In private practice it is likewise important that the lying-in room should be provided with plenty of light and air. The physician should insist upon the value of ventilation as a means of contributing to the speedy recovery of childbed women. By hermetically sealing the windows, through false fears of his patient's taking cold, he exposes her to the risk of becoming poisoned with her own exhalations.
But the early experiences of the Hôpital Cochin and the Hôpital Lariboisière, costly, palace-like structures, with every appliance of art, prove that fresh air alone does not protect patients from the consequences of inoculation.
The great improvement in the condition of maternity patients in recent years has been due to the application of Lister's principles to obstetric practice. Complete antisepsis in the surgical sense is, of course, impracticable. Adequate antisepsis has, however, been proved to result from the observance of a variety of precautions which have been the slow outcome of experience. These, in brief, in hospitals, consist in protecting the patient from every known form of contamination, and in the prompt removal and isolation of every puerperal woman who manifests febrile symptoms.
In citing the examples of the Hôpital Cochin and the Hôpital Lariboisière, I was led to the selection because these hospitals most strikingly illustrate the extent of the triumph of the new doctrines. Whereas at the Lariboisière the mortality in 1854, the year of its opening, exceeded 10 per cent., as a result of the prophylactic measures adopted by M. Siredey the mortality was 1 to 145 in 1877, and 1 to 199 in 1878. And at the Hôpital Cochin, in 1878, Lucas-Champonnière, with 770 confinements, was able to report but 2 deaths from puerperal causes.
As regards details, the bedsteads should be of iron and should be frequently scrubbed with a carbolic solution; after each confinement the palliasse upon which the woman lay should be washed in boiling water and the straw should be burned; in place of the usual rubber covering to the bed, Tarnier recommends tarred paper, which is antiseptic, and costs so little that it need be used in but a single case; all soiled linen should be instantly removed from the ward, either to be burned or disinfected by prolonged boiling; sponges should be banished, as, when they have once been soaked with blood, not even carbolic acid can make them safe; nurses employed in the puerperal wards ought not to have access to cases of labor, as D'Espine and Karewski66 have shown that the lochia of even a healthy person on the third day will poison a rabbit; a patient attacked with fever should be immediately removed, and the nurse in attendance should go with her. At the Emergency Hospital, with the first appearance of catarrhal affection of the genital organs or of so-called milk fever, the wards are immediately emptied and fumigated with sulphurous acid. In spite of recent scepticism regarding the value of the fumes of sulphurous acid as a germicide and disinfectant, I do not hesitate to express, after long experience, my firm conviction as to their efficacy.
66 D'Espine, "Contributions à l'étude de la septicémie puerpérale," p. 18; Karewski, loc. cit.
Doléris67 formulates the indications for effective prophylaxis as follows: 1, prevent the introduction of germs (antisepsis before confinement); 2, paralyze their action (antisepsis after confinement); 3, shut up the doors—veins, lymphatics, and Fallopian tubes (employment of means which promote uterine contraction).
67 La fièvre puerpérale, 1880, p. 303.
The first duty of the physician is to refrain from attending a case of labor when fresh from the presence of contagious diseases or from contact with septic materials, whether derived from the dissecting-room or the clinic. Scepticism regarding these sources of danger is sure in the long run to be severely punished. In a doubtful case the least concession should consist in a full bath and a complete change of clothing. A special coat for confinement purposes, stained with blood and amniotic fluid, is liable to convey infection. In every case of labor, whether in hospital or private practice, the hands and forearms should be freely bathed in a carbolic solution before making a vaginal examination. A nail-brush should form a part of the ordinary obstetric equipment. Frequent examinations during labor should be avoided. All instruments employed during or subsequent to confinement should be carefully disinfected. In prolonged labors, after operation, in cases of dystocia, or where the membranes have ruptured prematurely and the foetus is dead, it is a useful precaution after delivery to wash both uterus and vagina with warm carbolized water or solution of corrosive sublimate (1:2000). In Vienna both Spaeth and Braun after difficult labors introduce a suppository of iodoform, 2 to 2½ inches in length, into the uterine cavity. The formula recommended consists of—
| Rx. | Iodoformi, | 20 grammes; |
| Gummi Arabici, | ||
| Glycerinæ, | ||
| Amyli puri, | aa. 2 grammes; | |
| Ft. Bacilli, | No. iij. |