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24 [Appendix IV.
sanitary matters. But does the cause of puerperal septicaemia reside chiefly in drains?
I am afraid that text-books have been rather inclined of late to attach the blame to some of
the other possible sources of infection. Let us suppose a case has been notified to you, and
that your inspector has found the sanitary condition of the premises good. What steps does
the Committee propose to take next ? Will inquiries be made about the nurse? And if she
is above suspicion, will a bacteriological examination of the doctor be made? I presume
that the patient herself is not always an impossible source of the disease. But whatever the
cause, the task of tracing it might be invidious in some cases.
"I am afraid that I have written rather a long letter. My first reason for so doing is to
bring to your notice the difficulties that occur to me. Secondly, I still want to know what
puerperal fever is for purposes of notification? In the third place, although no case of
puerperal fever infection has yet occurred in my practice, it is impossible to predict that such
a calamity will never happen. I am therefore desirous of learning what steps the Committeeproposes
to adopt on receipt of a notification of a case of puerperal fever."
In his reply the Medical Officer of Health observed:—
"All my Committee desire is that practitioners should consider the term to include the
cases which fall within the definitions (practically identical) drawn up by the Royal College
of Physicians and the Obstetrical Society. I may say that my own opinion is that all febrile
conditions during the puerperium not being due to specific infection, such as scarlet fever,
diphtheria, &c., are really septic.
"As to what the Committee desire to accomplish by notification, I may say, on behalf"
of the Committee, that, as regards the medical practitioner, we leave him to adopt every precaution
which medical science indicates as necessary. That, as regards the nurse, a special
communication is sent to her pointing out her duties with regard to infection. For some
time past I have seen every woman, be she nurse, midwife, or 'friend,' who has had anything
to do with a notified case of puerperal fever. The clothes, instruments, &c., of the
nurse are always disinfected, and I think that I can say that for some years past no secondary
case has occurred which could be attributed to infection carried by a nurse who has carried
out my instructions. As regards the house (although here the action is, in my opinion, toolate),
a full inspection is made and steps taken to remedy any defects found. Disinfection, &c.,
of the bedding and premises is carried out. As to the patient herself, I do not believe in
'auto-infection,' as taught by some gynaecologists, and regard all cases of sepsis as due to
conditions external to the patient. Consequently there is nothing in this connection
requiring action by my Authority, except disinfection at the conclusion of the case.
"I cannot help thinking that the efforts which have been made by the Authority of this
Borough have accomplished something in the past, and I think that better results will be
obtained in the future if practitioners will extend the interpretation of the words 'puerperal
fever ' to the limits of the definitions of the Royal College of Physicians and the Obstetrical
Society. By so doing the case of sapraemia you mentioned would be one for notification.
"White leg'' is, I believe, usually due to thrombosis, and not of aseptic nature. Consequently
notification of such a case would not be asked for.''
Dr. X. replied:—
"I wrote to you because I take a good deal of interest in the subject of infectious
diseases, and for the same reason I venture to reply to some of your remarks.
"I still think the definition of the College and the Obstetrical Society unsatisfactory,
nor do I think that they really include the sapræmic case I mentioned, although I should
have notified it as puerperal fever myself. I cannot regard all febrile conditions during the
puerperium as really septic, as I am certain that the temperature of lying-in women may go
up from very slight cause to 100°, or exceptionally much higher. I know of an interesting
case in which fright due to a fire sent the temperature for a short while up to 104°. A foul
discharge is generally a much better criterion than fever.
"The communications made to the nurse are admirable, and of undoubted value, I
should think, amongst the lower classes, in which case untrained women frequently, I believe,
make examinations on their own account. The inspection of drains and the disinfection
are excellent in a general way, but not likely to affect the mortality from puerperal fever
to any extent. As regards auto-infection, it is obviously possible to introduce septic germs
from the vulva, if they exist there; and if the bedding may carry them, so may the woman.
The practitioner amongst the lower classes is not likely to shave and disinfect every patient.