are cognate diseases is in a fair way to be solved by recent
investigation. Orth took the contents of a vesicle from an
erysipelatous patient which contained bacteria in great abundance, and
employed the same for injections under the skin of rabbits. In this
way he succeeded in producing in these animals a species of erysipelas
malignum. In the subcutaneous oedema and affected portions of the skin
he found enormous masses of bacteria, so far exceeding in quantity the
amount introduced as to prove an abundant new production.[41] Samuel
produced similar results by the injection of ordinary putrid fluids
containing round bacteria. An affection resembling simple erysipelas
he obtained most frequently by the application of fluid to a wound
torn open after the second or third day.[42] Lukomski found that
erysipelas could be produced by fluid containing micrococci even when
putrefaction did not exist. The contents of erysipelatous vesicles
containing no micrococci excited no morbid manifestations. Where the
erysipelatous process was fresh and progressing micrococci were found
in great abundance in the lymphatics and canalicular spaces. Where the
process was retrogressive, there were no micrococci to be found, even
in cases in which inflammation existed to an intense degree.[43]
Doléris submitted to the culture-process of Pasteur fluid obtained
from vesicles which developed in the course of facial erysipelas in a
man of forty years. Micrococci in chains were found in the liquids
employed identical with those he had discovered in puerperal fever. In
many cases I have seen an erysipelatous inflammation start from a
puerperal diphtheritic ulcer {1003} upon the introitus vaginæ, and
extend outward over the buttocks, the thighs, and the lower portion of
the abdomen.
[Footnote 41: "Untersuchungen über Erysipel.," _Arch. für exp. Pathol.
und Pharmakol._, Bd. i. S. 81.]
[Footnote 42: _Arch. für exp. Path. und Pharmak._, Bd. i. S. 335, u.
ff.]
[Footnote 43: "Untersuchungen über Erysipel.," _Virchow's Archiv_, Bd.
lx. S. 430.]
Virchow[44] has so far given in his adhesion to the new school as to
say: "Especially in this connection are to be mentioned the
diphtheritic process and the erysipelatous, especially erysipelas
malignum. The granular deposit in diphtheritically affected tissues,
of which I formerly spoke, has more and more proven to be of a
parasitic character. What we formerly regarded as simple, organic
granules, as infiltration or exudation, has since proven to be a dense
aggregation of micro-organisms which penetrate into the tissues and
cells to compass their destruction."
[Footnote 44: _Die Fortschritte der Krieg's Heilkunde_, Berlin, 1874.]
Thus we find in surgical fever, in puerperal fever, in diphtheria, and
in erysipelas the presence of a common element which links them
together, and which establishes the relationship which has long been
recognized as existing between these various processes.
4th. _The differences between surgical and puerperal septicæmia are
due to differences partly structural and partly physiological in the
wounded surfaces exposed to septic contamination._
A certain amount of misapprehension has arisen from the circumstance
that along with many coincidences in the symptoms of puerperal and
surgical fever there are observable differences which, from a purely
clinical point of view, would justify a separate classification of the
two affections. It will not do, however, to ignore the fact that the
conditions which prevail in the parturient canal subsequent to labor
have no strict analogue in the lesions which the surgeon is called
upon to treat, and that therefore a complete identity as to all the
clinical features of puerperal and surgical fever would hardly be
within the range of possibility.
In the puerperal state it is necessary to take into account the
blood-changes induced by pregnancy, the effects of shock and
exhaustion in protracted labors, the frequency of hemorrhage, the deep
situation of puerperal wounds, the presence of clots, decidua, and
dead tissue in a state of disintegration or decomposition, the ease
with which deleterious matters are absorbed by the wide lymphatic
interspaces, the serous infiltration of the pelvic tissues, the
exaggerated size of the lymphatics and veins, and the proximity of the
peritoneal cavity.
Samuel,[45] in speaking of the immunities and dispositions to septic
poisoning, says: "The statistical frequency of septic puerperal
disease is due to the length of the parturient canal, to the fact that
through this long passage there must pass all the pathological and
physiological excretions, and to the soiling of these parts with
fingers, instruments, and secretions which have become the bearers of
sepsis." He found, on the other hand, that it was extremely difficult
to produce a progressive ichorous condition by daily painting an open
stump with a septic fluid,[46] though the same was readily obtained
when an infinitesimal quantity of septic fluid was injected underneath
a fascia.
[Footnote 45: "Ueber die Wirkung des Faülniss Process auf den lebenden
Organismus," _Arch. f. exp. Pathologie_, vol. i. p. 343.]
[Footnote 46: _Loc. cit._, p. 339.]
5th. _In the present state of our scientific knowledge it is necessary
to admit that there is a limited number of febrile and inflammatory
disturbances occurring in puerperal women, the bacterial origin of
which may be fairly questioned._ As illustrations of this class may be
{1004} mentioned: 1. Cases of catarrhal endometritis due to errors of
diet and exposure. Indeed, I have frequently, in hospital practice,
been able to trace severe cases of cellulitis, pelvic peritonitis, and
general peritonitis occurring in the winter season to the patient
getting out of bed dripping with perspiration, and clad only in a
night-dress, and going thus barefooted over a cold, uncarpeted floor
to the water-closet. 2. Cases of puerperal disorders proceeding from
emotional causes, the nervous system furnishing the first impulse to
the disturbed action. 3. Cases of excessive vulnerability in
non-pregnant women; individuals are sometimes found so susceptible
that a parametritis follows a simple application of the tincture of
iodine to the cervix. 4. Cases of pelvic peritonitis starting from old
intra-peritoneal adhesions. 5. Cases of peritonitis and
retro-peritoneal inflammations secondary to ulcerative processes in
the cæcum or the descending colon. This condition is apt to be masked
during pregnancy, but starts into activity during childbed as a
consequence of fecal accumulation or of excessive purgation.
It is by no means easy to decide as to the precise nature of local
inflammations following lacerations of the cervix and the bruising or
crushing of the soft parts in long or instrumental labors. The
marvellous absence of heat, pain, redness, and swelling in wounds
treated in strict accordance with the principles of Lister, the very
slight reaction when the atmosphere is pure, and the severity of these
symptoms in overcrowded hospitals, tend indeed to strengthen the
belief that even the simplest inflammations proceeding from wounds owe
their origin in great part to septic germs. But, on the other hand, in
hospital practice it is not uncommon to observe puerperal
inflammations and febrile conditions which possess this distinctive
peculiarity--that they in no wise visibly affect the health of
puerperal patients in their vicinity. The symptoms of blood-poisoning
too are either absent or present to a subordinate extent. Probably the
difficulty is best solved by assuming with Genzmer and Volkmann[47]
that there is such a thing as an aseptic surgical fever due to the
absorption of the products of physiological tissue-changes at the seat
of injury. In surgical cases, even where the precautions of Listerism
have been faultlessly observed, febrile movements of considerable
intensity, but of no prognostic signification, are of frequent
occurrence. While in puerperal women we can never exclude the
possibility of the septic infection of puerperal wounds, it is in
accordance with clinical experience to assume that a high fever
belonging to the aseptic class may coincide with a septic process of
insignificant proportions.
[Footnote 47: Genzmer and Volkmann, "Ueber septisches und aseptisches
Wundfieber," _Samml. klin. Vorträge_, No. 121.]
GENERAL SYMPTOMS.--As in other infectious diseases, there is, from the
time of the entry of the poison into the system up to the outbreak of
fever, a distinct period of incubation. The first febrile symptoms
usually occur within three days of the birth of the child. An attack
coming on a few hours after childbirth is indicative of infection
during or previous to labor. The third day is the one upon which
ordinarily the beginning of the fever is to be anticipated. After the
fifth day an attack is rare, and at the end of a week patients may be
regarded as having reached the point of safety. Apparent exceptions to
this rule are probably referable to cases of mild parametritis, in
which the initial {1005} fever and the pain were insufficient to
attract attention to the existence of local inflammation.
The symptoms of puerperal fever vary with the character of the local
affections and with the extent to which the general system
participates in the disturbed action. The different groups of
puerperal processes possess the following pathognomonic symptoms--viz.
increased temperature, enlargement of the spleen, disturbed
involution, and sensitiveness of the uterus upon pressure (Braun).
In most cases the fever is ushered in by chilly sensations or by a
well-defined chill. This symptom, however, does not possess much
prognostic importance. A chill is significant of a sudden change
between the temperature of the skin and that of the surrounding
medium. It may, therefore, be absent in pernicious forms of fever,
provided only that the temperature changes are inaugurated slowly,
whereas it may follow a trifling increase of the body-heat if, as
sometimes happens in sleep, the moist skin is exposed to cool currents
of air. Repeated chills indicate phlebitis and pyæmia.
In order to grasp the many symptoms of puerperal fever, it is
necessary to keep separately in mind the clinical features of each of
the local processes, although in fact the latter rarely occur singly,
but to a greater or less extent in combination with others.
The symptoms of ENDOMETRITIS AND ENDOCOLPITIS.--The uncomplicated
catarrhal inflammation of the uterus and vagina is the most frequent
and the mildest of the diseases of childbed. In endometritis the
uterus is large, flabby, and sensitive upon pressure; the after-pains
are often unusually severe, involution is retarded, and the lochia
become fetid, remain sanguinolent for a longer period than usual, and
at the outset may be temporarily suspended. Sometimes the large
intestine is distended with flatus. In endocolpitis the vaginal
discharge is thin and purulent, the patient experiences pain and
burning in the acts of defecation and urination, and, where the wounds
of the vulva and vagina assume an ulcerative character, there is often
found at the same time inflammatory oedema of the labia.
The fever in these cases is ushered in frequently, but not always, by
chilly feelings, and the temperature reaches its height usually upon
the evening of the third or fourth day, is remittent, almost
intermittent in character, and rarely exceeds 102° to 103° F. In mild
forms the occurrence of the fever is often overlooked or is referred
to disturbance produced by the secretion of the milk. In severer
attacks the febrile symptoms may continue from three to seven days. At
the end of a week the swelling of the labia subsides, the discharge
becomes thick, and ulcers, if present, begin to assume a healthy
granulating appearance.
In diphtheritic ulcerations, and in endometritis due to decomposing
remains of the ovum, the load condition is often complicated by the
invasion of the neighboring tissues.
The symptoms of PARAMETRITIS and PERIMETRITIS (Pelvic
peritonitis[48]).--The symptoms of these two affections, as would be
naturally {1006} expected from the proximity of the peritoneum to the
pelvic connective tissue, for the most part overlap. It must be very
rare for one form to occur entirely independent of the other. For this
reason it will be found convenient to consider first the symptoms
common to both morbid processes, and subsequently to direct attention
to what are believed to be points of distinction between them.
[Footnote 48: The following clinical history, together with the
statistical details, is borrowed in great part from the description of
Olshausen ("Ueber puerperale Parametritis und Perimetritis,"
_Volkmann's Samml. klin. Vortr._, No. 28), the exactitude of which I
have had abundant opportunity to verify.]
During the period of incubation there are usually no prodromic
symptoms. Elevations of temperature in the course of the first twelve
hours following labor are equally frequent under perfectly normal
conditions. Suspicious symptoms are disturbed sleep, excessively
painful after-pains, and a pulse of 80 to 90.
The beginning of the fever occurs in 90 per cent. within the first
four days of childbed; most frequently upon the second or third day,
and taking place upon the fourth day in scarcely 12 to 15 per cent. of
the cases. If five days have elapsed without fever, the period of
danger, with very rare exceptions, may be regarded as having passed.
At the outset the fever, especially in perimetritis, is ushered in by
chilly sensations or by an intense chill. The temperature rises
rapidly, though the highest point is usually not reached before the
second, and in rare cases not before the third, day. In most cases the
heat in the axilla exceeds 103°, and may even mount up to 105°. The
decline occurs gradually, the fever ending in 70 per cent. in the
course of a week, in 20 per cent. in two weeks, and only in 10 per
cent. extending beyond that period. Protracted cases indicate abscess
formation.
The fever does not, however, always pursue a regular course. In place
of progressively declining until the termination is reached, the high
temperature of the second day may be attained upon one or more
occasions. The morning remissions are at first slight, but become
marked as the disease approaches its close. In cases of long duration
the morning hours are often free from fever, a circumstance calculated
to mislead a physician who sees his patient but once a day. A pulse of
80 to 90 beats, a disturbed sleep, lack of appetite, and sensitiveness
to pressure upon the sides of the uterus are, however, symptoms which
should serve as a warning of some disturbing cause, and should lead
the physician to renew his visit in the latter part of the day.
If, from a mistaken notion that the morbid process has come to an end,
the patient is allowed prematurely to resume her household duties, the
pains across the abdomen and along the hip and thigh return, and an
examination reveals the existence of exudation in the pelvic cavity or
upon an iliac fossa.
Errors of this kind are most frequent in cases of parametritis
associated with slight peritoneal inflammation, as the local pain is
then insignificant, and the initial chill, happening on the third or
fourth day, is apt to be ascribed to engorgement of the breasts.
Relapses after the complete disappearance of febrile disturbance occur
in 15 to 20 per cent. They are usually shorter, but sometimes more
obstinate, than the original attack. As a rare exception may be
mentioned cases with evening remissions and morning exacerbations.
In circumscribed pelvic inflammations the pulse rarely exceeds 120
beats to the minute. A pulse of 140, of more than half a day's
duration, betokens severe septic complications, and is therefore of
evil omen. In {1007} some cases the slow pulse observed after labor
makes its influence felt in the first day or two of the fever, so that
the curious phenomenon may be witnessed of a temperature of 104°
coinciding for a time with a pulse ranging between 50 and 70 beats to
the minute.
As regards other symptoms, headache and sleeplessness are rarely
absent. Profuse sweating follows the first febrile attack, and
frequently recurs during the course of the disease.
Pain is present at the onset in the majority of cases, and is then
usually most violent. The spontaneous pain, which is due to the
affection of the peritoneum, subsides in great part in the course of
one or two days, but the sides of the uterus remain sensitive to
pressure. In the rare cases of pure parametritis, however, this
symptom may be absent altogether. The pain, like that from the
inflammation of serous membranes, is of a lancinating character.
Sometimes it is associated only with the contractions of the uterus.
After-pains occurring under unusual circumstances, as in primiparæ or
after the third day, are to be regarded with suspicion.
Vomiting occurs occasionally, but is comparatively rare unless the
peritonitis becomes diffused and spreads to the region of the stomach.
The appetite is lost, and only returns, as a rule, with the departure
of the fever. The tongue is coated and moist, and constipation is
common. In other cases there is diarrhoea with rumbling in the bowels,
but without pain or tenesmus. The urinary secretion is rarely
interfered with, and when this is the case it indicates the extension
of the inflammation to the peritoneum covering the bladder.
Most cases of perimetritis and parametritis terminate in five or ten
days, the fever and other symptoms gradually subsiding. When, as may
happen in exceptional instances, the temperature falls suddenly from a
high degree to one below the normal level, the body grows icy cold,
the pulse becomes small and irregular, and symptoms of collapse
develop. But in twelve to twenty-four hours the symptoms of collapse
subside, and the disease reaches its end with a disappearance of the
alarming manifestations.
If the fever subsides within a week exudation is somewhat rare. Its
continuance beyond that date should lead to a careful exploration of
the pelvic organs. The exudation is usually demonstrable in the course
of the second week or at the beginning of the third week. It is
recognized, according to its location, by external or by internal
examination, or, where the deposit is considerable, by both methods.
In most cases the deposit is extra-peritoneal, and is situated between
the folds of the broad ligament, above and to the sides of the vaginal
cul-de-sac. It has generally a rounded form, though with less
convexity than fibrous and ovarian tumors. Sometimes, however, the
tumor is flat below, like a board. It seldom exceeds in size that of a
large apple. In fresh exudations the sensation produced is often that
of a hard tumor surrounded by a softer layer, due to continued
succulence of the soft parts. In a few weeks they may reach or exceed
the hardness of a fibroid tumor. The older the tumor, unless
suppuration sets in, the less sensitive it becomes. Often the
exudation extends to the pelvic walls. The uterus, as a rule, is
fixed, and in cases of large tumors becomes pushed toward the opposite
side, while as a consequence of later shrinkage the fundus may be
drawn permanently toward the affected side.
{1008} The cul-de-sac of the vagina is rendered broader and flatter by
the pressure of the deposit, or, when the tumor is deep enough, the
vaginal surface may be rendered convex. Behind the uterus the
exudation is as it were flattened antero-posteriorly, and in some
cases it may be felt in the form of rigid bands between the posterior
ligaments which enclose the cul-de-sac of Douglas. The ante-uterine
tumors have a spherical shape and depress the vagina anteriorly.
Tumors situated in the iliac fossa have a more or less convex form,
and may be of such considerable size that the swelling may be
recognized by the eye through the abdominal walls. As the exudation
between the broad ligaments may in these cases have been slight from
the beginning, or may have subsequently disappeared by absorption, the
iliac tumors have often apparently a spontaneous origin.
Sometimes the uterus is surrounded by exudation, and the entire pelvis
appears as though it were a mould filled with a solid mass. The fornix
is then often pressed downward, and irregular rounded masses are to be
felt through the vaginal walls.
The recognition of parametritic tumors through the abdominal coverings
is possible when they are situated above Poupart's ligament, in the
upper portion of the broad ligaments, and in the iliac fossæ.
The pain and the functional disturbances in the pelvic organs depend
upon the size and situation of these inflammatory deposits. Of the
functional troubles may be mentioned frequent and painful micturition,
obstinate constipation and difficult defecation, contractures of the
ilio-psoas muscles when the exudation is seated beneath the sheath or
between the muscle and the pelvic bones, disturbances of motility in
the abductor muscles, paresis of the lower extremities, and radiating
pains in the upper portion of the thigh and in the renal and lumbar
regions, produced by pressure upon the obturator, the crural, the
cutaneous, and the sciatic nerves.
So long as fever is present the exudation rarely diminishes. If
absorption takes place in one point, growth almost certainly follows
in some other direction. When, however, the apyretic period is
reached, the exudation, as a rule, disappears rapidly, so that often
in the course of six weeks no trace of its existence remains. In a
smaller number the solid mass may persist for months or even years.
After the fever has departed the patient usually feels well. The sleep
and appetite return, the night-sweats disappear, the pulse often falls
to 50 or 60 beats, and the temperature is in many cases for a time
subnormal in character.
Where the fever persists for from five to six weeks there is always a
suspicion of abscess formation. With the exception of afternoon fever
and night-sweats the patient may feel very comfortable. Then the
exudation becomes sensitive, the spontaneous pains recur, sleep is
lost, and locomotion, defecation, and urination occasion acute
suffering. The fever becomes violent, chills announce the presence of
pus, and finally, about the seventieth or eightieth day, perforation
of the abscess takes place. The usual seat at which the pus is
discharged is just above Poupart's ligament; next in frequency
perforation takes place into the colon, and in rare instances into the
bladder, the uterus, and vagina. Fortunately, of very rare occurrence
is the discharge of pus into the peritoneal cavity, which is {1009}
naturally followed by acute peritonitis. Another likewise unfrequent
but most dangerous accident is the septic infection of the abscess--an
occurrence referred to by Olshausen to the diffusion of intestinal
gases through the walls of the tumor.
In suppuration of parametritic exudations the pus commonly forms in
small scattered collections, and rarely gives rise to large abscesses.
Although parametritis and perimetritis are usually found associated
together, there are always cases in which the one form of inflammation
so far predominates over the other as to justify an attempt to
establish a clinical distinction between them.
In the beginning of the attack, sharp pain, high fever, and tympanitic
distension of the lower abdomen are symptomatic of inflammation in the
pelvic peritoneum. Whether the cellular tissue is simultaneously
implicated can only be determined by a digital examination after the
abdominal sensitiveness has subsided. The absence of the objective
signs of cellulitis would then contribute to prove that the case had
been one in which the peritoneum had been in the main affected. On the
other hand, moderate fever, pain elicited only on pressure, and
tympanitic distension confined to the colon, coinciding with exudation
between the folds of the broad ligament, would be indicative of a
nearly pure cellulitis.
A palpable exudation is by no means the necessary product of
peritoneal inflammation. Indeed, in many cases, the distinctive
symptoms of the latter may be present for from four to eight days, and
may then subside without leaving a trace of its existence at the
pelvic brim.
The demonstration of a fluid effusion by noting the change of level
upon shifting the position of the patient is rarely possible, either
because the quantity is too small or because it quickly becomes
confined by pseudo-membranous adhesions between the intestines.