FREQUENCY.—In a careful search through the records preserved by the Health Department of New York City, I found that from 1868 to 1875 inclusive the total number of deaths for nine years was 248,533. Of these, 3342 were from diseases complicating pregnancy, from the accidents of child-bearing, or from diseases of the puerperal state; or, in other words, 1:75 of all the deaths occurring during that period was the result of the performance of what we are in the habit of regarding as a physiological function.
The deaths from miscarriage, from shock, from prolonged labor, from instrumental delivery, from convulsions, from hemorrhage, from rupture of the uterus, and from extra-uterine pregnancy, and deaths from eruptive fevers, from phthisis, and from inflammatory non-puerperal affections complicating childbirth, made a total of 1395, or about 42 per cent. of the entire number. The remaining 1947 cases, variously reported as puerperal fever, puerperal peritonitis, metro-peritonitis, phlebitis, phlegmasia dolens, pyæmia, and septicæmia, represent the very serious sacrifice of life resulting from inflammatory processes which have their starting-point in the generative apparatus. If we apply the general term, puerperal fever, to this class of cases, it will be seen that the malady is the cause of nearly one one-hundred-and-twenty-seventh of all the deaths occurring in the city. The actual number of births for the nine years in question was roughly estimated at 284,0002—an estimate erring upon the side of liberality. The total number of deaths to the entire number of confinements was, then, at least in the proportion of 1:85, or, from puerperal fever alone, in the proportion of 1:146. Garrigues3 examined the records of the various city institutions during the period in question, and from them estimated the number of births which took place in hospitals at 10,572. The recorded deaths were 420. Deducting these from the totals given above, the general death-rate in civil practice from puerperal causes in New York City was in the proportion of 1:94. Max Boehr4 in his now-famous statistics reckons that one-thirtieth of all married women in Prussia die in childbed. The Puerperal Fever Commission5 appointed by the Berlin Society of Obstetrics and Gynæcology arrived at the conclusion that from 10-15 per cent. of the deaths occurring in women during the period of sexual activity were due to childbed fever, and that this disease destroyed nearly as many lives as small-pox or cholera. But puerperal fever differs from either small-pox or cholera in that the latter presses largely upon the aged and the very young, while the former gathers its victims exclusively from a selected class—viz. from women in adult life, the mothers of families, whose loss, as a rule, is a public as well as a private calamity.
2 This estimate was based upon the assumption that the natural birth-rate is 33 to the 1000—a proportion believed by the statisticians of the Board of Health to be approximatively correct, though probably somewhat in excess of the reality. P. Osterloh has recently stated that my statistics were computed in so arbitrary a manner as to render deductions from them valueless. In this, however, he is mistaken. The most conscientious care was taken in their preparation; wherever the possibility of error existed the fact was distinctly indicated, and all calculations were made in such a way that whatever corrections might be required would strengthen the conclusions.
3 "On Lying-in Institutions," Trans. Am. Gyn. Soc., vol. ii., 1878.
4 "Untersuchungen über die Haüfigkeit des Todes im Wochenbett in Preussen," Zeitschr. f. Geburtsk. und Gynaek., vol. iii. p. 82.
5 Zeitschr. f. Geburtsk. und Gynaek., vol. iii. p. 1.
For those who regard statistics with habitual distrust it may perhaps be well to state that the foregoing frightful picture is no exaggeration, but is less sombre than the actual truth.
Before proceeding to consider the nature of puerperal fever it is desirable to first recall the anatomical lesions with which it is associated. These, it will be found, are for the most part inflammatory processes having their starting-point in injuries of the genital passage produced by parturition, complicated in many cases by septic changes in the blood, by secondary degeneration of parenchymatous organs, and at times by phlegmonous and erysipelatous affections in remote as well as in the adjacent serous and cutaneous tissues.
MORBID ANATOMY.—The primary lesions connected with puerperal fever are so various that the student will find it convenient to classify them according as they are situated in the mucous membrane of the utero-vaginal canal, the parenchyma of the uterus, the pelvic cellular tissue, the peritoneum, the lymphatics, or the veins. Not, indeed, that such an arrangement is strictly in accordance with clinical experience—as a rule, the inflammatory processes are rarely limited to a single tissue—but because the prognosis and treatment are determined in great measure by the tissue-system which is predominantly affected. The significance of puerperal inflammations, wherever seated, likewise depends upon whether they are local and circumscribed or whether they present a spreading character.
Personally, I have found the following classification of Spiegelberg6 of great utility as a means of keeping in mind the principal points to which inquiry should be directed in estimating the significance of the febrile conditions of childbed: