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Report of Medical Officer of Health.] 23
at home for scarlet fever. Disinfection had been carried out 8 days prior to the confinement,
the period of isolation having been 35 days.
In the Report for 1899 the following paragraph occurs :—
"The exact interpretation of the term 'puerperal fever' has been a subject of discussion
since the introduction of notification in 1890. There is no doubt that the term as commonly
used includes not one, but many diseases, so much so that the last edition of the 'Nomenclature
of Diseases' recommended that the term should be abandoned and the disease more
correctly described according to the phenomena presented. The difficulty experienced in
defining the term has resulted in neglect to notify many cases which were intended to be
reported. The only argument which could justify such neglect has now been put out of
court by the official opinions given at the beginning of the year by the Royal College of
Physicians of London and the Obstetrical Society. Briefly put, the opinions were to the
effect that 'puerperal fever' included 'septicaemia, pyaemia, septic peritonitis, septic
metritis, and other septic inflammations in the pelvis occurring as a direct result of
child-birth.' "
In the course of the past year the Public Health Committee directed that the attention of the
medical practitioners in the Parish should be called to the opinion given by the Royal College and
the Obstetrical Society, and that the practitioners should be requested to notify all cases coming
within the term of puerperal fever as defined above.
It is easy to say what terms should be included in a name such as puerperal fever, but there
will still remain some doubt as to the cases which exactly agree with the terms specified. The
difficulties experienced in practice are to a certain extent indicated in the following correspondence
between one of the practitioners in the Parish and the Medical Officer of Health.
On the issue of the circular letter, Dr. X. wrote thus:—
"I do not know whether any special reason exists in Paddington for the issue of your
letter on the notification of puerperal fever, but it seems to me that the difficulties in
obtaining such notification are insuperable. In the first place, what is puerperal fever? Do
the opinions of the College of Physicians and the Obstetrical Society bring us any nearer to
a definition ? The septic conditions mentioned by those bodies are of too uncertain limits to
lead to uniform notification. I know of a case, not in my own practice, which occurred a
long time ago, in which the woman on the third day after confinement had an attack of
sapraemia. I say 'sapræmia,' and not 'septicæmia,' because the term usefully distinguishes
cases of absorption of a large dose of toxin from those in which there is a multiplication of
the poisonous agent in the blood. At any rate, this hypothesis held good in this case. The
patient had rigors and a high temperature. Foetid clots were cleared out of the uterus, the
temperature came down, and the patient recovered uninterruptedly. This was not a case of
septicaemia, or pyaemia, or septic peritonitis; possibly, however, there may have been slight
temporary septic metritis, but it disappeared at once on removal of the clots. In any case,
the condition was septic.
"To take another case. A patient three weeks after confinement suffered from a white
leg, apparently owing to undue exertion. There are some gynaecologists who hold that
phlegmasia is due to the entrance of germs through the uterine veins. Although I think
that the length of time after the confinement negatives such an explanation in this patient,
yet a man who maintained this view might notify such a case as one of 'acute septic
inflammation in the pelvis.' This, of course, is an exaggerated view of sepsis; a remark
which will apply also to the opinion of another gynaecologist of my acquaintance, that any
rise of temperature in the puerperium is due to sepsis. However, these opinions show the
difficulty of defining septic inflammation.
"I now turn to the hope you express that medical men will co-operate with the
Committee in endeavouring to reduce puerperal mortality. The question arises, in what way
the Sanitary Committee proposes to deal with this mortality. The causes of puerperal sepsis
must be found either in (1) the patient herself; (2) her medical attendant; (3) her nurse; or
(4) her general surroundings. May I ask if the Committee proposes to deal with all these
sources of possible infection, or only with some of them? As far as I can see, the only point
with which the Committee can deal is that numbered (4), viz., the general surroundings; and
in this case, too, very little could be dealt with except the condition of the drains and such