LONDON SATURDAY JANUARY
THE HISTORY OF THE PREVENTION OF PUERPERAL FEVER *
MILES H. PHILLIPS, M.D. (Hon.), B.S., F.R.C.S., F.C.O.G.
Etieteituis Professor of Obstetrics anid Gyniaecology,
University of Shleffield
This title having proved too ambitious a one for a lecture
of an hour's duration, I have found it necessary to restrict
my subject to a theme which can be indicated by the
Manciple admonishes the drunken cook:
"Hoold cloos thy mouth man
Thy cursed breeth infecte wole [will] us alle."
Consideration of the study of the development of a thera-
peutic or a prophylactic measure will often be found to
The Principle of Contagion
The history of the prophylactic measure which I shall
later on advocate may be held to begin about the middle
of the nineteenth century.
principle, that of contagion, was at last accepted by most
of the leading obstetricians of the day.
been long-since suggested by Alexander Hamilton, in 1781,
demonstrated by Alexander Gordon, in 1795, and more
recently supported by Oliver Wendell Holmes,
It suits my purpose to cite only one of these converted
authorities, one who had already conferred a great boon
on parturient women by the introduction of chloroform.
In the discussion which followed a paper on puerperal
fever read by Dr. Arneth of Vienna before the Medico-
Dr. James Y. Simpson said:
not believe that the disease is usLually propagated directly
from individual to individual, but indirectly, through the
medium of a third person; and that person generally the
medical attendant or nurse."
confesses that in 1836, when he had his first experience
of puerperal sepsis in his own practice, he had "no full
Otherwise, he leads
necropsies in two cases of fatal puerperal sepsis to four
cases of midwifery, all of which became infected.
and particularly those who are members of the staff of
Simpson had been not a little influenced by reading an
account of an outbreak of puerperal sepsis in the district
maternity practice of the Manchester Lying-In Charity
the forerunner of the present-day St. Mary's Maternity
Hospital. Simpson had read of this in a letter published in
the Lotndon Medical Gazette in 1832-under the heading
"Is Puerperal Fever Infectious?"-by Dr. John Roberton.
* The Lloyd Roberts Memorial Lecture, delivered at St. Mary's
Maternity Hospital, Manchester, on November 10, 1937.
At that time a fundamental
This theory had
" But in this country we do
In the same speech Simpson
a Manchester audience,
to hear or
Dr. Roberton was appointed to the hospital staff in 1827,
and he was the last member to bear the title of man-
midwife,this being changed to surgeon in
letter had been written in response to a communication
to the Gazette by Dr. William Campbell, and it is advisable
to quote directly from it, as Simpson, apparently trusting
to memory, is inaccurate in not a few of the figures he
Dr. Roberton begins thus:
The letter of Dr. Campbell on puerperal fever, which
appeared in the Medical Gazette of December 10, has recalled
my attention to certain facts in my possession, calculated to
throw some light on the query which heads this communi-
" 'On the question of infection' (Dr. Campbell observes)
'I am as much as ever impressed with the belief that unless
the practitioner has been engaged in the dissection of the
bodies of those who have fallen victims, the disease cannot
be conveyed by him from females labouring under it to others
recently delivered ; but if he have been so engaged, I have
strong reasons for believing that he may be the means of
My experience," Roberton comments,
not in unison with this conclusion.
last  a meeting of the medical officers of the Man-
chester Lying-in Charity was summoned in consequence of
a great mortality having occurred, during the four preceding
weeks, among the patients of one of the midwives.
circumstances we found to be these: Mrs. A. B., a midwife in
great practice among the patients of the Charity, had on the
4th of the preceding month delivered a poor woman, who
soon died with symptoms of puerperal fever.
to the 4th of January inclusive-exactly one month-this
midwife delivered thirty women residing in different parts of
an extensive suburb, of which number sixteen caught the
disease, and all of them ultimately died.
cases of puerperal fever which had for a considerable time
occurred in Manchester.
The midwives, commonly twenty-five
in number, deliver, on an average, ninety women per week.
Now of this number delivered during the month in question,
none had puerperal fever except the patients of Mrs. A. B.
Yet all this time this woman was crossing the other mid-
wives in every direction, scores of the patients of the Charity
being delivered by them in the very same quarters where her
cases of fever were happening....
" The decision of the medical officers of the Charity was to
the effect that Mrs. A. B. should abandon her practice for a
short period, and go into the country."
Dr. Roberton concludes:
"The fact that sixteen cases of puerperal fever occurred
in one month in the practice of a single midwife, while the
disease, leads naturally to the conclusion that this midwife
was the mlediuiml of communicating (I take not upon myself to
say in wh/lat manner) the malady, from one woman to another
-from one affected with the fever to another in health."
On the 4th of January
From this date
These were the only
were exempted from
HISTORY OF THE PREVENT
The modern conception of a carrier had not of course
been considered in those days.
I myself have taken a small part in the investigation of
two similar epidemics in the practices of one only of each
of two groups of midwives-both of whom had clean
records for several years.
In each epidemic
that some of the patients were infected during the puer-
perium and not at the labour.
lytic streptococci were found in the throats of the midwife,
and both were cured by removal of the diseased tonsils.
Simpson came to the conclusion that the unfortunate
to which pathologists
No one at that time had any conception of
the nature of that virus.
Some even held it could never
opponent of Oliver Wendell Holmes's views, wrote in his
"The student will naturally be desirous to learn. if childbed
fever be really
a contagious di'sease, what the principle of
that contagion is: and
to rest content with the solitid of the word contagion, a word
which, being interpreted, means communicable from person
to person, or by individual to individual.
meaning of the word; for, as to how, and the what, no man
hath vet obtained the least definite notion, since no man hath
known or can know what a miasm or a contagion is.
and contagion are words, nothing more:
precise material idea of the mind."
account of the Manchester epidemic
had been previously cited by Oliver Wendell Holmes (1843).
Within the last few years
it was clear
In each instance haemo-
in question must have been, unlike the other
"connected with some form of that morbific
give the name
oni Obstetrics, 1856:
I apprehend that here he shall have
This is the whole
The High-pressure Sterilizer
It is also of great interest to record that John Roberton
played a small part in an investigation which led to the
invention of the high-pressure sterilizer,
famous physicist (1775-1836),
making experiments on sterilization by heat, at the request
of a cotton importer, in the hope of preventing the intro-
duction of plague in cargoes of Egyptian cotton landed
Dr. Henry (1831) states that "the most
important point to be ascertained, and that on which the
utility of the inquiry hinges, is whether temperature below
Fahrenheit is capable of destroying the contagion of
test the effect of different temperatures,
for varying periods of time, Henry made use of fresh
Among others, Dr. John Roberton, " one
of the surgeons of the Manchester Lying-In Hospital,"
supplied Dr. Henry with the vaccine lymph.
jacket steam sterilizer was devised as the direct result of
Thus this powerful means of destroying the cause of
contagion was invented and in use thirty years and more
micro-organisms of Anthony van Leeuwenhoek, micro-
scopic protozoa which he had discovered
1675, and, in 1681, in material from the human mouth.
It was ignorance
to the nature of these fomites-
of the "precise material " of Charles Meigs, of the body
or substance which could be conveyed by a third person
from one patient to another-that had long delayed the
wide acceptance of the theory of contagion.
acceptance had been
proved to be, microscopic malefic object was discovered,
so essential to
also of Manchester, was
it was proved that the actual fomites were the
-ION OF PUERPERAL FEVER
although, one is amazed to find, the transcendent brain
of William Harvey had in 1651 used the term "fomes"
and had conceived the idea of "seeds of epidemic and
contagious diseases" which "propagated
through the air," and"in a hidden fashion silently multi-
plying themselves by
destruction far and wide among man and beast."
Skoda of Vienna, inspired by the theory of Semmelweis
that poisonous animal matter was introduced by the hand
of the accoucheur
into the genital
gated by experiments on animals.
at first, later
metritis, or pus from an abscess,
uterus of rabbits recently delivered.
of microscopical examination nothing of
value was learnt.
a kind of generation
in 1849 that the problem should be investi-
By means of a brush
a case of endo-
was introduced into the
syringe, exudate from
were studied, but
The Indictment of Bacteria
It was Louis Pasteur who initiated the investigations
the indictment of bacteria
The study of diseases of grapes, of silkworms,
of cattle, had fired his imagination
knowledge of the causes of putrid and contagious dis-
eases'? in human beings.
After investigating septic cases
in the surgical wards of hospitals he studied
puerperal infection in the Maternite, finding in certain
of them "a microbe in the shape of chain or chaplet,
which lent itself very well to culture."
The description by Monsieur Roux of
(March 11, 1879) on which Pasteur proclaimed this dis-
covery is well worth recalling to our minds.
in a discussion on puerperal fever at the Academy, one
of his most weighty opponents was eloquently enlarging
Pasteur interrupted him: 'None of those things cause
carry the microbe from an infected woman to a healthy
never be found, Pasteur went
blackboard and drew a diagram of the chain-like organ-
He had found streptococci in the lochia of dying patients
and had cultivated them from the blood, taken both
must have undermined the opposition of any remaining
anti-contagionists, and one can appreciate the satisfaction
the contagiousness of puerperal
"But I shrieked my warning
louder and longer than any of them, and I am pleased
I took my ground
evidence, before the little army of microbes was marched
up to support my position."
The new science of bacteriology thus arose, and was
ardently pursued by a rapidly increasing army of investi-
all civilized couLntries.
discovered, isolated, and proved to be the cause of rarer
types of puerperal infection, most of which were much
less severe and less frequently fatal than that caused by
It is impossible, and really unnecessary for my purpose,
the story of the discovery of these
This was admirably done by Arnold W. W.
Lea (1910), also
as the long-desired
to " arrive
" One day,
it is the nursing and medical staff who
as the orator replied that he feared that
' There, that is what it is like!'
a discovery which
is able to boast:
on the existing
Other organisms were
a member of the surgical staff of St.
JAN. 1, 1938
HISTORY OF THE PREVENTION OF PUERPERAL FEVER
addition to streptococci it includes staphylococci, the colon
diphtheria, of tetanus, of typhoid even, the Bacillus aero-
genzes capsiulatius of Welch, and the Bacillius pyocyanieuts.
the bacillus of
The Introduction of Antiseptics
The discovery of bacteria was quickly followed by
Lister's introduction, in 1867, of the chemical antiseptic
with which microbes in septic wounds or on the skin of
the patient or the hands of the surgeon could be rendered
Lister, employing the method with meticulous care,
was soon able to revolutionize surgical operative practice.
Certain obstetricians-and one must mention Hayes of
the General Lying-in Hospital, London, and Tarnier of
Paris-convinced of the identity of surgical and puerperal
sepsis, introduced antiseptics into their midwifery practice,
with a striking reduction in the occurrence of infection
in the maternity hospitals they controlled.
must not forget that many years previously Robert Collins
of the Rotunda (in
1829) and Semmelweis
(in 1847) had used a solution of chloride of lime to destroy
the unknown virus of infection.
The use of antiseptics soon became the first line of
defence in the campaign against puerperal sepsis, and so
it remains to this day.
Many forms have been introduced
since the days of Lister's carbolic acid.
the ideal antiseptic has a story of its own, which some
consider is not yet complete; many others are perfectly
satisfied with the one of their choice.
Although the incidence of puerperal sepsis has been
greatly diminished, the dread disease has by no means
Sporadic cases are of not infrequent
occurrence, and even epidemics occur in hospital as well
asin private practice.
the chief causes of puerperal mortality.
maintain that this is only the consequence of the neglect
inefficient use of the
doubting this simple solution of a grave problem, have
with infinite pains searched more and more deeply into
the life-history of the microbes chiefly concerned, and
must be destroyed or between which and the woman
in labour an effective barrier must be set up.
Pasteur's day it has been recognized that streptococci cause
the great majority of the serious and fatal
They have been intensively studied by devoted specialists,
and gradually the complexity of the- nefarious clan has
Streptococci are subdivided according to
the way in which they grow: some are haemolytic, others
have no action on blood, while others will only grow in
the absence of oxygen.
Of the haemolytic strains only
one group (Group A) is capable of causing severe infec-
tionin human beings, and this group
divided by intricate serological means into about twenty-
five distinct types.
Some half of these known types have
been found to play a causative part in puerperal infec-
The history of these investigations is beyond my purpose
and, indeed, my powers.
unravel the story of the tracking of the villain to his
chosen lair and the provision of a means to intercept him
at its exit.
surgical face mask.
The source of the problematical virus had for long been
a matter of speculation, the most favoured being decom-
posing animal matter associated with necropsies and dis-
sections. cancers. and surgical woulnds, especially where
The search for
still one of
in which they
is further sub-
I have chosen to attempt to
I refer, of course, to the human throat and the
midwifery cases and cases of general disease were housed
under the same roof.
Semmelweis and Holmes both laid
down rules of conduct against these dangers.
of conveyance were debated ; clothes, the hands, the atmo-
sphere were accused.
ridiculed the idea: he tells of
" another friend of mine who had been chased, so to speak,
by a series of such cases, seventy in all, left the city, was
absent many days, and on returning, shaved his head, got
a new wig, new clothes, new gloves, new pencil.
into a bath, was washed clean, dressed himself, and then
visited and assisted a woman in labour who was seized next
day and died."
If the man " was poisonous," says Meigs.
"how was he so?
Everything except the man was new.
could not have carried the atmosphere of his last patient's
chamber with him to -the country, keep
an invisible cloud," and " then carry it into the last patient's
to destroy her with exhalations more pestiferous
than the breath of Cacus."
By the irony of fate Meigs's satirical flights of imagina-
tion had brought him near the truth: the "new pencil"
wetted by the lips might have infected the doctor's fingers
the "'exhalations more pestiferous than the breath of
Cacus" may well have conveyed virulent streptococci.
In fact this was so; for Meigs's friend was no other than
the unfortunate Dr. Rutter of Philadelphia, who within
five years had ninety-five cases of puerperal infection in
his practice, with eighteen deaths.
suffered from ozaena due to chronic rhinitis.
Many years later, in 1924, two outbreaks of pyrexia at
the Portsmouth Municipal Maternity Hospital were proved
to be associated with the presence of a pupil midwife who
suffered from atrophic rhinitis and in whose nose haemo-
lytic streptococci were found.'
it about him like
It is known that he
Relation of Streptococcal Sore Throats to
The discovery of microbes gradually led to the eclipse
of mere conjectures; theories could henceforth be scien-
The comment of Dr. John Clarke (1793)
-that " it is a curious circumstance that before the attack
of the epidemic of lying-in women at Paris in the year
1746, in the month of January, there had been an epidemic
low fever, with an ulcerous sore throat'"-has thus been
illuminated by the discovery that certain members of
Group A of the haemolytic streptococci can be much
more readily found in human throats at the time of year
Gordon, who wrote in 1795 on the "Epidemic Puerperal
Fever of Aberdeen (1789-92)," prepared a set of tables
showing the simultaneous prevalence of "inflammatory
Fleetwood Churchill (1849) speaks of the
"epidomic season," between November and May, and
shows that the eighteenth century writers on puerperal
sepsis-Leake, Armstrong, Campbell, Hey, Joseph and
John Clarke-all agreed that the "puerperal fever pre-
vails most during the winter and spring months."
Although streptococcal sore throats are most prevalent
from October to May, demanding specially careful pre-
cautionary measures in surgical and midwifery practice,
they may occur at any season, and so the same precautions
are actually always desirable.
coverer of this source of contagion I arrived at a paper
by W. Hubener (1898) based on experimental work carried
out at the Breslau Surgical Clinic of Professor Mikulicz.
Hubener begins by referring to the pioneer work of
'British Medical Journal, 1924. 2. 623.
In my quest for the dis-
HISTORY OF THE PREVENTION OF PUERPERAL FEVER
that the micro-organisms found in the human mouth might
be pathogenic, but had demonstrated the "surprising and
words) "that when speaking, coughing, and sneezing
spreading about of the mouth and nose secretions takes
Even at a distance of several metres he had shown
that agar plates were covered with colonies after some-
what louder and
exclusion from aseptic operations of all persons suffering
from acute catarrh.
surgical technique and
this time experimenting with
was deeply concerned by
set to work to parry
In July, 1897, he described the
(mouth bandage) which he was using for
the subject. The material used was the finest mull, " steril-
ized of course," he
Although Mikuticz claimed that he had quickly become
accustomed to their use and " could breathe through them
as easily as a lady who in the street wears
find that ie had asked Hubener to search, by experiment,
for a comfortable as wel as a secure means of protection.
In his lengthy paper Hubener describes his method of
thoroughly rinsed with a diluted culture of B. prodigiosus
spoke and coughed, at varying distances and angles, over
appropriately arranged agar plates.
the prodigiosus colonies made
germs "spoken out from the oral cavity" from those
deposited from the
Flugge had not only proved
use HIubener's own
source of infection.
is, I believe, the first publication on
says, and " fastened to the similarly
a- veil," we
whose mouth had been
The green colour of
it easy to distinguish the
Evolution of the Face Mask
These experiments led to the gradual evolvement of a
metal frame-a modified Esmarch chloroform mask-
with spectacle ear-pieces, carrying a double layer of close-
As evidence of the exhaustive character
Hubener demonstrated that the mask should be held at
a distance of a few centimetres from the mouth, and this
not for comfort only but to increase its efficiency as a
types of mask, but
a snout-like projection, by means of a stiffened dart on
each side of the simple oblong of folded gauze so much
Concurrently with the investigations of Mikulicz and
Hubener the problem was being studied in Paris.
famous surgeon Paul Berger read a paper "On the Use
of a Mask in Operating" before the Surgical Society of
Paris on February 22, 1899.
" For several years I have been worried as to the
part that drops of liquid projected from the mouth of
or his assistants may exercise on the out-
breaks of infection which one still sees from time to time
under conditions of surgical asepsis which are apparently
Berger's suspicions had been aroused by
the association of a short series of cases of suppuration
in clean operations with an assistant who was suffering
from an alveolar abscess.
The same mishaps occurred
several months later, when he himself was suffering from
a dental periostitis.
His attention directed to the point
to notice that drops of saliva were projected
from the lips of the operator or his assistant even when
is a requirement which
it can be easily achieved by giving
is ignored in most
He began with the state-
Aware of Flugge's discovery of the presence of pathogenic
bacteria in the saliva, he had set to work to find a means
of " shielding his operation wounds from this cause of
contamination," even before Mikulicz had published his
In October, 1897, he began to wear a rectangular
compress of six layers of gauze, sewn at its lower edge
to his sterilized linen apron (he had a beard to safeguard)
and the upper border held against the root of the nose
by strings tied behind the neck.
to have been purely clinical, but in the course of fifteen
himself -that he had markedly
diminished the incidence of sepsis after clean operations.
His paper ends thus:
"It is exactly because I realize that perfection in the carrv-
ing out of operations aseptically must not concern itself with
anv one point but with all, and must neglect no detail, that
I have been so anxious to insist on a precaution, the use of
which has contributed not a
little to improve my operative
to custom for
His surmise was correct: in the discussion that followed
a Monsieur Terrier scoffed at the proposal,
have never worna mask, and quite certainly
shall do so."
However, in time surgeons did adopt the
precaution, and probably the
insist, in a textbook, on the use of the face mask was
that master of operative technique Berkeley Moynihan
in his Abdominal Surgery (second edition,
pours ridicule on the scoffers "who claim to be satisfied
with their results."
Berkeley and Bonney in their Textbook of Gynaeco-
logical Surgery, first issued
periment the validity of the danger, stated their conviction
that the surgeon and his staff should wear masks.
in their work Obstetrical Emergencies, even in the third
edition of 1921, they do not mention the possibility of
shared by all, or nearly all, of us who have during the
His investigations appear
I do not blind myself to the fact that this is too
saying, " I
in 1911, after testing by ex-
The Pioneer in the Use of the Mask
In seeking the pioneer in the use of the mask in obstetric
practice I have come to the conclusion that Professor
Benjamin DeLee (known at the moment to the American
entitled to the credit for this.
tell the story in DeLee's own words, from
a recent letter:
"I cannot say just when I first started to use face masks in
time, or even before, the surgeons used them.
"Just about the turn of the century we had a small epidemic
of puerperal infection among the mothers and the babies at
the Chicago Lying-in Hospital Dispensary, the home service,
which of course was astonishing.
" On investigation
liked to teach and demonstrate to the students while he was
delivering the women, had a slight salivation and little tiny
droplets of saliva were present frequently at the corners of
All of the cases that got sick were handled by
this particular intern, and one mother and one baby died of
"I made a careful study of this intern's nose and throat
and found a short-chain streptococcus.
service and gave him a position in the laboratory of a South
as "Number One
at the -same
I found that one of the interns, who
I relieved him from
JAN. 1, 1938
HISTORY OF THE PREVENTION OF PUERPERAL FEVER
had no trouble in this regard since.
" I immediately instituted rules and regulations regarding
talking on obstetric cases (such as averting the face when
taiking over a patient so as not to spit upon her, keeping the
hands away from the face and mouth while on duty so as
not to infect them with saliva, not to attend a labour case if
suffering from a head cold or sore throat. etc.), but I do not
remember that I insisted on masks.
"The first record that I have of the use of masks is in
1907 while I was preparing the third edition of my book on
obstetrics for nurses, which was published in 1908.
a picture in this book of the doctor aiding the parturient to
bear down, and he wears a face mask."
The first protection used by DeLee was " a thick scarf
Finding that spittle could be driven
through the mesh of this he used thick towelling, and
this again he fortified with a four-inch square of adhesive
plaster during epidemics of colds or if he himself had a
sore throat and had to continue at work.
Kanter and Pilot (1924) appear to have published the
first account of a bacteriological investigation of the likeli-
hood of droplet infection in obstetrical practice.
carried out in the extern department of the Presbyterian
They found " no evidence to support
auto-infection from vaginal streptococci," but concluded
that " droplet infection from attendants
that the use of masks during delivery and the exclusion
of those having sore throats from the delivery room and
from attendance on puerperal women is clearly indicated."
The epidemic ceased abruptly and we have
is possible and
Delay in the Use of the Mask
Apart from its use in Caesarean section there has been
an astonishing delay in the employment of the face mask
in hospital and, even more so, in domiciliary midwifery
rigid use in this or that institution, on this or that mater-
district, has so often been and
consequence of an epidemic, more or less rapidly con-
trolled, in the hospital itself.
even await the stimulus of legal proceedings.
It is sad to reflect that its adoption or more
stillis the direct
It would appear that some
Investigation into Hospital Epidemics
Many such epidemics have been laboriously investi-
gated by bacteriologists especially skilled in the recog-
nition of the various types of streptococci.
in this way that the origin
epidemic or of the sporadic case can be detected and
indicted with a degree of probability almost amounting
The first of these thoroughly investigated
epidemics was that which occurred in the Sloane Hospital,
New York, in January and February of 1927.
twenty-four (15 per cent.) developed
haemolytic streptococcal infections; eight of- these died.
It was fully reported in the August number, 1928, of the
Obstetrics and Gynaecology by
P. Watson and Dr. Frank
complete bacteriological examination of the hospital failed
to demonstrate haemolytic streptococci
the floor or walls, in the operating room, in dressings,
supplies, or water.
The only place where streptococci
were found, other than in the infected patients, was in
members of the domestic staff.
papers it was laid down that it is "important to exclude
carriers from maternity hospitals and
on complete masking by
parturient and puerperal women."
or the originator of the
In the summary of these
Thus one result of
this epidemic was the much more rigid masking of both
mouth and nose.
The Sloane Hospital Report aroused widespread interest
in a source of infection which, as we have alr-eady seen,
had been suspected by a few for years but had never
before been strongly attested.
and warmly welcomed by Professor DeLee in the section
Practical Medicine Series"
At last he had powerful scientific support for the
complete masking of mouth and nose, which he had
already been employing and advocating
In June, 1929, Nixon and Wright reported two fatal
cases of pneumococcal septicaemia during the puerperium
from University College Hospital, London.
patient was a hospital "district nurse."
tests it was found that the throat of one of her attendants
pneumococci of the same type-Type I-as the vagina,
uterus, and blood of the woman.
first case recorded in which the bacteriological evidence
attained such a degree of probability.
face masks, which had been used at deliveries within
the hospital since early in 1927, were made compulsory
on the district.
Just one more instance of a compelled change of policy.
In the early months of 1936 one of the most famous
maternity hospitals in the world, the Rotunda (see Annual
Report), experienced an epidemic of streptococcal sepsis;
four out of fourteen cases ended fatally.
with a severe outbreak of streptococcal throats among
the hospital staff and in the city. A full investigation
was made, and among the conclusions we read:
to this time masks had not been used in the inaterniity
department, but this epidemic and the knowledge of the
mode of origin decided a change of policy."
The report was reviewed
This is, I believe, the
As a consequence
Many similar investigations have been made since 1928,
It is impossible to enumerate or analyse them.
I believe that all authorities would wish to give a special
recognition to the work of Dr. Leonard Cblebrook.
a chat with Professor DeLee in Chicago last autumn I
was asked to convey the Professor's personal gratitude
to "the Colebrooks " for their work on the sources of
has summarized this work; referred freely to that of
others ; and given his own conclusions in The Prevenition
of Puerperal Sepsis, published in 1936.
and administrator-concerned for the safety of childbirth.
In 1925 puerperal sepsis was the chief subject for dis-
cussion at the British Congress of Obstetrics and Gynae-
cology, held in London.
The possibility of droplet infec-
Williams, who took part in the discussion, was impressed
by the fact that in a series of streptococcal infections in
his service 30 per cent. of the patients had had spontaneous
labours without even a vaginal examination:
bacteriological evidence pointed to the rarity of endo-
genous auto-infection-all recent work has supported this
After stating that there must be "some form of
external infection which escaped recognition" he drew
attention to the possibility of parturient women conveying
the organisms on their fingers to the vulva or vagina.
This is a danger well recognized by the supporters of
Dr. Leonard Colebrook
This should be
JAN. 1, 1938
HISTORY OF THE PREVENTION OF PUERPERAL FEVER
the theory of droplet infection, and special precautions
are laid down
mask for the woman known to have an infected throat;
careful and repeated cleansing of their hands; and, in
my own practice,
prevent the hands of the woman in twilight sleep from
wandering to the vulva.
As the experts at this congress were oblivious to the
droplet danger it is not surprising that the current text-
books on midwifery contained no reference to
same necessity for rigid
as in surgical practice.
In the seventh edition (1912) of
Hirst's Obstetrics the mask
surgery, and not
obstetrical examinations and manipulations.
cious view has been held to a ridiculous extent.
recently seen a gynaecologist wear a mask in an operating
theatre whilst repairing a perineal tear of thirty years'
duration, but disdain its use when suturing, in a labour
most of us acted less than ten years ago.
The English textbooks on midwifery were late in draw-
ing attention to the danger.
not refer to it in 1925 in its sixth edition.
edition of 1931, however, we read that the human throat
is the chief habitat of the haemolytic streptoc-occus, and
that masks completely covering mouth and nose should
be worn by all who are in attendance on labour and
by nurses during the puerperium.
It will be asked:
Is there evidence of benefit from
the rigid use of these, together with other rational pre-
treatment of attendants who have infected
air passages and the immediate investigation and segrega-
tion of lying-in women at the onset of pyrexia?
obvious that the masks must be efficient and that they
should be in position before the hands are sterilized and
from the sterilizer and laid out ready for use-preferably,
indeed, before the labour room
is convincing evidence from several
maternity ho'spitals where for the last five years or more
there has been thorough bacteriological control of the
work of the hospital-both indoor and outdoor.
parison of the results in these two departments has yielded
unexpected figures of great significance.
Dr. Joan Rose of the Elsie Inglis Hospital, Edinburgh,
in a second report (1936) on "Bacteriological Control,"
streptococci in lying-in women have been continued over
a period of six years.
The figures for the past three years
show that while the general morbidity in hospital and on
remains low, the pyrexial
on the district than
Dr. R. G. Douglas (1937) states that all these precautions
-and he lays great stress on efficient masking-have been
rigidly employed at the New York Lying-in Hospital since
He shows that the incidence of strepto-
coccal pyrexia was two and a half times as frequent in
the home as compared with the hospital deliveries.
same result has been obtained in comparable conditions
in the practice of the Jessop Hospital, Sheffield, under the
control of two whole-time bacteriologists.
The Report of the Obstetric Registrar of University
College Hospital, London, for 1936 records that 'whilst
a double clove-hitch on the wrists to
it would seem that, thinking logically, there
One of the best-known did
In the seventh
rate associated with
two cases of haemolytic streptococcal infection occurred
in 348 district deliveries there were no cases among the
1,034 deliveries in the hospital itself.
Dr. Leonard Colebrook reports that during the last five
years the risk of developing a haemolytic streptococcal
infection has been 30 to 40 per cent. higher for any
booked case delivered
similar booked cases delivered in Queen Charlotte's Hos-
pital, and this in spite of the hospital having to deal with
many already infected emergency cases. He continues: " I
am sure that whereas the risk of sepsis in well-conducted
maternity hospitals is growing less and less, we shall never
have adequate control over the manifold dangers of familial
infection in the overcrowded houses of the poor.
glad, therefore," he adds, "to see the tendency for more
hospital deliveries, and I think we should encourage and
facilitate that movement."
in her own home than it is for
Air-borne Infection in Dust
These results have led Colebrook and others to revive
investigations into the possible danger of air-borne infec-
tion in dust.
That the atmosphere was the chief vehicle
of contagion was believed by many a hundred years and
The belief was substantiated when Pasteur
showed that the air was populated with microbes which
caused putrefaction and fermentation.
physicist, devised beautiful experiments and apparatus to
demonstrate the presence of germ-laden dust in the atmo-
sphere, and thus upset the theory of spontaneous genera-
Lister attempted to counter the danger by the use
of the carbolic spray, within the range of which surgical
operations and even childbirth were conducted.
bacteriological investigations drew attention away from
this to other more frequent sources of infection.
is our duty to leave no possible source of danger unheeded.
The most recent work on air-borne infection has been
carried out by William and Mildred Wells (1936) of
Harvard University. The experiments are ingenious and the
In an air-conditioned room with an air
centrifuge respiring at the human rate
Bacterial samples of the air were collected by the centri-
fuge into blood-agar tubes.
crowding in enclosed rooms we are breathing one another's
intestinal flora in our water supplies."
means to effect air sterilization they have found that germs
are killed by ultra-violet rays.
rays are now in use in a corridor of the Children's Hos-
pital, Cambridge, Massachusetts, and in the number of
the Journal of Tlhoracic Surgery for October; 1936, there
is a picture of an operation being conducted within the
range of a battery of these lamps.
Charles White, the founder of St. Mary's Maternity
Hospital, keenly alive to the dangers of " the foul and
ventilators and "every other assistance
clearing the wards of foul air."
I fully realize that I should be doing a great disservice
a cause which I have much at heart if I left the
impression that it is only against streptococcal infections,
advocate precautionary measures.
John Tyndall, the
These workers demonstrate
"it would seem obvious that under conditions of
once drank each
In searching for
Floodlights emitting these
He would no doubt be
the droplet danger,
It is largely a matter
JAN. 1, 1938
HISTORY OF THE PREVENTION OF PUERPERAL FEVER
of time that has led me to confine myself to this one
The history of the discovery of infections by other
organisms-staphylococci, the gonococcus, pneumococci,
coli, the bacillus of Welch, etc.-and the
special precautions required to anticipate and thwart each
one of them, are of great interest and importance.
would be folly to neglect them while concentrating on
one special danger.
The most complete surgical
nique is essential in really safe midwifery practice.
knowledge may lead to its modification, and it may be
that 'a future Lloyd Roberts lecturer will find this paper
of mine useful in composing his own on "The Rise and
Fall of the Obstetrical Face Mask."
Buill. Mem. Soc. Chirturgie Paris, 25, 189.
Soc.), p. 35, London.
Report Series, No. 205.
Sherratt and Hughes,- Manchester.
Collins, Robert (1835).
Practical Treatise on Midwifery, London.
Congress, British (1925).
Douglas, R. G. (1937)
Amiter. J. Suirg., 35, 352.
Eden, T. W., and Holland, W. E. (1925, 1931).
Fligge. 0. (1895).Z. Hyg. Inifektkr., 25, 179.
Gordon, Alexander (1795).
Epidemic Puierperal Fever of Aberdeenl,
Hamilton, Alexander (1781).
Hart, D. (1936).
Harvey, William (1651).
Henry, William (1831).
Philosophical Magazine, 10, 363.
Holmes, Oliver Wendell (1843).
Puterperal Fever, Boston.
Hiibener, W. (1898). Z. Hyg. Infektkr., 28, 348.
Kanter, A. E., and Pilot, I. (1924).
Lea. A. W. W. (1910).
Puerperal Infections, London.
Meigs, Charles D. (1856).
Treatise on Obstetrics, 3rd Ed., p. 635,
Meleney, F. L., et al. (1928).
Amer. J. Obstet. Gvnec., 16, 180.
Mikulicz, Johann (1897).
Clb. Chir., 24, 713.
Nixon, Joan, and Wright, H. D. (1929).
The Life of Louis
Vallery-Radot, p. 291., Paris.
Roberton, John (1832).
Lonidon mned. Gaz., 9, 503.
Rose, Joan K. (1937).
Rutter, Dr. (1882).
W. S. Playfair:
Practice of Midwifery, 2, 342.
Simpson, James Young
Skoda (Vienna) (1850).
Amer. J. med. Sci., 20, 529 (Abstract).
Tyndall, John (1902).
Fragments of Scietnce, 6th Ed., London.
Watson, B. P. (1928).
Amer. J. Obstet. Gynec., 16, 157.
Wells, Wm. F. and Mildred W. (1936).
White, Charles (1773).
Berger, Paul (1899).
J. Obstet. Gnlaec. Brit. Enmp., 32, 239.
Manuial of Mid-
Outtlintes of Midwifery, p. 263, Edin-
J. thlorac. Suirg., 6, 45.
Trans. by Willis (Syd.
Essay on the Contagiouisness of
Suirg. Gynec. Obstet., 38, 96.
Lancet, 1, 1242.
Pasteuir, by Rene
British Medical Jouirnal, 2. 623.
J. Obstet. Gynaec. Brit. Emp., 44, 278.
Treatise oni the Science and
J. Amner. med. Ass., 107,
Treatise on the Management of Lying-in
A report by the Food Council to the President of the Board
of Trade on its inquiry into the costs and profits of retail milk
distribution in Great Britain has now been published by H.M.
Stationery Office, price 9d.
The main objects of the inquiry
were to examine the extent and the causes of the differences
between the financial results, per gallon of milk sold, of various
businesses; to ascertain whether retail milk distributors are,
on the whole, making an unduly high rate of net profit or
rendering unnecessarily expensive services; and to consider the
possibility of eliminating any such services and achieving
generally a more economical retail distribution of milk.
its conclusions the Council suggests possible lines of action by
which a reduction might be made in the average margin cover-
ing the expenses and profit of the distributor, in order to achieve
a reduction in the retail price of milk.
THE LYMPHOID TISSUE OF THE
H. GORDON THOMPSON, M.D., F.R.C.S.
(From the Division of Clinical Research, Henry Lester
(WITH SPECIAL PLATE)
The lymphoid tissue of the alimentary canal consists of
the tonsillar and pharyngeal ring, the Peyer's patches, the
vermiform appendix, and the solitary follicles of the large
intestine, but in order to come to a proper understanding
of these lymphoid foci a few words about the lymphatic
system as a whole are necessary.
It is the accepted belief now that in vertebrates the
lymphatics form a closed tube system and do slot com-
municate with the tissue spaces, with the serous cavities such
as the peritoneal and pleural cavities, or with the ventricles
of the brain or the central canal of the spinal cord.
lymphatic capillaries form dense networks in most of the
tissues of the body, these unite to form larger vessels,
and the largest, the right and left thoracic ducts, empty
lymphocytes to the blood stream.
and Field (1933) point out, care must be taken to dis-
tinguish between true lymph obtained from lymph vessels;
tissue fluid, the fluid
in the region outside blood and
lymph capillaries in the cellular interspaces ; and plasma,
the unclotted fluid of the blood, which differs markedly
from lymph and tissue fluid in protein content and to
a less degree in salt content.
"the three fluids should not be confused with one another
or with blood serum as is frequently done-particularly
Moreover, as Maximow (1935) asserts:
"The lymphatic networks are distinguished from the blood
capillaries by ending blindly in rounded or swollen ends. This
is best seen in the mucous membrane of the small intestines,
where a network of lymphatic capillaries or a single blindly
ending vessel, the central lacteal, extends in the lamina propria
up to the end of the villus.
The lymphatic capillaries form
expanded networks of considerable size round the solitary and
aggregated lymphatic follicles of the intestine.
lymphatic vessels have valves and slightly thickened walls con-
Maximow concludes his description of lymphatic capil-
laries and vessels with the important statement, " As the
a closed endothelium-lined system of
tubes the tissue juice must pass through the endothelial
cytoplasm to reach the lumen of the lymphatics."
the lymphatic system does not consist only of
collections of lymphoid tissue known as lymph nodes-
sometimes called lymphatic glands-and
follicles, the latter being solitary or aggregated follicles
to whether they are single or gathered into
I do not propose to refer further to the lymph nodes,
although their internal struCture
collections of lymphoid
* A lecturegiven attheHenry
Moreover, as Drinker
As Drinker and Field say,
muscle, andinterlacing col-
have associatedwith them
is very similar
tissue elsewhere, blut
I wish to