PROGNOSIS.
Whenever then we find rise of temperature in a puerpera, we ought to be anxious lest some grave complication is going to develop, and give a guarded prognosis. Al though, indeed, the purely inflammatory affections almost always termi nate in recovery, the same does not hold true of those which are depend ent on infection, and although putrid infection often ends favorably, it is far otherwise with peritonitis, the purulent and gangrenous metritides, purulent infection and septicaemia, in which death is almost constantly the rule. We must, however, here draw a wide distinction between the cases which occur in private practice, and those which arise in maternity hospitals. As long ago as 1858 Tarnier showed that the mortality at the Paris Maternity was 1 in 19, while in the twelfth ward of the same city it was only 1 in 322. In 1861, Ilusson reported that the mortality in Paris was 1 in 172 outside of hospitals, while in them, taken collectively, it was 1 in 10. In 1866, Lefort, comparing the mortality rate in general of maternities and of cities, gave the following figures: Maternities and hospitals, 888,312 confinements, with 30,594 deaths; cities, 934,781 confinements, with 4.405 deaths, that is to say, in mater nities and hospitals 1 woman died in 29; in cities 1 in 212. Lefort was, therefore, justified in drawing the following conclusion: The mortality of women delivered in hospitals and maternities is out of all proportion to that of those delivered in cities. '['0 explain these facts, the following influences have been stated as being effective: the influence of the hos•.
pital, the social state and the morals of the women confined there, and the efflux into the hospital of the grave cases which can not be terminated in town. These are not the true causes, but rather the overcrowding in hospitals, and above all contagion—a contagion the more likely to dissemi nate the greater the crowding, and which may even result in an epidemic.
Latterly, happily, these views in regard to contagion have become classic, and the means taken by accoucheurs in charge of maternity ser vices have considerably reduced the mortality rates. We content our selves with citing the figures given by Beurmann, from the statistics of the Lariboisiere and Cochin hospital.
At the Lariboisiere hospital, Siredey takes two chief precautionary meas ures: The one aims at purifying the surroundings of the lying-in woman; the other aims at cleansing from morbid germ those who are in attend ance on the puerpera.
A study of the following tables shows the proportionate decrease in the mortality rate: On the other hand, Polaillon, who is a resolute partisan of the antiseptic method, and has used it at the Cochin hospital, has obtained the following figures: To resume: In five years at the Cochin hospital there were 3,697 labors with 34 deaths, of which 23 were from puerperal causes after simple or complicated labors, or 1 in 160.3, and 16 after simple labors, or 1 in 229.9.
3lultipara? 1 death in 97 labors; primiparte 1 death in 119 labors.
Finally, in 1878, Championniere, at the same hospital, had 770 con finements, with 5 deaths, 2 of which were from puerperal causes, and 3 from accidental causes (phthisis, acute pericarditis, eclampsia), a puer peral mortality of .232 per cent.
In 1879, there were 685 confinements with 11 deaths. Of these 11, 3 were brought to the hospital with rupture of the uterus, 1 dying of eclampsia, 1 tubercular; in reality then, 6 deaths from the fact of labor, or .85 per cent., a figure which he claims may be reduced to .41 per cent.
[Statistics from other institutions might be added, all going to prove that year by year the mortality rate from puerperal causes is being lowered.
C. Braun has recently published the statistics of his lying-in wards during the past- twenty-nine years. From 1863 to 1880 the mortality percentage was 13 per 1000, and from 1881 to 1885 only 4 per thousand.
Lusk, of New York, and Richardson, of Boston, report equally favora ble results in the institutions with which they are connected. The former, in 1885, recorded his belief that " a woman is safer who comes into our Emergency Hospital than her more fortunate sisters in the elegant parts of our city." Garrigues gives the following data from the records of the New York Maternity hospital: Hirst, of Philadelphia, states that the total number of women delivered in institutions in the United States, during 1880-1885, was 19,902, with 516 deaths, or 2.59 per cent.
Parvin is authority for the statement that at Munich, Winckel has reduced his mortality rate to about .5 per cent. Fritsch states that in Berlin the mortality has been reduced (in Gusserow's service) to .9 per cent.; at Strasburg to .27 per cent. In Breisky's clinic 527 women have been delivered with but one death, and Fritsch has recorded 300 deliver ies with no deaths.
Further statistics which we might collate would simply bear out the broad truth which we desire to emphasise, which is that each year gives promise of better results in the future, so that we are justified in looking forward to the day when no woman will perform the physiological func tion of labor with any more risk than she performs other physiological functions. Mortality from puerperal causes can be lowered to nil, for such mortality is to-day absolutely preventable, except in those very rare instances where as yet our prophylaxis and our therapeutics are powerless. The means of attaining the end we all have in view are outlined in the next chapter.—Ed.]