Puerperal Infection : a Review of Five Hundred Cases

In a series of 500 cases of Puerperal Infections Liability to infection was found least below the age of 21, greatest between 26 and 35. The incidence was high after abnormal labour, and, correspondingly, after confinements attended by doctors. 16.4 per cent followed abortion. 19.2 per cent were fatal. High mortality was associated particularly with illegitimacy, with abnormal labour and abortion, and with infections of early onset; to a less extent, with 1st, 2nd, and 3rd pregnancies. Uncomplicated infection, a painless and insidious disease, formed the most common clinical type (65.6 per cent of the series). The sapraemic and septicaemic forms often were indistinguishable, many grave cases showing the local signs of putrefaction. No evidence of relationship with Scarlatina presented itself. The duration was usually short: not more than a week in 67 per cent. Pneumonia was the commonest immediate cause of death. Mortality 15.5 per cent. Gases presenting pelvic inflammation (12.4 per cent) more often followed normal labour, rarely abortion. Slower of onset, the infection was characterised by the occurrence, sooner or later, of pelvic pain. Parametritis, the milder form, more common on the right side, caused but slight disturbance, and sometimes brought about a general improvement; perimetritis caused more local and general reaction, especially on invasion of the Fallopian tubes. Both forms not infrequently ended in suppuration. The risk of incomplete resolution, with consequent chronic invalidism, is slight in hospital-treated cases. Mortality only 6.4 per cent. General Peritonitis (7 per cent), early of onset, was most frequent in primiparae, after abnormal labour, and after abortion. Not always obvious, and by far the most fatal manifestation of infection, it should be borne in mind in the examination of every grave case* Vomiting was the most constant sign; the abdomen often misleading. Mortality 94.6 per cent. Pyaemia (4.8 per cent), also very common in primiparae, and after abnormal labour, but rare after abortion, usually started late and ran a prolonged course. Metastatic foci appeared to depend, to some extent, on trauma; joint-invasion was the most serious. Mortality 25 per cent. Phlegmasia (10.2 per cent) was more frequent in older women; three fourths of cases followed normal labour. Likely causes were early getting up, Fowler's position over a long period, and anaemia. The left limb was more often affected; from the right, spread to the other side was more common. The thrombotic and lymphatic forms appeared to differ only in degree. Striking general improvement sometimes followed the onset. Bacteriological examination of blood, uterine smears, and purulent effusions showed that, with rare exceptions due to B.coli or Staph. aureus, the disease was caused by streptococcus. Haemolytic types were responsible for all the most serious infections, non-haemolytic, as a rule, for those less severe. There was no evidence that gonococcus gives rise to general infection. Of 46 autopsies, diffuse peritonitis, whose frequency in fatal infections is not sufficiently realised, was a feature of more than half; two examples were associated with perforation of the uterus. Common also were fatty degeneration of the organs, pneumonia, and purulent pleural effusions. As regards treatment, fresh air and good nursing did more than the administration of drugs; but stimulants and hypnotics were often necessary. Curettage of the uterus during the febrile period proved, in the absence of haemorrhage, not only unnecessary, but harmful; no disadvantage was observed to follow the substitution of conservative methods. Curettage during convalescence was found harmless. For diffuse peritonitis, laparotomy with drainage was performed whenever there seemed likelihood of success; but, very often, the patient came to hospital too late to benefit by any treatment. Pyaemia and pelvic inflammation often demanded surgical measures for the release of pus. The response of acute infections to serum and autogenous vaccines was disappointing. Serum was doubtfully beneficial in less severe illnesses, vaccines more definitely so in the presence of suppurating residua. Intravenous eusol proved useless. Abscess of fixation, a heroic remedy not always justified, gave promising results, and merits more widespread recognition