favor of regarding the genitalia of puerperal women as the exclusive
point of entry of infectious materials into the system, it seems
impossible at the present time to make all the facts coincide with
such a theory. I have the records of a number of cases occurring
during an epidemic of puerperal fever in which patients were either
attacked with fever previous to parturition, or in whose cases the
unusual length of labor, the frequency of post-partum hemorrhage, and
the imperfect contraction of the uterus immediately after confinement
were signs of some abnormal influence exercised upon the economy at an
early period of labor previous to the existence of traumatism. That
deleterious materials may find other channels for entering the system
than a wounded surface is evidenced by the cachectic condition not
unfrequently produced in physicians by too assiduous attendance in
dissecting-rooms and places in which _post-mortem_ examinations are
conducted. One severe and rapidly fatal case of puerperal fever which
occurred in Bellevue Hospital I find it impossible to attribute to any
other cause than that the woman for five months previous to her
confinement served as a helper in a lying-in ward. The post-mortem
examination disclosed no special local lesions, but her symptoms were
those of intense septicæmia. French writers report instances of
toxæmic conditions developing in young midwives during puerperal-fever
epidemics. While we are not prepared to go as far as Tarnier, who
says, "It is probable that the lungs, by their extent and activity,
offer conditions most favorable to absorption, and that often, if not
always, it is by them that poisoning occurs," it does not yet seem
time to give up the idea that under exceptional circumstances the
respiratory and the digestive tracts may allow the passage of
materials of a septic character.
Another and frequent source of puerperal fever is by direct
inoculation. Any material of a septic character, introduced into the
genital passages of a woman during or after confinement, may produce a
general infection of the system. But the point upon which I wish
especially to dwell is that it is possible to trace epidemics of
puerperal fever directly to the carrying of puerperal poison from
patient to patient through the medium of attendants. In such cases
changes in wards and the most rigid sanitary precautions avail but
little, so long as the affected personnel is continued {1017} in
charge. Unless this fact is fully recognized, all the cleverest
devices in hospital construction will fail to prevent the occurrence
of disasters. In theory, the doctrine of the contagiousness of
puerperal fever has ceased to be the subject of dispute; and yet no
longer than thirty years ago it was combated as a pernicious heresy by
both Meigs and Hodge of Philadelphia, at that time regarded as the
best authorities upon obstetrical questions in this country. Hodge,
addressing his students, said: "The result of the whole discussion
will, I trust, serve not only to exalt your views of the value and
dignity of our profession, but to divest your minds of the
overpowering dread that you can ever become, especially in women under
the extremely interesting circumstances of gestation and parturition,
the ministers of evil--that you can ever convey, in any possible
manner, a horrible virus so destructive in its effects and so
mysterious in its operations as that attributed to puerperal fever;"
and Meigs, in his letters to students, writes: "I prefer to attribute
them to accident or to Providence, of which I can form a conception,
rather than to a contagion of which I cannot form any clear idea, at
least as to this particular malady." Contrasted with these rhetorical
utterances, in an essay published in 1843 by Prof. Oliver Wendell
Holmes, entitled _Puerperal Fever as a Private Pestilence_, the
opposing testimony in favor of contagion was presented with equal
literary and scientific skill. The evidence was complete and
conclusive, and has exercised a most beneficial influence upon the
practice of midwifery in America. With his many claims to our
admiration and esteem there is probably no title which Prof. Holmes
wears with greater pride than that of pioneer in a movement that has
done so much to prevent the slaughter of innocent women and the
wrecking of happy homes.
Thanks to changed theoretical views, physicians seem now rarely to be
the carriers of contagion. At least, in studying the records of New
York City for nine years, I find that the occurrence of two deaths
from puerperal disease, following one another so closely as to lead to
the suspicion of inoculation, occurred to thirty physicians; a
sequence of three cases occurred in the practice of three physicians:
one physician lost three cases, and afterward two, in succession; one
physician had once two deaths, once three deaths, and twice four
deaths, following one another; finally, a physician reported once a
loss of two cases near together, then of six patients in six months
and then of six patients in six weeks. Thus in the practice of more
than twelve hundred physicians in nine years I find, excluding cases
occurring in hospitals, that the experience of thirty-six only lends
color to the idea that puerperal fever is due to criminal neglect on
the part of the medical profession. Undoubtedly in many of these
cases, too, the responsibility is only apparent, as when a
practitioner has, for example, had the misfortune to lose in one week
a woman from puerperal convulsions, and another in the following week
from placental hemorrhage. Singularly enough, not one of the sequences
mentioned occurred in the practice of a physician connected with a
lying-in hospital. In face of the charge that the physicians holding
obstetrical appointments in public institutions are active
disseminators of puerperal fever through populous communities, I find
that the total loss from all puerperal causes, occurring in the
private practice of ten physicians intimately associated with such
institutions, numbered during the nine years but twenty-one cases. Of
these, thirteen were the result of ordinary {1018} accidents, and only
eight cases of metria proper, of which one was developed before the
physician was called in attendance; whereas a single physician,
holding no hospital appointment, lost during the same time
twenty-seven cases, of which twenty-one were cases of metria.
There is, however, a survival of the older ideas, chiefly to be seen
among the laity, in propositions to secure absolute immunity from
puerperal fever in hospital patients by confining them in wooden
structures or by conducting births under carbolic acid spray.
I have been interested in endeavoring to ascertain how far experience
corresponds with Semmelweis's original theory that puerperal fever
owes its origin to poisonous materials obtained from dissecting-rooms
and introduced into the genital canal by the hands of physicians
attending cases of labor. With this view I have made personal
application to a number of gentlemen who have engaged in midwifery
practice while performing the functions of demonstrators of anatomy in
our medical schools. H. B. Sands, of the College of Physicians and
Surgeons, reports that in the five years during which he held the
office of demonstrator he attended about sixty cases of labor. All did
well. He lost his first patient, from childbed, a short time after he
had resigned his position in the dissecting-room. J. W. Wright, the
present professor of surgery in the Medical Department of the New York
University, who held for one year the position of demonstrator in the
Woman's College, writes me that "during the year I attended one
hundred and four cases, including twenty-two forceps cases, two of
craniotomy, two of podalic version, and four of breech presentation.
Of this number I lost two cases, one from phlegmasia dolens
complicating uræmia, from both of which troubles the patient had
suffered during her previous labor, and one from double pneumonia, the
result of unusual exposure following confinement. Out of these one
hundred and four cases I can recall but three or four cases of
metritis, and those of a mild character; I have never thought they had
any special connection with my duties in the dissecting-room. I may
add that for ten years I have attended a pretty large number of
confinements each year, and that during the whole of this time I have
been in the habit of making autopsies as occasion has offered, and of
handling and examining pathological specimens both in and out of the
dissecting-room, notwithstanding which my death-record among this
class of cases has been unusually low." Samuel B. Ward, formerly
demonstrator at the Woman's College, at present professor of surgery
in the Medical School at Albany, writes: "While I was daily in the
dissecting-room during the winter sessions of the school from 1868 to
1872, I attended thirty-two confinements, of which I have notes. All
of the patients recovered, nor did any of them suffer from any
complication that could be traced to infection." It is familiarly
known that after Semmelweis had introduced the practice, among the
physicians attending patients at the large lying-in hospital in
Vienna, of washing the hands in a solution of chloride of lime, there
was a great diminution in the mortality which prevailed,
notwithstanding which G. Braun reports, however, that in 1857, in the
month of July, in two hundred and forty-five deliveries there were
seventeen deaths. The following month Klein gave orders to suspend the
use of disinfectants. By chance, in August there were only six deaths
out of two {1019} hundred and fifty confinements, and in September, of
two hundred and seventy-five patients, none died. From 1857 to 1860
the mortality was slight, though disinfectants were not used, while
during the three following years, in spite of the systematic and
persistent employment of these agents, the death-rate once more
assumed formidable proportions.[52]
[Footnote 52: Braun, _Rückblicke auf die Gesundheits Verhältnisse
unter den Wöchnerinnen_, u. s. w., S. 32, 33.]
Of course I do not wish to underrate the importance of Semmelweis's
labors. There is no question but that it is a perilous experiment to
pass from the dissecting-room to a patient in labor without employing
rigorous measures to disinfect the hands and all parts of the person
brought into contact with the dead body. But it is well to call
attention to the fact that puerperal fever is not due to any single,
simple cause, nor can be effectually guarded against by a single
precaution; and, again, that an infectious poison does not of
necessity exist in every cadaver examined. Hausmann found that
injections into the vagina of gravid rabbits, in the latter half of
pregnancy, of serum from the corpse of a person who had not died of
septicæmia produced no fatal results, while rapid death resulted from
injections, under the same conditions, of pus from the abdomen of a
woman who had died from puerperal infectious disease.[53]
[Footnote 53: "Untersuchungen und Versuche über die Entstehung der
übertragbaren Krankheiten des Wochenbettes," _Beitr. zur Geb. und
Gynaek._, Bd. iii, Heft 3, S. 374.]
Barnes and other English writers lay considerable stress upon cases of
puerperal fever due neither to contagion nor to atmospheric
conditions, but to the poisoning of the patient by her own secretions.
There is justification for this view in the fact that even normal
lochia contain bacteria, and when inoculated into animals produce in
them affections of an ichorrhæmic and septicæmic nature. When death
takes place the tissues of animals thus treated are found to be filled
with round bacteria. Furthermore, the disease artificially produced is
in itself infectious, and can be continuously propagated in other
animals. But it may be asked, "Does not this admission cut both ways?
How is it possible, if even normal lochia possess virulent qualities,
that childbed is ever unattended by accessions of fever?" To this we
can only answer that the reasons for immunity in ordinary cases are
only known in part. Karewski[54] and other experimental investigators
have shown that the virulence of the lochia increases proportionately
to the number of days that have transpired since the birth of the
child, and that during the first three days the lochia are
comparatively harmless. Meantime, the retraction of the uterus, the
closure of the sinuses, and the formation upon the wounded surfaces of
protecting granulations, all act as natural barriers to the
penetration of poison-germs. But, aside from these reasons, there is
undoubtedly an unknown quantity calling for further investigation,
which, in the absence of positive knowledge, we are content to term
the predisposition of the individual patient. The vagina after
childbirth possesses all the conditions most favorable for the
production of putrefaction--viz. the access of air, fostering warmth,
and stagnating fluids charged with dead tissue. It is probable that
the first of these needful conditions is, in normal labors, happily
wanting in the uterine cavity. In these days of intra-uterine
medication it is well to {1020} bear in mind the relatively greater
frequency of infection through vaginal and cervical wounds, as
compared with that which takes place through the denuded intra-uterine
surface. The term auto-infection may, with propriety, be employed as a
distinctive appellation to designate those attacks of fever which, in
the absence of any demonstrable cause, occur in the early days of
childbed, and which there, quoad vitam, pursue a favorable course, and
to cases of so-called late infection--_i.e._ where, after the fifth
day, the accidental opening of a healing wound permits the tardy
absorption of poisonous secretions; but with the reserve that the
primary cause is, in point of fact, atmospheric, and the predisposing
condition the susceptibility of the individual. Cases of
auto-infection are in this country extremely rare, if not unknown
altogether, in salubrious or rural districts.
[Footnote 54: "Experimentelle Untersuchungen ueber die Einwirkungen
puerperaler secrete auf den thierischen organismus," _Zeitschr. f.
Geb. und Gynaek._, Bd. vii, 2te Th., S. 331.]
On another occasion I have shown that in New York City the death-rate
from puerperal fever is nearly twice as great during the six months
from December to May, inclusive, as from June to November. The
greatest mortality occurred in February and March, comprising rather
more than one-fourth the entire amount. The smallest number of deaths
occurred in September and October, in which months but one-thirteenth
of the entire number took place.
That puerperal fever, in its harvest of death, does not spare the
wealthy and well-to-do classes is too familiar a truth to be worthy of
discussion. That, however, the wealthy do enjoy special immunities as
compared with the less-favored members of society, I have shown by
comparisons made between sections of the city which, though lying side
by side, exhibit in a marked degree the two extremes of wealth and
poverty. Thus, the mortality among the representatives of the lower
social strata, in proportion to population, was from three to six
times as great as that among the more fortunate classes.
RELATIONS TO ZYMOTIC DISEASES.--In investigating, some years ago, the
nature, causes, and prevention of puerperal fever,[55] I prepared,
from the statistics of the Health Board of New York City, tables
extending over a period of nine years to answer the inquiry as to
whether there was any relation between the frequency of deaths from
scarlatina, diphtheria, and erysipelas and those from metria. Previous
to their publication I was anticipated in my deductions by a paper
upon the same subject by Matthews Duncan.[56] Neither Duncan nor
myself found any such relation existing between the statistical
frequency of puerperal fever and the zymotic diseases mentioned. There
was, however, nothing in our investigations to invalidate any direct
testimony which tends to show that, in individual cases, a real
connection between puerperal fever and the zymotic diseases may exist.
Indeed, it seems to me to be fairly established that a poison may be
conveyed from patients suffering from either of the foregoing morbid
processes which may be absorbed by the puerperal woman, and may in her
give rise to an infectious fever possessing an intense degree of
virulence. My friend Prof. Barker has recently drawn attention to the
important relations of intermittent fever to the puerperal state. I
have not, however, thought it advisable to complicate {1021} the
present discussion with any extended notice of his very valuable
observations. So far as malarial fever occurs unequivocally as such in
puerperal women, there is no more reason for establishing a special
category for puerperal malaria than for puerperal typhoid or puerperal
small-pox. In the class of cases characterized by sharp chills,
intense fever, irregular remissions, and profuse perspiration, which
pursue a pernicious course unaffected by antiperiodic remedies, the
nature is extremely dubious. The same symptoms are likewise
characteristic of certain forms of pyæmia, and I cannot learn that
such cases are familiar in the practice of those of our physicians who
practise outside of cities in districts where malarial affections are
most prevalent.
[Footnote 55: _Trans. of the International Med. Congress_,
Philadelphia, 1876.]
[Footnote 56: "On the Alleged Occasional Epidemic Prevalence of
Puerperal Pyæmia, or Puerperal Fever and Erysipelas," _Edinburgh Med.
Journal_, March, 1876, p. 774.]
PREVENTION.--Of the 3342 deaths from puerperal causes in New York City
from 1868 to 1875, inclusive, 420 occurred in hospital, or one-eighth
of the entire number. Of the 1947 cases of metria, about 300, or not
quite one-sixth, were contributed by the hospitals. After such a
showing the first impulse would be to cry out loudly for the
suppression of the maternities. But a wiser policy suggests an inquiry
as to whether the large mortality mentioned is an evil necessity. The
following reports will show how much may be done in the present state
of our scientific knowledge to so control the conditions which favor
the generation of puerperal diseases in large hospitals as to make
them safe asylums for the needy.
Goodell[57] has stated that at the Preston Retreat in 756 cases of
labor there have been but 2 deaths from septic disease. Winckel[58] of
the Lying-in Institution in Dresden reported, in 1873, 18 deaths from
metria, or 1.8 per cent., but from the 10th of January to the 7th of
July in 570 births there was but 1 case of septic disease; in the year
1872 the death-rate exceeded 5 per cent. The reduction in mortality
was no fortuitous circumstance, but was due to rigid measures for the
prevention of disease. Stadfeldt[59] reduced the mortality from
puerperal fever in the Maternity Hospital of Copenhagen from 1 to 37,
the proportion between the years 1865 and 1869, to 1 in 87 between the
years 1870-74. Johnston[60] reports, in the Rotunda Hospital of
Dublin, during the seven years of his mastership, 7860 births with 169
deaths, of which 85, or 1 in 91, were from metria. Braun von
Fernwald[61] in sixteen years reports 61,949 confinements in the vast
Maternity Hospital of Vienna, with 825 deaths from puerperal fever, or
1.3 per cent. In a visit made by me to the Vienna Maternity in 1883, I
was informed that the recent mortality, including difficult
operations, had been reduced to one-half of 1 per cent.
Spiegelberg[62] lost, in 901 confinements at Breslau, only 5 cases of
puerperal fever. Beurmann[63] reports that in the Hôpital
Lariboisière, under the administration of M. Siredey, the death-rate
in 1877 was 1 in 145, and in 1878, 1 in 199, confinements; in the
Hôpital Cochin, under the charge of M. Polaillon, the total mortality
from 1873 to 1877 was 1 to 108.7. In 1877 there was but 1 death from
puerperal causes in 807 confinements. Upon Prof. Streng's division of
the magnificent {1022} maternity in Prague, I was told that, in
1882-83, in over 1100 confinements there had been no death from septic
causes.
[Footnote 57: _On the Means employed at the Preston Retreat for the
Prevention and Treatment of Puerperal Diseases_, p. 13.]
[Footnote 58: _Berichte und Studien_, Leipsic, 1874, S. 183.]
[Footnote 59: _Les maternités, leur organsation et administration_,
Copenhagen, 1876.]
[Footnote 60: _Clinical Reports_, from 1870 to 1876, inclusive.]
[Footnote 61: _Lehrbuch der gesammten Gynaekologie_, S. 885.]
[Footnote 62: _Ibid._, S. 748.]
[Footnote 63: _Recherches sur la mortalité des femmes en couches dans
les hôpitaux_, Paris, 1879.]
When the maternity service was transferred in 1872 from Bellevue
Hospital to Blackwell's Island, it became necessary to make some
provision for so-called street-cases--_i.e._ women taken suddenly in
labor without homes, and representing the extremes of penury and want.
At first they were received, in part, by the various private
institutions of charity in New York City, but these in 1877 decided to
exclude them thenceforth, on the ground that their condition at the
time of their reception was such as to endanger the lives of the
inmates for whom the charities were specially provided. An old
engine-house was then put in readiness by the city, and under the name
of the Emergency Hospital was placed under the charge of Henry F.
Walker[64] and myself. The number of confinements in the Emergency has
averaged 220 annually. The death-rate from all causes has been 2 per
cent., which, though large, is not an unfavorable showing when we
remember that the patients all belong to the homeless class, that all
were taken in labor before their entrance, and that many of them were
in a deplorable condition at the time of their admission. The
hospital, too, receives a considerable number of patients annually who
are sent there only after protracted, and often severe, operative
measures have been fruitlessly attempted outside its walls.[65] The
building possesses, for maternity purposes, two fairly ventilated
rooms. Excellent nurses are furnished by the New York Training School
for Nurses. Mr. Osborn, a liberal private citizen, has had constructed
in the rear, but detached from the main house, a small pavilion,
modelled after that of Tarnier, for the reception of infectious cases.
The Commissioners of Charities have promptly responded to every call
made upon them to extend the facilities for the care of patients.
[Footnote 64: Dr. Walker has since resigned, and my present colleague
is Prof. Wm. M. Polk.]
[Footnote 65: From Oct., 1883, to Aug., 1884, there have been confined
168 women in the hospital. Twenty were brought in from the street just
after the birth of the child. Of these 188, not one suffered from any
puerperal affection. There were 2 deaths--1 from intestinal
ulcerations, possibly the result of the corrosive sublimate
irrigations, and 1 from exhaustion. This latter patient had been
thirty-six hours in labor before she was brought to the hospital, and
died four hours after admission. Under the admirable management of
Miss Hart, the matron, in addition to the slight mortality, there has
likewise been almost complete absence of even trivial temperature
elevations.]