RETAINED DEBRIS 
as one; ok the 
Causes of Puerperal Fever 
THE INTRA-UTERINE DOUCHE AND CURETTE. 
BY 
Dr. Chas. Warrington Earle, 
CHICAGO.  of so/n<? FfegardiQg pu<?rp<?ral peuer. 
The Theories of the Etiology—The Intra-Uterine Douche 
—The Use of the Curette. 
BY CHAS. WARRINGTON EARLE, A.M., M.D. 
Prof, of Obstetric* Collegp of Physicians and Surgeons, Chicago. Prof. Diseases of Children, 
Woman’s Medical College, Chicago. 
A former student of mine, now practicing 
in Michigan reports that a neighboring prac- 
titioner has lost twelve parturient women 
during the last six months. An examination 
of our mortality reports always shows deaths 
from puerperal causes and an inquiry among 
obstetricians and midwives will reveal the fact 
that deaths from fever, malaria, etc., occasion- 
ally take place. Many say that they have 
never seen a case of child-bed fever, but 
nevertheless deaths occur. 
I need not speak of the terrible mortality 
which has been present in times past in the 
large hospitals of the old world, such as in 
the Hospital Lariboisiere, where it has been 8 
per cent; or in the Maternity in Paris where 
it was formerly 10 per cent. In Berlin at 
one time there was one death from child- 
birth in every 152 confinements, and in 
Vienna 10 per cent were lost. In all proba- 
bility it has arisen to 15 per cent during 
some epidemics. Notwithstanding these fig- 
ures we have men in our profession who say 
that parturition is physiological,—a process 
as natural as the digesting of food. If it is 
a physiological process, surely something is 
wrong, and we need to study it, and if it is 
pathological, with such a mortality it is cer- 
tainly our duty to investigate the causes that 
bring about such terrible results. 
It seems that it should be enough that a 
woman pass through all the discomforts and 
inconveniences and solicitudes of pregnancy, 
and the pains and anxiety of parturition, 
without being subjected to additional dangers 
at the close of these processes. But it is not 
so. During the few days following there 
comes about, in almost a multitude of cases, 
such a series of unfortunate results, that 
many of the most valuable members of the 
community, and among them those who are 
surrounded with the most beautiful prospects 
for the future, are consigned to young and 
untimely graves. 
It is a well-known fact that in Carl Braun 
and Spaeth’s wards in Vienna the mortality 
has been reduced to 56-100 of 1 per cent or a 
little over half of 1 per cent. 
As I walked through their wards during 
the past summer and came into rooms where 
thirty women had been confined during the 
preceding thirty-six hours and would find the 
air in that room perfectly pure, absolutely 
free from odor, and every one with normal 
temperature, or so nearly normal that it is 
not worth mentioning, and then remembered 
that in private practice, with only a single 
woman in a house, and sometimes in new 
residences, where contagious or infectious 
diseases never existed, most terrible odors 
and high temperature and continuous fevers 
were sometimes noticed—indeed a much 
worse condition with a single patient in a 
private house than was noticed in a ward 
with thirty patients in a hospital atmosphere. 
I was convinced that their method of practice 
was worth imitating. 
In these wards when a woman’s tempera- 
ture rises to 103 she is given a uterine douche 
and the curette is frequently used. I pro- 
vided myself with the necessary appliances 
and determined should occasion demand, to 
try their efficacy. I did not wait long. A 
few days after my return I was called to see 
a case in this city, with the following history: 
A young woman from a neighboring state 
came to the city and had a criminal abortion 
performed. At the end of the week her 
symptoms were so alarming that she changed 
physicians. He found her temperature 1030 
and called me in consultation. Intra uterine 
douche of carbolized water did not bring it 
down, and she was curetted and a consid- 
erable amount of membranes and debris was 
brought away. A coil was placed upon her 
abdomen, and her temperature, which had 
been came down to normal in twelve 
hours, and she made a recovery without a 
single bad symptom. 
Case 2. A lady on North Hoyne avenue 
was confined and did well until the tenth 
day. I was requested to see the patient and 
Read before the Chicago Gynecological Society; The Chicago Pathological Society and the Chicago 
Medical Society, found her temperature 1040. Gave intra- 
uterine douche and curetted. Temperature 
came down and she made an excellent recov- 
ery. 
Case 3. A lady on the south side aborted 
at the end of four months. It is probable 
that this loss was from gonorrheal infection. 
Temperature the second day 104 1-5 ; anx- 
ious look; bad pulse; more or less distention 
of the abdomen. Symptoms were all bad. 
Gave intra-uterine douche and curetted. 
Temperature came down to normal the fol- 
lowing morning and she made a good recov- 
ery. 
Other cases have been operated upon and 
in every instance where contra-indication did 
not exist a favorable result has always taken 
place. 
Operations undertaken as the last and only 
resort have not been uniformily successful, 
but no bad symptom has ever been produced. 
There is no doubt in my mind but that 
puerperal diseases are more frequent than 
many are willing to believe ; that they take 
place frequently in the practice of physicians 
who say they have no cases of puerperal in- 
fection or puerperal fever. It demonstrates 
that we need to study this matter to a greater 
extent than ever before. 
Of the three cases which I briefly narrate, 
the temperature coming down at once, and 
an excellent recovery taking place, it is safe 
to say that without the operation they would 
have had a lingering sickness with all the 
symptoms of septicemia. It is possible that 
one would have died, and entirely probable 
that those recovering would have had an 
illness of from three to six weeks. 
Where does this disease come from? Are 
we always certain that all of the membranes 
and all the placenta come away? Can any 
one always tell by an examination that there 
is not a small amount of debris still remain- 
ing in the uterus? Do all practitioners exam- 
ine the placenta carefully? Are these women 
poisoned by themselves, or must the doctor 
or nurse bear the responsibility? 
These are some of the questions which 
come to me as I write. Of course I can not 
consider them all in this paper. 
I desire more particularly at this time to 
speak of the retention of membranes and 
small pieces of placenta as a cause of puer- 
peral fever, but in order to understand the 
relation between these substances as the 
cause of this terrible disease and other factors 
which enter into the etiology of puerperal 
fever, it will be profitable to discuss very 
briefly a few of the different theories respect- 
ing this disease. 
The great fight carried on during the past 
forty years has been to decide whether puer- 
peral fever is produced by causes from within 
or from without; in other words, is puerperal 
fever autogenetic or heterogenetic. It is en- 
tirely useless to discuss old theories which 
long since have been or should have been 
consigned to the museum of antiquities, and 
so it will not be profitable for us to speak of 
any theory previous to the time when Sem- 
melweiss, in 1847, advanced his theory. In 
the main this was that puerperal fever was 
due to absorption of decomposing matter and 
that it may come from either auto or hetero 
infection. 
Among our own countrymen the ideas ad- 
vanced by Fordyce Barker have held firm 
sway. 1 will not give his entire confession ot 
faith as he terms it, but will quote briefly 
from it. 
He believes that the disease comes from 
some unknown blood change and that we 
are as ignorant of it as we are of the blood 
changes in scarlet fever or any of the other 
essential fevers. He believes that it may be 
epidemic, infectious and contagious. He 
says in conclusion that septicemia may be 
developed in a puerperal woman either from 
autogenetic or heterogenetic infection, with- 
out puerpeial fever, but that this infection 
may also complicate puerperal fever. In the 
celebrated discussion on puerperal fever in 
New York in 1884 he held substantially the 
theories advanced above, although his ideas 
were promulgated in 1874. 
One other authority in this country has 
studied with very great earnestness the germ 
theory of puerperal diseases, and his opinions 
are held in very high regard, not only by us, 
but by fpreign authorities. I refer to Prof. 
Lusk who, with some restrictions, evidently 
believes in the germ theory, but says the 
difficulty is best solved by assuming with 
Genzmer and Volkmann that there is such a 
thing as an aseptic surgical fever, due to the 
absorption of the products of physiological 
tissue changes at the seat of injury. He also 
says that we never can exclude the possibility 
of infection in puerperal wounds, and in the 
sixth proposition in which he discusses the 
subject, he uses the following language: 
“In the present state of our systematic 
knowledge it is necessary to admit that there 
is a limited number of febrile and inflamma- 
tory disturbances occurring in puerperal 
woman, the bacterial origin of which may be 
fairly questioned.” 
Parvin in his late work is probably more in 
sympathy with advanced German ideas on 
this subject than any other American author. 
He says the doctrine of autogenesis is a con- 
fession of ignorance, the creed of fatalism, 
the cry of distress. Self-infection means 
that the house sets itself on fire, and that 
the powder magazine is exploded without 
any mischievous spark, and that this doc- 
trine of the autogenetic origin of puerperal 
septicemia is, to his mind, the very pessim- 
ism of obstetric medicine. He concludes by 
exclaiming, “Why should the city guard its 
gates when the enemy can already be in the 
citadel and begin the battle there.” 
We now turn to the English authorities. 
Galabin says that the first possible internal 
source of poison is the blood itself. Owing to the rapid absorption accompanying the 
involution of the uterus, a large quantity of 
effete material is poured into the blood to be 
disposed of by the excretory organs. He 
discusses both autogenetic and heterogenetic 
forms of the disease, and says that even in 
autogenetic forms the poison is generally pro- 
duced by germs received from the air, or 
some way from the outside, and that the 
sanitary condition of the house or locality 
may have a great influence. 
Barnes in his work of 1885 certainly 
believes in the autogenetic origin of puerpe- 
ral fever, and describes rather fully what he 
calls excretory-autogenetic puerperal fever. 
Speaking somewhat in doubt in regard to 
the germ theory Barnes asks how these 
infective microbes are introduced. He 
makes the statement that some women are 
attacked with puerperal fever before labor, 
and he also asks the question, “How do 
organisms find entrance into the system in 
those most terrible cases of all in which 
death results in a few hours ?” 
Let us now examine into the teachings and 
methods of practice of continental authori- 
ties, the German, French and Italian 
teachers. 
In the main, I think they agree as to 
etiology. If the question is asked in regard 
to the probability of recovery after a given 
obstetrical process or operation, the reply 
has come to us repeatedly: “She will recover, 
if I have not infected her.” 
The summary of everything is that puer- 
peral fever in every instance is produced by 
some cause from without; that there is no 
such thing as autogenetic infection. Retained 
membranes and placenta, according to this 
theory, are perfectly inert if infection from 
without does not take place. This makes 
the responsibility simply terrible. Kucher 
speaking on this subject acknowledges that a 
physician has a perfect right to his own 
theories, but says that in a question of great 
consequences no such liberty can be per- 
mitted. 
The cause of puerperal lever is infectious 
matter which undoubtedly exists in many, 
forms and gains entrance into the system in 
many ways. Whatever the supposed cause, 
as we formerly thought, whether contused 
tissues or clots, or pieces of membranes or 
placenta, it is now believed that the addi- 
tional element of infection must be obtained 
from some source foreign to healthy tissue. It 
is explicitly stated by some authorities that 
blood coagula and pieces of placenta in a 
uterus firmly contracted is perfectly inert, 
unless infection takes place. In the main 
matic infective disease, the microbes or their 
germs must come from without. He makes 
some statements which modify this to a cer- 
tain extent, but he is coming to believe, as is 
evident throughout his entire oration, in the 
impossibility of auto genetic infection. 
Every practitioner of experience has seen 
pieces of placenta and quite large clots of 
blood come away and no signs of fever follow. 
On the other hand the same practitioner has 
seen pieces of placenta or small clots expelled 
by the intra-uterine injections which had 
been ordered after a high temperature with 
sepsis undoubtedly present. What makes 
the difference? Simply this:—In one case 
the debris has escaped infection, in the other, 
from some cause (sometimes absolutely un- 
discoverable), the debris has become infected. 
I do not believe it is possible that we can 
ever be sure that every particle of placenta 
or all of the membranes are expelled, no mat- 
ter how careful we may be in the examination. 
Inasmuch as it is impossible in the present 
state of our knowledge to always say that our 
hands and instruments, and the hands and 
appliances of the nurse are perfectly aseptic, 
it is our duty to take extraordinary precaution 
in regard to the introduction of septic mat- 
ter. Not only this, but we should inspect the 
placenta, wash it out and place it together to 
look for small pieces that may be absent, 
with all these precautions we cannot be cer- 
tain that everything has come away. There 
may be small pieces of placental tissue 
which have existed on the membranes some- 
what remote from the main body of the pla- 
centa. These may be entirely detached from 
the membranes and no earthly power can 
detect it. And then there is evidence some- 
times that all of the decidua does not come 
away—that there is something of this left 
in the uterus. There is no doubt but that we 
have very frequently some debris left in the 
uterus, which will give rise to septicemia if 
only an infectious element comes in contact 
with it. 
It appears to me that in the present state 
of knowledge no one is justified in disbeliev- 
ing the germ theory and not taking the pre- 
cautions which have given such remarkable 
results in some of the lying-in hospitals. I 
quite agree with the authority whom I have 
already quoted, that we have no right to 
take such a great responsibility as to be dis- 
believers, even if we cannot accept all the 
advanced ideas of the German teachers. 
Their results have been so good that we are 
not justified in practicing obstetrics in the 
slipshod way in which a great many of our 
practitioners have practiced, and it is to be 
feared are practicing today. 
One of the most valuable contributions to 
our present state of knowledge in regard to 
micro-organisms and suppuration has re- 
cently come to hand in a prize essay furnished 
by Geo. Klemperer, an under-graduate 
clinical student in Berlin. It is in regard to 
the question as to whether the irritants in the 
tissue will produce suppuration when no bac- 
teria is present. It is regarded by this gen- 
tleman that the precautions taken by pre- 
vious experimenters, who have gone over 
this subject before, to prevent entrance of 
germs into the tissue cavities containing these 
irritants have been uncertain and inadequate. He has gone over the method formerly 
adopted by Straus, of Paris, in 1883, and his 
process is something as follows: 
After producing an eschar on the skin with 
a Paquelin cautery, he introduces the canula 
of a sterilized syringe through the eschar be- 
neath the skin. After the puncture is made 
he again occludes that opening with cautery. 
Such irritants as turpentine, croton oil and 
mercury are used, and with the above precau- 
tions in three cases only has pus containing 
micrococci been found. A considerable degree 
of inflammation is produced by this injection, 
but no pus. Among his conclusions are the 
following: Injections of alkalies, organic or 
inorganic acids, never produce suppuration, 
if micro-organisms be excluded. The irri- 
tants mentioned above produce violent in- 
flammation but no suppuration. If the 
results of these experiments are demonstrated 
to be true, it will be safe to say that no sup- 
puration occurs unless through the agency of 
micro-organisms, and its bearing on infection 
of pieces of placenta in a contracted uterus 
will be important. 
Another question in regard to these organ- 
isms in healthy tissues has been recently gone 
over by Hauser of Erlangen with the result 
that micro-organisms do not occur in tissues 
of healthy animals. All of these arguments 
and investigations go to prove that auto- 
genetic poison is impossible and consequently 
if our cases are followed by sepsis it must be 
due to an infection which has come from the 
outside. 
Dr. Galabin, in his Hunterian oration on 
the etiology of puerperal fever delivered re- 
cently, used the following language: (It will 
be remembered that in the early part of this 
paper I quoted from an obstetrical work of 
this gentleman, and in that he leaned toward 
the auto-genetic origin of puerperal diseases.) 
He says in substance that the old divisions oi 
puerperal fever into auto-genetic and hetero- 
gene tic classes may clearly be regarded as a 
less radical and scientific division when it is 
remembered that in every case of true trau- 
matic infective disease, the microbes or their 
germs must come from without. He makes 
some statements which modify this to a cer- 
tain extent, but he is coming to believe, as is 
evident throughout his entire oration, in the 
impossibility of auto-genetic infection. 
If it is true that some debris may remain in 
the uterus notwithstanding the greatest pos- 
sible care, and also true that the most ardent 
believer in the germ theory sometimes has 
infection following his obstetric procedures, 
it seems to me that the operation of relieving 
the uterine cavity of this poisonous matter, if 
it can be done early, is one of the first oper- 
ations to which we should resort in the cure 
of this dreadful disease. 
In every parturient woman whose temper- 
ature goes to 103, something should be feared. 
It will not do for us to fold our hands and 
try to convince ourselves that it is a little 
malaria, or that it is milk fever, or something 
that may not jeopardize the life of that wo- 
man. I am free to admit that we do occasion- 
ally have a temperature of 103 to 104 which 
is trivial and disappears in a very short 
time. On the other hand I do know that a 
great number of practitioners who try to con- 
vince themselves that this temperature is not 
due to septic influences, have these cases 
which last with fever, and sweats, and pros- 
tration for weeks, and sometimes months. 
It has appeared to me that in the majority 
of cases that I have watched carefully, that 
the first explosion, the result of infection, 
takes place about the third or fourth day and 
again about the seventh or eighth day. If 
the uterus of any woman whose temperature 
goes to 103 on the fourth day could be thor- 
oughly washed out in a way which I shall 
describe, it is my belief that a very large num- 
ber of them would have no more fever, that 
they would have a safe puerperal convales- 
cence. If they are left until the seventh or 
eighth day, until the second explosion, in 
many cases the infectious matter and the 
prognosis will be more grave. Intra-uterine 
injections first of carbolized water, or, if 
sublimate solution is used, the uterus must be 
washed out with perfectly pure water. Then 
if the temperature does not go down the fol- 
lowing day the curette should be used with 
all possible antiseptic precautions. It does 
not do to use the finger as a curette, nor 
does it do to use the small short curettes, as 
they are entirely inadequate and do not 
reach the point of disturbance. 
If puerperal fever is due, in a given case, to 
a poison introduced through the lungs, and 
the general system is invaded before confine- 
ment, of course, neither intra-uterine injec- 
tions or curette is admissable. If, too, the 
infection comes from an inflammation 
or suppuration in the tubes, which may 
have been latent till the irritant and trail 
matism incident to parturition takes place, 
these two curative agents are not indicated. 
But if they can be excluded we must look 
along the genital tract for the place through 
which the infection has taken place. If no 
abrasions are found and the odor does not 
disappear with the ordinary vaginal douches, 
then it appears to me we must look to the 
cavity of the uterus. 
THE OPERATION.— INTRA-UTERINE INJEC- 
TIONS. 
I have in the first place a piece of good- 
sized rubber tubing, one end of which is 
provided with a sinker, and the other with 
an apparatus for regulating the amount of 
fluid running from the tube. An appliance 
may be placed upon the tube which will 
catch upon the side of the pail or pitcher, 
and serve to keep it in place. The intra- 
uterine tube is of glass, about fourteen inches 
in length, somewhat smaller at the uterine 
point, grooved on the front and back with 
good-sized perforations. The operation is 
best done if the patient is placed upon a table, with an oil cloth under her, extending 
to a slop-jar on the floor, so that all the fluid 
shall run into this receptacle. The external 
genitalia should be made thoroughly aseptic, 
then the vagina should be thoroughly 
douched, and the speculum introduced. The 
uterus may now be pulled down with the vul- 
sellum and an intra-uterins douche given. 
There is no rule that can be given in regard 
to the amount of fluid which should be used 
at eace time, but each operator must judge 
for himself. Carbolized water should usually 
be used. Injections of bi-chloride solutions 
in the uterus at full term have been followed 
by mercurial poisoning, and it is not now 
regarded as good practice to use this agent. 
If for any cause it should be used, the cavity 
of the uterus should be washed out with pure 
water to rid it of the mercurial salt. The 
operation may be concluded by the introduc- 
tion into the uterine cavity of a suppository 
of iodoform, containing from 15 to 75 grains. 
Experience has taught us that it is safe to 
use as high as 75 grains. Any amount above 
that may be followed by symptoms of iodo- 
form poisoning. If at this or any subsequent 
time it is deemed advisable to curette the 
uterine cavity, the same steps in the operation 
are taken, including at first an intra-uterine 
douche to clear out all the septic material 
that is possible, and then using the curette. 
CURETTING THE UTERUS. 
The instrument that I have been in the 
habit of using is twelve and one-half inches 
long. It is not flexible, although I am not 
certain but that the instrument would be im- 
proved for some cases if it was. Its operat- 
ing end is provided with a dull fenestra 
about three-quarters of an inch in diameter. 
A little experience usually teaches one where 
to find the site of the placenta, over which 
the curette is drawn, using, of course, only 
a small amount of pressure. After this is 
completed, the instrument may be passed 
around until the entire uterine cavity has 
been carefully but entirely scraped. This 
being completed, a very large uterine douche 
should be given, and then an iodoform sup- 
pository introduced. In several cases the 
temperature has gone down within a very 
short time, and the patient made a recovery 
without a single bad symptom. A coil placed 
over the abdomen is a very valuable adjunct 
to be used immediately after this operation 
when the temperature is high, and it is also 
an important agent to prevent any inflam- 
matory action which might follow the opera- 
tion. In part of the cases, I am in the habit 
of giving an anesthetic, but in others the 
patient stands the operation well without this 
agent.