Such may be considered a fair statement of the views held to-day in Germany, and largely in this country, in regard to the relationship existing between germs and puerperal fever.
Robert Barnes, in his system of obstetric medicine and surgery, thins summarizes his views in regard to puerperal fever: " By the term puer peral fever, we must understand fever in a puerpera. As fevers of vari ous kinds may assail non-puerperal persons, so they may assail puerperie. We must, therefore, abandon the vain attempt to find one definite puerperal fever, and we must recognize the clinical truth that there are puerperal fevers. There is, however, one constant underlying condition of all the puerperal fevers, that is, the puerperal constitution. This puerperal constitution is the soil in which all the disturbing influences work, in which noxious matters, from whatever source, germinate; and which, without always destroying the individual properties of the foreign poisons, imparts to all some common features. It is also highly probable that, under the mutual reactions of ingested poisons, and the puerperal consti tution, new innominate poisons may be engendered. The puerperal fevers may be classified under the two great divisions of autogenetic and heterogenetic. The autogenetic fevers are: 1. The simple excretory puer peral fever, the result of endosepsis, or the arrest of the excretion of waste stuff of involution. This form complicates all other fevers. It is in itself the only true puerperal fever. 2. The fever resulting from the ab sorption of foul stuff from the parturient canal, either from unbroken mucous surface, or by the open mouths of vessels, or from traumatic surfaces, this is autoseptic. This form also is likely to complicate other fevers. 3. This, the proper septimmic puerperal fever, is revealed under the forms of metritis, peritonitis, pelvic cellulitis, thrombosis and general toxemia.
The heterogenetic fevers are due to the reception of a poison from with out. These may be divided into: 1. The cadaveric poison, the septic stuff from other puerperve, animal poisons of obscure origin. 2. The known zymotic poisons, as smallpox, scarlatina, typhoid, diphtheria, erysipelas.
All the various modes of infection recognized as acting in non-puerperal subjects act in the puerpera. But she is especially open to invasion by direct inoculation of the parturient tract; and empoisonment by the ordi nary routes is enormously favored by the peculiar activity of the absorptive function of the puerpera. Pathological anatomy fails to differentiate the fevers. In cases of various origin the anatomical changes may exhibit close similarity. The constancy of pathological effects illustrates the proposition that all the fevers acquire some common character from the underlying puerperal constitution. The symptoms at the onset of puer peral fever rarely indicate with precision the source or nature of the fever. Most are ushered in by the common signs of toxemia. Differen tiation, or the identification of the particular poison at work, is established sometimes by watching the clinical evolution of the disease, by the ante cedent history, by search into the surrounding influences, and not seldom the problem baffles solution. We must then be content with the general fact that we are dealing with a puerperal fever." In the Am. Journ. of Obstetrics for May, 1886, Dr. Emil Noeggerath described a species of puerperal fever dependent on a microbe which lie cultivated and is represented on the annexed plate. The special features of this variety of puerperal fever, as deduced from study of a reported case, are that: " 1. There is an invasion of a septic element, notwithstand ing the most complete aseptic management of the confinement. 2. Long
duration and obstinacy of a moderate amount of fever against early, per sistent, and energetic local and internal treatment. 3. Its remittent, almost intermittent character. 4. The inflammatory action of the poison upon the tissue of the uterus. 5. The absence of deposits in remote organs, notwithstanding the length of time the patient was under the in fluence of the fever germs." The special microbe on which this variety of puerperal fever depended belonged to the bacteria called saprogenes, and Noeggerath thus describes it: " Its length, although varying in size according to the medium on which it is raised, is between a large coccus and a bacillus. It is a short rod, separated in the middle by a slight constriction just visible with a very high power, which gives it the appear ance of two oblong cocci joined closely together. Sometimes two or three rods are joined in one. Fig. 1 (vide plate) represents, near a, their charac teristic appearance. It is about one-quarter larger than bacterium termo." Fig. 4 shows this microbe growing in meat-peptone, when it acquires the shape of a cone, point downwards, and it resembles very much a comet with a large nucleus. As it grows, it developes a very intense odor of putrefaction. Fig. 3 represents the ordinary puerperal streptococcus, for purposes of comparison. " The life history of this parasite, enables us to classify it among the saprophytes, and we must call the fever de scribed, not as symptomatic of septicaemia, but of sapremia. This dis tinction is now fully established as existing in fevers occurring during the puerperal state, especially through the researches of Duncan and Ogston. Sapremia is simple putrid infection, not a poisoning from an organism which goes on developing in the blood, but a reception into the circulation of decomposed lymph and gases. The organisms which produce sepsis and pyemia have probably nothing to do with putrefaction at all." The very practical conclusion which Noeggerath draws from his study, a conclusion worth emphasis, is: " A so-called good plumbing, from an engineering point of view, is no guarantee of a sanitary condition of a dwelling." • Parvin, in his recent work on obstetrics, thus summarizes his own views in regard to puerperal fever: " From what is known of so.called puerperal fever, it should not be regarded as a specific disease, and, strictly speaking, there is no puerperal fever, that which is so denominated being a febrile affection caused by the entrance into the system of a poison from without, the nature of which we do not know, the entrance taking place through a wound of the uterus, or of some part of the vulvo-vaginal canal." From the above extracts it is evident that there is still ample diversity of opinion in regard to the cause or causes of puerperal fever or fevers, to use Barnes's expression, except in the minds of those convinced be lievers in the influence of microbes. For them "no microbe, no fever" is the cry. For us, we are content to leave the matter in the doubt forced upon us by the present state of our knowledge. To dogmatize, as yet, we do not believe is scientific. The wise course is to accept the doctrine of septicaemia as applicable to the vast majority of cases. Fortunately for the woman, our treatment of the disease is to-day more certain than our theory as to its origin, and if in the future a better explanation of the cause is offered than that at present acceptable to the majority of ac coucheurs, we do not hope for much change in the generally accepted treatment, which is outlined further on.—Ed.]