The above instances of contagion have been observed over and over again, both in private and in hospital practice. We would cite simply the epidemics observed by Danyau, Trousseau, Dubois, Wells, Atthill, Boardman, Hecker, Holmes, Braxton-IIicks, Thierry, and others.
Having thus established the fact of contagion, we need not be astonished to see the disease develop simultaneously, rapidly, and successively, in a large number of puerperal women, when they are crowded together. Epi demics, indeed, are purely the result of a wider dissemination of the con tagion, the cause and the mechanism remaining the same. In order that an epidemic may exist, we need the infectious spark in the shape of the germ, and the diffusion of this germ. Now one single circumstance brings together these conditions, and this is, says Doleris, overcrowding.
2. Overcrowding as a Cause of Epidemics.-1. The morbid germs are thus multiplied. 2. The points of contact are thus increased. 3. There is insufficient aeration, oxygenation. 4. The resistance to disease of the woman is thus lessened. Now where are these injurious conditions better found than in the lying-in wards of maternities, where the same nurse cares for the well and the sick puerperm, where isolation wards do not always exist, where instruction is given, and where, it must be said, dis infection is not practised as vigorously as it should be. Is it surprising then to find such fearful mortality, often, compared to that in private practice ? Besides these facts of contagion by the vaginal or uterine wound, it seems to us impossible not to admit contagion by other routes. How otherwise explain those cases noted by Depaul, Tarnier, Hervieux and others, where women were infected before labor, and therefore before the existence of any wound? And how explain those instances where young nurses have been poisoned by the simple fact of sojourn among puerperte during an epidemic? Tarnier says: " It is probable that by the lungs, offering as they do conditions favorable for absorption, infection often, if not always, occurs." Others grant absorption by the intestines: " When ever some cause or other destroys the integrity of the mucous membrane or augments the proportion of the germs, whether absolutely by the direct introduction of septic substances by the digestive tract, or relatively by an arrest of the faecal current, then the fight becomes unequal, and sep ticaemia results." (Doleris.) The experiments of Schweninger, 1866, of Hemmer, Coze, Feltz, 1869, Meyer, Legros, Humbert, 1870-73, Doleris, 1879, have conclusively proved the possibility of infection by the intestine.
We would resume then as follows: Although we may no longer consider puerperal fever from the standpoint of the older writers, we cannot deny but that there exists an ensemble of phenomena, of puerperal accidents, which are the result of puerperal septicaemia, and which we may collect under the generic classic name of puerperal fever. These affections are the result of infection, and they are consequently infectious to the highest degree. Rire endemically, they are met with in particular in Maternities, where they assume the epidemic form. The most recent researches point to their origination from the penetration into the economy (by the veins or lymphatics, often by both simultaneously) of a septic agent (cadaveric poison, product of decomposition according to some, proto-organism ac cording to Pasteur), a septic agent which may gain access to the economy either, and this is the rule, by the vagina and the vaginal and uterine wounds, or else, exceptionally, by the lungs and intestines. According
to the different entrance points, and according to the varied conditions of development in the economy, this agent will determine different affec tions and phenomena, which will impress on each epidemic its special characteristics.
[Among the recent contributions to the subject of the relationship exist ing between micro-organisms and puerperal fever, we would note the article published by Lomer, of Berlin, in the Am. Journal of Obstetrics, July, 1884. The aim of the writer was to collect the facts which have been offered as such regarding this relationship, and we here insert his conclusions as being representative of the most recent views on this sub ject. After an impartial statement of the knowledge derivable from pa thological anatomy, and from culture experiments, Lomer studies the relation of scarlet fever, diphtheria, erysipelas, pyemia, etc., to puerperal fever, and then draws the following conclusions: 1. Of all organisms found in puerperal fever, the chain-liko micrococci seem to be those to which we should especially direct our attention, and which are the most important. 2. When in any case of puerperal fever their presence has been detected in the exudations, they have also been found in the deeper organs. 3. They have been found in erysipelas, scarlet fever, diphtheria, and puerperal fever, and in each possess the same form, and show the same disposition towards fertilizing fluids and coloring matters. 4. Al though it is very probable that different varieties do exist among these diseases, we as yet have no positive evidence of the fact. 5. A differen tiation according to size is an extremely difficult, perhaps hopeless task, but according to manner of growth, it may be possible. 6. Vaccinations, with cultivations of these miurococci from different diseases, have proved fatal to animals, but have given no typical or characteristic results. 7. Chain-like micrococci have also been found in infected wounds, and in the blood of pyemic patients. 8. The pathologico-anatomical investiga tions thus show that these clinically related diseases (puerperal fever, ery sipelas, diphtheria, scarlet fever, and pyemia) possess similar micro-organ isms. 9. Besides the chain-like form, other micro-organisms may be present in puerperal fever (i.e., mixed infection.) 10. The presence of these latter in the cadaver does not always prove that they existed in the living body; on the contrary, they are often the result of post-mortem decomposition. 11. It is probable that the processes of decomposition are sometimes present before death actually takes place; different varieties of micro-organisms therefore found, for instance, during the death strug gle, may have nothing to do with the cause of the disease. 12. It is as yet impossible to classify puerperal fever, as regards course and prognosis, according to the varieties of micro-organisms found (Doleris), or according to their mode of invasion (Fra3nckel.) 13. In some cases no micro-organ isms have been found, but this does not prove that they did not exist.