Puerperal fever

“ But puerperal fever differs from either small-pox or cholera in that the latter presses largely upon the aged and the very young, while the former gathers its victims exclusively from a selected class—viz. from women in adult life, the mothers of families, whose loss, as a rule, is a public as well as a private calamity. ”

“ Many of the diseases peculiar to women have been deprived of much of their terrors within a hundred years. In 1800, for every thousand children born, from ten to twenty mothers died. Puerperal fever occurred in epidemics, following certain physicians and nurses, but nothing was known as to its causes or nature. To-day puerperal fever is almost unknown in the hospitals or in the practice of a skilled physician. ”

“ It is not enough that a practitioner should have had a single case of puerperal fever not followed by others. It must be known whether he attended others while this case was in progress, whether he went directly from one chamber to others, whether he took any, and what precautions. It is important to know that several women were exposed to infection derived from the patient, so that allowance may be made for want of predisposition. ”

“ Those who have never made the experiment can have but a faint conception how difficult it is to obtain the exact truth respecting any occurrence in which feelings and interests are concerned. Omitting particulars, then, I content myself with remarking, generally, that from more than one district I have received accounts of the prevalence of puerperal fever in the practice of some individuals, while its occurrence in that of others, in the same neighborhood, was not observed. Some, as I have been told, have lost ten, twelve, or a greater number of patients, in scarcely broken succession ”

“ Puerperal Fever, or Peritonitis, commonly alledged to be peculiar to women after delivery, has been dignified by the moderns, from its danger and fatality, with a generic name: happily for the fair sex, it does not often occur: sometimes it is epidemic, from some unknown quality of the atmosphere; and in such circumstances a considerable number of puerperal women are afflicted at the same time. It generally attacks one or two days, but sometimes a few hours after delivery ”

“ However ignorant we may be of the nature of the puerperal fever, of this we are certain, that the female system is in such a state, on delivery, that errors in either of these respects are apt to produce the disease; too much heat will cause it full as often as too much cold.
That particular state or predisposition of their bodies, must be inquired into, before we can throughly understand this disorder. ”

“ This is undoubtedly the most serious of all those maladies that so often follow labor. It appears from medical records that puerperal fever has been known from very remote times, and that it has frequently become epidemic, or has spread from one to another, like the Cholera. In hospitals this has often been observed, and also in cities, sometimes almost every female delivered in the place having been attacked while it prevailed. ”

“ Warrington stated that a few days after assisting at an autopsy of puerperal peritonitis, in which he laded out the contents of the abdominal cavity with his hands, he was called upon to deliver three women in rapid succession. All of these women were attacked with different forms of what is commonly called puerperal fever. Soon after these he saw two other patients, both on the same day, with the same disease. ”

“ On the occurrence of a single case of puerperal fever in his practice, the physician is bound to consider the next female he attends in labor, unless some weeks at least have elapsed, as in danger of being infected by him, and it is his duty to take every precaution to diminish her risk of disease and death. ”

“ It is true that some of the historians of the disease, especially Hulme, Hull, and Leake, in England; Tonnelle, Duges, and Baudelocque, in France, profess not to have found puerperal fever contagious. At the most they give us mere negative facts, worthless against an extent of evidence which now overlaps the widest range of doubt, and doubles upon itself in the redundancy of superfluous demonstration. ”

“ Collins's mastership, there was one case of puerperal fever to 178 deliveries, or less than six to the thousand, and one death from this disease in 278 cases, or between three and four to the thousand a yet during this period the disease was endemic in the hospital, and might have gone on to rival the horrors of the pestilence of the Maternite, had not the poison been destroyed by a thorough purification.
In private practice, leaving out of view the cases that are to be ascribed to the self-acting system of propagation, it would seem that the disease must be far from common. ”

“ In my practice I have had several single cases of puerperal fever, some of whom have died and some have recovered. Until the year 1830 I had no suspicion that the disease could be communicated from one patient to another by a nurse or midwife ”

“ In opposition to the doctrines of the so-called localists, the theory that puerperal fever is an essential fever, and as much a distinct disease as typhus fever, typhoid fever, or relapsing fever, has been strenuously advocated by some of the most distinguished clinical teachers who have devoted their attention to obstetrical science. ”

“ The use of cathartics, tonics, stimulants and other drugs after delivery.
It is within the power of every woman that she shall not be subject to these causes of puerperal fever.
Some late teachers claim that all child-bed fever is pyæemia, blood-poisoning, and can not be avoided. Why is it, then, that it is notably absent in those who have led a hygienic life? Why is it that those physicians who insist on preparatory treatment seldom meet with it in their practice? Others claim that the disease is contagious, and that the poison can be conveyed by physician and nurse. ”

“ Pathogenic bacteria are invariably associated with puerperal fever, and to them the infectious qualities of the disease are due. I have been explicit regarding the evidence concerning bacteria in septic diseases, because it places the question of the infectious group of puerperal fever cases in the following position: Experiences occurring clinically, as well as those produced upon animals, teach us that certain lesions and symptoms, similar to those we are accustomed to regard as characteristic of puerperal fever, results from septic poisoning. ”

“ Rigby. "That the discharges from a patient under puerperal fever are in the highest degree contagious we have abundant evidence in the history of lying-in hospitals. The puerperal abscesses are also contagious, and may be communicated to healthy lying-in women by washing with the same sponge; this fact has been repeatedly proved in the Vienna Hospital; but they are equally communicable to women not pregnant ”

“ But it is obvious that, in the majority of cases, it must be impossible to decide by which of these channels the disease is conveyed, from the nature of the intercourse between the physician and the patient.
3. It is not pretended that the contagion of puerperal fever must always be followed by the disease. It is true of all contagious diseases that they frequently spare those who appear to be fully submitted to their influence. Even the vaccine virus, fresh from the subject, fails every day to produce its legitimate effect, though every precaution is taken to insure its action. ”

“ A general practitioner, in large midwifery practice, lost so many patients from puerperal fever that he determined to deliver no more for some time, but that his partner should attend in his place. This plan was pursued for one month, during which not a case of the disease occurred in their practice. The elder practitioner, being then sufficiently recovered, returned to his practice, but the first patient he attended was attacked by the disease and died. ”

“ If within a short period two cases of puerperal fever happen close to each other, in the practice of the same physician, the disease not existing or prevailing in the neighborhood, he would do wisely to relinquish his obstetrical practice for at least one month, and endeavor to free himself by every available means from any noxious influence he may carry about with him. ”

“ The successful control of that terrible disease—puerperal fever—which formerly destroyed such a multitude of women, is a striking conquest of humane method in modern medicine. When I was a student in La Maternité of Paris in 1849, this destructive malady of lying-in women produced a mortality varying from 10 to 15 per cent. ”

“ If there is any appetite for facts so craving as to be yet unappeased,—Lesotho, necdum satiata,—more can be obtained. Dr. Hodge remarks that “the frequency and importance of this singular circumstance (that the disease is occasionally more prevalent with one practitioner than another) has been exceedingly overrated.” More than thirty strings of cases, more than two hundred and fifty sufferers from puerperal fever, more than one hundred and thirty deaths appear as the results of a sparing estimate of such among the facts I have gleaned as could be numerically valued. ”

“ Floating spores, when sparsely distributed, rarely possess the power of invading a healthy organism. In the inauguration of an epidemic the first patient severely attacked is usually one whose powers of resistance are broken down by prolonged labor, by hemorrhage, by poverty, or some other condition leading to impaired vitality.
Puerperal-fever epidemics due to contamination of the atmosphere, and not to direct contagion, do not at once reach the maximum of intensity. At first the temperature tables indicate the prevalence of milk fever ”

“ Max Boehr4 in his now-famous statistics reckons that one-thirtieth of all married women in Prussia die in childbed. The Puerperal Fever Commission5 appointed by the Berlin Society of Obstetrics and Gynæcology arrived at the conclusion that from 10-15 per cent. of the deaths occurring in women during the period of sexual activity were due to childbed fever, and that this disease destroyed nearly as many lives as small-pox or cholera. ”

“ Dr. Hulme, supposing that the proximate cause of the puerperal fever is an inflammation of the omentum and intestines, says, that the predisponent cause is the pressure of the gravid uterus against these parts. But Mr. White, another eminent English practitioner, asks, if this were the case, whether the disorder, would not take place before delivery, and be mitigated immediately after that period? ”

“ The presence of germs in puerperal fever serves not only to fix cases hitherto doubtful in the category of septic diseases, but affords the most satisfactory explanation of the protean phenomena of puerperal fever itself. ”

“ I will only say, that the evidence appears to me altogether satisfactory that some most fatal series of puerperal fever have been produced by an infection originating in the matter or effluvia of erysipelas. In evidence of some connection between the two diseases, I need not go back to the older authors, as Pouteau or Gordon, but will content myself with giving the following references, with their dates; from which it will be seen that the testimony has been constantly coming before the profession for the last few years. ”

“ Therefore Semmelweis said, "Not only can the particles from dead bodies generate puerperal fever, but any decomposed material from the living body can also generate it, and so can air contaminated by such materials." ”

“ It is not likely ever to increase among native Americans, or again gain such a foothold as it had in the Middle Ages.
Puerperal Fever.—Perhaps one of the most striking of all victories of preventive medicine has been the almost total abolition of so-called child-bed fever from the maternity hospitals and from private practice. In many institutions the mortality after child-birth was five or six per cent., indeed sometimes as high as ten per cent., whereas to-day, owing entirely to proper antiseptic precautions, the mortality has fallen to three-tenths to four-tenths per cent. ”

“ Roberton, of Manchester, makes the statement which I here give in a somewhat condensed form.
A midwife delivered a woman on the 4th of December, 1830, who died soon after with the symptoms of puerperal fever. In one month from this date the same midwife delivered thirty women, residing in different parts of an extensive suburb, of which number sixteen caught the disease and all died. ”

“ In civil hospitals, as well as in general and private practice, the mortality from these diseases was, until twenty-five years ago, simply frightful; while frequently, and over wide areas of territory, endemics and epidemics of puerperal fever would result in the death of almost every lying-in woman. ”

“ Such meddlesomeness is more likely to do harm than good." This corresponds with my own experience. In theory, the proposition to treat the uterus as one would any other pus-secreting cavity seems rational, but I have found that every attempt to carry the theory to its logical conclusion in hospital practice has been followed by a rise in the puerperal death-rate. Runge reports an epidemic of puerperal fever in Gusserrow's clinic brought about by the employment of intra-uterine irrigations, during which the mortality rose to 3.8 per cent. ”

“ Such a disease as puerperal fever, for instance, is simply an expression of the fact that within the living human body there is going on active putrefactive action by which the internal cells are being destroyed. ”

“ Before the middle of the nineteenth century most of the puerperal fever was due to infection from over-zealous but unclean attendants. Now men are proudly reporting hundreds of cases of delivery without even a vaginal examination. ”