Literature.-R. Lee, Researches on the Pathology, &c., London, 1833, übers von Schneemann. Hanover, 1834.-Eisenmann, Die Kindbettfieber, Erlangen, 1834, and Wund- n. Kindbettfieber., Erlangen, 1837.-Helm, Monographie der Puerperalkrankh. Zürich, 1840.-Kiwisch, D. Krankh. d. Wöchnerinnen. Prag, 1840-41, and Klin. Vorträge, 4 Aufl., I B. Prag, 1854, p. 600.-Litzmann, Das Kindbettfieber. Halle, 1844.-Berndt, Die Krankh. d. Wöchnerinnen. Erlangen, 1846.-Meckel, Charitéannalen, 1854, V, p. 290.-C. Braun, Chiari, Br. u. Sp., Kl. d. Geb., p. 423.-Silberschmidt, Darst. d. Path, d. Kindbettfiebers. Erlangen, 1859. Hugenberger, D. Puerperalfieber. Petersb. Med. Zeitschr. Sep.-Abdr., 1862.-Leyden, Charitéannalen, 1862, X, H. 2, p. 22.-Fischer, e. 1. 1864, B. XII, p. 52.-Hildebrandt, M. f. G., B. 25, p. 262.-Veit, Puerperalkrankheiten, 2 Aufl. Erlangen, 1867, aus d. Handb. d. spec. Path. u. Ther. von Virchow.-Le Fort, Des maternités. Paris, 1866.-Winkel, D. Path. u. Ther. d. Wochenbettes. Berlin, 1866, 2 Aufl., 1869.-Schroeder, Schw., Geb. u. W., p. 197.-Discuss. der geb. Section d. Petersb. Aerzte. Petersb. Med. Z., 1868, H. 6, p. 313.-Hervieux, L'Union Méd., 1869, Nr. 139, and Traité des Mal. puerp., &c., I. Paris, 1870.Evory Kennedy, Dublin Quarterly Journal, May, 1869, p. 269.-Spiegelberg, Ueber d. Wesen des Puerperalfiebers in Volkmann's Samml. klin. Vortr. Leipzig, 1870, No. 3.-Semmelweiss, Die Aetiologie, d. Begr. u. d. Prophyl. d. Kindbettfiebers, 1861, und Offner Brief an sämmtl. Prof. d. Geb. Ofen, 1862.-Hirsch, Historisch-geograph. Pathol. Erlangen, 1862-1864, B. II, p. 433.-Veit, M. f. G., B. 26, p. 173.-Ferber, Schmidt's Jahrb., B. 139, Nr. 9.-Boehr, M. f. G., B. 32, p. 401.-Stage, Under sögelser, &c. Kjöbenhavn, 1868; s. Virchow-Hirsch'scher Jahresbericht über 1868, B. II, Abth. 3, p. 637.-Martin, Berl. klin. W., 1871, No. 32. Virchow, Ges. Abh., p. 597, and Virchow's Archiv, B. 23, p. 415.-Buhl, Hecker u. Buhl. Klinik d. Geb., B. I, p. 231.-Erichsen, Bericht, &c. Petersburger Med. Z., B. VIII, p. 257 and 359.-Klob, Pathol. Anat. d. weibl. Sex., p. 235 sequ. -Maier, Virchow's Archiv, 1864, B. 29, p. 526.-Veit, M. f. G., B. 26, p. 127.— König, Archiv d. Heilkunde, 1862, 3 Jahrg, p. 481.-Schroeder, M. f. G., B. 27, p. 108.-Baumfelder, Beiträge zu d. Beob. über Körperwärme. Leipzig, 1867.Gruenewaldt, Petersb. Med. Z., 1868, H. 9, p. 152.-Ölshausen, Volkmann's Samml. klin. Vorträge. Leipzig, 1872, No. 28.-Martin, M. f. F., B. 25, p. 82.-Dohrn, M. f. G., B. 25, p. 382.-Breslau, Archiv der Heilkunde, 1863, IV, p. 97 and 481, and Deutsche Klinik, 1865, No. 5.-Ferber, Schmidt's Jahrb., B. 139, H. 10, p. 327.Simpson, Edinburgh Monthly Journal, February, 1854, p. 97, and Select Obstetric Works, Edinburgh, 1871, p. 569.-Craig, Edinburgh Medical Journal, July, 1870, p. 24.

CHAPTER II

DISEASES NOT DUE TO INFECTION

A.-FEBRILE DISEASES APART FROM INFLAMMATION OF THE GENITAL ORGANS

PUERPERAL Women are, of course, liable to the various febrile diseases which only form an accidental complication of the puerperal

state.

Those diseases do not generally offer any special characteristics. The diagnosis may be difficult when the symptoms are closely allied to those of grave puerperal processes. It may, therefore, be very difficult to distinguish a severe typhoid fever from puerperal infection of a septic character. The explanation also of the inflammations of many organs, especially that of the lungs, may be difficult, inasmuch as they occur, either as accidental complications of the puerperal state or as ichorrhæmic inflammations of puerperal fever. The latter, however, are distinguished by the absence of the typical course characteristic of the former. A similar mistake has frequently occurred between true scarlatina and a scarlatina-like exanthem, which often occurs in puerperal fever.

Although there can be little doubt that occasionally puerperal women are affected by the real contagion, and suffer from true scarlatina, yet they are by no means especially predisposed to infection by that poison, and the large majority of grave diseases termed puerperal scarlatina, with an erythematous dermatitis extending over the surface, is nothing but puerperal fever with such a cutaneous affection.

There are also other causes which, independently of infection or local inflammation of the genitals, very frequently produce fever in puerperal women. These are, first of all, very great distension of the intestine with fæcal matter. We have already stated that, during pregnancy, the action of the intestines is so sluggish that not infrequently enormous quantities of fæcal matter accumulate, and that before or during labour only a very small part is evacuated. The pregnant woman quite commonly enters the puerperal state with a greatly distended intestinal canal, and within the first few days after her delivery the bowels continue to be sluggish.

The retained fæces may produce very decided symptoms of intes

tinal irritation. In the milder cases there is fulness and swelling of the intestine, with slight inflammatory irritation of the mucous membrane; but certainly, in rare instances, the irritation is continued to the serous coat, and it may assume the proportions of peritoneal irritation, and even that of acute peritonitis.

The abdomen, already somewhat swollen and hard, swells still more. A circumscribed, or more frequently a more diffused, tenderness, which may reach a very high degree, is observed (chiefly in the cæcal region), and prolonged and even persistent vomiting may follow.

The due evacuation of the intestine causes a rapid subsidence of all the symptoms. The diagnosis must rest chiefly upon feeling the fæcal masses. A greatly distended rectum has less value, but more so the distension of Douglas's pouch with a very distended intestinal coil, which can be felt through the posterior wall of the vagina; but the uniform distension of the whole intestinal canal is most distinctly observable by means of palpation of the abdomen, for although in normal puerperal women the abdomen is quite commonly somewhat distended, yet it is soft and easily compressed; but by the retention of large masses of fæces it becomes hard, as a rule uniformly unyielding, so that the uterus can be felt only with difficulty, even in the first days of the puerperal state. In other cases diffused swellings are felt. If also, by a combined examination, the sides of the uterus are found to be free from pain, and if there is tenderness, especially in the cæcal region, we have not to do with peritonitis in consequence of infection, but intestinal irritation through koprostasis. And in spite of the woman's assertion that the bowels have been opened regularly, that diagnosis must be persisted in, for it sometimes (and not rarely) occurs that, in spite of daily evacuations, the intestine is enormously distended. The line of treatment to be adopted is evident.

It is advisable to pay attention to the intestinal functions in all puerperal women immediately after delivery, and especially in cases in which the bowels appear to be greatly overfilled. Aperient medicines ought to be given on the first or at the least on the second day after delivery. They are, as a rule, always indicated when the woman has had no stool until about the fourth day. Castor oil is the mildest aperient, it irritates the bowels the least, and yet causes with great certainty a free evacuation. In rare instances only, repeated doses of it do not act, and preparations of senna or rhubarb or calomel should then be administered. If castor oil is refused on account of its nauseous taste salines may be given, which, of course, usually produce watery stools. But diarrhoea need not particularly be feared in the puerperal state. Often very large quantities of fæces are evacuated by means of purgatives, but Poppel relates a case of koprostasis which was relieved in the course of four days by forty-four very copious stools.

Profuse hæmorrhage is another frequent cause of the elevation of the temperature of puerperal women. There is pretty constantly increased frequency of pulse, lasting for a long time. The temperature, as a rule, rises up to 39° C. (102.2° F.), and remains, with less regular morning remissions, between 38° C. and 39° C.

B.-CHANGE OF POSITION OF THE UTERUS AND VAGINA

1. Flexions and Versions of the Uterus

We have already mentioned in the chapter on the physiology of the puerperal state that an empty uterus is pushed forwards by the pressure of the abdominal muscles acting on its posterior surface, so that it falls upon the symphysis, and that it remains in that position during the first few days of the puerperal state unless other causes (most frequently a distended bladder) press it backwards.

In the first days after delivery the cervix hangs down in the vagina like a loose sail. On the next day or two it is so far formed that its direction can be determined in relation to the axis of the uterus. The cervix is again distinguishable, as a rule, and forms an obtuse, sometimes a right, but often also an acute angle with the axis of the uterus. According to this variation anteflexion is more or less distinctly pronounced. It is most so when the body of the uterus is strongly inclined forwards, and the cervix is directed from behind and above forwards and downwards. The flexion may then become so considerable that the anterior wall of the uterus and that of the cervix almost touch each other. It is rare for the direction of the cervix to be so much inclined backwards that there is, whilst the body of the uterus is bent forwards, exclusively an anteversion, and not also a flexion.

The uterus is usually found directed forwards in the first few days of the puerperal state; it is rarely found inclined backwards. This can be easily explained. In the first few days of the puerperal state the uterus is still too large to fall down beneath the promontory, and in the usual posture the pressure of the intestine is directed the posterior wall of the still greatly enlarged organ.

upon

The altered position of the uterus does not give rise to any special symptoms in the early days of the puerperal state. Women with either anteflexion or retroflexion do not complain of it as long as they remain quietly in bed, but we have found in some puerperal women with anteflexion that the discharge of the lochia was prevented by the flexion at the internal os, and when the fundus has been raised some ounces of a brownish fetid liquid flowed off.

But not even that has given rise to complaint. Treatment of the anteflexion is unnecessary because it always gradually disappears of itself.

Retroflexion should be attended to in cases in which the altered position had previously existed and where there is reason to fear that it will recur. We therefore keep the woman in bed for some time.

2. Prolapsus of the Uterus and Vagina

During pregnancy the vagina hypertrophies so greatly that its anterior wall, as a rule, projects into the vaginal outlet, and not infrequently prolapses to a slight degree beyond it.

In the puerperal state this latter appearance is quite common. But this prolapsus gradually disappears in consequence of the changes in the vagina. The posterior wall rarely projects beyond

the outlet. It most frequently occurs in pluriparæ in whom previously prolapsus of the vagina had existed, and a laceration of the perinæum had healed by granulation. If the prolapsus of the posterior vaginal wall becomes more considerable the uterus itself may be drawn downwards.

The uterus may also primarily descend in the puerperal state, or even be prolapsed. At an early period a true prolapsus scarcely ever occurs, on account of the great size of the organ; but as soon as the uterus has commenced to undergo its retrogressive formation it may prolapse suddenly under certain circumstances. This occurs most easily if the vulva is very large and if there had previously been a prolapsus. Much more frequently it occurs gradually some weeks after delivery.

The treatment of prolapsus consists in maintaining a dorsal posture in the first few days, but afterwards it is the same as in the non-puerperal state.

We may also state that the prolapsus which had previously existed, is in rare cases cured during the puerperal state; the body of the uterus is then fixed by adhesion to the pelvis, or the vagina becomes strictured in consequence of gangrene.

C.-SOLUTIONS OF CONTINUITY IN THE GENITAL ORGANS

Lacerations of the genital organs almost exclusively occur during parturition. They have been sufficiently spoken of in the pathology of parturition. Here we shall only say a few words on the febrile disturbances which occur in consequence of these lacerations. We omit, however, the perforating ruptures, in which the symptoms of peritonitis very soon predominate.

Traumatic fever, though not regularly, yet very frequently occurs after severe lacerations of the vagina or vaginal outlet, and especially in those of the perinæum. It comes on soon after delivery, within the first few days. It very rarely begins with a rigor, more frequently with slight shivering, and, as a rule, the temperature is not much elevated; exceptionally only it reaches 40° C.

The fever is more or less remittent, exceptionally only intermittent, and at times lasts for five days. Sometimes the fever occurs somewhat later.

D. NEW GROWTHS IN THE PUERPERAL STATE

Fibroid tumours of the uterus are a very rare but important complication of the puerperal state. These may give rise to danger during the puerperal state in a variety of ways. By preventing the uniform contraction of the uterus they may cause profuse hæmorrhage; then they undergo changes which are of great interest. The surface of the tumour may putrefy, and the putrid substance absorbed by the smaller lacerations may lead to septic infection. It appears that the acute softening of fibroids, a participation, on account of the similarity of their structure, in that retrogressive metamorphosis which the uterine parenchyma passes through, may cause considerable danger. It is probable, also, that the acute