When we remember the protean aspects of puerperal fever, it is diffi cult to grant that always one single infectious agent, one single micro organism, is the cause, all the more so when we bear in mind the infinite variety of organisms in the lochia of the diseased puerpera, fresh legions of which are constantly being introduced into the uterus. Each invasion causes chill, and new elevation of temperature, and in those cases where the battle is prolonged, death results only after many days of suffering, with alternations of betterment and of aggravation. In these instances, if the uterine lymphatics are the route by which the microbe enters, we will witness the development of lymphangitides, purulent pleurisies, metastatic abscesses, etc., and the case must be a rapid one indeed where we will not find visceral lesions, peritonitis, or suppuration. The woman dies septic, oven as may a man after an amputation.
Such is Pasteur's theory, but it is not as yet accepted by all authorities, and the following are the objections made to it: If these germs are every where around us, if we inspire them by hundreds, if they infect every object near us, why is it that they only exert their noxious influence on puerpera; in lying-in wards, while in our private practice they are inno cent of harm? Has not the puerpera in the country an open uterine wound, even as has the puerpera in a hospital ? The germs reach the one as well as the other, and yet the one almost always recovers, while the other frequently dies. What do the germs do in the intervals of puerperal fever epidemics? To-day our wards are perfectly healthy, the puerperium is unclouded; but let the number of lying-in women increase, and the disease breaks out and the mortality is fearful.
Finally, how have the germs gained access in those most frightful of all cases, where death supervenes in a few hours? The uterus, perfectly contracted, has left no open-mouthed vessel, the lochia have not been at all foetid, there exists neither phlebitis, nor lymphangitis, nor phlegmasia of any kind. How then have the germs entered in order to invade, not the puerpera, but the gravida and the infant she is carrying, and the nurses as well, not pregnant, but living in the midst of puerperal women? For even these latter may become affected, and present the peritonitis which is so characteristic of puerperal infection? Pasteur replies that the atmosphere contains but few germs, that they are particularly spread over solid objects,where they adhere and where they accumulate, and that it is especially -by the accoucherr's hand that they are brought to the puerpera, as well as by the towels, etc., in hospi tal wards.
All the above objections, however, are not refuted by this explanation, and further still, we might state others, as for instance, how explain by the germ theory peritonitis observed by Lorain in foetuses still within the uterine cavity? We must admit that the germs have penetrated the multiple epithelial layers which, at the placental site, separate the mater nal from the fcetal organism. But experience up to the present teaches
us that no organic matter passes from the maternal into the fcetal blood. If the germ theory is true, we must grant either that the peritonitis ob served by Lorain was not of septic origin, or else that these proto organisms penetrated into the foetus by effraction." (Raymond.) It is apparent then that many a point is still to be elucidated, and that we are far from having reached a definite solution. There is, however, one fact on which every one agrees, and this is that puerperal fever is eminently infectious, and that epidemics of puerperal fever are the im mediate result of this contagion. The idea of the transmissibility of puerperal fever is to-day unanimously accepted. But what is the manner of infection? Here still, the vast majority of accoucheurs admit that, whether infection be due to or hetero- cause, it occurs through the wound, whatever the conveyance of the infectious agent. If we are dealing with auto-infection, this is created at the wound-site itself, by the decomposition of putrid placental debris, or lochia, or blood clots. If, on the other hand, we are dealing with hetero-infection, it is conveyed by a direct cause, whether accoucheur, nurse, clothing, etc.
Doleris, on the contrary, who grants but a single cause, the microbe, does not admit auto-infection properly so-called. The morbid germ, the microbe, must tie introduced into the economy, and for him, hence, it is always hetero-infection. But, and here we agree with him perfectly, if infection by the wound is the most frequent, this is not the only route of access, there are others to which we proceed to refer.
1. Contagion by the Wound.—a. In certain instances there exist viru lent vaginal discharges before labor; certain infusoria, which are after wards found in the lochia, may pre-exist in the genital passages—in a word, the vagina contains before labor infectious germs introduced by chance. b. Contagion may occur through the linen, towels, syringes, the injected fluid even, which are often filled with inferior organisms of all sorts. c. It may occur through dirty, improperly cleansed instruments. d. Through septic uterine debris in the curtains, the sheets, the bed-pans. r. Through an infant contaminated by ecthyma, abscess, erysipelas, pur ulent ophthalmia, peri-umbilical lymphangitis, etc. f. Through the nurse, the physician, etc. g. Finally, through propinquity to a surgical service where there exists lymphangitis, erysipelas, ete.