noticeable, a number of resistant points or tumors near the pelvic
brim or above one of the iliac fossæ, due to a matting together of the
intestines or to their adhesion to the uterine appendages. They are
distinguished from solid tumors by their emitting a tympanitic sound
upon percussion and by their changing position in consequence of an
accumulation of urine in the bladder or of feces or gases in the
bowels. Again, all tumors may be reckoned as intra-peritoneal which
very rapidly form behind or to the side of the uterus from enclosed
exudation-products, and which at the same time rise far above the
level of the pelvic brim. If, however, they start from the cul-de-sac
of Douglas, and do not much exceed the linea terminalis, or if they
occupy an iliac fossa, it becomes very difficult to decide whether
they are of intra- or extra-peritoneal origin. The peritoneal
exudation, however, long remains soft and fluctuating. It arises, as a
rule, behind the uterus, and does not exhibit a tendency to spread to
the sides or to the anterior or posterior pelvic walls.
[Footnote 49: _Handbuch der Frauenkrankheiten_, red. Von Billroth, 5te
Abschnitt, p. --.]
Still more difficult is it to decide as to the seat of exudations met
with beneath the abdominal walls. When diffused and continuous with a
pelvic deposit the diagnosis is uncertain. It is only safe to assume
the peritoneal origin of extravasations of a rounded form, of a
fluctuating consistence, and when they are situated high up and are
disconnected from exudation at the pelvic brim. An opening of the
abscess through the {1010} navel would indicate a peritoneal source,
while the discharge through the abdominal parietes would point to a
seat in the connective tissue.
After the perforation of an abscess the fever and pain subside; the
wound, if external, either closes in the course of one or two weeks,
or fistulas form which become the source of protracted suppuration.
In psoas abscesses the exudation extends beneath the sheath of the
muscle or between the iliacus and the bone. In puerperal patients they
proceed from an inflammation originating in the broad ligament. They
are situated too deep to be easily palpated. The pains they occasion
are referred rather to the hip or knee than to the abdomen. The
contracture of the psoas muscle furnishes a diagnostic sign which
distinguishes this form from the superficial abscesses of the iliac
fossæ. The pus eventually is discharged beneath Poupart's ligament, in
the lower portion of the inguinal fossa, at some point upon the crest
of the ilium, or exceptionally along the thigh. Often the discharge is
maintained for months.
The symptoms of GENERAL PERITONITIS.--This form generally begins with
the usual symptoms of pelvic inflammation, but the tenderness, which
at first was limited to the side of the uterus, gradually spreads over
the entire abdomen. The abdominal pain is of a tearing, lancinating,
sometimes colicky character. It is increased by the slightest bodily
movement, by jarring of the bed, or even by the weight of the
bed-clothes.
As a consequence of the peritoneal inflammation and of the
accompanying exudation, the muscular walls of the bowels become
paralyzed, and tympanitic distension results from the accumulation of
gases. In the dependent portions of the peritoneal cavity it is often
possible to demonstrate by percussion the presence of fluid exudation,
though distinct fluctuation is rarely to be made out. The size of the
abdomen is due much more to the tympanites than to the amount of
effusion. Sometimes the liver, with the diaphragm, is pushed by the
swollen bowels to the level of the fourth or third rib, and exercises
such a degree of compression upon the posterior portion of the lungs
as to place the patient in danger of suffocation. The respirations are
jerky and attended with a moaning sound.
The loss of muscular power in the intestines permits the contents of
the middle portion to pass unchecked toward the duodenum, and thence,
upon accidental contractions of the abdomen, they may pass to the
stomach and be ejected by vomiting. The first vomited matter has a
dark-green color, and that ejected afterward presents the color of
intestinal matter. Constipation at the outset may be subsequently
followed by colliquative diarrhoea.
The fever begins, as a rule, though not always, with an intense chill,
the temperature rises to 104°, and the pulse becomes small, hard, and
resistant. Its frequency rapidly increases, varying from 120 to 160
beats to the minute. The skin is sometimes dry, sometimes dripping
with perspiration. In fatal cases, as the end approaches, the
temperature frequently falls, while the pulse becomes more rapid, the
face assumes a pinched, anxious expression, sweat gathers upon the
forehead, the extremities grow icy cold, and the patient dies in
collapse. The duration of peritonitis averages not more than from four
to six days.
In cases of recovery the pulse improves, the vomiting ceases, and the
tympanites disappears. The diffuse exudation then becomes converted
{1011} into circumscribed tumors, which on palpation are felt on the
side of the pelvis and extending upward to the level of the umbilicus.
Upon internal examination the uterus is often found depressed by the
weight of the fluid, which likewise may bulge the cul-de-sac of
Douglas into the pelvic cavity. Sometimes the exudation may become
encysted above the pelvis and leave the contents of the latter free.
In still other cases the uterus may become attached high up to the
abdominal walls, so that the vaginal portion disappears and the os is
reached with difficulty.
The peritoneal exudation may, as in pelvic inflammations, become
absorbed and disappear. When, however, it is surrounded by loops of
intestines it is apt to undergo purulent and septic changes, and the
abscesses may then become discolored and filled with stinking gases.
The patient, whose previous improvement has been watched with delight,
now loses appetite, the pulse becomes frequent, the strength fails,
and death may follow from septic fever or from rupture of abscess into
the abdominal cavity.
In the pyæmic form--a still more deadly variety of peritonitis--the
symptoms differ materially from those which have been recounted. As,
however, it constitutes only a single one of the pathological changes
connected with the poisoning of the blood through the lymphatic
system, its consideration belongs properly to the study of the septic
infection.
The symptoms of SEPTICÆMIA LYMPHATICA.--The symptoms of
blood-poisoning in the infectious diseases of childbed vary to a
considerable extent according to the channel through which the septic
germs enter the general circulation. In the murderous epidemics which
prevail in lying-in hospitals the lymphatics are, as a rule, the
vessels primarily invaded. It is to this form that the cases already
described belong, where, with diphtheritic patches upon the
utero-vaginal canal and sero-purulent oedema of the parametrium, there
are associated pyæmic peritonitis and deformation of the
blood-corpuscles; or where, following the migrations of the round
bacteria, the serous cavities become successively involved, septic
vegetations gather upon the heart, and the glomeruli of the kidneys
become choked with micrococci. The lymphatic form of septicæmia
develops soon after labor, and is always ushered in by a chill. The
temperature rises to 104° or even higher, and the pulse is thin and
frequent. The abdomen swells rapidly, without being especially
painful. Indeed, painless distension of the intestines is one of the
characteristics of an acute invasion of the lymphatics. Peritoneal
effusion is absent in cases which run a rapid course, and is
distinctly recognizable only in a peritonitis of long continuance. The
effusion is not so much due to exudation as to a transudation of serum
with which micrococci are commingled. At the same time the tongue is
moist, but slightly coated, and at times quite clean. Sometimes there
is diarrhoea due to catarrh or to a diphtheritic affection of the
colon. When the bowels have been constipated the administration of a
purgative may provoke discharges which it may be found difficult to
arrest. The skin is bathed in perspiration. At the beginning and
during the course of the disease bleeding at the nose is of not
infrequent occurrence.
Toward the end the pulse runs up to 140 to 160 beats, while in many
cases the temperature falls. Immediately after death the heat of the
body may for a short time exceed the highest point reached during
life. The {1012} respirations are superficial and jerky. In many
instances the face, the neck, and the fingers are blue from defective
oxygenation of the blood. At the same time the skin becomes clammy and
the extremities cold.
The sensorium, in cases which run a rapid course, is usually affected
at an early period. The patients appear somnolent, are restless in
bed, have light delirium, and respond only when spoken to loudly. As a
rule, they make but little complaint, and, were it not for the
dyspnoea, would have nothing to disturb their sense of comfort. Very
few, even as death approaches, have any idea of the danger that
threatens them. Now and then, in place of stupor, great restlessness,
and even a maniacal condition, is developed. Albumen is usually found
in the urine.
Pleurisy, so frequently associated with lymphatic septicæmia, is
frequently double, more rarely single, and begins, as a rule, with
sharp pain in the side and an aggravation of the previous dyspnoea.
Pericarditis is less frequent, and occurs usually without symptoms
toward the close of life. The joint affections are characterized by
redness and swelling, and by pain, which is sometimes so great that
touching the inflamed part suffices to arouse the patient from sopor.
Sometimes fluctuation is felt, but death occurs before perforation and
discharge of the pus.
The most frequent ending is death, which follows in from two to
twenty-one days, and, as a rule, between four and seven days. Recovery
is, however, possible.
The symptoms of SEPTICÆMIA VENOSA (phlebitis uterina, pyæmia
metastatica).--The putrid infection of a thrombus at the placental
site may take place within twenty-four to forty-eight hours after
labor. Usually, however, the approach is insidious, and the disease
develops from an apparently insignificant endometritis or
parametritis; or the patient, with the exception perhaps of a tired
feeling, of slight chilly sensations, and of profuse perspiration, may
not have been conscious of any indisposition for days preceding the
attack, or even until the first getting up from childbed. The initial
chill in typical cases is characterized by its violence and duration.
In some cases it may last for hours. It is accompanied and followed by
high temperature, the febrile attack ending with profuse perspiration
as in intermittent fever, with which it is apt to be confounded. The
fall in temperature often assumes the form of a prolonged remission.
In many cases the pulse rises and falls with the variations in the
body heat, while in others it remains permanently above the average. A
frequent pulse is always a suspicious symptom in childbed, even where
the other symptoms are apparently normal.
Erratic chills announce the lodgment of emboli in distant organs. With
the formation of metastatic abscesses in the lungs and other
parenchymatous organs the typical character of the disease changes. In
place of chills occurring at irregular intervals, followed by
remissions and periods of apparent improvement, the fever is
continuous, the pulse becomes small and rapid, while sopor, slight
delirium, a dry skin, a dry, brown, cracked tongue, and a moderately
tympanitic abdomen, give the case the appearance of one of typhus
fever.
Peritonitis is present in hardly one-third of the cases. The abdomen
is therefore flat and soft, and often is not sensitive upon pressure.
Icterus, due to disintegration of the blood-corpuscles, is an ominous
symptom.
Death usually occurs in the second or third week. In the {1013}
typhus-like cases, however, it may follow the first attack speedily.
Recovery is possible where the organs secondarily affected are not of
too great importance.
A combination of the lymphatic and venous forms of septicæmia is not
uncommon in cases running a protracted course.
The symptoms of PURE SEPTICÆMIA.--Under the title of pure septicæmia
should be placed cases in which the absorption of putrid materials
into the blood gives rise to symptoms of intense blood-poisoning
without the development of local lesions. A common example of this
form is met with in the fever which results from the presence in the
uterus of decomposing coagula or portions of retained ovum, the fever
subsiding with the removal of the disturbing cause. In like manner we
sometimes meet with cases of intense septic poisoning followed by
speedy death, in which the post-mortem examination reveals only
changes in the blood and softening of the parenchymatous organs. The
symptoms are often similar to those produced by the injection of
putrid materials containing rod-like bacteria into the vessels of
animals. As the long bacteria do not possess the capacity of
self-reproduction in the blood, to produce fatal results the quantity
of putrid fluid injected must be large or be frequently repeated. This
form is said not to be inoculable.
CAUSES.--The effects of a poisoned state of the atmosphere as a cause
of puerperal fever is best observed in the so-called nosocomial
malaria of hospitals. In days gone by, before I had learned by
experience that the safe conduct of a lying-in service depends upon
the fastidious exclusion of every source of contamination, I had
frequent occasion to witness febrile outbreaks among puerperal women
in the Bellevue Hospital, which were instantly arrested by the simple
transfer of the inmates of the affected ward to a wholesome locality,
though no changes were simultaneously made in either the personnel or
the utensils of the service. In these instances it seems fair to
assume that the previous unhealthy condition was not due to the direct
transfer of an inoculable matter from patient to patient by the
attendants, but by something residing in the air of the vacated
apartment. In the inquiry as to the production of this condition it
can be assumed that it is not caused by aggregation alone. The medical
wards of Bellevue, always crowded, have often furnished in times of
need safe receptacles for puerperal patients. It is certainly not due
to the presence of the ordinary constituents of the atmosphere. We
must therefore look for some additional element capable of unfavorably
affecting the economy. What this element really is, is demonstrated by
a familiar clinical experience. When the disturbance produced by
nosocomial malaria is not at an early stage arrested by change of
locality, the secretions of patients affected become inoculable. Then
the epidemic spreads rapidly, and assumes continuously a more and more
severe type. If during an epidemic the external genitals be carefully
watched, now and then diphtheritic patches will be noticed to form
upon them. At first these patches may disappear or yield readily to
treatment. When an epidemic has assumed a pestilential form the
patches, which may in isolated cases make their appearance at any time
in a hospital, are rarely absent in fatal cases. The composition of
the patches tells the tale of what it is in the atmosphere which
accomplishes the charnel-house work. Favoring conditions have led to
the multiplication of disease-germs {1014} in the air, and have fitted
them to become the active producers of disease.
In a patient dying in the early stages of an epidemic there may be no
diphtheritic manifestations, though the tissues and secretions are
filled with bacteria. As, however, the epidemic gains headway, the
lesions of the generative apparatus, and especially of the external
organs, which are most exposed to air, become covered with patches
which swarm with micrococci. Under the conditions named it is
certainly more in accord with ordinary scientific reasoning to
conclude that the micrococci play an important part in the production
of puerperal fever than that the puerperal fever produces the
micrococci.
To be sure, bacteria or their spores are always present in the air,
and it may be fairly asked how patients are ever spared from their
perverse industry. The answer is, that the effect produced by the
atmosphere of a hospital is dependent partly upon the quantity, and
partly upon the quality, of the suspended germs. Floating spores, when
sparsely distributed, rarely possess the power of invading a healthy
organism. In the inauguration of an epidemic the first patient
severely attacked is usually one whose powers of resistance are broken
down by prolonged labor, by hemorrhage, by poverty, or some other
condition leading to impaired vitality.
Puerperal-fever epidemics due to contamination of the atmosphere, and
not to direct contagion, do not at once reach the maximum of
intensity. At first the temperature tables indicate the prevalence of
milk fever; next follow cases closely resembling those of mild paludal
poisoning; and, finally, if these warnings are unheeded and reliance
is placed upon antiperiodic remedies rather than upon prompt closure
of the threatened ward, the pestilence develops. In the conduct of
lying-in hospitals it should never be forgotten that with the
multiplication of the septic germs the danger increases.
At the same time, the quality of the agents which pervade the air
where hospital patients are confined is an important element in the
genesis of febrile outbreaks. The bacterium termo, which causes
putrefaction, is not in itself, as we have already mentioned, a source
of danger. A stinking odor is not necessarily incompatible with a low
mortality-rate. The importance of the common forms of bacteria,
according to Pasteur, results from the fact that by their power to
consume oxygen they pave the way for the active development of the
pernicious germs, nearly all of which thrive only in media in which
that element has been materially diminished. Again, there is reason to
believe that the same germs are not[50] always equally active for
evil. Gravitz claims that the ordinary varieties of aspergillus and
penicillium found everywhere on the surface of the ground, on
moistened walls, on food of every variety, on decaying leaves and
fruit, and whose spores are universally present in the purest air, can
by a succession of cultures be gradually brought to flourish in a warm
alkaline fluid, and that they then acquire the capacity to penetrate
living tissues, to proliferate in them, to excite local necroses, and
to cause death in the course of three days. The resistance of
micrococci to carbolic and salicylic acids is found experimentally to
depend in a measure upon the {1015} nature of the vehicle in which
they are cultivated (Buchholz). The action of septic fluids varies too
with the age of the infusions, with the materials employed, and with
the conditions under which the poison-germs are generated.
[Footnote 50: Gravitz, "Ueber Schimmel vegetationen im thierischen
organismus," _Virch. Arch._, vol. lxxxi, p. 355.]
Micrococci multiply in hospitals when organic materials favorable to
their growth are present in sufficient quantities. Perrin, Quenquand
and others have shown that the hospital wards in Paris, especially
those upon the surgical and maternity divisions, contain an infinite
number of vibrios, bacteria, and all the coccus forms (Charpentier).
Robin[51] has demonstrated the existence of albuminoid matters in
water condensed upon vessels containing freezing mixtures and placed
in overcrowded wards of hospitals. When the results of crowding become
manifest, these albuminoid matters not only impart a fetid odor and
putrefy with great rapidity, but rapidly impart putrefaction to
healthy muscle and normal blood with which they are brought into
contact. Pasteur was able by the microscopic examination of the lochia
from patients in the services of Hervieux and Lucas-Champonnière to
predict, from the character of the contained organisms, an impending
attack of fever in advance of the slightest symptom betokening danger.
[Footnote 51: _Leçons sur les Humeurs_, Paris, 1867, p. 195.]
It is unquestionably the lochial discharge which makes it such a
difficult task to keep a maternity ward in a healthful condition.
Putrid blood has been found to be the most favorable material for
septic experiments. It was noticeable in Bellevue Hospital that
febrile outbreaks always arose in, and were usually confined to, the
ward in the hospital which, by a bad arrangement, was assigned to
patients for the first four or five days following confinement--_i.e._
during the period of the lochia cruenta. As puerperal fever is rare
after the fifth day, this at first sight would seem natural. But if a
patient was transferred directly after confinement, during one of
these unhealthy periods, to the ward containing the patients who had
passed the first five days, but had not completed the ten days, she
would escape the fever. It was always the same ward that required to
be disinfected. In a communicating apartment all the confinements took
place, and at all times, therefore, the conditions were present for
loading the atmosphere with the products of decomposing blood. In the
summer months, so long as the windows were open and the air was
diluted by the continuous passage of fresh currents, the patients
enjoyed immunity from nosocomial malaria. In the autumn, so soon as it
became necessary to close the windows partially on account of the cool
nights, it was not uncommon for the more trivial disturbances, such as
so-called milk fever, the hospital pulse, and catarrhal affections of
the genitalia, to manifest themselves. Through the months of February,
March, and April the mortality was usually greatest. During the winter
months there was, as a rule, crowding of patients, insufficient
ventilation, stagnation of the air, and the rapid accumulation of
disease-germs. That the later winter months should prove the most
perilous is in accordance not only with the theory of continuous
accumulation, but with the experimental fact that weeks sometimes
elapse before a decomposing substance acquires the highest degree of
virulence.
Apart from the nosocomial malaria of hospitals, there is reason to
believe in the influence at times of certain general widespread
atmospheric {1016} states which affect the entire community. In the
year 1871 the mortality from childbed in New York was 399; in 1872,
503; in 1873, 431; in 1874, 439; and in 1875, 420. Now, the excess in
the deaths for 1872 was due wholly to an increase in the cases of
metria, those from ordinary accidents remaining nearly the same as in
the preceding years. The disease certainly did not extend into the
city from the hospitals serving as foci, for the mortality at Bellevue
Hospital was hardly more than half the usual average. There was no
especial mortality that year from either diphtheria, erysipelas, or
scarlatina, but the aggregate mortality was the largest known in the
history of the city. There are no positive data connecting the civil
deaths from puerperal fever in 1872 with parasiticism, but the
prevalence of epizoötics, of epidemic catarrhal affections, of
peculiarly fatal forms of pneumonia and other diseases which are now
attributed to the presence of minute organisms in the atmosphere,
renders such a source highly probable.