DISEASES ARISING FROM THE PUERPERAL STATE In the registration area of the United States, there occurred in r 916, 11,642 deaths during the puerperal state, equivalent to a rate per roo,000 of 16.3. These deaths are classified as follows: Accidents of pregnancy 985 Puerperal hemorrhage IIIS Other accidents of labor 1212 Puerperal septicemia Puerperal albuminuria and convulsions . . . 3087 Puerperal phlegmasia, alba dolens, embolus or sudden death Following childbirth (not otherwise defined) .. 34 Puerperal diseases of the breast. 5 During the period from 1901 to 1905 the annual average of the death rate from this group of causes was 14.2 per roo,000, in the next five year period it was r5.5 and during 1913, 15.8; 1914, 15.9; 1915, 15.2. In general it has shown an upward trend. Few classes of death seem more tragic or pitiful than these. We find here the young mother, looking forward with joy to the arrival of her first baby, or the mother of a family of several leaving orphans, broken homes, widowed fathers. Probably few deaths leave as great a load of sorrow as do these. It is interesting to compare the losses from these causes with those from some of the other preventable diseases; In 1916 typhoid fever caused 9,510 deaths; measles 7,946, and diphtheria 10,367. If these rates were calculated upon the basis of Too,000 women they would approximately be doubled, and be still higher if calculated in proportion to the women of childbearing age. A still more accurate idea may be secured from the number of maternal deaths per a given number of births. Data on this point can only be given for 1916 and for the birth registration area. The death rate per i000 live births from all diseases caused by pregnancy and confinement is 6.5, from puerperal septicemia 2.9, and from all other causes 3.6 (Fig. i12).
Of these deaths the most numerous are from puerperal sep ticemia. This is important, for of the above causes puerperal septicemia is the least excusable as its preventable character was recognized prior to the bacteriologic era. Holmes first pointed out in 1843 that this fever was similar to wound infec tions and was chiefly due to the carrying of infectious material on the hands of attendants from one case to another. In 1847 Semmelweiss advanced similar ideas. Previous to this time the mortality from puerperal fever in maternity hospitals was appalling. Subsequent to the introduction of antiseptic treatment the mortality immediately fell until now in hospital practice maternal deaths are negligible as shown in the table: Yet despite the demonstration that the disease is unnecessary it is still with us and shows no apparent diminution. In hos
pital practice in the United States it is as rare as indicated by the foreign experiences, but among home confinements it is still apparently undiminished. While puerperal septicemia is undoubtedly the most clearly preventable disease of this group, yet a large proportion of the other deaths must be regarded as due to preventable causes.
Nearly 8o years ago Holmes showed that childbed fever was transmitted from patient to patient by the hands of the atten dants. It is undoubtedly true that obstetric asepsis is drilled into medical students the country over. Why then these deaths? A formidable proportion of confinements in some localities, a major proportion in others, are not attended by physicians but by midwives. The degree to which the assist ance of midwives is relied upon is largely proportional to the extent of the foreign born population. Thus during 1916 in the borough of Manhattan, 11,266 mothers were confined in hospitals and institutions and 47,384 in their homes. Of the latter, 19,524 or 41.4 per cent. were attended by midwives. These people regard the service of a physician at this time as an unnecessary expense. The majority of midwives have no special qualifications for their task in so far as training is con cerned. Most can handle normal confinements but if complica tions ensue, call in a physician. They have no idea of asepsis or antisepsis, make unnecessary and frequent vaginal examina tions and introduce unsterilized instruments as well as unclean hands into the parturient canal. The knowledge they possess of obstetrics is extremely rudimentary and is largely acquired in a haphazard manner, never from competent instruction. Is it any wonder that puerperal sepsis is still with us? It probably will be a long time before the midwives disappear. If they are to be tolerated, the welfare of women demands that they acquire a reasonable competence in their profession. Some provision should be made for their formal instruction in obstetrics and none should be permitted to practice without a license from the state. Death certificates for women who die in the puerperal state should record the name of the attendant during the confinement and those who show a disregard for asepsis, as manifested by the development of cases of septice mia, should be barred from practice.