\ATQ. R94. I—- 188* ^ «^J^w'l j Wf'UJi ■ iitaw^iitjWWWBWi* ie Prevention and Treat- i ment of Puerperal Fever. FORDYCE BARKER, M. D., LL. D. PU«SIr>KNT OF THIi NEW TOXIC ACADEMY 07 MKDICINK. REPRINTED FROM Elje Weto ¥orft JtAebical Journal for February 9 and 16, 188£. r al Dep't, c* •^GEOA !^t « NATIONAL LIBRARY OF MEDICINE NLM DDSflD35T D V_- '» ■«> ■ :-* J£* "?"- U.S. NATIONAL LIBRARY OF MEDICINE I 'A. ■^'■^ * r - . * *■ • NLM005803290 THE ,S^ PRETENTION AND TREATMENT. V\ \ PUERPERAL FEVER. By FORDYOE BARKER, M. D., LL. D., PRESIDENT OP THE NEW YORK ACADEMY OF MEDICINE. :\ s: REPRINTED FROM 7IJE NEW YORK MEDICAL JOURNAL FOR FEBRUARY 9 AXD 16, 1884. NEW YORK: D. APPLETON AND COMPANY, 1, 3, and 5 BOND STREET. 1884. WQ ARMtD FORCES MEDICAL LIBRARY WASHINGTON. D. C THE PRETENTION AND TREATMENT OF PUERPERAL FEVER* During the five years which I have had the honor to occupy this chair I have never before seen a meeting of this Academy so enthralled by the charm of elocution, the fascination of rhetoric, the glow of conviction, and the air of one who speaks by authority—an air which can never carry weight unless it has been before fairly and justly earned by good work—as on the evening of December 6th, when the paper was read on " The Prevention and Treat- ment of Puerperal Fever." Its authoritative tone, its earnestness and sincerity, its coloring of being based on experience and observation, in- stead of being unconsciously deduced from preconceived theory, give the paper such a plausible air of scientific truth as must secure its acceptance without question by many minds whose belief rests on authority, without examina- tion of the data or analysis of argument. The more emi- nent the author of errors which may dangerously influence * Read before the New York Academy of Medicine, February 7, 1884, at the adjourned discussion of the paper on this subject by T. Gaillard Thomas, M. D., which was read before the Academy December 6, 1883, and published in full in the " New York Medical Journal," De- cember 16, 1883. 4 THE PREVENTION AND TREATMENT OF medical practice in matters of such vital importance as the saving of life of those who have just become mothers, the more striking the literary excellence and the more admira- ble the artistic merits of a paper promulgating such errors, the more necessary it is that such errors should be boldly met and promptly refuted. Any paper read before this Academy, by one to whom all concede a place among the most eminent in the department of the profession to which his life has been devoted, if allowed to pass without exami- nation and discussion, will be accepted by great numbers in all parts of the country as a statement of the science and medical practice as enunciated by the most prominent men of the period. It is therefore a duty to carefully examine those novelties in doctrine and in practice which are brought here, and subject them to the test of the advanced science of the day and the accumulated experience of the past. I will mention one other reason which has had a strong influence in overcoming my reluctance to do this work, and that is in the interest of the Academy. In view of some past controversies outside of the scien- tific aims of this body, it seems to me desirable and impor- tant that the profession at large should understand that in this hall there can be the strongest antagonism in scientific doctrines and in questions of practice, and the keenest en- counters in intellectual gladiatorship, carried on with all the courtesy of the duello, without individual hostility or the interruption of personal friendship. I think most present know the great reluctance which I have to writing, especially the mechanical part—and that other engrossing work leaves me little time for this, except what should be passed either in rest or in recreation, and will therefore thoroughly appreciate the great reluctance with which I have undertaken the duty. All will agree that the" paper was remarkable for its PUERPERAL FEVER. 5 originality, in that some of its pathological doctrines and the practice inculcated for the prevention and treatment of puerperal fever have never been taught in .any work on ob- stetrics, or by any writer of acknowledged repute. If they are accepted by the common intelligence of the profession, they will assuredly be found in the obstetrical works of the future. As there are many others who will take part in this dis- cussion, whom all will be anxious to hear, and as the author of the paper is entitled to all the time he may wish to close the debate, I shall, in the most concise language consistent with clearness of statement, give my reasons for thinking that the whole tone and coloring of the paper are mislead- ing and dangerous, because it is supersaturated with septic infection. I would not " speak disrespectfully" of puer- peral septicaemia. I believe it to be one of the most dan- gerous incidents which may occur to women after child- birth, and I trust that it will not be regarded as indelicate if I allude to the fact that in a work on puerperal diseases, published more than ten years ago, a lecture devoted to the consideration of this subject in all its relations fills thirty-seven pages. With the most anxious desire to correct any errors of opinion, and to accept any new views which progressive science or increased and more accurate clinical observation have demonstrated to be true, I have yet found no reason to make any essential change of the views expressed in that lec^ ture. In the paper which we are now to discuss, the author distinctly avows his belief, without any qualification, that "puerperal fever is puerperal septicaemia," and that "it matters not whether it assume the form of metritis, phle- bitis, cellulitis, peritonitis, or lymphangitis, the essence of the disorder is a poison, which is absorbed into the blood of the parturient woman through some solution of con- THE PREVENTION AND TREATMENT OF tinuity." Not. only the sentence quoted, but the whole tenor of the paper must convey to the unbiased mind that it is the well-defined opinion of the author that metritis, phlebitis, peritonitis, and cellulitis are never seen in the puerperal woman except as the result of an initial lesion, which permits the absorption of a specific poison through the parturient canal, either from the atmosphere—or from direct infection by doctors or nurses from neglect or care- lessness—or other agents brought in contact with the sexual organs. The tendency to this pathological view has been rapidly growing within the past few years, as a result of the enthusi- astic interest excited chiefly by the important investiga- tions of our German co-workers, who have so zealously studied the character and effects of the micro-organisms in puerperal women in hospitals. In several of the most recent and the most excellent systematic works on obstetrics I have observed that nothing is said of the various local phlegmasiae which are liable to arise in puerperal women as a conse- quence of parturition, and that they are only alluded to in connection with the subject of septicaemia. This seems to me a very grave omission, which must seriously embarrass young obstetricians, who consult these works for informa- tion when normal convalescence is interrupted by any of the local inflammations. No one, as yet, has maintained that the process of parturition and the puerperal state ex- empt a woman from those causes which induce local inflam- mation in the non-puerperal, or will deny that the process ot parturition, and other attendant conditions besides the ab- sorption of septic poison, may be the efficient cause of local inflammation; and I here state my conviction that in private practice, when there is no epidemic influence, twenty cases of local inflammation, due to such causes, will be met with where one will be found due to septic absorption. PUERPERAL FEVER. 7 It is hardly necessary to say, as I have before expressed the same opinions in a work published some years ago, that I am in entire accord with the author in his preliminary remarks as to the peculiarities in the system of puerperal women. I suppose that all educated men now know that the blood of a pregnant woman is in a state of hyperinosis, and that, as a rule, " her nervous system is in a plus state of sensitiveness and excitability, and influences which are very controllable in the non-puerperal state produce very evil results here." But it is very evident that in certain points our opinions are wide apart. He regards certain conditions, which always are found following normal labor and always occur in normal puerperal convalescence, as pathological, but which I believe to be purely physiological. The ancients believed in the poisonous nature of the menstrual fluid. Pliny described the menstrual fluid as a " fatal poison—which corrupts and decomposes urine, de- prives seeds of their fecundity, destroys insects, that it blasts the garden flowers and grasses, and causes fruits to fall from their branches." I had supposed this superstition to be extinct until in- formed by a letter from my friend, Dr. Weir Mitchell, that he knew " old men who would not permit a woman to enter their wine-room, for fear that, if menstruating, it would in- jure their wines." He also informed me that "in Roque- fort women are not allowed in their cheese cellars." I sup- pose the theory must be that menstrual bacteria will destroy the bouquet of the Roquefort cheese. But on the evening of December 6, 1883, in this Acad- emy of Medicine, I first heard the full evolution of this doctrine clearly enunciated. The lochia are described as an offensive fluid, made up of dead and decaying animal tissues, which poisons freshly made unprotected wounds. I quote textually two paragraphs : .8 THE PREVENTION AND TREATMENT OF " In every case of child-bearing the endometrium is thus encumbered, and freed by a process of exfoliation and sloughing; in every case the cervix, vaginal mucous mem- brane, perinaeum, and vulva are, in varying degrees, lacer- ated ; and in every case the offensive fluid, called lochia, poisons these freshly made, unprotected wounds." Again the writer says: " Here we have a number of recent wounds constantly and unavoidably bathed with a fluid made up of dead and decaying animal tissue in a woman whose blood and nerve states are, with reference to septic disease, like flax prepared for the spark, and who is exhausted by pain, anxiety, loss of blood, and deprivation of sleep." Other quotations might be given of a similar tenor, and the prophylactic measures, which he asserts " should be adopted in all midwifery cases, whether they occur in hos- pital or in private practice," are based mainly on this theory. Can it be true that tne process necessary for the birth of the human race is always attended with the development of a deadly poison whose malignant effects must inevitably prevent the spontaneous and kindly healing of such little traumatisms as always result from the process, and that, therefore, it is the duty of the accoucheur to take prevent- ive measures of the character proposed ? Does every partu- rient woman, in performing the function of maternity, like the scorpion,* that carries in its tail an agent for suicide, if * The late Professor William H. Van Buren used to narrate that, when a surgeon in the army and stationed in Florida, he had often seen the soldiers amuse themselves by placing a scorpion within a circle of fire. After vain and frantic efforts to escape, it would stop, strike its tail into its head or body, and instantly die. Byron refers to these insect Catos in the following lines : " The mind that broods o'er guilty woes Is like the scorpion girt by fire, In circle narrowing as it glows, PUERPERAL FEVER. 9 death is threatened by fire, physiologically generate an equally fatal poison in a corresponding locality, which the obstetrician must guard against by means that are most inconvenient, alarming, and not altogether free from danger! I do not intend now to examine the question, which I have before discussed very thoroughly, and my views have long been published, whether there is not a distinct disease, most appropriately denominated puerperal fever, when, if there be any septicaemia, it must be a consequence of a pri- mary disease, and not a cause. Nearly a hundred years ago the eminent obstetrician of London who succeeded Denman, Dr. John Clarke, wrote as follows in regard to puerperal fever : " Unfortunately, the uniformity of the dis- ease was assumed, and each author erected his own expe- rience into a standard, by which to judge of the descrip- tions and the practice of others." This observation, which I read early in my professional life, made a strong impression on my mind. I trust that it will not be deemed egotistical if I say that it had great influence on my mind during the twenty-five years that I was engaged in teaching medical students, as I felt strongly the responsibility of the position, and that I should be culpably negligent in my duty if I simply gave the results of my own observations, or the opinions of a limited number of observers, or the theories of a few popular authorities, but that I was bound to give the sum of the knowledge which had become a part of the The flames around their captive close, 'Till, inly scorch'd by thousand^throes, And maddening in her ire, One sad and sole relief she knows : The sting she nourished for her foes, Whose venom never yet was vain, Gives but one pang, and cures all pain, And darts into her desperate brain." —The Giaour, 10 THE PREVENTION AND TREATMENT OF common stock of the profession. For reasons which will be obvious, I felt this more strongly in regard to puerperal fever than any other subject which I had to discuss either before medical students or in medical societies. More has been written on this than on any one disease. It has been a terribly fatal disease in lying-in hospitals in all the great cities where such hospitals are found. It has been fatal as an epidemic in rural districts, where within a certain area every woman in a sparsely settled population, who gives birth to a child, for a certain limited period is affected, and a large proportion die. I could refer to very many pub- lished reports of such epidemics which have occurred in villages and towns where for twenty-five or thirty years previously not a single death has occurred in childbirth except from the casualties of labor, such as rupture of the uterus, haemorrhage, and convulsions. All we know of any disease is derived from the study of its aetiology, its clinical phenomena, and its anatomical lesions. The epidemic disease to which I have just re- ferred differs in all characteristic points from what is known as septicaemia. It differs in its origin, its modes of attack, its symptoms, and its anatomical lesions. The symptoms are frequently manifested a day or two before or even dur- ing labor, even when the child is subsequently born alive. In septicaemia the symptoms are never observed before or during labor, except when the foetus is putrid. The former disease, puerperal fever, originates from epidemic causes, and from contagion and infection. The latter, from noso- comial malaria, from autogenetic infection, and from direct inoculation. Can a woman after childbirth be exposed to the danger of receiving the poison which produces septi- caemia in larger doses than when she has retained in her uterus a portion of putrid, decomposed placenta ? Yet I do not believe there is a single person who has had consider- PUERPERAL FEVER. 11 able obstetric practice for twenty years who has not had more than once to remove portions of putrid placenta which has been retained for days, and the patient has had no dis- turbance of such severity that he would call it puerperal fever. In the Texas " Courier-Record of Medicine," December, 1883, Dr. H. C. Ghent, of Belton, Texas, gives an amusing report of a case to which he was called three days after labor. She was attended during labor by an ignoramus, who appears to have used considerable force, and probably made some efforts to extract the after-birth. The patient, before he left, called his attention to something like a cord protruding from the vagina, which he said would, perhaps, come away by piecemeal. On his visit the next day, he at first said that a protrusion from the vagina was a false conception, but afterward pronounced it a falling of the womb, which, after a considerable length of time, he succeeded in replac- ing, and had the anxious husband engaged for twelve hours in constructing an abdominal supporter. On the third day, Dr. Ghent removed a large portion of the placenta and membranes, a putrid mass, with a stench which " was about as much as an ordinary pair of olfactory nerves could well bear." The patient had a quick pulse and high tempera- ture, but the constitutional disturbance was easily allayed, as it seems that a "few thorough washings with hot car- bolized water" was all the treatment required. Before leaving this part of the subject now under dis- cussion, I will briefly allude to one other. point, which strikingly illustrates the difference between puerperal fever and septicaemia. I think there can be no doubt that the majority of the profession believe that all those causes of nosocomial malaria, such as aggregation, bad ventilation, contact with septic material, etc., which have a tendency to induce septicaemia in surgical cases, have an equal tendency to develop the disease known as puerperal fever in women 12 THE PREVENTION AND TREATMENT OF recently confined. But this does not prove that the dis- eases are identical, for I think there is abundant evidence that, while these causes are always requisite for the develop- ment of surgical septicaemia, puerperal fever may be a very epidemic when these causes are wholly wanting.* In the early months of 1873 puerperal fever prevailed in the best parts of the city, and in that class of society possessed of abundant means and living under as good sanitary conditions as are possible in any large city, to a de- gree and extent here unknown for the previous twenty-five years. The deaths from this disease in the hospitals and in the wards of the city where the poor are aggregated were much fewer than in many former years. In five of the best wards of the city, in which are the residences of a great pro- portion of those of wealth, and few of the class of dwellings known as tenement-houses, with a population of 307,046, there were 80 deaths from puerperal fever, while in the re- maining wards of the city, with a population of 605,245, there were but 63 deaths. In other words, I may say that during this period, in those wards of the city where the causes of septicaemia must have existed in the greatest abun- dance, the mortality was nearly one third less from puerpe- ral fever, in proportion to the population, than in the best parts of the city, where these causes of septicaemia could have existed only in a very limited degree. I have good cause to remember this epidemic, as the excessive work, mental strain, and loss of sleep which it brought upon me, as my medical friends know, affected my health to a degree that required nearly six years for perfect recovery. I saw ninety-five cases during this epidemic, of which nineteen were fatal. Most of the latter I believe to have been fatal in their character from the history which I received, and I only saw them once. I had three cases in * See "Puerperal Diseases," by Fordyce Barker, Appendix, p. 515, PUERPERAL FEVER. 13 my private practice, in one of which the patient died. After this, most of the ladies whom I had engaged to attend, by my advice, went out of town for their confinement, and all these had normal convalescence. From all these considerations, I think that if all the knowledge of this disease be derived from authors who have studied it in hospitals exclusively, it will be limited and one- sided, and the deductions, both as to its pathology and as to its treatment must in many instances be erroneous and un- safe. Especially must this be the case with those whose well-deserved eminence as operators compels them to be brought in frequent contact with surgical septicaemia and to witness the terrible results which this produces after the most skillful performance of such operations as laparotomy and ovariotomy. Indeed, one can hardly understand how such a surgeon, who accepts the theory and believes in the necessity of such a prophylaxis and such treatment as is in- sisted upon in the paper under discussion, would ever dare to enter the room of a puerperal woman. There are many other details in this connection which I am tempted to discuss, but these will doubtless receive due attention from the speakers who will follow me. I will, therefore, content myself by expressing an opinion which will surprise many who have been carried along by the popular wave of the septic theory as the initial cause of most of the puerperal diseases. My conviction is strong, based partly on individual experience, but chiefly on a care- ful study of the clinical midwifery reports of private prac- tice and all the literature of the subject in my possession— and this is very full as regards the English and French lan- guages—that, outside of hospitals, less than two per cent, of the puerperal diseases and not half of one per cent, of the deaths after childbirth are due to septicaemia. There are no statistics of private practice which demonstrate the error of 14 THE PREVENTION AND TREATMENT OF this opinion. The belief of the septicaemists that terrible dangers threaten every woman in childbirth is based wholly on theory. Because the maternal system has certain pe- culiarities differing from its normal condition—because the lochia are a poisonous fluid—and because there is always a certain amount of traumatic lesion in the parturient canal following parturition, every child-bearing woman incurs a most hazardous risk. This is a blunt statement of the argu- ment and its deductions. I do not care to summon in support of the opinion that I have just expressed any higher authority, even if it were possible to do so, than the writer of the paper which we are now discussing and from which I make the following quotations: " And yet what are the usual results ? Recovery, uni- formly, I might say universally, unless some unusual occur- rence manifests itself to prevent this happy consummation. Theorizing about the matter, one would suppose that the mortality resulting from such a state of things must be excessive." "And yet the facts are these: only about one or two in every one hundred parturient women ordinarily die when properly cared for during labor, even in public hospitals." Now, if we recall the fact that a large proportion of deaths from childbirth result from the casualties of labor, such as convulsions, rupture of uterus, haemorrhage from placenta praevia, nervous shock, etc., it will be seen that the belief which I have expressed differs but slightly, if any, from his. I certainly find it much more agreeable to refer to our points of agreement than our points of difference. The limit of time which, in justice to others who follow, I have allowed myself will permit but a very few remarks on " the prophylactic measures which should be adopted in PUERPERAL FEVER. 15 all midwifery cases, whether they occur in hospital or in private practice," as the author of the paper distinctly avows. If "she who is about to bring forth" must "be treated as one about to go through the perils of a capital operation " ; if all those preparations, so definitely enumer- ated, which gynaecological surgeons insist upon previous to an ovariotomy or a laparotomy, are necessary in ordi- nary labors; if the danger from child-bearing be so great that a wise and prudent obstetrician is justified in subject- ing his patient to the hazardous depression of intense anx- iety and fearful doubt as to results, and in surrounding her with the vivid apprehension of her family, instead of stimu- lating and cheering her with the great happiness of mater- nity and the hope of increased interest and love from her husband; if all or even a considerable part of the details mentioned are necessary " to save thousands of lives which are now lost," and to spare " thousands of desolate house- holds the sorrow of losing their female heads "—then it seems to me evident that the State should make child-bear- ing a penal offense for all those families who do not have a sufficient annual income to make it possible to carry out all these requirements. Such a law could only be made effect- ive by adopting the facetious suggestion, which appeared in the "Medical Record" of January 19th over the signature of Seth Hill, Stepney, Conn., making it compulsory for all women unable to carry out these requirements " to wear an antiseptic pad over the vulva from the inception of the catamenia until the menopause, to be non-removable with- out strict antiseptic precautions under the carbolic spray " ; and, to secure this pad, it would be necessary that some State official should apply the lock, which, no doubt, many present have seen in the Museum de l'Hotel de Cluny, said to have been used by the noblemen of France to prevent their wives from falling during their absence in the Crusades. THE PREVENTION AND TREATMENT OF The description given of puerperal fever, true as it may be, in its outlines, of the septicemia which gynaecological surgeons are so often forced to encounter, I think, will strike obstetricians familiar with the disease in the lying-in chamber as the ideal picture of a poet, differing as much from the scientific description of trained clinical observa- tion as the pictures of natural scenery by a Byron or a George Sand would differ from a scientific description of a mountain or a lake by Humboldt. As to diagnosis, I can not regard the symptoms men- tioned, even in their totality, as pathognomonic of septi- caemia, as all of them are to be found in other puerperal affections, when there is no evidence of septic absorption, unless with the author it be assumed that all puerperal dis- turbances are due to this cause alone. It is made an im- portant point by the author to determine whether " the sep- tic disease which is developing has originated in wounds situated between the os internum uteri and the vulva, or in the endometrium, above the former point." He says that " usually the question has to be decided by the efficacy or in- efficacy of frequent germicide vaginal injections in bringing down the temperature and controlling other grave symptoms." Now, I look at this subject from an entirely different point of view, and, as I have not the time to examine in detail the treatment inculcated in the paper we are now discussing, I must be content with the expression of my convictions by a few general propositions. In puerperal fever, as met with in private practice, we have to treat the consequences of some form of blood-poi- soning. This may or may not be septic poisoning. In pri- vate practice, I think it generally due to some occult, possi- bly atmospheric, epidemic influence ; in hospital patients, nosocomial malaria, often associated with septic poisoning. No treatment which interrupts the normal physiological PUERPERAL FEVER. 17 processes—such as the retrograde metamorphosis of involu- tion, the fatty transformation of the component fibers of the uterus, or the cicatrization of its internal surface by the exudation of organizable lymph, and the development of a new layer of mucous membrane, or the healing of trau- matic lesions—can be justified, unless positive symptoms, now well understood in science, demonstrate their necessity. Antiseptic injections, both vaginal and intra-uterine, are of great service when the indications for their use are clearly shown by local signs or general symptoms, but they can not be recommended with safety as a routine practice on theoretical grounds, as, for obvious reasons, they may be most detrimental in retarding the cicatrization of lesions and the other processes of normal convalescence, and are otherwise sometimes dangerous. In several cases which I have seen with others, where antiseptic injections, both vaginal and intra-uterine, had been used with all the care and precau- tions inculcated by the author and kept up for several days, the temperature rapidly fell, the profuse and sometimes offensive vaginal discharges speedily diminished, the pulse and general condition manifestly improved after the injec- tions were discontinued. I will only add a few words in regard to refrigeration as a means of reducing fever in puerperal diseases. I have no question that it may be useful in some cases, but my own experience in this method of treatment has not been favora- ble. Many years ago I tried it in several cases in Bellevue Hospital, but I soon gave it up, as the results were less satis- factory than where other plans of treatment were pursued, and I know that this was the conviction of my house staff. Cold will effectively and usefully reduce the temperature in active inflammations and acute fevers, but in adynamic diseases and in hectic fever this must be attended with a rapid waste of tissue more dangerous than the pyrexia. In 18 THE PREVENTION AND TREATMENT OF three cases which I have seen with others—two a year ago and one this winter—where the coil had been assiduously kept over the abdomen, most of the time two or three days, the conditions in each were remarkably similar. The abdo- men was blanched, colorless, and not sensitive to pressure ; the patients all avowed that the coil gave them great com- fort, but the temperature was very high in all—in one 104-3°, and in the other two over 105°; the pulse was very rapid and feeble, the heart's action extremely weak, with pulmo- nary symptoms—such as short, rapid, and shallow respira- tion—which caused grave apprehension that there might be latent centric pneumonia. After some discussion, I in- duced my friends to remove the refrigerating coil, and, in its place, to cover the abdomen with flannel saturated with the oil of turpentine, for the purpose of stimulating vaso-motor action, restoring the capillary and equalizing the general circulation. All were taking quinine in large doses. This was greatly diminished or wholly stopped, and digitalis and ammonia in full doses were substituted. In a few hours the change in each of these cases was most remarkable ; the temperature was reduced from two to three degrees, the pulse was greatly lessened in frequency and increased in force, and all pulmonary symptoms, which had caused so much anxiety, had disappeared. Two of these patients re- covered and are still living. The third, who had also been treated by antiseptic vaginal and uterine injection, was ap- parently convalescent, when suddenly she became much worse; collapse supervened, which was found to be due to a sudden development of diphtheritic membranes which cov- ered the mucous surface of the vulva and vagina, the result of carelessness and dirtiness of the nurse. The patient died in a few hours. I now ask permission to refer to a matter outside of the question of the prevention and treatment of puerperal fever, PUERPERAL FEVER. 19 but in behalf of the "truth of history." I ask any who may feel sufficient interest to turn to the 320th page of my work on the " Puerperal Diseases," where they will find on this and the following pages the subject of intra-uterine injections fully discussed. Instruments for this use, which had been devised more than fifteen years ago, were shown to the class, and explicit directions were given as to the meth- ods and indications for these injections, differing in no essential from those we heard in this hall on the 6th of December. The lecture was delivered in the amphitheatre of Bellevue Hospital, in February, 1869, and the work in which it was printed was published in January, 1874. Then it may interest some to look at page 85 of Volume IV of the " Transactions of the American Gynaecological Society," and read the papers by Dr. Edward W. Jenks, of Chicago, and Dr. James R. Chadwick, of Boston, on intra- uterine injections, and the discussion which followed. In conclusion, I will only add that my creed to-day is fully avowed on page 476 of the book to which I have be- fore referred, and, unless in the future I learn new facts and new arguments to change my faith, I shall " die impeni- tent." After the reading of the paper, Dr. Barker said: The subject is now open for general discussion. So many of the fellows of the Academy have signified their willingness to speak, and there are so many whom all will be anxious to hear, that I felt it to be a duty to limit my re- marks in the paper just read to a very restricted time, and to content myself with the enunciation of such general prin- ciples as I believe to be important truths, without entering much into details. But there is one point which I hope will receive atten- tion from the speakers who are to follow. Very early in 20 THE PREVENTION AND TREATMENT OF my practice I began to direct the use of vaginal antiseptic injections for the first week after labor, the antiseptic being Labarraque's solution. When I went on duty at Bellevue Hospital, now nearly thirty years since, this was made the invariable rule in the lying-in wards. Subsequently carbolic acid was substituted, and I give a formula for its proportions in the work on " Puerperal Diseases." I have habitually directed its use in all my obstetric cases until the past two or three years. At the time of the International Congress in London, in 1881, I happened to be seated at a dinner next Dr. Thomas Keith, of Edinburgh, and had a very interesting conversation with him as to the use of antiseptics in ovari- otomy. What he said was very suggestive, and led to a good deal of subsequent reflection on my part as to the use of antiseptics in obstetrics. I recalled to mind the fact that often in my practice I had seen disturbances and interrup- tions of puerperal convalescence the first week after labor, and it occurred to me whether this might not be due to the carbolic acid; and the following autumn I decreased the proportion of the carbolic acid one half, and thought that my patients did better. On further reflection on the sub- ject, I said to myself the carbolic acid, even in the larger proportions which I have formerly used, was not strong enough to destroy the micro-organisms. Is it not possible that Nature has wisely arranged to furnish the best fluid for constantly bathing the bruised and lacerated tissues of the parturient canal in the much-maligned lochia? Are not absolute rest and freedom from disturbance of these tissus much more favorable to their restoration than any washes that can be used ? Since that time I have considerably sur- prised nurses by directing that no injections should ever be used unless specially ordered. It is scarcely necessary to say that absolute cleanliness was strongly enjoined, and that PUERPERAL FEVER. 21 not a spot of blood, either on the bedding or on the cloth- ing of the patient, should be found. Dr. A. A. Smith, who frequently visits my patients when I have other engagements, during the first puerperal week, tells me that this direction was given more than two years ago. Since September, 1882, it is only in a small proportion of my obstetrical cases that I have seen any reason for ordering even vaginal injections, and Dr. Smith informs me that this is true of his own cases. We both can declare that since that, including even instrumental deliver- ies, we have not had a single case in our practice which during the puerperal period has given us any anxiety or required more than an ordinary attendance of one daily visit for nine days. This may be only a happy coincidence, but it seems to me significant, and I think most present may like to hear the views of others on this new departure. ARMLD FORCES MEDICAL LIBRARY WASHINGTON. D. C. The New York Medical Journal, A WEEKLY REVIEW OF MEDICINE. The New York Medical Journal^ now in the twentieth year of its publication, is published every Saturday, each number containing twenty- eight laive, double-columned pages of reading-matter. By reason of the condensed form in which the matter is arranged, it contains more reading- matter than any other journal of its class in the United States. It is also more freely illustrated, and its illustrations are generally better executed, than is the case with other weekly journals. It has a large circulation in all'parts of the country, and, since the pub- lishers invariaDly follow the poliay of declining to furnish the Journal to subscribers who fail to remit in due time, its circulation is bona fide. 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