infectious fevers, but this substance, when employed in the treatment
of pyæmia, should be given in the formative stage of the disease. The
use of drastic cathartics should be avoided, as should that of
sudorifics, on account of their prostrating effects. In some cases
hypnotics may be required to secure sleep.
Tonics are always more or less useful. The free use of stimulants and
nutritious food is also indicated. Brandy, wine, and whiskey may be
advantageously used as stimulants. Musk, ammonia, and camphor are
occasionally required. However, it should not be forgotten that in
cases where the disease has become fully developed the usual
termination is death, few recoveries being recorded. In the early
stages of this affection, by the removal of the patient from an
overcrowded hospital ward to some place where pure air and proper
hygienic arrangements can be obtained, recovery may take place, but
under other circumstances the prognosis is exceedingly grave.
The treatment of septicæmia in most particulars is the same as that of
pyæmia. The first effort should be to prevent the development of the
disease, and the second to care for the patient in cases where the
affection has already developed. It is not, of course, in our power to
limit or in any way {983} regulate the primary injury, for we are
obliged to take the patient as he is. The amount of injury to living
tissue may be great or small. The question of an operation, the
character of the same, and the subsequent management must be
determined in accordance with the circumstances of each particular
case.
The primary death of the parts is generally due chiefly to the injury
itself; the secondary, frequently to bad surgical management. Let us
now take a case in which the primary injury has been severe, greatly
diminishing, but not destroying, the circulation in the injured parts.
Here the immediate application of ice would be injurious, but a warm
application might assist nature. It is humiliating to the profession
that we are obliged even at this date to admit that the treatment of
septicæmia is largely symptomatic. The profuse choleraic diarrhoea
which generally accompanies this disease may be regarded as an effort
of nature to eliminate the septic poison; but, nevertheless, it is so
prostrating in its effects that it requires to be controlled with
properly selected astringents, and these remedies may be still further
aided by the use of stimulants and tonics.
The treatment of septicæmia may be summarized as follows: (1) A strict
adherence to the five rules given under the head of the prophylactic
treatment of pyæmia. (2) The avoidance of all putrefaction in contact
with the wound, especially prior to the development of sufficient
granulations to completely cover its surface. This object is to be
accomplished by the removal of all necrotic tissues, the avoidance of
putrescent fluids by cleanliness, and the proper use of antiseptic
agents. (3) Free use of the alkaline sulphites and hyposulphites.
These drugs should be used in all cases where there is reason to
anticipate the development of septic diseases, as soon after the
receipt of the injury as practicable, but should not be neglected even
after the disease has become fully developed. (4) Sulphate of quinia
should be used in all cases where the temperature is above 100° F.,
and its persistent use in large doses may be necessary to prevent the
fever from rising still higher. It will be remembered in this
connection that experience has taught us that "a temperature of 108.5°
F. is the limit beyond which life can no longer exist,"[43] and even a
much lower temperature is not without dangers. "The essential danger
of fever in acute diseases consists, then, in the deleterious
influence of a high temperature on the tissues."[44]
[Footnote 43: Liebermeister, _New Sydenham Soc. Trans._, vol. lxvi. p.
278.]
[Footnote 44: _Ibid._, p. 280.]
The treatment of puerperal septicæmia, although requiring the
application of the same principles as any other form of this disease,
may be briefly described as follows: The womb should be maintained in
a firmly-contracted state by the proper use of ergot, even as a
prophylactic measure, and also during the whole course of the disease;
the uterus and vagina should be kept in an aseptic condition by the
efficient use of antiseptics; sulphate of quinia should be given in
large doses, and repeated as often as may be necessary in order to
lower the temperature; and morphia or some form of opium should be
employed for the relief of the pain.
{984}
PUERPERAL FEVER.
BY WILLIAM T. LUSK, M.D.
DEFINITION.--Puerperal fever is an infectious disease, due, as a rule,
to the septic inoculation of the wounds which result from the
separation of the decidua and the passage of the child through the
genital canal in the act of parturition.
To maintain this definition it is, however, necessary to group by
themselves cases of childbed fever dependent upon causes which are
operative in the non-puerperal condition, though the latter imparts to
these causes oftentimes an exceptional activity and virulence. In this
category are to be placed especially scarlatina, typhus, typhoid, and
malarial fevers. It is to be borne in mind that the zymotic fevers may
provoke in the puerperal woman the same inflammatory lesions commonly
associated with puerperal fever.[1] This is in accordance with the
well-known surgical experience that a febrile paroxysm from any cause
exerts an unfavorable influence upon a wounded surface.
[Footnote 1: Hervieux, _Traité clinique et pratique des maladies
puerperales_, pp. 1073 _et seq._]
Like all brief statements, the writer is well aware that the foregoing
definition is necessarily imperfect, and stands in need of further
limitations to meet the requirements of exactness. Exceptions,
however, either apparent or real, will be noted hereafter in their
proper connections.
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 {985}
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 284,000[2]--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. Garrigues[3]
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 Boehr[4] in his now-famous statistics reckons
that one-thirtieth of all married women in Prussia die in childbed.
The Puerperal Fever Commission[5] 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.
[Footnote 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.]
[Footnote 3: "On Lying-in Institutions," _Trans. Am. Gyn. Soc._, vol.
ii., 1878.]
[Footnote 4: "Untersuchungen über die Haüfigkeit des Todes im
Wochenbett in Preussen," _Zeitschr. f. Geburtsk. und Gynaek._, vol.
iii. p. 82.]
[Footnote 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 {986} 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
Spiegelberg[6] 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:
1. Inflammation of the Genital Mucous Membrane.--Endocolpitis and
endometritis.
_a_. Superficial.
_b_. Ulcerative (diphtheritic).
2. Inflammation of the Uterine Parenchyma, and of the Subserous and
Pelvic Cellular Tissue.
_a_. Exudation circumscribed.
_b_. Phlegmonous, diffused; with lymphangitis and pyæmia (lymphatic
form of peritonitis).
3. Inflammation of the Peritoneum covering the Uterus and its
Appendages.--Pelvic peritonitis and diffused peritonitis.
4. Phlebitis Uterina and Para-uterina, with formation of thrombi,
embolism, and pyæmia.
5. Pure Septicæmia.--Putrid absorption.
[Footnote 6: "Ueber das Wesen des Puerperalfiebers," _Volkmann's
Samml. klin. Vortr._, No. 3.]
ENDOCOLPITIS AND ENDOMETRITIS.--In the superficial, catarrhal form of
inflammation the mucous membrane of the vagina is swollen and
hyperæmic, the papillæ are enlarged, and the discharge is profuse; in
the vaginal portion of the cervix the labia uterina are oedematous and
covered with granulations which bleed at the slightest touch; in the
cavity of the body there are increased transudation of serum and
abundant pus-formation. The deep structures of the uterus are usually
not affected. Sometimes the inflammation extends to the
tubes--_salpingitis_--or, passing outward through the fimbriated
extremities, it may spread over the adjacent peritoneum.
The small wounds at the vaginal orifice are at times converted into
ulcers with tumefied borders. These so-called puerperal ulcers are
covered with a greenish-yellow layer. They are associated usually with
oedematous swelling of the labia. Under favorable sanitary conditions
the deposit, which consists in the main of pus-cells, clears away and
the surface heals by granulation. The ulcerative form of inflammation
is very rare outside of crowded hospitals.
Diphtheritic ulcers are situated with greatest frequency in the
neighborhood of the posterior commissure or around the vaginal
orifice. In rarer instances they are found upon the anterior wall and
in the fornix of the vagina, in the cervix, and upon the site of the
placenta. The borders are red and jagged; the base is covered with a
yellowish-gray, shreddy membrane; the secretion is purulent, alkaline,
and fetid; and the adjacent tissues are oedematous. From the vulva
they may extend to the perineum or pursue a serpiginous course down
the thighs. In the uterus and about the cervix they vary as regards
size, and are either of a rounded shape or form narrow bands. The
intervening portions of tissue which have not undergone destructive
changes swell and stand out in strong {987} relief. Where the entire
inner surface has become necrosed, it is often covered with a smeary,
chocolate-brown mass which, when washed away with a stream of water,
leaves exposed either the deepest layer of the mucous membrane or the
underlying muscular structures.
The difference between the superficial ulcerations of the genital
canal and the diphtheritic form involving destruction of the deeper
tissues is due to the presence in the latter of minute organisms
termed micrococci, the relations of which to puerperal infection will
be considered in a subsequent division.
METRITIS AND PARAMETRITIS.--In ulcerative endometritis, and even in
the extreme catarrhal form, the parenchyma of the uterus likewise
becomes involved. The changes which are designated under the term
metritis consist in the first place of oedematous infiltration of the
tissues. As a consequence, the organ contracts imperfectly and becomes
soft and flabby, so that sometimes, upon post-mortem examination, it
bears the imprint of the intestines.
In diphtheritic endometritis the gangrenous process may attack the
muscular tissue, and give rise to losses of muscular substance--a
condition known as necrotic endometritis or putrescence of the uterus.
Inflammatory changes are rarely lacking in the intermuscular
connective tissue, which exhibits in places serous or gelatinous
infiltration, with afterward pus formation, and with here and there
small abscesses. The sero-purulent infiltration of the connective
tissue is specially marked beneath the peritoneal covering of the
uterus either behind or along the sides at the attachment of the broad
ligaments. In the same situations the lymphatics, which normally are
barely perceptible to the naked eye, are sometimes enlarged to the
size of a quill, and are characterized by varicose dilatations
occurring singly or presenting a beaded arrangement. In the substance
of the uterus the dilated vessels are liable to be mistaken for small
abscesses. The pus-like substance contained in the lymphatics is
composed of pus-cells and of micrococci. From the cellular tissue
surrounding the vagina, or that beneath the peritoneal covering of the
uterus, the inflammation may spread by contiguity of tissue between
the folds of the broad ligament, and thence pass upward to the iliac
fossæ. Usually the process is unilateral. After the inflammation has
crossed the linea terminalis it may take a forward direction above the
sheath of the ilio-psoas muscle to Poupart's ligament, or it may creep
upward, following the course, according to the side affected, of the
ascending or descending colon, to the region of the kidney. It is rare
for inflammation of the cellular tissue to travel around the bladder
to the front. In such cases it pursues its course between the walls of
the bladder and the uterus, and along the round ligament to the
inguinal canal. In a few cases the cellulitis mounts above Poupart's
ligament, between the peritoneum and the abdominal wall.
The course of the inflammation is not simply fortuitous, but follows
prearranged pathways in the connective tissue. König[7] and
Schlesinger[8] have shown that when air, water, or liquefied glue is
forced into the cellular tissue between the broad ligaments the
injected mass has a tendency to invade the iliac fossæ. In
Schlesinger's experiments, if the canula of the syringe was inserted
into the anterior layer of the broad ligament, {988} the glue spread
between the folds to the abdominal end of the Fallopian tube; thence,
following the track of the vessels, it passed to the linea terminalis;
and finally mounted upward along the colon or swept forward to
Poupart's ligament until the advance was stopped at the outer border
of the round ligament. If the injection was made to the side of the
cervix through the posterior layer at the junction of the cervix and
the body, the posterior layer gradually bulged out, the peritoneum was
lifted from the side wall of the pelvis, and the glue passed beyond
the vessels to reach the iliac fossa. If the injection was made to the
side of the cervix through the anterior layer, the glue passed between
the bladder and the uterus, and forward along the round ligament to
the inguinal canal, while another portion of the fluid passed between
the layers of the broad ligament, and reached the peritoneal covering
of the side walls behind the round ligament. If the injection was made
in the median line in a peritoneal fold of Douglas's cul-de-sac, the
fluid travelled forward upon one side along the round ligament and
thence to the posterior wall of the bladder.
[Footnote 7: _Arch. der Heilkunde_, 3 Jahrg., 1862.]
[Footnote 8: _Gynaekologische Studien_, No. 1.]
The term parametritis, introduced into use by Virchow, is, properly
speaking, limited to inflammation of the connective tissue immediately
adjacent to the uterus, the older one of pelvic cellulitis furnishing
a more comprehensive designation for cases where, as a consequence of
a progressive advance from the point of departure in the genital
canal, the remoter regions have likewise been invaded.
Connective-tissue inflammation presents, as the first essential
characteristic, an acute oedema, the fluid which fills the gaps and
interspaces consisting of transuded serum rendered opaque by the
presence of pus-cells or possessing a gelatinous character. In the
mild, uncomplicated cases the oedema disappears rapidly. Where the
cell-collections are of moderate extent the entire process may vanish
without leaving a trace of its existence. If the cell-elements, on the
other hand, are present in great abundance, they, as a rule, first
undergo fatty degeneration, and, after the absorption of the fluid
portion, form a hard tumor composed of a fine granular detritus, which
under favorable circumstances likewise after a few weeks becomes
absorbed. In rare cases abscess-formation in the tumor results.
In the cellulitis resulting from septic infection, especially in cases
complicated by diphtheritis, the tissues seem as if soaked with dirty
serum, and contain scattered yellowish deposits, which soon present,
even to the naked eye, the appearance of pus-collections. This
sero-purulent oedema is always associated with lymphangitis, the
lymphatic vessels possessing varicose dilatations and beaded
arrangements similar to those already described in the uterine tissue.
The foregoing changes are most distinct in the firm connective tissue
adjacent to the uterus and at the hilum of the ovary, while they are
less clearly traced in the looser structure of the broad ligament
(Spiegelberg).
In favorable cases the inflammation is circumscribed, or at least is
limited, by the nearest lymphatic glands. In cases of intense
infection it spreads rapidly, and justifies the title bestowed upon it
by Virchow of parametritic malignant erysipelas.
PELVIC AND DIFFUSED PERITONITIS.--Inflammation of the pelvic
peritoneum may result from severe attacks of catarrhal endometritis,
the inflammatory process either traversing the uterine tissue or
passing {989} through the Fallopian tubes to the adjacent serous
membrane; or it may proceed, secondarily, from the stretching and
irritation occasioned by an associated parametritis.
As a rule, pelvic peritonitis is not attended with much exudation. The
latter is situated upon the folds of the peritoneum limiting the
cul-de-sac of Douglas, upon the ovaries, and upon the broad ligaments.
In favorable cases it consists of fibrinous flakes and fluid pus. If
the latter is abundant, it may become encysted by the formation of
adhesions between the pelvic organs.
General peritonitis may result from the extension of a pelvic
peritonitis, or from the transport of poison through the lymphatics
into the peritoneal sac. In the first case the entire peritoneum is
injected, and the contents of the abdominal cavity are loosely bound
together by pseudo-membranes, composed of pus and coagulated fibrine.
The intestines are at the same time distended and the diaphragm is
pushed upward. In the so-called peritonitis lymphatica the
inflammatory symptoms are at the outset lacking. The abdominal cavity
is found filled with a thin, stinking, greenish or brownish fluid
composed of serum and micrococci. The intestines are lax and
oedematous, and the muscular structures are paralyzed, with resulting
tympanitic distension. The peritoneal covering of the intestines is
devoid of lustre, and covered with injected patches, or is stained of
a dark-brown color. Death often ensues before the occurrence of
exudation.
Septic forms of pelvic inflammation are often associated with
oöphoritis, the dilated lymphatics either extending to the substance
of the ovaries, where they may lead to the production of small
abscesses, or, as a result of blood-dissolution, the organs become
soft, pulpy, and infiltrated with discolored serum, and present
hemorrhagic spots distributed over the surface.