Puerperal Fever. In its most general sense this term may be applied to any acute febrile disease affecting women during the puerperal or lying-in state. In this sense it might be taken to include the febrile states induced by the poisons of scarlatina, typhus, and other zymotics. But, while the zymotic poisons induce manifestations in the puerperal woman in some respects widely differing from the results of their action in the non-puerperal state, their features are quite distinct and recognisable, and the special characteristics of their action depend on the peculiar condition of the subject for the time being, and not on any difference in the specific character of the poisons. The term puerperal fever is now in its narrower sense restricted to that special acute febrile disease resulting from the septic infection of the puerperal woman, and may be considered to be synonymous with the term puerperal septicaemia.
It is a frequent and much dreaded disorder, and accounts for a very large number of the deaths arising from child-bearing. Its dread character and symptoms were recognised by Hippocrates and by him regarded as due to the suppression of the lochia or discharge after childbirth—a view which held ground for nearly 2000 years—for in 1680 Sydenham taught practically the same opinion. From this time until 1847 various views as to its cause and nature prevailed. But in this year the true nature of the cause was recognised by Semmelweis of Vienna, who noticed that in a clinic in the maternity which he conducted, and which was attended solely by midwives, puerperal fever scarcely ever occurred, while in another attended by students, many of whom came straight from the dissecting-room, its ravages were appalling. From this he argued, after careful analysis of his observations, that the students brought into the maternity a poison that induced in the women they attended and examined the disease, which was conspicuous by its absence in the ward attended by the midwives only. Abundant evidence has accumulated since to show that his views were correct, and it has been shown that of all the causes of this malady the poison termed cadaveric (i.e. derived from the decomposing dead body) is one of the most active and fatal. Modern research has shown us that the activity of this and other septic poisons is due to the influence of microbic organisms or 'germs,' and we are well aware that a great variety of such germ-bearing substances exist, each capable of inducing the symptoms and condition which we recognise under the name of puerperal septicaemia. Thus, while the results are to all intents the same, the causes may vary considerably in their ultimate nature, and may be derived from a variety of sources; for example, the cadaveric poison already referred to, the pus from a septic abscess, sewage gas, &c. It would seem that the septic poison may be introduced into the system in two different ways, and this distinction has an important clinical and practical bearing. (1) The so-called Heterogenetic mode includes those cases in which the poison is applied to the tissues of the patient directly, as from the hands of the accoucheur. The microbe then enters the tissues and produces its effects by developing in and influencing the vitality of the tissues themselves. (2) The so-called Autogenetic mode. In this case a piece of the retained placenta, blood-clot, or slough remains in the genital tract. Putrefactive changes set in as the result of microbic infection, and the products of the putrefaction enter the system and exert their morbid influences upon it. In this class of cases the patient as it were manufactures the immediate poison in her own body (hence the term). But it will be evident that in both the ultimate cause is the presence of microbic organisms. The symptoms may occur in from two to fourteen days after labour. They begin with a rigor or 'chill,' followed by a rapid rise of pulse and temperature. Thereafter pain in the abdomen usually sets in and the lochia become fetid or suppressed. The local manifestation of the disease consisting of inflammatory changes varies in kind, degree, and site. Almost all the organs may be involved, more especially the uterus, peritoneum, kidney, liver, &c. In some cases the influence of the poison is so overpowering and rapid that death ensues before any gross change in the tissues occurs, but usually there is abundant evidence of the extent of the anatomical changes.
Once the disease is fairly established the prognosis is grave in a high degree. The chances of recovery where the treatment is appropriate and vigorous are very much greater in the autogenetic variety than in the other. The seat of the mischief can be attacked, and the decomposing matter either entirely removed, or the putrefactive process stopped by the use of efficient antiseptics. Where the sepsis has been introduced directly (heterogenetic form) the possibility of direct interference is almost nil, and the matter resolves itself into a contest between the vitality of the victim and the activity of the poison, in which the former often succumbs.
The preventive treatment (prophylaxis) of this scourge is, however, one of the triumphs of modern medicine. Up to 1870 the special home of puerperal septicaemia was the lying-in hospital, where the atmosphere and furniture were saturated with the septic material derived from the emanations and excreta of previous patients. Such institutions were seldom long free from outbreaks of this scourge, and from time to time epidemics arose with a violence and effect that made the total mortality appalling. But from 1870 and onwards the increasing knowledge of the influence of germ poison in disease-production and the power of antiseptics in keeping this influence in check began to tell, with the result that such outbreaks are now entirely unknown and the mortality is practically reduced to nil. No better illustration of this advance can be found than the experience in the Royal Maternity Hospital of Edinburgh. In 1879 the new hospital was opened, and though it was constructed on the most advanced sanitary ideas several fatal cases occurred during the first three or four months after its opening. The source of the mischief was never discovered; but a vigorous antiseptic and aseptic course was instituted in the management of the practice, and since then no single case of septicæmia has occurred.
A similar result has been attained in the great maternity hospitals on the Continent, and indeed it is found everywhere that the more rigorous the antiseptic practice the more nearly perfect is the immunity from the disease. In no department of practical medicine have the discoveries and teaching of Lister produced more brilliant results. For while it might well have been said that until recently a woman in entering a maternity hospital took her life in her hands, it now appears that since antiseptics in midwifery have been rigorously adopted a woman is actually safer in such an institution than in her own home. For while careful antiseptic practice is practically a routine in the hospital, it is apt to be faulty in a private house by reason of some constructional fault in the dwelling or ignorance or carelessness on the part of the attendants. And thus, while septicæmia is practically stamped out of hospital practice, it is still far too common in private.
The chief points attended to in hospital practice are (1) the thorough cleanliness of the bedding and clothes of the patient—all soiled articles being at once removed and disinfected before being washed. (2) The scrupulous cleansing of the wards and delivery rooms from time to time. (3) The extreme personal cleanliness of all attendants—accoucheur and nurses—the hands being carefully disinfected on every occasion before a patient is touched. (4) The rigid exclusion from the clinics of all who are in attendance on infectious or septic cases or in the post-mortem or dissecting rooms. (5) The prevention of septic absorption by the free use of antiseptic lotions and dressings. While such practice can, with due care, be constantly maintained in hospital, it is obvious that the conditions of private practice render its application more difficult; and while antiseptics have rendered the disease immensely less frequent, it is doubtful if we can hope for the almost complete immunity in private which we have attained in hospital practice.