[Reprinted from the American Gynaecological and Obstetrical Journal 
for May, 1895.] 
PUERPERAL SEPTICAEMIA IN THE PRACTICE OF THE 
COUNTRY PHYSICIAN* 
By John Mann, M. D., Jericho, N. Y. 
Bad cases of puerperal septicaemia are, fortunately, of rare occur- 
rence in the practice of the country physician. This is due, I believe, 
more because of the hygienic surroundings and constitutional vigor of 
his clientele than to any especial care as to aseptic midwifery. 
Cases which cause anxiety occur, however, and I report two; not 
that they are especially interesting per se, but illustrative as types of 
the two most prolific causes of the disease with which we have to con- 
tend-viz.: ignorant and superstitious nurses and careless practice. 
Case I.-Bad Nursing.-Primipara, aged thirty, delivered with 
forceps after a tedious labor of thirty-six hours' duration. Lacera- 
tion of the perinaeum, first degree, not sutured. The patient's condi- 
tion was normal when visited the three succeeding days. An interval 
of three days then occurred before she was again seen, during which 
time she was under the care of a younger sister, as nurse, a person of 
little intelligence and no experience. 
She had pinned the binder, the three-tailed variety, as tightly as 
possible, especially the part that crossed the perinaeum and held the 
pad of carbolized cotton, thus effectually damming back the lochial 
discharges. 
The patient was found with a temperature of 104.2° ; pulse, 125 ; 
uterus tender, relaxed, and reaching nearly to the umbilicus. As it 
was impossible to tell when the first rise in temperature had taken 
place, it was deemed best to use the curette at once. 
This was carefully and thoroughly done with the usual antiseptic 
precautions, the bichloride of mercury (1 to 8,000) being used as the 
antiseptic. 
Nothing especial came away with the curette beyond a few small 
clots and shreds of membrane, and there was no abnormal odor. 
* Read before the New York State Medical Society, February 5, 1895. 
CoPYRIGHT, 1895, BY J. D. EmMET AND A. H. BUCKMASTER. 2 
John Mann, M. D. 
After a thorough intra-uterine douche of bichloride (i to 8,000) a 
strip of sterilized iodoform gauze was loosely placed within the uterine 
cavity, and a pad of carbclized cotton used to collect the discharges,' 
which was changed every two hours. She was given half an ounce 
of whisky, followed in an hour by a tablespoonful of the sulphate of 
magnesia. 
A saturated solution of the magnesia was made, of which she was 
ordered to take one drachm every four hours, alternating with four 
drachms of whisky. 
Temperature taken in six hours was 101.40, and in twelve 
hours 990. 
The gauze was removed in thirty-six hours, and an intra-uterine 
douche of the bichloride (1 to 8,000) was given. 
The temperature did not again rise above ioo° until the ninth day, 
when it was 102°. An intra-uterine douche of bichloride (1 to 8,000) 
was used, and the sterilized gauze replaced within the uterus. 
The temperature reached the normal in eighteen hours. The 
second strip of gauze was not removed for three days, when a-thor- 
ough vaginal douche of sterilized water completed the treatment. 
The care of puerperal women in the rural districts is almost 
wholly confined to untrained and uneducated women, usually past 
middle life, who have taken up the calling as a means to increase a 
limited income. They are often uncouth, uncleanly and possessed of 
that supreme assurance that so often accompanies ignorance ; ever 
ready to give you points about the management of cases that old Dr. 
So-and-So told them years ago, and almost certain to put them in 
practice during your absence. 
The nurse as well as the people have not as yet been fully im- 
pressed with the importance of aseptic midwifery, possibly from a 
lack of courage, on the part of the physicians, to carry out the neces- 
sary details, certainly from the lack of the fearful examples of its 
neglect that often occur in the more populous centers. 
Case IT.-Careless Practice.-German woman, aged twenty-four. 
Second pregnancy. Came under treatment in the seventh month of 
gestation for a very severe attack of zoster involving the region sup- 
plied by the external saphenous nerve of the right leg, which was fol- 
lowed in two weeks by an abscess on the inner aspect of the calf of 
the same leg. This was lanced, and discharged for about two weeks 
when the patient was supplied with iodofrom gauze and instructed to 
dress it herself. She was not seen again until her confinement No- 
vember 21, 1894, when she was delivered after a normal labor of about Puerperal Septicamia in the Practice of the Country Physician. 
3 
twelve hours' duration without any complications beyond a slight 
laceration of a previously repaired perinaeum which was immediately 
sutured and the surface painted with a mixture of iodoform and col- 
lodion (four per cent). 
She did well until the evening of the fourth day when she was 
taken with a severe pain in the lower abdomen. Temperature was 
103.40 ; uterus relaxed and very tender. In looking for a cause of 
the sepsis it was found that the abscess had never fully healed and 
had not been dressed for six days until the dressing had been removed 
by the nurse the third day after her confinement. As the surround- 
ings and accommodations were such that a curetting was impractica- 
ble that night she was given a quarter of a grain of morphine hypo- 
dermically and four drachms of sulphate of magnesia. 
She had several chills during the night and the next morning her 
temperature was 106°. The principles governing the treatment of the 
first case were applied to this, viz.: thorough curetting, bichloride 
douche and sterilized gauze drainage. The results were fully as satis- 
factory, the temperature falling 40 in twenty-four hours, but it re- 
mained in the neighborhood of 102° until the eighth day when it rose 
to 105°. The gauze was then removed, another bichloride douche 
given and fresh sterilized gauze introduced. The temperature was 
101.40 in twelve hours after and gradually fell until the normal was 
reached on the eleventh day. 
The drain was then removed and a thorough vaginal douche was 
given. 
Physicians in the country of from twenty to forty years' practice 
are as a rule like the eminent Scotch surgeon, not very firm believers 
in the germ theory and although their statistics as far as fatal cases 
of sepsis are concerned may be quite good, I believe many of us are 
not so particular about absolute and perfect cleanliness. Hayseed 
and dust are apt to collect in our obstetrical bags unless carefully 
watched, and few of us, I believe, would be willing to exhibit the 
same before this Society as model outfits for the practice of aseptic 
midwifery. 
The aetiology of puerperal fever, as promulgated by the authorities 
of the present day, recognizes little else but its septic nature and 
heterogenetic origin, and unless we accept these facts our treatment 
must be faulty and our patients in great danger. 
Some may wish to classify more closely, calling these cases, in 
which the temperature is not so high and the evidences of septic poi- 
soning not so pronounced, sapraemia, or the absorption of the toxines 4 
John Mann, M. D. 
of putrefaction, and septicaemia the result of the entrance into the 
circulation direct of the germs themselves. While that may be a 
commendable division for the expert, those of us who see few cases 
would better leave so fine a diagnosis until the results of the cases 
are more positively known and keep the one point sepsis constantly 
before us. 
The aetiology being so firmly established the diagnosis ought to be 
comparatively easy, and while there may be many forms of puerperal 
fever, still I think the only safe rule is to assume that any marked rise 
in temperature occurring during the puerperium is the result of sepsis 
unless positively accounted for by some other pathological condition. 
Great reliance is often placed upon some abnormal odor to the lochial 
discharges. This, I think, is a very unreliable symptom. It did not 
occur in either of the cases reported, and I have often noticed it 
where no signs of septic absorption were present. 
In considering the treatment of a given disease the subject of 
prophylaxis demands careful attention, and when the cause is thor- 
oughly understood and its prevention made possible by proper care on 
the part of the attendants, its occurrence ought to be very rare indeed. 
This being the fact in regard to puerperal septicaemia, the physician 
occupies a very responsible position. The prophylaxis of puerperal 
fever is embraced in the practice of aseptic midwifery, which in the 
country districts presents, as elsewhere, many difficulties. Cases of 
spontaneous delivery are of frequent occurrence. The nurses and 
attendants are not of the best (unless, as often occurs, the physician 
himself performs all the duties), and births are not confined to the 
model country farmhouse, with its large sunny rooms and snow-white 
linen. The small but dirty tenement, with its foreign occupants, are 
very frequently in evidence, where scarcely anything but fresh air can 
be obtained, yet, notwithstanding all these drawbacks, hot water and 
soap can usually be had for the asking, and there can be little excuse 
for the physician himself turning the so-called physiological process 
of childbirth into the pathological one of septicaemia. 
Instruments should be boiled or sterilized at home after use and 
then wrapped in sterilized towels before being placed in the obstet- 
rical bag, and when required for use placed a few minutes in boiling 
water. Creoline or lysol can be used both as antiseptics and lubri- 
cants. Certainly no physician should undertake any obstetrical oper- 
ation without the most scrupulous care, especially of himself and in- 
struments ; also of the patient and attendants so far as he is able to 
control them. Puerperal Septiccemia in the Practice of the Country Physician. 
5 
Injuries to the pelvic floor should be immediately repaired and the 
surface painted with a mixture of iodoform and collodion (four per 
cent). Should symptoms of septic absorption manifest themselves the 
treatment to be effective should be prompt, thorough and aseptic. 
Drugs, with the exception of sulphate of magnesia and alcohol, 
can play but little part in its management, and the chemical anti- 
pyretics are especially to be condemned as not only useless but posi- 
tively harmful. 
The disease for the most part being situated within the uterine 
cavity, the local treatment should be directed to this point and the 
curette carefully and thoroughly used. The external genitals and 
vagina having been thoroughly cleansed, the curette is usually easily 
introduced guided by the fingers of the opposite hand (a speculum is 
not a necessity) after the instrument has entered the cavity. The other 
hand should be placed on the abdomen over the fundus of the uterus 
as a guide and the surface carefully scraped consecutively with a firm 
steady pressure. 
The curetting is to be followed by a flushing of the cavity with 
sterilized water to which a mild antiseptic may be added and a strip 
of sterilized gauze introduced simply as a drain. 
Although this is a simple surgical operation it is well to bear in 
mind the points made by Grandin in a recent work that " lack of 
asepsis will ruin the most expert technique " and " that each ad- 
ditional manipulation carries with it an additional risk of septic 
infection." 
Some of our text-books, even of quite recent date, advise us to 
rely on the antiseptic douche, the curette to be used only upon the 
persistence of the symptoms. 
When we know that septic absorption is taking place it would 
hardly seem proper to watch it for any great length of time. If it 
is necessary that the hands be scrubbed with a stiff brush and soap 
and water for five minutes and soaked in solutions of permanganate of 
potassium and then in oxalic acid to render them safe to use, what can 
we expect to accomplish by any simple flushing of the surface with a 
fountain syringe with a three-foot pressure and antiseptics of a strength 
that it is safe to use ? 
After a thorough curetting a mild antiseptic douche is advisable 
or better still the douche-curette where the stream is applied directly 
to the track of the curette ; but to place much confidence in the 
douche itself as a curative agent would seem to be a waste of valuable 
time. 6 
John Mann, M. D. 
A second curetting may be necessary when the temperature shows 
a tendency to rise and is not lowered by a removal of the gauze drain 
and its fresh renewal. Of drugs, the sulphate of magnesia should be 
freely given for its well-known property of removing poisonous ma- 
terial from the blood by free watery evacuations with very little irri- 
tation to the intestinal canal. 
Alcohol administered in good doses at short intervals sustains the 
strength, retards tissue metamorphosis and is an antipyretic of value. 
Is a post-partum curetting safe in the hands of the country prac- 
titioner alone and unaided as he often must be, or with such assist- 
ance as he has at his command ? 
It ought to be with such instruments as the Skene or the more 
modern douche-curette, but the ordinary sharp instrument should be 
used with great caution by one who is not very familiar with the dif- 
ference in the feeling of pathological material and firm healthy mus- 
cular tissue. 
Should symptoms of pelvic cellulitis or peritonitis manifest them- 
selves the advice of the expert abdominal surgeon should be sought 
at once. 
In conclusion, I believe that aseptic midwifery is not extensively 
practiced in the country and that it should be. That mild cases of 
puerperal septicaemia are of quite frequent occurrence, but are classi- 
fied as milk-fever, malaria, etc. That the treatment should be sur- 
gical almost exclusively and that asepsis should be the rule and guide 
of our faith and practice.