THE RATIONAL TREATMENT OF CERTAIN PUERPERAL DISORDERS


THE RATIONAL TREATMENT OF CERTAIN PUERPERAL DISORDERS. IT is related of an ambitions but pretentious lawyer that during his first argument before the Supreme Bench of the United States, it became necessary for the Chief Justice to interrupt him with the suggestion that “This court may be presumed to know something about law!” The admonition of the eminent jurist is not unheeded. I assume that he who takes the time and the trouble to read or to listen to these words is tolerably familiar with the present teachings of the science of bacteriology, the present state of development of the germ-theory.


IT is related of an ambitions but pretentious lawyer that during his first argument before the Supreme Bench of the United States, it became necessary for the Chief Justice to interrupt him with the suggestion that “This court may be presumed to know something about law!” The admonition of the eminent jurist is not unheeded. I assume that he who takes the time and the trouble to read or to listen to these words is tolerably familiar with the present teachings of the science of bacteriology, the present state of development of the germ-theory.

Bacilli have been devoted attendants upon the human race, lo, these unnumbered ages. We made their acquaintance but yesterday. Not too late, however, for they will continue to abide with us a few centuries longer. It is for us simply to determine upon a proper style of department toward our newly-discovered companions.

The practical relations of human beings to such tiny yet murderous associates are susceptible of a threefold division natural at once and logical. The underlying conditions are: 1. The obnoxious microbes outside the unbroken covering, cuticular or mucous, of a vigorous healthy body. 2. Their actual storming of more or less accessible breaches in the vital armor, establishment by violence or by physiological processes. 3. Their establishment of camps within the human frame.

Evidently, the functions of a physician toward these conditions are as diverse as the situations indicated, although in any given instance he may be compelled to discharge them all. Concerning the bearing of a surgeon toward disease-germs, I will not presume to speak, although elsewhere I have intimated, by reference to unimpeachable authority, his subjection to the same principles which should govern his brother.

If a physician is consulted concerning pertinent matters when thoroughly satisfied none of these little creatures have discovered an entrance to his patron’s body, he must act simply as a hygeist. To the performance of that duty, however, he should bring all attainable knowledge of the resources of sanitary science. This service has, singularly enough, been dubbed by some “preventive medicine,” an incongruous and absurd appellation.

Should a doctor succeed in catching any of the well-nigh omnipresent wanderers in an attempt to scale any breach opening to the citadel of life, he would at once thoroughly, though gently, sweep thence the invading hosts, for, as was shown in detail one year ago, experience and bacteriology alike forbid the application of corrosive or irritating substances to raw surfaces.

If aid has not been summoned until invasion has been measurably accomplished, the attendant’s duty is still unmistakable. Since the chief physiological disturbances and anatomical changes (pathological conditions) subsequent to the lodgment of these impalpable foes within the human frame are the direct result not of themselves nor yet of their work, but of the efforts of the organism to free itself from their presence, it follows as naturally and as inevitably as does the day the night that the proper course of action is the administration of medicaments which shall intensify and sustain (reinforce) the exertions of the affected organism in its endeavors to expel the intruders; in other words, the dispensation of remedies capable of producing corresponding phenomena when given to the healthy and sound. The possession of such property by any substance can be definitely known, of course, only through antecedent experiment.

Parenthetically, it may be remarked (a) that it is perfectly proper to speak of a person’s being threatened with any one of many of the so-called diseases. Should an invading host be routed before it had deployed its columns, before it had clearly manifested its character, any assumption consistent with the apparent phenomena would be legitimate. (b) The inherent possibility of overwhelming the enemy at any time is also evident, although the synchronous destruction of his works is neither claimed nor expected. A reported cure at any stage of any case of an infections disease requires, therefore, no stronger proof than other commonplace statements of alleged facts. .

To resume: Since the laws of nature are general, not to say universal, originating not in human formulation, but in the established constitution of things, and since the known field of infections disease is broadening with marvelous rapidity, while extreme uncertainty attends the limitation of its boundaries, it is clear that with him lies the burden of proof who dares affirm that the administration to the sick of remedies capable of producing corresponding phenomena when given to the healthy, is not the proper course of action in all curable cases.

Finally, since the character of the work of many microbes varies with the age, sex and condition of their victim, and since autopsies frequently reveal their unsuspected pressure at important points, there is no reason to expect a parasitic pathology will prove a more reliable guide the healing art than have been the humoral, the methods and the pneumatic. Hence naught remains for the true physician but to exemplify the singularly significant motto of this World’s Congress, and day by day to treat.

NOT THINGS, BUT MEN”.

DISCUSSION.

L.C. GROSVENOR, M.D.: Mr. President, Ladies and Gentlemen. – If there is an evil principle in this world, it is always ready to jump on us when we are down. If we see a boy going to the bad, we say that is all I expected of him. I know him when he was a little fellow. There is another principle always ready to boost us when we are going up. Now, these two principles are just as active in our physical life as in our educational life, in our moral life, or anywhere else, when we are in high health or when we are in diseased condition. These microbes are of all denominations.

They are ready to jump onus and abuse us. When we are, in a general way, in fine health, they pass by an the other side of the street and take off their hats to us. This is one of the inducements, not only to us as doctors, but to our patients, to always live a high physical plane.

ALONZO BOOTHBY, M.D.: I could say anything on the other matter when you spoke to me, but when I get a chance on this subject, I always take advantage of it. I believe that remedies have a great deal of influence on septic disease, but I would not say that we have to depend upon them in all cases; and while the paper has hardly committed the writer to that position, yet that is what it leads to, or what has it led to? If we have a perfect condition of things, e do not need any antiseptic, but we do need the aseptic principle put into practice in every case; and I presume that hardly anybody here would think of attending a case of confinement, any more than they would attempt making a surgical operation, without having everything clean about them.

If you have everything clean and a healthy subject to deal with, I say you need nothing more than that. But suppose you have a diseased vagina; then are you not going to use your antiseptics, and is it not true that a cut surface anywhere will bear these applications with perfect immunity? I think that those who use them speak most positively in regard to them, and it is not to the advantage of any member of this Congress to suppose that they will do harm, because the one who has used them says that they did not do any good in the proper way. Some one spoke of using one to ten thousand of the bichloride solution.

Now, you might just as well use hot water. That is what you get when you use such an antiseptic. If you use an antiseptic, you must enough of it and use it long enough to produce some action on microbes. They would bear that solution for two or three minutes, and be just as lively as ever. Beside, we have not to adopt the germ- theory. It is possible that it is the poison accompanying the germ; but whether it is the one or the other, the effect is the same.

DR. FOSTER: Mr. Chairman, Ladies and Gentleman.-I have nothing to add to what has been said already. I might give you my own opinion about antisepsis in midwifery and asepsis, and I don’t know that it would carry any particular weight with this body. I think that if we have the evidence of septic infection present, we ought to use antiseptic measures to antidote the evil and if we haven’t any evidence whatever that there is any such thing wrong with the patient, then we ought not to have anything to do with antisepsis or asepsis, for our patient is aseptic already. One gentlemen said, what I don’t understand, that a solution of corrosive sublimate one to five thousand would be no more efficacious than hot water.

DR. BOOTHBY: I beg to correct that. It was one to ten thousand that would have no beneficial effect.

DR. FOSTER: Well, one to ten thousand has sometimes produced serious symptoms. One to five thousand has caused death, and that in more cases than one, so I don’t think corrosive sublimate is always safe even when made in as high a solution as one to ten thousand.

R. LUDLAM, M.D.: I think it is important to be specific in what we are talking about. Two or three have the same opinion, but they haven’t specified. My good friend, Dr. Boothby, thinks that such a weak solution as one to ten thousand of the bichloride would be of no great service in the vagina. My good friend, Dr. Foster, speaks inferentially, of the bichloride upon the perinaeum. The bichloride in contact with the perinaeum is very poisonous in a very weak solution, but it is not so in the vagina, unless it chances to get through into the perinaeum. So I submit that these two very clever fellows are talking about two things.

C.H. COGSWELL, M.D.: I don’t know that I dare tackle this subject. I had occasion to prepare a paper for the American Institute last year, but it is very seldom that I do. I stated in my paper then-I can only reiterate the statement to-day-that I have no use for antiseptics in obstetrical practice. I have never seen a time when they were needed. I know of a great many cases that have been injured by the use of them. I reported twenty cases last year from the use of the bichloride (one to three thousand) in labor. I try to be clean and keep my patients clean and when I have done that I believe i have done all that the good Lord asks me to do.

H.W. ROBEY, M.D.: One point, I think, would profit all of us to ponder. It seems to me that the Homoeopathic profession is gradually and surely taking ground against the germ-theory of the origin of disease, and we, I believe the majority of us, are coming more and more clearly to the conclusion that it is merely one of the passing fancies of the age-that diseases are not, as a rule, produced by these germs, but they are simply the accompaniments of disease; they act as scavengers of the system to throw out the morbid product of disease and that they are blessings in disguise and not our great enemies. We find connected with all the products of decomposition, both in the animal and vegetable kingdom, certain kinds of scavengers which nature seems to have provided in her great law of conservation.

DR. SHELDON LEAVITT: I have been slow to put myself on record with regard to this matter of antisepsis. I have been undecided in my own mind just what course it is best to pursue. I spent some six weeks with Tate in Birmingham, England, and I saw there the utter disregard for these things which he manifested, and at the same time the excellent results which he obtained in a surgical way. In regard to practice of an obstetrician I may say that this is an important matter.

I make no allusion now to the puerperal state wherein we may have indications of pathological conditions, but I allude to parturition. I always wash my hands thoroughly before in operation, and I usually employ no antiseptics. If the nurse asked me if I wished to use in antiseptic solution, I would say: “Yes, with thanks.” If nothing is said, I do not use it. In am particular to wash my hands very clean. I carry in my case the bichloride and Carbolic acid, but in three cases cut of four I make no use of them. I have in my private practice for a number of years seen no evidence of septic infection.

My practice in the hospital is difficult. The conditions and circumstances and surroundings are different, and I feel called upon to exercise still greater precaution. Now, I believe that we ought to exercise unusual care in the hospital, but what I have been alluding to, in my remarks just made, is to practice of a private nature, and you have my modus operandi in these cases.

DR. HARVARD: I would like to ask one question of Dr. Leavitt. If we, as physicians, are not responsible for our example, and if we have positive opinion upon subject we should say “yes” when we mean it, and if we think it is not necessary say “no”, with thanks”.

DR. LEAVITT: As I said, my opinions on this subject are not very positive, but I am giving my practice.

J.W. HINGSTON, M.D., North Platte, Neb.: All who have yet spoken have been from the cities, and their practice is mostly among the better classes. They have a privilege, to a certain extent, of choosing their patients. Now, it has been my experience to be called into places from which I would gladly have staid out-called there was neither fame nor name. When we look around for a nurse, we find one of the same class. When we wish to give instructions as to the work, we find that, no matter how particular we are, our words are entirely neglected. If we ask for a syringe, it is black with fifth; if we ask for a basin to wash our hands in, it is one used in the kitchen. So that it is often a question in my mind whether we should do anything at all in the way of antisepsis.

PHOEBE J. B. WAITE, M.D.: We must remember that there are many things to be learned form experience, and from the experience of those who have gone before. The fact remains that notwithstanding all the antisepsis that we are talking about to- day, our grandmothers and our mothers had families of six to ten and even up into the teens, and they lived and that children lived, and the doctors who attended them had never seen a fountain syringe, had never heard of the bichloride, and the disgusting smell of Carbolic acid was unknown in the world.

I suppose there is not a gentleman in this room who does not believe that cleanliness is next to godliness. When I began the practice of medicine I understood that. I have had no case of septic poisoning and have used an Carbolic acid or bichloride. Among the “well-to-do” I can have things more comfortable, but I dare not say I have had any better success than among the lower classes.

F.B. RIGHTER, M.D.: I am very desirous of hearing the end of Dr. Hingston’s story, and I have just asked him if he was troubled in his cases with peritonitis and other septic diseases, and he says no. Now this is enough to shatter the rankest bacteriologist. I was in hopes, when I came here, that I would gain some knowledge as to whether this World’s Congress believes in the germ-theory as the cause of disease. The discussion of the subject by the essayist wandered over a large territory. I may be doing him an injustice, but he seemed to me to treat this subject with something like levity. I don’t catch the drift of his paper; however, what I did get of it reminded me of that great American humorist who, when he announced his subject, never referred to it again during the whole lecture.

In regard asepsis, I, with Dr. Hingston, have seen many cases which occurred where the conditions were as bad as they could be, and no bad results occurred. Now that may be due to our atmosphere and our climate. I never in my practice of obstetrics use the vaginal douche unless there is some special call for it.

F.J. BECKER, M.D.: I must apologize for speaking here, but I cannot refrain from saying something in the face of these remarks, which seem to leave the impression that we, as physicians, are allowing ourselves to stand in the face of the facts which are taught us by bacteriologists. If these men who have spoken to-day knew what has been accomplished in German hospitals in the way of antisepsis, they would be friends of antisepsis. I am a friend of asepsis, but there are cases in which antisepsis must be practiced in order to obtain asepsis. Take the germ of cholera and put it in gelatine, and the germ can be produced and reproduced. The fact that many persons escape septic disease is no argument whatever against antisepsis.

MARTHA G. RIPLEY, M.D.: I should say that the practitioner who comes from a case of erysipelas has no business in the obstetrical room.

The younger men and women may learn something from the practical experience of those who talk to them. There is something to be said for the country practitioner in the way of good air, which in crowded cities we don’t get. If I could choose my patients, I would have their surroundings pleasant and the best of nursing, the best of care. But in general practice we must do the best we can. I think we forget that an obstetrical case is not necessarily a pathological case; that it is physiological. I live in a city where I presume that two-thirds of the women are attended by midwives. We have a large Scandinavian element, and they rarely call in a physician. They take no antiseptic precautions, and often the doctor’s business is to stand by and watch, and merely help when it is needed.

Now, in the maternity hospital of which I have charge there are hundreds of woman, and almost up into the thousands, who have been confined within a few years. We have not had a single case of sepsis. I treat these cases according to common-sense-my idea of common-sense. My hands are cleaned, the nurse’s hands are cleaned-not necessarily with bichloride, although we have it. No antiseptic treatment is used at all unless there is a bad uterus. Then we cleanse it. Fifty years ago it was better for a woman to be confined in a gutter than in a hospital. In our days things have changed. It is better for a woman to be confined in a hospital than at her own home. Why is that? Because we have found out the close relationship between the puerperal state and septic disease.

DR. BECKER: I am inclined to look at the case somewhat in the manner of Dr. Ripley. Lying-in is a purely physiological case. We have heard a great deal about the bright side of obstetrical cases. I have had, within the last two years, two cases where there was trouble. I found it was not due, however, to the lack of antisepsis, but in both cases could be traced to taking cold. Now we recognize the matter of a woman’s keeping warm during the menstrual period. We know, as physicians, the serious results arising from the suppression of this function, and I believe is we were as careful to keep our patients warm as a great many are, I do not believe we would have one-half of the bad results we now have in practice.

DR. KINYON: I want to enter a protest against one point. My friend Dr. Robey makes a statement that the majority of the Homoeopathic fraternity do not believe in the germ-theory of disease. If this is true, I feel sorry for the Homoeopathic profession. I simply wanted to make this point, when somebody objected, and said we ought not to go from a case of erysipelas to a case of confinement. Why does he object?.

GEORGE B. PECK, M.D.: I flattered myself that the members of this Institute read my paper carefully at their homes, and if they did, they found that I confined myself strictly to my subject, and furthermore, have said all there is to be said on that subject. I am well satisfied of the truth of the germ-theory of disease. I wish it was absolutely demonstrated, for in the practical working of the germ-theory I find the strongest proof and the best explanation of the cure of disease I have found anywhere. The profession as a whole believes thoroughly in aseptic precautions. That is to say, at least three-quarters, as was indicated by the statistics which I presented last year, when this subject of the germ-theory came up.

I object to the use of corrosive sublimate on chemical grounds. The instant that substance comes in the presence of liquid albumen, it forms an insoluble precipitate. That being the case, I have no use for corrosive sublimate in a vaginal douche. It has been stated that the testimony of city doctors who enjoy select practices has been given here. I am a city doctor and I defy any one, unless it be some one who has practiced in the neighborhood of Five Points in New York, to have a meaner class of patients than I myself have in regard to one class of them.

George B Peck