PUERPERAL FEVER. A medical term implying a general blood-poisoning of the same nature as that arising from an in fected wound (see SEPsIs), its specific name indicating merely its origin from childbirth or miscarriage. The area becoming the seat of infection is usually the raw surface inside the womb left after separation of the afterbirth, though lacerations at the mouth of the womb and elsewhere in the genital passages may also provide an avenue for the entry of organisms.
The infecting organisms are the pus-producing cocci, of which the streptococcus pyogenes is the commonest and its haemolytic forms the most serious. Other pyogenic cocci (e.g., staphylococ cus, gonococcus, pneumococcus) and bacteria from the bowel (e.g., colon bacillus and the gas-forming B. Welchii) are occa Ronal infecting agents.
Infection may either be exogenous, i.e., introduced from with out by those attending the woman, or autogenous, i.e., due to further spread of organisms already present in the patient's geni tal tract (cervix or vagina) or from septic foci elsewhere in herbody (mouth, tonsils, etc.). It is generally accepted that the majority of puerperal infections are exogenous, but the auto genous infections are held by some to be more frequent than is commonly supposed. Rarely cases of puerperal fever arise in patients who have delivered themselves naturally and without any internal examination being made, and streptococci are not infrequently discovered before labour in the neck of the womb or vagina, especially in women who have suffered from gonorrhoea or have had previous labours or abortions, but they are very rarely of a haemolytic or virulent type.
Some idea of the frequency and seriousness of the disease may be gathered from the fact that over i,000 women die from it every year in England and Wales, and a much larger number recover, many of them being left with some permanent invalidity or disability. The Registrar General's returns show that the death-rate from puerperal fever is about 1.5 mothers per i,000 live births registered. It forms about 4o% of the total maternal mortality in childbearing.
Symptoms commonly arise about the third day after delivery, the first sign being fever with quickening of the pulse. If the
temperature exceeds 103° F rigors may occur and heavy sweats with remissions of the fever. The womb remains enlarged, the discharges from it may be profuse and foul-smelling or more rarely scanty and free from odour. Serious symptoms are per sistent high fever and pulse-rate, repeated rigors, presence of streptococci in the blood, especially if haemolytic, sleeplessness, delirium and diarrhoea. Lung and abdominal complications are of evil omen. The disease has always grave possibilities but the case-mortality is under io%.
Prevention on antiseptic principles has not succeeded to a like degree to that accompanying the prevention of sepsis after surgical operations, and the reasons therefor are not fully under stood. The more natural the labour and the less the interference, the less is the incidence of fever. Conversely, the more pro longed and extensive (i.e., the higher up the genital canal) the interference and the greater the trauma caused, the greater the risk of infection. Cleansing of the external genitals, disinfection of instruments and dressings, wearing of sterilized gloves, lessen the risk but will not wholly eliminate infection, because it is impossible to render the external genitals, anus and surrounding skin absolutely germ-free. Hence the introduction of hands and instruments within the genital passage carries with it the risk of conveying organisms. Manual removal of the afterbirth retained in the womb is specially liable to be followed by fever and this time-saving manoeuvre must be avoided to the greatest extent possible.
Infection is readily carried from other puerperal patients and from septic wounds and may be spread by the coughing or breath ing of those with septic tonsils over instruments and dressings. The readiness with which the infection may be carried by doc tors, nurses and instruments from patient to patient accounts for the appalling mortality that used to obtain in lying-in hospitals and institutions. Such mortality is now a thing of the past.