History of the Prevention of Puerperal Fever.

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BRITISH
MEDICAL
LONDON SATURDAY JANUARY
JOURNAL
1 1938
THE HISTORY OF THE PREVENTION OF PUERPERAL FEVER *
BY
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
following
words
from
Geoffrey
Tales-thewords,
written
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
strengthen
our
intention
to
question.
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-
Chirurgical
Society
of Edinburgh
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
and
proper
belief
in
the
puerperal
fever."
Otherwise, he leads
would
not
have
gone
from
necropsies in two cases of fatal puerperal sepsis to four
cases of midwifery, all of which became infected.
It should
especially
interest
and particularly those who are members of the staff of
St. Mary's
Maternity Hospital,
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.
Chaucer's
1389,
Catnterbury
which
in
with
the
employ
the
measure
in
At that time a fundamental
This theory had
in 1843.
on April
16,
1851,
" But in this country we do
In the same speech Simpson
contagious
propagation
us to
participation
of
infer, he
active
in
a Manchester audience,
to hear or
recall
that
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
gives.
Dr. Roberton begins thus:
" Sir,
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-
cation.
" '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
propagating
My experience," Roberton comments,
not in unison with this conclusion.
last [1831] 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.
tothe 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
patients
of
the
other midwives
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."
1828.
His
it.'
" is
On the 4th of January
The
From this date
These were the only
were exempted from
the
4017

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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
midwife
midwives,
principle
to which pathologists
contagion."
No one at that time had any conception of
the nature of that virus.
Some even held it could never
be
known.
Charles
Meigs
opponent of Oliver Wendell Holmes's views, wrote in his
Treatise
"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."
Dr. Roberton's
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
or virus
give the name
of
Philadelphia,
a
bitter
oni Obstetrics, 1856:
I apprehend that here he shall have
This is the whole
Miasm
the)
represent no
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,
modern
aseptic
technique.
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
at Manchester.
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
2120
Fahrenheit is capable of destroying the contagion of
fomities."
To
test the effect of different temperatures,
for varying periods of time, Henry made use of fresh
vaccine lymph.
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
these experiments.
Thus this powerful means of destroying the cause of
contagion was invented and in use thirty years and more
before
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
as
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
actually
evidence alone.
Years
were
to elapse
before
proved to be, microscopic malefic object was discovered,
so essential to
William
Henry,
also of Manchester, was
Dr.
the
The double-
it was proved that the actual fomites were the
in water
in
The final
based
on circumstantial
the
elusive and,
as
it
-ION OF PUERPERAL FEVER
TiLE BRITISiH
MEDICAL JOURNAL
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
Semmelweis
gated by experiments on animals.
at first, later
a
metritis, or pus from an abscess,
vagina and
uterus of rabbits recently delivered.
the post-mortem
appearances
absence
of microscopical examination nothing of
value was learnt.
to
a distance
a kind of generation
spread
tract, suggested
to
in 1849 that the problem should be investi-
By means of a brush
a case of endo-
was introduced into the
syringe, exudate from
Later
in the
real
were studied, but
The Indictment of Bacteria
It was Louis Pasteur who initiated the investigations
which
were
to lead
to
the indictment of bacteria
microbes
tagion.
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
upon
the
causes
of
epidemics
Pasteur interrupted him: 'None of those things cause
the epidemic;
carry the microbe from an infected woman to a healthy
one.'
And
microbe would
never be found, Pasteur went
blackboard and drew a diagram of the chain-like organ-
ism, saying,
He had found streptococci in the lochia of dying patients
and had cultivated them from the blood, taken both
before and
after death.
This
must have undermined the opposition of any remaining
anti-contagionists, and one can appreciate the satisfaction
with
which
Oliver
Wendell
Chadwick
in 1883
on
the contagiousness of puerperal
fever,
"But I shrieked my warning
louder and longer than any of them, and I am pleased
to remember
that
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-
gators
in
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
the streptococcus.
It is impossible, and really unnecessary for my purpose,
to review
the story of the discovery of these
organisms.
This was admirably done by Arnold W. W.
Lea (1910), also
Mary's
Hospital.
The
or
as the long-desired
in1ateria
peccans
of
con-
to " arrive
at the
cases of
an occasion
" One day,
in
lying-in
hospital~:
it is the nursing and medical staff who
as the orator replied that he feared that
to the
' There, that is what it is like!'
was
a discovery which
Holmes,
writing
to
Dr.
is able to boast:
on the existing
Other organisms were
various
a member of the surgical staff of St.
list
he
gives
still
stands:
in
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JAN. 1, 1938

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J.vk.
1, 1938
HISTORY OF THE PREVENTION OF PUERPERAL FEVER
THIEBRirsHt
3
addition to streptococci it includes staphylococci, the colon
bacillus, pneumococci,
the gonococcus,
diphtheria, of tetanus, of typhoid even, the Bacillus aero-
genzes capsiulatius of Welch, and the Bacillius pyocyanieuts.
thebacillus 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
inert.
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
been eliminated.
Sporadic cases are of not infrequent
occurrence, and even epidemics occur in hospital as well
as in private practice.
Puerperal sepsis
the chief causes of puerperal mortality.
maintain that this is only the consequence of the neglect
or the
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
particularly
intotheir habitat-the
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
been revealed.
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-
tion in 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-
tions.
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
However, we
in Vienna
The search for
is
still one of
Some authorities
antiseptic
ritual.
Others,
lair
in which they
Since
infections.
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.
Charles
Meigs,
the
anti-contagionist
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
chamber
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.'
The means
ali eady
quoted,
He went
He
it about him like
It is known that he
Relation of Streptococcal Sore Throats to
Puerperal Fever
The discovery of microbes gradually led to the eclipse
of mere conjectures; theories could henceforth be scien-
tifically tested.
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
when
puerperal
sepsis
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
sore throat."
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.
is
most
prevalent.
Alexander
In my quest for the dis-

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HISTORY OF THE PREVENTION OF PUERPERAL FEVER
Flugge, reported
that the micro-organisms found in the human mouth might
be pathogenic, but had demonstrated the "surprising and
extraordinarily
important fact"'
words) "that when speaking, coughing, and sneezing
spreading about of the mouth and nose secretions takes
place.
Even at a distance of several metres he had shown
that agar plates were covered with colonies after some-
what louder and
livelier speaking."
exclusion from aseptic operations of all persons suffering
from acute catarrh.
Mikulicz,
searching
for
surgical technique and
at
this time experimenting with
sterilized
thread gloves,
was deeply concerned by
newly recognized
set to work to parry
In July, 1897, he described the
" Mundbinde
(mouth bandage) which he was using for
this purpose.
This
the subject. The material used was the finest mull, " steril-
ized of course," he
sterilized operation-gown."
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
experimentation.
An
assistant
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
air.
in
1895.
Flugge had not only proved
(to
use HIubener's own
a
Flugge urged
the
an
"absolutely
germless"
this
source of infection.
it.
He immediately
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-
meshed mull.
As evidence of the exhaustive character
of
these
pioneer
experiments
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
filter.
This
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
in use.
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.
ment:
" For several years I have been worried as to the
part that drops of liquid projected from the mouth of
the operator
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
satisfactory."
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
led him
to notice that drops of saliva were projected
from the lips of the operator or his assistant even when
isolated
vwrds,
ord.rs
in
it must
be
notedthat
is a requirement which
it can be easily achieved by giving
is ignored in most
The
He began with the state-
monosyllables,
were
given.
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
paper.
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
months
he
convinced
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
results.
great
to custom for
favourable
welcome
than
that
surgeons
to
an
analogous
Mikulicz."
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
droplet
infection.
This
illogical
shared by all, or nearly all, of us who have during the
last
twenty
years
practised
midwifery.
His investigations appear
I do not blind myself to the fact that this is too
a shock
it
to receive
accorded
communication
a much
the German
by
Professor
more
by
saying, " I
I never
first English
surgeon
to
1906).
He
in 1911, after testing by ex-
Yet
position
was
indeed
both
gynaecology
and
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
lay
press
entitled to the credit for this.
Let me
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
obstetric
practice.
I
believe
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
his mouth.
All of the cases that got sick were handled by
this particular intern, and one mother and one baby died of
streptococcus infection.
"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
Obstetrician,
U.S.A.")
is
it
was certainly
at the -same
I found that one of the interns, who
I relieved him from
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MEDICAL JOURNAL
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JAN. 1, 1938

Page 5

HISTORY OF THE PREVENTION OF PUERPERAL FEVER
THE BRITISH
MEDICAL JOURNAL
5
Side hospital.
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
of cheese-cloth."
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
Hospital, Chicago.
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
There is
It was
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
practice.
rigid use in this or that institution, on this or that mater-
nity
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.
inthis way that the origin
epidemic or of the sporadic case can be detected and
indicted with a degree of probability almost amounting
-to certainty.
The first of these thoroughly investigated
epidemics was that which occurred in the Sloane Hospital,
New York, in January and February of 1927.
delivered women
twenty-four (15 per cent.) developed
haemolytic streptococcal infections; eight of- these died.
It was fully reported in the August number, 1928, of the
Ainericani
Journial of
Obstetrics and Gynaecology by
Professor
B.
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
the
nose and
throat
of
certain
members of the domestic staff.
papers it was laid down that it is "important to exclude
streptococcal
carriers from maternity hospitals and
insist
on complete masking by
parturient and puerperal women."
It
is only
or the originator of the
Of 163
Meleney. A
in
the
air, on
doctors,
In the summary of these
nurses, and
to
on
all
in attendance
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
of
obstetrics
of "The
Practical Medicine Series"
1928.
At last he had powerful scientific support for the
complete masking of mouth and nose, which he had
already been employing and advocating
practice-against
much
opposition-for
twenty years.
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
(who
was
suffering
from
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
for
in midwifery
no
less
than
The second
By serological
a
severe
"cold ")
yielded
This is, I believe, the
As a consequence
This coincided
" Up
Other Investigations
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
infection
in puerperal
sepsis.
has summarized this work; referred freely to that of
others ; and given his own conclusions in The Prevenition
of Puerperal Sepsis, published in 1936.
carefully
studied
by
everybody-midwife,
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-
tion
was
not even
mentioned.
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:
generally
accepted
proportion.
bacteriological evidence pointed to the rarity of endo-
genous auto-infection-all recent work has supported this
view.
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
However,
In
Dr. Leonard Colebrook
This should be
accoucheur,
Professor
Whitridge
this
that
is a
all
He
thought
JAN. 1, 1938