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 1875 ?HE RELATI°N OF PUERPERAL FEVER
INFECTIVE  DISEASES AND  PYEMIA.
AN ADDRESS
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DEMVEREH AT THE OBSTETRICAL SOCIETV OF LONDON, JULY 7, 1875.
By FORDYCE  BARKER, M. D.,
Of New York.
      LOTJISVILLE:
Richmond and Louisville Mkdical Journal Print.

            1875- 
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U.S. NATIONAL
      LIBRARY
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    MEDICINE
 
 
 
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THE RELATION OF PUERPERAL FEVER

            ^ ft t&y c^ (KlGU/'^v
INFECTIVE DISEASES AND PYEMIA.
AN ADDRESS
DELIVERED AT THE OBSTETRICAL SOCIETY OP LONDON, JULY 7, 1875.
By FORDYCE BARKER, M. D.,
         Of New York.

       LOTJISVILLE:
Richmond and Louisville Medical Journal Print.
             1875. 
WQ


 1815
ARMED FORCES f'TDICAL LIBRARY
     WASH INST Oh. 0. C , 
RELATION  OF  PUERPERAL FEVER
                      TO THE

   INFECTIVE  DISEASES AND PYEMIA.
  I feel  that I have no  right to waste any of your time in
personal topics, except briefly to  express my grateful appre-
ciation of the honor that I have received at your hands, and to
appeal to your courtesy to excuse such deficiencies as may be
charitably ascribed  to  weakness  of the vocal  organs, or to
that  embarrassment which a stranger  must feel in addressing
such a body of obstetrical men on  such a topic as puerperal
fever.  I may be permitted to say that this discussion is now
watched with the greatest  interest by your brotherhood  on
the other  side of the  Atlantic;  but, as yet, this discussion
does not appear to have led to that  happy result spoken of
by the Psalmist, that 'w maketh men  to be of  one  mind in a
house."
  I shall  aim, in the  remarks that I am about to make, to
confine myself closely  to a discussion of the questions pro-
posed to the Society, and to state my opinions, and my reasons
for holding such opinions,  in the  most terse, compact lan-
o-uao-e compatible with clearness.  If  these opinions  seem to
be in antagonism with  a  great majority of those which have
been expressed in this  discussion, I ask that they may not be
regarded as partisan in  their tone, but as a presentation of
views necessary for a full and comprehensive study of the 
4            Fordyce Barker, M. D., Address.
subject.  I ask, for such arguments as may be urged, that
candid analytical sifting  of evidence  which  is requisite  for
sound  decision as  to what is the true answer to the several
questions  now before us.  I concede to all, and I beg all to
concede to me, that it  is the truth and  not  forensic success
which is sought for by us all who speak in this discussion.
  Of the six questions proposed, the second  and third only
admit a'direct categorical answer of yes or no,  and this will be
one or the other, depending upon the answer given to the first
question.  If  the  first be answered  in  the affirmative,  the
second must be answered in the negative, and  the third in the
affirmative; or the  answers may be exactly the reverse.
  I suppose the meaning of the first question is clearly de-
fined by the second and third to  be, whether there is a disease
peculiar to women in childbirth, never met with under any
other circumstances, as distinct as typhus  or typhoid fever,
scarlet fever, measles, or  small-pox.
  I can not think that the proposer of these questions regards
it as necessary that those who believe that puerperal fever is
a distinct essential disease must, therefore, accept all the qualify-
ing phrases |of the first  question.  For example, " distinctly
caused by a  special morbid poison," is  one of the  qualifying
phrases.  Is this a necessary characteristic of a distinct disease ?
Has science yet determined the "special morbid poison which
causes typhoid fever?"   When a disease is induced by conta-
gion or infection, then it is " distinctly caused by a special
morbid poison."  If the phrase had been " often caused by a
special morbid poison," I should have  accepted it as true of
puerperal fever, as  I believe it to be true of diphtheria and
some other diseases.  It  is just this phrase  which seems to
have debarred Dr. Farre and Dr. Richardson at the last meet-
ing from answering the first question in the affirmative.  And
here I wish  to remark that it seems to me that the idea  in-
volved in this phrase  has  been a great barrier to a clear con-
ception of the disease, and has greatly contributed to the  ob-
scurity and ambiguity of its discussion.  It implies that puer- 
             Fordyce Barker, M. D., Address.            5

peral fever can not  be properly ranked as a distinct disease
unless its cause can be proved to be an unit, " a special morbid
poison."  But this test is not demanded for many other affec-
tions which  the  profession  universally accept as distinct dis-
eases.  There  are many such which originate from multiple
causes, so far as science has yet been able to determine, of
which I may instance typhoid fever, diphtheria, erysipelas, and
rheumatism.
   The  distinct character  of a  disease is determined by the
evidence derived from three sources :  the causes, the  clinical
phenomena, and the pathological anatomy.  Some diseases
give  us proof of their distinctness by evidence  derived from
all three of these  sources, others  from only two, others from
one  alone.
   Directly in connection and associated with the idea implied
in the phrase " distinctly caused by a  special morbid poison,^
is another idea, which fallaciously colors and  obscures much
of the reasoning on  puerperal fever, and that is,  that identity
of cause  must be followed by identity of result.   In other
words, a given cause, a special  morbid poison if you please,
known to develope  a  special  distinct disease, must  always
produce this particular disease.   In a wealthy family belonging
to my clientele, a year ago, I saw a lady dangerously ill from
pyaemia, in consultation with Dr. Sayre, who wasattendingher
for a traumatic injury.   By our suggestion, the house was
carefully examined by a plumber, but  no defect was then dis-
covered which could explain the source of the blood-poison-
ing.   Very soon, three  members of the family were severely
ill from a typho-malarial fever.   As soon as the  condition of
the patients would permit their removal, I insisted that the
walls of the rooms  covering the plumbing  should be torn
down, when it was found that there was a defect in the leaden
waste-pipe sufficient  to permit the noxious gases to permeate
the house, but not  sufficient to cause an escape of fluids to
stain  the walls of the rooms.  During the past  winter, I at-
tended  a  gentleman with  severe  typho-malarial fever.  His 
6            Fordyce Barker, M. D., Address.
 residence was in a large house, constructed on the plan of the
 French  apartments, which was  entirely occupied by families
..jof refinement and abundant means.  During the time of con-
 valescence of this gentleman, diphtheria appeared in another
 family in this apartment house.  I saw the first child attacked,
 in consultation with Dr. Morris.  Subsequently, the  father
 and two other children, one of whom  died, were severely ill
 from  diphtheria.  It is worthy of mention, that, while these
 were ill, the wife and mother was removed into another house,
 and she  was confined with her fourth child, under the care of
 Dr. I. O. Stone, one of our  most  prominent  physicians,  and
 her convalescence was not impeded by any puerperal disturb-
 ance from either diphtheria, typho-malarial, or puerperal fever.
 On  examination,  it was found  that  the waste-pipes  in  this
 house were in  precisely the same condition as that of the
 house of which I have just spoken.
   Who can doubt that the pyaemia, the  typho-malarial fever,
 and the diphtheria were all caused by the same " special mor-
 bid poison?"   At the last meeting of this  society, Dr. Play-
 fair related some facts  which  recently occurred at Xotting1
 Hill, where puerperal septicaemia in  a wife, " from which she
 barely recovered with her life," and  diphtheria  in  the hus-
 band, " from which  he  nearly died," seem to have  been due
 to the same causes  which I have mentioned.  I ask  you to
 note.the language by Dr. PI ay fair, for I shall again have oc-
 casion to refer to this.   He says, " Who could rationally dis-
 believe that those two  diseases were  produced by  the same
 septic poison? "'  One he names, because of his theory of its
 cause, septicaemia; the other, produced  by the same  cause, he
 names, from its clinical  phenomena, diphtheria.
   The other qualifying phrase to which I  will simply  allude,
 but which time will not permit me to discuss in detail, is the
 following: " as definite  in its progress  and  the  local lesions
associated with it" as certain specified diseases.   This qualifi-
 cation involves two distinct  and different  points, the clinical
 history and the pathological  anatomy.  I  will only say that 
Fordyce Barker, M. D., Address.
7
in my judgment these several diseases mentioned differ in de-
grees as to their definiteness in progress and the definiteness of
their locaf lesions, and consequently puerperal fever cannot be
compared or contrasted with them as a group in these partic-
ulars.
  I will now give my reasons for believing that there is a dis-
tinct disease which ma}T be properly called " puerperal fever."
I think the definition  given in the Nomenclature of Diseases,
emanating from the College of Physicians, is absolutely per-
fect: a "continued  fever  communicable by contagion, occur-
ring in connection with  childbirth, and often associated with
extensive local lesions, especially of the uterine  system."  It
is a disease which presents a group of general symptoms, in-
dependent of local inflammations, resulting from the absorption
of some poison into the system.  It is needless for me to dis-
cuss this point here, because it is  evident from all that has
been said that " localism " or " Broussaisism" has no status in
this Society.  Those who  would call  this disease septicaemia
or pyaemia  are in agreement on this point with those who call
it a fever.
   We can arrive at truth in medical  discussion only by using
language accuratel}*.  There can be no accuracy of idea with-
out accuracy of language.  It is the established usage of stan-
dard authorities  in  medicine to designate as  fever all those
diseases which result from the  absorption  of some  poison
which produce certain morbid blood-changes and give rise to
certain general  characteristic symptoms, where the  specific
poison is unknown.  Under the  denomination  of fever are
properly  and legitimately included  not  only those diseases
which are  severally called typhus, typhoid, relapsing, remit-
tent, intermittent, and yellow fever, but all the infectious con-
stitutional diseases which occur either epidemically or  endem-
ically.
   When the specific poison is  known which causes the mor-
bid blood-changes and induces certain general characteristic
symptoms, the disease is named from that poison, and so we 
8            Fordyce Barker, M. D., Address.

have the accepted  terms in  medicine of uraemia, septicaemia,
pyaemia, and others of like character.  I will here only allude
to the fact that none of this latter class are known to be con-
tagious or to occur as epidemics.   The point we are trying to
settle is not a question of name, except so far as this : I doubt
not that we will all agree that the  name given to a disease
should be significant and appropriate.
  The gist  of the  matter, stripped of its superfluous and ob-
scuring elements, lies in  the  inquiry whether there be a dis-
ease which  attacks puerperal women and only puerperal wo-
men.
  A necessary preliminary is  to  ascertain from what sources
we  are to obtain our evidence by which we  can settle  the
question whether there be a  distinct disease  peculiar to wom-
en in childbirth.   I think we will agree that this  evidence
must be derived either—1.  From the causes  of the disease ;
2. From  the clinical phenomena;  or 3. From the pathologi-
cal  anatomy.                                           .
  I do not think that we are  able, at the present day, to de-
rive much information from studying the causes of this disease
in settling this question  any more than we can in settling the
question whether typhoid fever, relapsing fever, or yellow fe-
ver are distinct diseases.  In a sanitary point of view, I think
a study of the causes of this disease to be of vast importance,
and for this reason I esteem the paper which was read by Dr.
Braxton Hicks before this society in 1870 as a most valuable
contribution.
  If a puerperal woman, not  protected by the immunity  of a
previous attack or  by idiosyncrasy, be exposed to  the poison
of scarlet fever  or of any other  infective continued fever, I
have no doubt that she  will  have scarlet fever, or whatever
specific disease she may  absorb the poison of.  The puerperal
state does not protect her from the influence of such poison.
Dr. Hicks, as I understand him, does not claim that puerperal
fever is only scarlet fever in the puerperal women, but names
this as one  of the causes in the  same category with erysipe-
las, diphtheria, mental emotions, etc. 
Fordyce Barker, M. D., Address.              9
  I think the evidence is conclusive to the  minds of a great
majority of the profession, established by numerous incontes-
table facts—facts observed not only in  sporadic  cases, but in
very many epidemics which have occurred, not in hospitals or
cities alone, but in epidemics  which have ravaged large tracts
of country in sparsely settled  rural districts, that the poison
of erysipelas may cause in women after  childbirth a distinct
disease, which  some of us choose to call puerperal fever;  and
that the poison of puerperal fever, if absorbed into the system
of a man or a child, will cause in  that  man or child erysipe-
las.   But the clinical phenomena and the anatomical lesions
which result from this  common  poison are so diverse as to
warrant o    regarding them ar  two distinct diseases.
  Of court'   - is quite needless for me to refer to the medical
his 0*   of Great Britain for  proofs of this  assertion; but I
may  be permitted to refer to that  of my  own  country  for
most striki    corroborative evidence.
  A reprint  if Kunneley On  Erysipelas was published some
thirty years since, with notes  by Dr. John  Bell, of Philadel-
phia, in which he gives most  striking facts  in regard to sev-
eral epidemics  iu the United States, in  which  erysipelas  and
puerperal fever have appeared together.
  I will also refer to a valuable monograph on Erysipelas and
Childbed Fever, by Dr. Thomas C. Minor  of Cincinnati, pub-
lished during the last year, and which I had the  pleasure of
reading on my voyage over.   The  work  is  based on a most
painstaking and laborious  study of the vital statistics of the
census of the United States for 1870, and of a puerperal fever
epidemic which prevailed in South Western Ohio in the win-
ter of 1872.  The work is well worthy of perusal by all who
assume to influence medical  opinion on the subject of puer-
peral fever.  This careful study of these vital statistics by Dr.
Minor does not appear to show any connection of typhus fe-
ver, scarlet fever, septicaemia, and pyaemia, with puerperal fe-
ver.   Epidemic scarlatina was very seldom associated with
an outbreak of epidemic puerperal  fever;  but epidemic ery- 
10           Fordyce Barker, M. D., Address.

sipelas was " invariably  associated with an  outbreak of epi-
demic puerperal fever, or vice-versa."
  I have but a single remark to add in regard to the question
of causes of this disease.  The argument of those who deny
that puerperal fever is  a distinct  disease, rests mainly on the
o-round that the disease so  called is the result  of a septic poi-
soning. ^ Septic poisoning  is a term now used  very frequently
and somewhat vaguely : but  even those who  contend  that
there is, properly speaking,.no distinct disease of puerperal
fever, do not allege that all  the  resulting disease from septic
poisoning is one  and the same  thing, and that this disease
should be called  septicaemia.   Is  there anything improbable
or unphilosophical in the hypothesis that septic poison, acting
on a system in a peculiar state, such  as never is found in the
human system under any other  conditions, the state which
has been so graphically described in this discussion by Dr.
Richardson and Dr. Farre, results in a distinct disease, which
never is found except when the system is in  this condition ?
  Has  any proof been  offered by  any one, anywhere,  that
epidemic and endemic influences, noscomical  malaria, conta-
gion or infection, do not develope this poison in such a sys-
tem, which results in a distinct disease ?
  We  must fir\d the answer in  a study of the clinical  phe-
nomena and the anatomical  lesions of the disease.  If septic
poisoning never  occurs  as an epidemic, I do not say endemic.
among those who are suffering from traumatism, and if it never
develops contagion  in  this  class of subjects,  and if septic
poisoning in puerperal  women  does occur as  an  epidemic,
and is contagious and  infectious, are not these elements suf-
ficient  to warrant us in regarding the two diseases as quite
distinct?
  The  advocates of the septicaemia theory of puerperal fever,
both on the Continent and in this country,  have seen  that
they must accept this issue, and consequently  they  are driven
to deny that puerperal  fever  ever occurs as  an epidemic, or
that it is contagious  or infectious.  One of your speakers at
the last  meeting  said: "I do not believe that there is anv 
Fordyce Barker, M. D., Address.
11
specific condition justifying the name of puerperal  fever;"
and  he logically adds "nor do  I  believe that there is any
special miasm arising  from the puerperal patient capable of
being conveyed to another patient; nor do I think that there
is any  evidence whatever to show that there has been an epi-
demic  of puerperal fever in the strict sense of that word."
  The author of the Address on Obstetric Medicine before the
British Medical Association last year, said in that address : " I
have not  been able to find anything worthy of the  name of
evidence to  prove  its epidemic prevalence at any time or in
an}T  large  district."  The  same  author, in his work On the
Mortality of  Childbed and Maternity Hospitals, says :  " I feel
certain, and believe I can prove, that an epidemic of  puerpe-
ral fever never occurred."  He also denies, with equal positive-
ness, that the disease is ever contagious.
   Now if,  during  certain years or seasons,  puerperal women
in a giveu territorial  district die of a  disease, call it either
puerperal fever, puerperal  pyaemia, or puerperal septicaemia,
in numbers fiftyfold or a hundredfold greater in proportion to
the births than they have in preceding years, or than  they do
in following  years, I think the profession generally would call
this  disease  an  epidemic.   When  the mortality from puer-
peral disease, call  it puerperal fever or  puerperal pyaemia, in
that part of Xew York which is in the best sanitary condition
of any part of the city, and in which  are  the  residences of
the most wealthy part of the population, iu four months of the
year 1873 is twenty times as great as it had been for twenty-
five  years before, and  the percentage of deaths in proportion
to births is more  than double what it  is in the parts of the
city  where the poor women are crowded in tenement houses,
and  quadruple the proportion  of deaths  during  the same
period from the same cause in the lying-in hospitals,  I think
we are justified in saying that an epidemic exists in this part of
this  city.   If in Cincinnati, Ohio,  in 1873, the number of
deaths from  puerperal  fever was one  hundred and  twenty-
two, while the  annual average of deaths from this cause for 
12           Fordyce Barker, M. D., Address.

five  previous years was  thirteen  and three-fifths, I think
most men would say that the disease was epidemic that year.
In view of all the similar  facts abounding  in medical litera-
ture, I will not borrow a phrase  from one  of the speakers at
the last meeting, and say that those who deny that  this dis-
ease ever occurs as  an  epidemic " must have minds which I
believe  to  be not open to  conviction;" but I will say that
such persons must attach  a subtlety of meaning to the word
epidemic not consonant with the common sense.   Please  to
observe that I use the article, and say the common sense,  as
otherwise the remark might seem discourteous.
  I will not detain you now by a discussion of the question of
contagion, for all have undoubtedly fixed  opinions  cv  ih\s
point,   Those who  regard puerperal fever as a distinct di 3e?se,
believe  it to  be  "communicable by.contagion ;" while those
who believe it  to  be only pyaemia  or septicaemia  in women
after childbirth, do not consider the disease contagious.
  Can a woman  after childbirth  be  exposed to the danger of
receiving  the poison which produces typical  septicaemia  in
larger closes than when  she has  retained within her uterus a
portion  of  decomposed placenta ?  If puerperal fever be sep-
ticaemia, would not the disease under these circumstances ap-
pear in its  most virulent forms?  But we all know that this
is far from the fact.  One  very important idea in this connec-
tion was first distinctly enunciated  by Dr.  Barnes  in this So-
ciety some years ago; and that is that septicaemia  in puerpe-
ral women is not actively contagious.  " When arising from
decomposition of the placenta, it generally began and ended
with the patient attacked."  During this discussion, Dr. Brax-
ton Hicks has expressed a very similar sentiment; and I feel
quite sure  that  all clinical  observers will  coincide with  this
statement.
 I will submit for your examination the following propositions:
  1.   The clinical phenomena of puerperal fever are quite dif-
ferent from those which are  met with in surgical septicaemia
or pyaemia. 
Fordyce Barker,  M. D.,  Address.           13
  2.  These affections do  u^jt occur in puerpera1  women, and
the result is a disease which does not constitute a continued
fever " communicable by contagion."
  3.  When either of these affections complicate puerperal fe-
ver, they modify the clinical phenomena by symptoms which
can be distinctly appreciated and described  by any close ob-
server.
  I will  not  take up  your time by giving  the  evidence on
which these  propositions are based, because I think that this
has been done in a work On- the  Puerperal Diseases, which it
will be indelicate for me to  refer to in more definite terms.
  I will add  only a few words  in regard to the pathological
anatomy of the disease  now under discussion.  On the first
evening of the discussion, Dr. Richardson  argued  that there
were no  local lesions "which would lead us in the dissecting
room in  any case to say  this was a case of  puerperal fever, as
we should say this was a case  of scarlet fever or of typhoid
or of typhus fever."  I think it would be impossible to prove
by the anatomical lesions that  scarlet fever or typhus fever,
or relapsing fever, are distinct diseases.   A child is put in bed
at night apparently well.  A few hours afterwards, it is awak-
ened by vomiting, it is very delirious, its pulse is very rapid,
and the temperature  is six  or  seven degrees  higher than is
normal, and the child  dies in the early  morning without the
slightest  irruption on the  skin.  No anatomical lesions can
be found to characterize the disease.  But scarlet fever is ep-
idemic in the neighborhood, or another child in the same
family is taken ill with well marked scarlet fever within  a
few hours after the death; and any physician would feel war-
ranted in registering  the cause  of  death  as  scarlet fever.
Such cases are not very rare, and, I dare say, have been met
with by  several gentlemen now present.   Would the most
able of the recent authorities on the continued  fevers—would
Sir William Jenner, or Murchison, or Hoffman, or Lebert—
insist that no one  would have  a right to  register a death as
resulting from typhus fever  or  relapsing fever, unless certain 
14          Fordyce Barker,  M. D., Address.
characteristic  anatomical  lesions are found in the dissecting
room?  All of these writers declare that these diseases have
no pathognomonic lesions.
  It was asserted by the author of the Address in Obstetric
Medicine, that " pathologists  believe that they have  torn  to
tatters the view " that the disease we are now discussing "is
an essential fever peculiar to puerperal women, as much a dis-
tinct disease as typhus or typhoid."
  When ? How ? Where ? Show us the proof.  Is there evi-
dence that such  pathologists have studied  the  disease any-
where  except in  hospitals  and  large cities, where the disease
is very probably  complicated with septicaemia or pyaemia?
  Of what value would be the researches of the ablest pathol-
ogists  of Germany  or  England on questions relating to the
pathology of  yellow fever, if such  a pathologist had no op-
portunity of  studying this disease except in Germany  and
England ? Have Spiegelberg, or Schroeder, or Schmiedeberg,
or Mayrhofer, or Orth, or  Heiberg, or  Olshauser, or Fehling,
or Cohnstein, or Breisky, or Yon Haselberg, ever studied pu-
erperal fever as  it  is found  in epidemics in rural districts,
where pyaemia and septicaemia are rarely met with?  German
is a difficult language to acquire;  and  it gives an attractive
appearance of learning to introduce such names, even if noth-
ing be  quoted from  them.   I am familiar with their writings,
and would not undervalue the merit of their researches ; but
so far as the elucidation of the  question now under discussion
is concerned, I think it of equal importance that  we should
carefully study for the clinical phenomena of the disease your
English classical writers—Hulme, Leake, Kirkland,  Clarke,
Gordon, Hey, Armstrong, and Robert Lee.  The hint on this
point thrown out by Dr. Farre  at the last meeting seemed  to
me most appropriate and timely.
  What progress is  made in science ?  ifow do " we free our-"
selves from error," or gain in scientifi/ precision or accuracy
of description in giving to this  disease a new name—pyemia,
as  Dr.  Duncan would call  it;  while he  confesses  that it has 
Fordyce Baker, M. D., Address.            15
no etymological signification  in  this disease, and, in fact, has
no definite positive meaning?
  What propriety is there in giving to an obstetrical disease
a name significant and appropriate  to  a surgical disease, un-
less it can be demonstrated that  the two diseases are identical
in their  clinical  phenomena and their anatomical lesions?
The burden of proof to show  this identity belongs to those
who would call the disease puerperal septicaemia.  Some think
that the negative has already been established.
  I have neither the time nor the  voice to discuss the other
questions which  have  been  proposed.  With  my  warmest
thanks for your courtesy in listening to me so patiently, allow
me to  close  with the suggestion  that it  may be well  for all of
us who discuss puerperal  fever  to remember the exhortation
of Oliver Cromwell, when he lost patience with a Scotch As-
sembly:  "I beseech you, brethren, by the  mercies of God,
conceive it  possible that you may be mistaken."
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