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
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