, shaved head and face, wore a wig, changed his clothing and even left the city for a period of ten days; on his return, some two weeks later, the first case of obstetrics, although an easy and normal one, died of septicaemia. It might be argued that had the doctor bestowed as much time in rendering his patients as aseptic as he did on himself, his experience would have been different, and, yet a prom. inent man with a practice among the best, it is to be presumed that most of his cases were among a class whose attention to the details of personal cleanliness could not be questioned.

In one ward in one of the maternity hospitals of New York, not long since, it is recorded that two women were delivered on the same day; the first a macerated foetus and a stinking placenta. The uterus was promptly irrigated with the regulated

antiseptic solution; the patient did well. The second, a healthy woman and a natural labor, conducted under strict antiseptic precautions, narrowly escaped death from puerperal sepsis. The infection, the author tells us, was conveyed from patient No. 1. Here you will perceive a freak of the microbe, a soil sick in elements for its developments is abandoned, and a field at a distance less favorable, by reason of a rigid adherence to the rules of asepsis (with antiseptics, I will add) is selected, takes root and develops the conditions.

Without multiplying instances occurring in the presence of a practice in accordance with modern teachings, let us pass at once to the consideration of the question. Whether or not the attending physician in a case of obstetrics must be held responsible for the occurrence of puerperal sepsis? I am aware, for the most part, the trend of medical thought, as daily reflected through the journals, is to the effect that the causes are clearly preventable, and a case in the practice of an accoucher, if not less than criminal, is certainly very reprehensible and worthy of severe condemnation. To assume so radical a position one must deny a class of cases, where the source of infection was autogenetic and not from external causes. Dealing, however, with the subject purely from the standpoint of the latter, are all cases traceable to failure to secure surgical cleanliness, as maintained by many? What, we may ask, constitutes surgical cleanliness? Is asepsis to be obtained only through the use of antiseptics? The modern surgeon contends so, and his practice is always rigidly along this line, and the modern obstetrician is none the less emphatic in his demands in the same direction.

What are some of the methods in vogue to secure the prevention of puerperal sepsis? Before and after labor, unquestionably, the most common is the vaginal douche, with antiseptic solutions of given strength and medicament. Is this practice itself devoid of danger? Is it always necessary? And does it commend itself upon sound common sense principles? Statistics, gathered from the records of Guy's hospital are worthy of reproduction here, since they present an array of facts altogether too strong to be brushed aside without proof to the contrary. These figures show that during a period of three years, with 9,097 cases of confinement, there was a septic mortality of only 10 per cent., without the use, too, of the vaginal douche in a single case of this given number. This would appear, indeed, to be an excellent test as to the value of this method of treatment.

In this connection the argument is too often advanced that the syringe itself is frequently the means of infection, since it is occasionally an old one, having been used for all sorts of cases

and conditions. I am of opinion that too much stress is attached to this point and not enough to the questionable propriety of the practice; with even a new syringe, and the regulated solutions, let us, gentlemen, examine for a moment briefly into the practice so often advocated and carried out in a few hours after childbirth, in the absence, too, of any evidence whatever of sepsis, with vaginal irritation of the carbolic and bichloride solutions. Is the process based upon sound physiological reasoning, and when rigidly enforced not without the dangers of pathogenic consequences? May not nature's efforts at repair be retarded and even prevented by this constant disturbance? Granting there are abrasions and breaches of continuity, does not the regular irrigating process rob nature of its provisional covering? Are not these surfaces kept clean thereby and in consequence in a perfect state for the absorption of hurtful matter? If the medicated solution is of sufficient strength to destroy these lower forms of animal life, may not the delicate mucous membrane and microscopical epithelium be destroyed, too, by its chemical and corrosive action? If so, may not this disintegrated tissue itself undergo decomposition and thereby afford a rich soil for the culture and development of the very condition we are endeavoring to prevent?

Finally, gentlemen, and a very pertinent query in this connection: Is the practice itself, except under the supervision of a scrupulous exactness, a condition confessedly not always attainable with the average nurse, unattended with danger to the parturient woman? Authentic reports of deaths from the use of these agents, as prescribed and recommended by those whose teachings are quoted and accepted as authority openly attest to the contrary. Coming down to my individual experience, admitted to be limited, and yet in a limited field we all sooner or later must encounter this condition, it has been a matter of forced observation with me that some of the most annoying, and, if you please, severe cases of puerperal sepsis in my own practice have been in cases where my efforts to avoid it have been more rigidly along the lines of modern methods. I will go further and make the unqualified statement that the smaller percentage of my cases have been among those where it was impractical to properly carry out asepsis and indeed where the surroundings have been more conducive to the propagation of the disease, from the standpoint of its microbic origin.

During a practice of a number of years among the negroes of the South, where not the slightest attention was paid to antiseptic precautions, and where the usual attendant in charge was an ignorant midwife, and where the lubricant for the finger in

making digital examinations was most usually rancid lard, exposed always to atmospheric impurities, I fail now to recall a single case of puerperal sepsis in my practice. My father's experience, covering a period of nearly forty years in the same locality, was largely confirmatory of my own. In short, the nearer we approach to nature's simple and unaided methods, as witnessed in animal iife, where the disease, if present at all, is so rare as almost to escape record, the greater the freedom from its ravages.

Now, I do not wish to be arrayed on the side as decrying the use altogether of antiseptics, or denying their efficacy under proper restrictions and in well defined indications; statistics and experience attést in unmistakable terms to their absolute need. No intelligent physician, at the present time, would undertake to oppose their proper use, and right here I desire to raise the question, when is it proper to use the vaginal syringe? What is the practice of the members in this direction? Personally my convictions are becoming more pronounced against this routine practice, and I am free to confess were I limited to its use before or after labor, I should incline to the former, thoroughly cleansing the vagina at the outset, discarding the post partum douche entirely, as long as all evidence of sepsis was wanting. I believe it to be perfectly consistent with a safe and efficient method for the attending physician in all cases, when called at the beginning of a given case of labor, to cleanse, or have it done, the va gina and external genitalia thoroughly with hot water and a good soap, using the same process with a nail brush in preparing his own hands His conduct, afterwards, throughout the entire course of active labor, should strictly forbid undue examinations per vaginam; in short, avoid anything tending towards meddlesome midwifery, observing cleanliness as far as it is possible to do so, to the full completion of the third stage.

The use of postpartum irrigation should be reserved until the third or fourth day, and not then unless the discharge become slightly foul; in this way nature's methods, always at repair, are not disturbed, and the case will, in the great majority of instances, be conducted to a successful issue without further aid.

Before closing, gentlemen, I wish to emphasize the position that in the face of this line of practice, either with or without antiseptic remedies, it is not always possible to prevent puerperal sepsis, and that its presence, even in this day of extreme modern antiseptic precautions, should not be given in evidence of crim inal neglect, as advocated by some. If such a sweeping conclusion is to be drawn, why, let me ask, does a second journal con tain a clipping giving a study of forty cases of puerperal sepsis in the wards of Johns Hopkins Hospital, where the facilities for executing the most rigid adherence to the rules of asepsis have not served to prevent its occurrence?