Puerperal fever is a wound infection.

The conditions of the pelvic organs during labor and post partum, are well adapted to receive and develop microorganisms, for the healthy antimicrobic power of the vaginal secretion is absent or diminished.

A long and exhausting labor, possibly accompanied by hÆmorrhage, or terminated by an operation, has diminished the immunity and broken the resistance of the tissues to a dangerous degree.

The mucous membrane of vulva and vagina are torn and bruised, the vitality lowered, and the surface covered with bloody lochia, which is an excellent nutritive medium for microbic development. The uterus is a vast, open wound, filled with fibrin, blood clot, and decomposing tissue, while the whole pelvis is maintained at exactly the proper temperature for germ propagation.

Through these wounds, toxins are carried into the circulation, and germs, nourished upon the abundant and favorable culture media, pass through the uterine walls or by way of the lymph channels first into the adjacent tissues and thence to all parts of the body.

Certain definite organisms reach the disintegrating tissues and produce a putrefaction. They do not, however, once their work is done, pass into the body. But in producing putrefaction, they also produce injurious poisons, called toxins, which do enter the body and cause an absorptive fever known as saprÆmia.

Other organisms are the pus microbes, which begin their growth in any favorable location and continue to spread and flourish onward and inward by blood vessel, tissue or lymphatic, until overpowered by the resistances of the body, or until by general sepsis, they have killed the patient. These are the streptococcus, staphylococcus, bacillus coli and bacillus pyocyaneus. These are the germs that the nurse or the doctor may bring to the patient on hands, clothing, or hair. These are the organisms against which our scrupulous asepsis and antisepsis is directed. It is against them and their activities that the doctor and nurse prepare by the long and painful scrubbing of the hands and elbows, the rubber gloves, by the shaving and scrubbing of the patient, and by all the paraphernalia and equipment that go to furnish the modern lying-in-chamber or delivery room. It is on account of these germs that the conscientious doctor or nurse lies awake nights and painfully reviews his technic when his patient has a temperature, and it is on their account that he shudders at the callous disregard of human life that is shown by those who do not observe the known laws of asepsis.

It is true that many women escape when the attendant is unclean, but this is due to a splendid immunity, and in no way absolves the man or woman who neglects his asepsis and has patient after patient running temperatures, some of whom are bound to die or be crippled for life. It is for this reason that a surgeon should do surgery and not general practice; it is for this reason that an obstetrician should limit himself to the care of women in childbirth and not endanger them by taking cases of scarlet fever, erysipelas, and unclean surgery.

In country practice, all kinds of work must be done since there are not enough men to specialize, but it is inexcusable in the city where a man can always be clean and keep clean, if he is willing to forego the income derived from attendance upon septic and infectious cases. Any article not surgically clean may contaminate the patient by contact; but ulcers, suppurating wounds, abscesses, and hands improperly or insufficiently cleaned are the deadliest causes of post partum temperature.

Infections are said to be either self-produced or brought to the patient from without.

The only organism that is demonstrably self-infectious is the gonococcus, which may be present in the vagina before labor and may infect the puerperal woman; but it is wiser, safer, and more nearly accords with the facts, to regard all infections as alien borne, as brought to the patient and introduced by the unclean hands or instruments of her medical attendants.

Prevention.—A conscientious and capable nurse or doctor will not go from an infected case to a confinement. Both will keep their bodies clean, the teeth filled, and pyorrhoeas scraped and treated. The occurrence of pus anywhere on the body is sufficient reason for the doctor to give up his confinements for a time, and the nurse to report off duty.

No raw, and but few mucous surfaces should be touched by the fingers of the attendants, where a sterile instrument can be used.

The nurse should never make vaginal examinations unless an emergency exists, and then only when her instruction has been thorough and her experience great. Every examination is a possible source of danger, no matter how carefully the hands and patient are prepared. The nurse is not to change the pads without washing her hands, and she must wash her hands always after changing the pads, before dressing the navel of the child.

The navel or eyes of the child may be infected easily by the hands of nurse, doctor, or patient. The breasts of the mother may be infected by the hands of nurse, doctor or patient. The vulva and vagina of the puerperal woman is highly susceptible to infection from the hands of nurse, doctor or patient.

Rule.—All temperatures arising in the puerperium are due to infection, unless satisfactorily explained by finding the source. The possibility of a slightly elevated temperature from insignificant causes may be kept in mind, but such temperatures are transient and yield quickly to appropriate treatment or to none at all.

Puerperal infection is most apt to appear during the first week of the lying-in period, and it generally develops about the third or fourth day post partum. If the symptoms come on later than this, there is always a hope that the infection has taken its origin in something else than the labor.

Symptoms.—In mild cases, a rapid pulse, headache, and a temperature of 101° or 102° F. may be the only symptoms. Severe cases begin with a chill, followed by a marked rise of temperature. The temperature is always irregular and generally remittent.

The pulse rises to 120 or 130 beats a minute, headache and prostration appear, occasionally associated with vomiting.

The flow of lochia may be either increased or diminished and either offensive or free from odor. Foul-smelling lochia is a sign of putrefaction but not necessarily of sepsis.

At the same time there is some tenderness in the lower part of the abdomen, usually most marked at the sides of the uterus. The uterus is larger than it should be, and not hard, but doughy and sensitive to touch.

The involution is arrested, except in cases of pure septicÆmia. This is an important reason for the daily observation and recording of the regular descent of the organ.

The disease runs a variable and more or less prolonged course and the prognosis is always doubtful until the event. Signs of grave import are: repeated chills, insomnia, pulse above 120, persistent vomiting and meteorism, with dry, brown tongue.

Treatment.—Mild cases without chill when the uterus is large and the lochia sometimes offensive, are usually saprÆmic. Free catharsis, ergot in full doses, and a half-sitting position to aid drainage will cause the symptoms to subside in two or three days.

In the severe type, the treatment is mostly a case for careful nursing. The more energetically the doctor acts, the more liable he is to do harm. The patient needs all her strength to fight the disease, and should not be required to fight the consequences of injudicious interference.

There is still some discussion about the advisability of assuring oneself that the uterus contains no remnants of the labor. Some feel that this should be determined by curetting the uterus with finger or instrument and following the operation with an intrauterine douche. If this is the view of the attending man, the nurse must aid, for the responsibility is his and not hers.

On the other hand, the weight of authority at present seems inclined to the view that any remnant of the labor will drain out naturally or be expelled by ergotdriven contractions without the necessity of opening up new raw surfaces by interference and thus spreading the infection.

The main idea is to promote drainage in every way possible. No curette, no douche, no uterine packing. Nevertheless, the vulva may be cleansed and the vagina carefully retracted and by appropriate means a culture obtained from the uterus. If this shows streptococci, all local treatment is to be abandoned at once.

In general, the food must be fluid, and as nutritious as possible. This means milk, beef and mutton broths, oyster stew, etc. The nourishment must be pushed artfully and ingeniously. Alcohol is not indicated. The bowels are kept open.

Normal saline, drop method, by rectum, will promote diuresis, skin action, and supply the body with the much needed fluid. Subinvolution is controlled by ergot in full doses. The room must be light and as many windows opened as the weather will permit. Frequent change of posture, from side to side, from dorsal to prone and especially to the half-sitting position, will give the patient comfort and prevent decubitus (bed sores). The daily bath with an alcohol rub, keeps the skin in good condition and eases the mind.

The child should be taken from the breast, because the milk is poor in quality and quantity and it may be infectious. Besides, the mother needs all her strength. Nature usually solves the problem by drying up the milk.

All pads soiled by the patient should be collected in paper bags or rolled in newspapers and burned. Sheets, towels, and pillow slips must be boiled in the house and not sent to the laundry. They should be soaked for half a day in a 2 per cent solution of lysol before being washed, and exposed to the hot sun for a day or so afterward, if possible. No comforts should be used on the bed, and the blankets must be left suspended in the room when it is fumigated at the conclusion of the case. All dishes and utensils can be boiled. Plenty of air and sunshine are essential for the cure of the patient and to prevent the spread of the disease.

The nurse must use every precaution to avoid carrying the infection to herself or others. Rubber gloves should be worn while changing the dressing. It is better to have the child cared for by another nurse. The nurse must get her rest and some exercise out of doors every day. It rejuvenates her and reacts to inspire the patient.

When she leaves the case the nurse should boil her linen and wash her hair with soapsuds and hot water, and bathe frequently.

Milk Leg.—This is an infection characterized by swelling of one, or rarely, both, limbs, from the foot to the groin. The leg is white from the edema, and as the condition is associated with fever and since the milk diminishes or disappears about the same time, it was thought in former days that the milk went to the leg.

The cause of the swelling is a phlebitis of the external iliac or femoral vein which becomes thrombosed or so filled with clots that the return circulation is impeded.

Symptoms.—The attack is signalized by a rise of temperature to 102° to 104° F. There is headache, pain in the affected limb, and general prostration. It is a true sepsis.

The disease appears usually in the latter part of the second week of puerperium, when the patient has begun to congratulate herself that all danger is over. In many cases the doctor has yielded to importunity and let the patient get up before involution was sufficiently advanced and the patient will report that she got up too early.

The limb must be immobilized and kept warm. The immobility should be maintained for at least ten days after the fever has subsided and the pain gone.

The convalescence may be protracted over weeks and months.

Bed sores may complicate a long convalescence. Bathing with alcohol or alcohol and alum, and the frequent change of the patient’s position will usually prevent them. Rubber rings and sheeting should not be used if it can be avoided. Ointments containing zinc are of great value in the cure of this affection.

Phlebitis, in minor degree or in localized sections, may occur in the veins of the leg and the site of the invasion will be outlined as red lines or as irregular nodules. Some fever may attend the condition. Rest of the affected member, with ice bags for the pain, constitute the treatment. Bed sores must be guarded against.

Sudden death in the puerperium is a shocking disaster. Rapid death may follow the complications of labor accompanied by hÆmorrhage, such as placenta prÆvia, rupture of the uterus, etc.; but death may be sudden, without warning, from pulmonary embolism, acute myocarditis, fatty degeneration of the heart, or the entrance of air into the uterine veins. This may happen several days after labor in a woman who is passing through a convalescence apparently normal in every respect. Such an event is probably due to a thrombus which may form in any of the veins of the body, but more frequently in those of the pelvis and legs. In the latter it may be recognized by hard lumps that form somewhere along the course of the veins in consequence of a phlebitis. There is always the menace that some fragment of this mass, which is merely a hard clot of blood, may become detached and float off in the circulation to other parts of the body, such as heart, lungs, or brain (embolism), and by interference with those structures, produce paralysis or instant death. When a thrombus is diagnosed, the affected part must be kept as quiet as possible. No massage is permissible. Tincture of iodine or 20 per cent ichthyol may be applied. The woman should remain quiet for at least ten days after the apparent disappearance of the symptoms.