[Reprinted from Tint Philadelphia Polyclinic, Veil. V, April it, iSc)<,. No. is] A CLASSIFICATION OF PUERPERAL SEPSIS. HY W. A. NEWMAN DORLAND, M.l>. Assistant Demonstrator of Obstetrics in the University of Pennsylvania; Instructor in Gynecology in the Philadelphia Polyclinic. Hy puerperal sepsis is meant that serious complexus of symptoms arising from the in- troduction into the system of the puerperal woman of the septic germs and their ptomaTns, and consisting in great alterations in the tem- perature and pulse-rate, in profound physical depression, and in marked local (vulvar, vaginal and pelvic) manifestations. Our knowledge of this grave disease has been marvellously developed within the past few years, largely owing to the wonderful pro- gress made in bacteriology and pathology, and we are in a position to-day to offer a more thorough classification of its various clinical phases than would have been pos- sible less than a decade ago. As has been concisely pointed out by Dr. Harold C. Krnst, of Boston, in order for the development of the disease there is required in the first place a specific virus ; secondly, a means of entrance for this virus into the system ; and thirdly, a certain constitutional condition that will favor the development of the disease, the other two factors being present. The specific virus ma.y be any one of a large number of patho- genic microbes that have been, from time to time, discovered in various puerperal scj>- tic patients; very probably, however, it is the streptococcus pyogenes (Fehleiscn’s di- plocoi cus of erysipelas) that is the most fre- quent causal organism. The investigations of Kdnig, Williams, Chase, and others would seem to demonstrate the truth of this state- ment. Whatever the variety of micro or- ganism concerned in ihe originalion of the disease, however, in order to become ]>atho- genically active, it must cither have lain dormant in the genital canal for some time prior to parturition, or it must l>e introduced therein during or shortly after labor. An entrance into this region once effected, fur- ther encroachment upon the organism is facilitated by the numerous abrasions and lacerations that are present after every labor, however normal. It must be borne in mind that a mere mucosal abrasion is fully as dan- gerous as is a more extensive destruction of tissue. The factors that would seem to favor the development of puerperal sepsis in any case may then l>c stated to be three, namely, a markedly reduced vitality, the presence of numerous abrasions and lacerations in the parturient canal, whereby a ready entrance is afforded the pathogenic microbes, and the great difficulty that will be experienced in preserving a proper degree of cleanliness owing to the anatomic peculiarities of the parts. It is probable that the great malig- nancy manifested by the streptococci is largely dependent uj)on their enormous power of propagation, rather than upon any special inherited virulence on the part of the germs. Be this as it may, it is certain that by their presence the following changes in the woman’s organism are effected. In the first place, there occurs an enormous propa- gation of the germs implanted within the parturient tract; these, by their presence, give rise to the formation of very deadly sub- stances known as ptomaTns, which are readdy absorbed by the vessels and lymphatics of the region, and quickly enter the general cir- culation. There then ensue grave altera- tions in the constitution of the blood and the vital fluids of the body; varying degrees of hydremia and of leukocytosis may be noted, and, finally, vast numbers of the germs them- selves as well as large quantities of their poison- ous products may be detected in the blood and body-scrum. Locally, there are frequently produced very marked alterations in the tis- sues of the genitalia. An inflammatory pro- cess of greater or lesser intensity may be noted ; this may consist merely in an en- gorgement of the parts with catarrhal mani- festations ; there may occur a marked diapedesis, and exudates of varying degrees of consistence be thrown out; or there may be produced such a devitalization of the tis- sues as to result in necrobiosis, or even abso- lute gangrenous changes with the formation of extensive sloughs. According to the amount of ptomam- intoxication, the method of introduction of the virus into the system, and the pathologic changes and clinical manifestations produced thereby, will depend the variety of the septic infection presented by the patient. It has only been of recent years that any classifica- tion of the various forms of puerperal sepsis has been attempted. The grouping of Spie- gelberg, and, more recently, that of Kehrer, are most probably the best that have as yet been offered, but both of these are largely defective in that they fail to include the rarer manifestations of the disease, and give no clue to their pathologic basis. In the prep- aration of the following classification, which is founded on a combined clinical and patho- logic basis, an effort has Ixren made to give a rational presentation of the various aspects of the disease, including not only the more familiar, but the rarer, forms as well. Clin- ically, hetcrogenetic puerperal sepsis is en- countered in two main varieties, namely, that in which there has occurred a general systemic infection, and that in which the general infection is quite subordinate to the local manifestations. Under these main divisions the various forms of the disease are grouped according to their pathologic features. Under general puerperal sepsis may be included all those forms dependent upon hemic or vascular infection. Here may be mentioned simple sapremia or true puerperal septicemia ; puerperal phlebitis in its various forms, including uterine and parauterine phlebitis, puerperal pyemia, puerperal pneu- monia and puerperal ulcerative endocarditis (both due to embolic infection), puerperal rheumatism, puerperal arthritis, and phleg- masia alba dolens; puerperal erythema; puerperal pemphigus; puerperal tetanus; and puerperal neuritis. Under the second heading are included those cases in which the sepsis is mainly localized in or around the uterus and its adnexa 'This embraces, in the first place, all forms of local lymphatic infection, includ- ing puerperal metritis in its various forms; puerperal pelvic cellulitis, and puerperal peritonitis, pelvic or general. Secondly, those cases in which there is a special in- volvement of the genital mucosa;, including vulvitis, endokolpitis, endometritis and en- dosalpingitis in their various forms. Thirdly, puerperal urethritis, cystitis, ureteritis, and pyelitis. Fourthly, puerperal proctitis. Finally, mention must be made of the very rare form of autogenetic puerperal sepsis or auloinfeclion. For convenience in reference the foregoing classification may be tabulated as follows : A. Heterogenetic Puerperal Sepsis. Class I. General Puerperal Sepsis. i. Hemic or vascular infection. (i) Puerperal septicemia. Synonyms: Sapremia (Duncan); resorptive fever; ptomainemia; ptomain poisoning; ptomain intoxication; septic intoxication ; septic fever; putrid infection; putrid intoxica- tion. tritis , puerperal ovaritis'). (3) Puerperal peritonitis, pelvic or gen- parametritis, puerperal perime- era I (peritonitis puerperalis). 2. Involvement of the genital mucosae. Nt) Vulvitis. (a) Catarrhal or suppurative (vul- (2) Puerperal phlebitis {infectiousphle- bitis ; septicemia venosa) with thrombosis {thrombophlebitis) and embolism (puerperal embolism). (a) Uterine and parauterine phle- bitis {phlebitis uterina ; pu- erperal metrophlebitis). (b) Puerperal pyemia (septico Pyemia; Pyamia metasta- tic a ; pyamia multiplex). (c) Puerperal (septic) pneumo- nia. (d) Puerperal (septic) ulcerative endocarditis. (e) Puerperal rheumatism.—Pu- erperal (septic) arthritis. if) Femoral (crural) phlebitis vitis catarrhalis). (b) Phlegmonous or ulcerative {vulvitis purulenta). (c) (i angrenous (vulvitis gangra- id) Diphtheric (vulvitis dip/i- nosa). theritica). (2) Kndokolpitis. (a) Catarrhal or suppurative (en- docolpitis catarrhalis). (b) Phlegmonous or ulcerative (endocolpitis purulenta.) (c) Cl angrenous endocolpitis gan- {d) Diphtheric (endocolpitis diph- granosa). theritica). (3) Kmbometritis. (phlegmasia alba do Uni). (3) Puerperal (infectious) erythema (scarlatiniform erythema). a) Catarrhal or suppurative {en- (b) Phlegmonous or ulcerative dometritis catarrhalis). (4) Puerperal {septic) infectious pem- phigus. (endometritis purulenta). (5) Puerperal tetanus (tetanus puerpe- rarum). (c) Gangreno\i%{endometritisgan- gran os a). id) Diphtheric {endometritis Class 11. Local Puerperal Sepsis. 1. I-ymphatic infection (septicemia lym- (6) Puerperal neuritis. (4) Endosalpingitis. diphtheritica) {a) Phlegmonous or ulcerative pha tica; puerperal lymphangitis). (r) Puerperal metritis. endosalpingitis purulenta ; puerperal or septic pyosal- {a) Phlegmonous (metritis puru- pin git is). lenta). 3. Puerperal {septic) urethritis, cystitis, ureteritis, and pyelitis. Ib) Grangrenous (metritis gan- granosa). B. Autogenetic Puerperal Sepsis (Au- 4. Pucr|>cral (septic) proctitis. (2) Puerperal pelvic cellulitis {puerperal toinfection). 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