PART VIII

THE PATHOLOGY OF CHILDBED

In the present section all those diseases of childbed will be considered which have a causal connection with the processes occurring during parturition or regularly after it, viz. the changes in the genital organs and the development of the mammæ for the maintenance of the child.

To speak of the affections of each organ separately would appear the best course to follow in the description of these diseases. But they make up together a group of diseases which is distinguished by its acutely fatal course or at least by a tendency to such, and they are all dependent upon one common cause. They are due to infection by septic material, and are commonly comprehended under the one name of "puerperal fever."

These affections are of such great practical importance, that it is advisable to give a uniform and comprehensive description of them from their common etiological point of view. Of course, this would be a deviation from the plan which it was proposed to follow in arranging the matter for the present work, viz. to consider separately the affections of each organ. Thus, whilst in the former parts the various diseases of each organ have been spoken of, now the pathological condition of various organs are taken together as being due to one common cause. The importance of the subject will serve as our excuse for thus attempting to describe the uniform aspect of the diseases of childbed depending on septic infection.

CHAPTER L

PUERPERAL FEVER

Undoubtedly cases have occurred at all times where lying-in women have been attacked by septic infection and died, and mention

of such is made by even the most ancient writers. Hippocrates gives the history of cases which, in all probability, were due to it, and so do Galen, Celsus, Avicenna, and other authors down to the seventeenth century.

But epidemics proper are only mentioned since special lying-in hospitals or special departments in general hospitals have been established. The first institution of that kind, in which men like Mauriceau and De la Motte received their obstetric education, was established in the Hôtel Dieu of Paris. Peu tells us that the mortality amongst lying-in women in that institution was sometimes immense, and especially in the year 1664. At the post-mortem examination the bodies were found to be full of abscesses. De la Motte also mentions an epidemic in the Hôtel Dieu in 1678, and another at the commencement of the eighteenth century in Normandy, especially in Caen and Rouen. In other towns also, where special obstetric departments had been established, the epidemic occurrence of puerperal fever was soon observed. Thus, in 1750 in Lyons; 1760 and 1761 in the British Hospital, London, and in a small private lying-in institution; 1765 and 1766 in the Copenhagen Lyingin Hospital; and in 1767 in that of Dublin, ten years after its establishment. In Germany the first epidemic was observed in 1770 at the Hospital St. Marx of Vienna. In 1772 it occurred in Edinburgh, 1777 in Berlin, 1781 in Cassel, &c. &c.

The greatest ravages were caused by puerperal fever in the Maternité (the separate obstetric department of the Hôtel Dieu) where it raged year after year. In 1829, of 2788 lying-in women, 252 died; in 1831, of 2907, 254 died. In February, 1831, six to seven women were delivered in one day, all of whom died. In Vienna also puerperal fever raged extensively. In March, April, May, 1823, out of 698lying-in women, not less than 133 died (19 per cent.), and every two days three deaths occurred; in 1842, in the Vienna hospital out of 3287, 518 died (almost 16 per cent.); in 1846, of 4010, 459 died; in 1854, of 4393, 400 died. From these few data, which can easily be multiplied by a great number of similar ones, it will be seen with what severity puerperal fever has sometimes raged in lying-in hospitals.

It would lead us too far to consider all those theories which have been brought forwards to explain the occurrence of puerperal fever, were it only from an historical point of view. Eisenmann and Silberschmidt discuss the subject very completely. More recently two opinions especially have contended for supremacy. According to the one, puerperal fever is due to a miasma formed by the crowding together of puerperal women, and according to the other it is due to the absorption of septic material. The purely miasmatic theory that puerperal fever is due to infection with a specific material formed under atmospheric, cosmic, and telluric influences, which, acting exclusively upon puerperal women, causes puerperal fever, so that puerperal fever rarely becomes a malarial fever is quite untenable, and now almost universally abandoned. The opinion, however, is still somewhat prevalent, that puerperal fever is, like typhus of miasmatic origin, and that under suitable conditions the diseased organism may reproduce the virus and propagate it to other predisposed individuals without the original miasma being still active; so that in the course of the miasmatic disease a

contagium is generated and propagated to others as the determining cause of the disease.

Latterly, the view that the origin of puerperal fever is due to the absorption of septic material from the surface of the wound has gained more and more adherents, and this view will be accepted in the present work. It is based upon a large number of observations, which, as Hirsch remarks, "have partly, at least, the conclusive evidence of experimental demonstration; and if, in the etiological research, with a correct appreciation of the known facts, the mathematical precision of a proof is for the present renounced, there are few questions of etiology which are able to be solved in a more unbiassed and certain way." In fact, whoever, after he has carefully perused the treatises of Veit and Hirsch on the subject, still doubts the possibility of the origin of puerperal fever by the absorption of decomposed organic materials, is not be convinced. It was, therefore, thought unnecessary to give even a digest of the numerous reasons and observations, and only a few striking cases will be related, which differ from experiments performed on animals only in so far that they were performed unconsciously, and not with the intention to infect.

The opinion which we follow originated with the English, and has been still furthered worked out by German physicians.

Denman was the first who contended that physicians and midwives who attended to cases of puerperal fever propagated that disease to other puerperal women. A great number of proofs of manual propagation soon accumulated in England, and many observations were made known where puerperal women had been infected by accoucheurs who attended, not only puerperal fever cases, but also cases of phlegmonous erysipelas and of ichorous wounds. It had, therefore, become the custom with some English physicians to give up practice for some time, if one of their puerperal patients suffered from puerperal fever. Semmelweiss has the merit of having worked out the subject carefully and pointedly, with special reference to lying-in hospitals, and he deserves to be mentioned amongst the first of the benefactors of man. In 1847 he first stated that puerperal fever depended upon an infection with cadaveric poison, an assertion which can easily be seen to be onesided and insufficient; but he himself corrected his opinion afterwards, and what is now known of the etiology of puerperal fever is essentially due to Semmelweiss.

A.-Definition and Origin of Puerperal Fever

Under the term puerperal fever we place all those diseases of puerperal women which are caused by the absorption of septic matter, that is, organic substances in the process of decomposition.

That absorption may take place, a fresh wound is required by which the septic poison can enter. Through the intact skin or mucous membrane, through the lungs or intestinal canal, septic materials, as a rule, never enter the blood as such, although a long sojourn in an atmosphere loaded with gases the product of organic decomposition can give rise to chronic illness. But fresh wounds exist in every puerperal woman. In every one some of the maternal

blood-vessels are opened up by the detachment of the placenta, and in almost all there are slight lacerations of the cervix and vulva.

The sources from which the infecting matter is derived are chiefly twofold; either it belongs to the infected organism itself-autoinfection, or it is introduced from without-external infection.

Auto-infection is possible in all cases in which parts of the maternal organism decompose during or immediately after delivery. This decomposition occurs very readily and rapidly in disintegrating new growth, as carcinoma of the cervix; it may also be produced by mortification of the maternal soft parts which have been exposed to great pressure, or through pieces of the membranes or placenta which have remained within the genital canal. The latter, however, is a comparatively rare cause of auto-infection, because, to produce the infection a recent solution of continuity is required, which, as a rule, does not occur a few days after delivery, when the ichorous decomposition begins. The wound at the placental insertion is then closed, and the lacerations of the mucous membrane have united by first intention, or have become granulating ulcers; but the proliferating granulations prevent absorption. Under exceptional circumstances a wound may remain capable of absorption, or a fresh excoriation of the mucous membrane, or the destruction of the granulations, may lead to inoculation.

The most favorable conditions for auto-infection exist at the time when the wounds are fresh, that is, when at the birth of the child there are already decomposed materials. This is especially the case (1) when the dead foetus, still contained in the uterus, has, after the rupture of the membranes, been exposed for a long time to the influence of the atmosphere. (According to our experience, a macerated foetus, if the access of air has been prevented, does not infect.) (2) When the pressure upon the maternal soft parts has lasted so long that gangrene sets in before delivery is terminated. (3) In carcinoma of the cervix, where the new growth readily undergoes putrefaction. Auto-infection rarely takes place when the bruised maternal soft parts decompose somewhat later, since the recent wounds have then ceased to be capable of absorption. This is so because the mortified parts are separated from the healthy tissues by the line of demarcation which does not absorb. The partial gangrene of the hymen sufficiently proves that, as a rule, the line of demarcation prevents the absorp tion of putrefying substances by the neighbouring healthy tissue. In every primipara it can be seen that by the pressure of the child's head some portions of the hymen are changed into a bluish-black mass. These portions mortify in a few days; and later, instead of the prominent lips, small ulcers are found. But since the gangrenous parts are thrown off a few days later infection does not follow. Billroth has shown by experiments that granulating sores do not absorb as long as the infecting agent does not destroy the granulations.

Infection from without takes place when septic materials are brought to the recent wounds of the genital organs by means of a sponge or of linen used for cleaning the parts, or by instruments, and very frequently also by the examining finger. It is possible also that septic substances floating in the air of the lying-in room may come in contact with the recent wounds; yet those substances never exist as

gaseous miasms, but rather as organic compounds suspended in the air. On the whole, there are no cogent reasons for such an assumption.

The infecting matter is derived from a great variety of sources. It is formed everywhere where organic compounds decompose; therefore it is derived from dead bodies, from suppurating wounds, disintegrating neoplasms, and especially from the secretions of diseased and sometimes also of healthy puerperal women. Puerperal fever, therefore, is nothing else but poisoning with septic matter from the genital organs.

This definition first of all shows that there is nothing specific in puerperal fever. Where the products of putrefying organic matter enter living tissues the consequences are essentially the same. Puerperal fever is quite the same state which is frequently observed in surgical wards, and designated as erysipelas, pyæmia, ichorrhæmia, and septicemia. A specific difference does not exist, although there are modifications in the symptoms; but they are due in a greater measure to the peculiar place where the septic material enters, and in a lesser degree to the changes of the genital organs in the puerperal state.

Infection with septic materials arising from the female genital organs occurs as a rule only in the puerperal state. Exceptionally it is seen also after gynecological operations. It is then followed by the same changes as in the puerperal state, as is shown in the very interesting cases communicated by Buhl. Changes were found in every respect like those following puerperal fever in the postmortem examinations of two girls upon whom episioraphy was performed, and in two others in whom the vaginal portion of the uterus was amputated on account of carcinoma.

That there is nothing specific in puerperal fever is shown also by the fact that puerperal women can be infected and puerperal fever produced in them by patients with phlegmonous erysipelas or with suppurating and ichorous wounds. It has also been observed in lying-in hospitals that, at a time when puerperal fever was prevalent, phlegmonous erysipelas developed in pregnant women and nurses, who, having slight excoriations, came in contact with the diseased puerperal women. The septic infection can also be transferred to the newly born child, and its action is most frequently favoured by the umbilical wound. The consequences are erysipelas of the abdominal walls, disintegration of the thrombi of the umbilical vessels, even peritonitis and inflammation of the subperitoneal connective tissue and ichorrhæmic metastasis into other organs. It is rather common to see during an epidemic of puerperal fever phlegmonous inflammations arising from small excoriated places on the hands and feet of new-born children. From all these facts we may conclude that puerperal fever is really not contagious, for by a contagious disease is meant one in which a specific poison is produced within a diseased organism, and which, transferred to other individuals, always produces the same specific disease, such as measles, scarlatina, smallpox, syphilis, &c. Although the secretions of puerperal fever patients transferred to other puerperal women may in them produce puerperal fever, there is nevertheless nothing specific in the secretion. Those secretions have only all the characters of the products of