THE 
Relation of the Urinary Organs 
TO 
PUERPERAL DISEASES. 
BY 
W. M. CHAMBERLAIN, A.M., M.D., 
Fellow of New York Academy of Medicine; of the New; York Obstetrical Society; one of the 
Obstetric Physicians to Charity Hospital. 
Reprinted from the American Journal op Obstetrics and Diseases of 
Women and Children, Vol. X., No. II., April, 1S77. 
NEW YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1877. THE 
RELATION OF THE URINARY ORGANS 
TO 
PUERPERAL DISEASES,1 
Modern Renal Pathology may be said to date from the year 
1827, when Dr. Richard Bright began to publish his now fa- 
mous observations and his elegant plates. For several years he 
was his own commentator, working mostly alone. But in 1839 
Christison in Edinburgh and Rayer in Paris published their 
important treatises confirming and extending the observations 
of Bright, and directed the attention of students to this interest- 
ing field. 
From 1840-1850 Kolliker, Rokitansky, Bowman, and Simon 
elaborated the histology of the kidney; Becquerel, Geo. John- 
son, Bence Jones, Berzelius, and Beale the chemistry and 
micrography of the urine. 
From 1850-1860 Frerichs, Virchow, Todd, and Traube 
classified renal diseases according to the tissues and functions 
implicated ; studied the relations of the liver and the heart to 
the urinary organs, and formulated theories of albuminuria 
from retarded circulation ; uraemia from restrained excretion; 
1 Read before the Medical Society of the County of New York, February 
26, 1877. 4 
Chamberlain : Relation of the 
ammonaemia from chemical conversion, and eclampsia from 
hydraemia. In the following decade, from 1860-1870, these 
theories were made the occasion of many experiments on the 
human subject and upon animals by Hammond, Ilarley, Oppler, 
Parkes, Richardson, Schottin, Treitz, and Zalesky, and many 
others. An immense amount of careful and well-distributed 
work was done, which recently has been collated, sifted, and 
condensed in the works of Rosenstein, Roberts, and Grainger 
Stewart. 
Early in the course of these studies, obstetricians recognized 
their important bearing upon the convulsive diseases of preg- 
nancy. 
The general similarity between puerperal convulsions and 
those of Bright’s disease had been already noticed by Simpson 
and Rayer, when Lever, of Guy’s Hospital, from 1843 to 1847, 
published a series of cases in which eclampsia and albumi- 
nuria were associated. Shortly after followed the observations 
of Litzman in Germany and Blot in France, agreeing in the 
statement that twenty per cent, of all pregnant women, and a 
still larger proportion of primiparae, showed albuminuria. In 
1855, Braun of Vienna made the formal statement that 
“ Eclampsia of parturient women is commonly the result of 
uraemic intoxication, arising from Bright’s disease.” 
Objections to this statement have been made by many ob- 
servers ; notably by Prof. Barker in papers read to the Hew 
York Academy of Medicine, and in his work on Puerperal 
Diseases, and by Dr. Braxton Hicks of London. 
They show that (1) Puerperal convulsions, in many cases, 
resemble those of reflex irritation quite as much as they do those 
of Bright’s disease; (2) that pregnant women suffering from 
well-marked Bright’s, sometimes go through child-bed without 
eclampsia; (3) that some women dead of eclampsia, have 
shown in life no symptoms, and in death no lesions of Bright’s 
disease; (4) that in others the evidences of Bright’s follow 
rather than precede eclampsia. 
Hence, these authors, while not excluding the theory of 
uraemia, incline to that of cerebro-spinal nervous irritation as 
the most common proximate cause of puerperal convulsions. 
And they find clinical support for this position in the accepted 
value of chloroform, chloral, and morphia in these conditions. Urinary Organs to Puerperal Diseases. 
5 
It is not the purpose of this paper to consider specially the 
subject of puerperal convulsions, but we may note in passing 
these objections, that the absence of convulsions does not speak 
for the absence of Bright’s disease, since, according to Grainger 
Stewart,1 three out of four of all cases of positive Bright’s also 
escape convulsions. Neither do the beneficial effects of mor- 
phine indicate that Bright’s disease may not be present, since, 
according to Prof. Loomis,2 morphine is of special use in the 
convulsions of Bright’s. The observation of Braxton Hicks,3 
that uraemia sometimes succeeds rather than precedes eclampsia 
does not show that the eclampsia is the cause of the uraemia, 
since it will, we think, appear that various puerperal condi- 
tions, not attended with eclampsia, tend to end in uraemia. It 
is necessary, to the full solution of these questions, (1) that the 
exact pathological value of albumen in the urine should be 
determined ; (2) that it should be eliminated from consideration 
when it depends upon extra-renal sources, sc., cystitis, vesical 
catarrh, hemorrhage, etc.; (3) that the equation between the 
extrication of albumen and the retention of urea should be 
fixed; (4) that it should be known whether the liver or the 
kidneys are most concerned in the production of urea; and 
(5) whether urea, or some of its derivatives, as carbonate of 
ammonia, is the real toxic agent. 
The observations of Litzman, as to the frequency of albumi- 
nuria in pregnancy, were quoted without being accepted, since 
Abeille,4 who followed him, reduced the proportion from 20 to 
10 per cent., and Elliott and Van Arsdale5 to 5 per cent. My 
own observations agree with the latter estimate. 
While treating thus fully of the relation borne by the kid- 
neys to eclampsia, authors upon puerperal diseases have not 
so much considered other modes of morbid action in the 
urinary organs or so fully developed the circumstances under 
which they arise, and the influence which they exert. Winkel 
and Joulin, the later representatives of the French and German 
Schools, hardly'discuss the subject. Dr. Barnes has an interest- 
Diseases, p. 106, Am. Ed. 
2 Med. Record, Vol. 7, p. 160. 
3 Transactions Lond. Obst. Soc., Yol. xii. 
4 Traite des Maladies a Urines Albnmineuses set Sucrees. 
6 New York Journal of Medicine, 1856. 6 
CiiambeblaijX : Relation of the 
ing lecture on Uraemic Excretory Fever, and Dr. Barker 
frequent casual allusions. 
On p. 73 lie says : “ Clinical evidence lias amply demonstrated 
that convulsions, the various phlegmasise incident to the puer- 
peral state, the pyeemic diathesis, septic absorption, and puer- 
peral fever, or any of these causes, may develop an albuminuria 
not previously existing, and lead to that aggregate of diseases 
of which albuminous urine is one symptom.” 
This compact statement might serve as the text for nearly 
all that I shall have to say this evening, and leads us to regret 
that the circumstances of publication excluded from a work, 
so replete in clinical interest, the chapters upon the thoracic, 
renal, and vesical conditions of child-bed, which, as we under- 
stand, had been partially prepared for it. 
Ilervieux,1 in his great work published in 1870, has very care- 
fully and fully discussed puerperal nephritis, both inflammatory 
and metastatic, and puerperal cystitis, but appears to attach little 
practical importance to them, since he declares them “incapable 
of diagnosis during life, and minor facts in the great category 
of puerperal poisoning.” 
In periodical literature, I have found in the third volume of 
the Archiv fur Gynaekologie, an article by Dr. lvaltenbach, 
of Freyburg, and in the second volume of the Transactions of the 
Berlin Obstetrical Society, a brief paper by Olshausen, of Ilalle, 
to which I am indebted for suggestions, and from which I may 
cite cases. 
My own attention was drawn to this subject by a case in 
private practice in 1873, and within the last two years, in my 
service at Charity Hospital, I have seen some cases whose clini- 
cal history and necroscopy have enforced the idea that the 
urinary tract in its whole length is especially liable to share 
in any and every morbid process which may follow child- 
birth, and that the diseases of the urinary tract thus excited 
have a very marked influence upon the issues of the puer- 
peral state, and sometimes assume the leading role among the 
causes of death. 
It was not until the preparation of this paper was far 
advanced that I saw for the first time that in two of his Lee- 
1 Traite Clinique et praticale des Maladies puerperales. Urinary Organs to Puerperal Diseases. 
7 
tures upon Puerperal Fever, Dr. Barnes had followed much 
the same line of thought that I had proposed to myself, and 
that some matters and forms of statement, which I had supposed 
somewhat original to myself, had been more fully traversed and 
better rendered by others. 
The compound word, genito-urinary, designed to indicate the 
intimate association of two sets of organs and functions, is com- 
monly used in reference to the male. But it is even more ap- 
propriate in the case of the female, since, morphologically,1 
the vagina and the bladder are both diverticula from the same 
pouch of the allantois, and the uterus and the ovaries are in 
much closer contiguity to the ureters and the kidneys than are 
the testes and the seminal vesicles, which are the corresponding 
organs of the male. 
The proper sexual organs of the male are all extra-abdominal, 
while those of the female are, for the most part, intra-abdomi- 
nal, and by a common peritoneal covering, and a common web 
of connective-tissue, are brought into closer relation to the 
urinary organs than in the case of the male. 
I am not aware that in the male there has been described 
anything analogous to the nerves connecting the uterus and 
the kidney, which Frankenhauser, of Jena, has demonstrated 
and figured, and which may be supposed to be concerned in 
the phenomena of hysteric urine almost, if not quite, peculiar 
to the female. 
Now, if in the male and the .non-pregnant female diseases 
and lesions of the superficial genital organs may conduct, either 
by the continuous mucous surface of their interior, or by the 
outer investment of connective-tissue, to acute, rapid, and fatal 
disease of the kidney, we can well understand how the contu- 
sions and lacerations, inevitable in the parturient process, may 
more readily and frequently lead to acute disease of the kid- 
ney in the system of the puerperal woman, increasingly pre- 
disposed, as it is, through the whole term of pregnancy to such 
a result. 
Three such cases I shall cite. The two first are from a re- 
port of Sir Charles Murchison to the Clinical Society of Lon- 
don. in Nov., 1875. 
1 Schroeder, Diseases of Female Sexual Organs, p. 568. 8 
Chambeklaih": Relation of the 
Case I.—A grocer’s clerk, aged 28, wlio had been regularly at his 
work up to the day before admission to the hospital, and was not 
known to be ailing in any other way than from a gonorrhoea, which 
had existed for some time, was received into the wards in a state of 
profound coma, varied by muttering delirium. There was no erup- 
tion on the skin—no sign of thoracic or visceral disease. He tlied 
in a few hours. Except some congestion of the base of both lungs 
and a few small patches of incipient pneumonia, there were no lesions 
except in the urinary organs. 
The entire length of the urinary tract, from the meatus urinarius 
to the pelves of both kidneys, showed a mucous surface deeply in- 
jected and covered with pus. Both ureters, and both renal pelves 
were filled with pus. Both kidneys were much enlarged, of very 
dark color, surface smooth and soft. Dark blood dripped from the 
surface of the section. 
Case II.—A woman of 25, domestic servant, had apparently been 
quite well on the day previous to her admission. She had made the 
trip from Paris to London in company with the cook of the same 
family, and had eaten a fair supper on arrival. Had been some- 
what restless during the night; in the morning had a convulsive fit, 
followed by profound unconsciousness, and was taken to the hospital, 
where she died on the third day, the symptoms continuing. Post- 
mortem examination showed the viscera of cranium, thorax, and 
abdomen in state of moderate liypersemia; but no structural lesion, 
except in urinary organs. Both kidneys were in the early stage of 
acute nephritis, large, smooth, and black from intense congestion. 
Bladder, ureters, and pelves contained abundant pus. Lining mem- 
brane of vagina, urethra, bladder, ureters, and pelves, intensely red. 
Case III.—(Prom Kaltenbaclx.) A woman of 35 was operated 
(colporrhaphy) for prolapse of anterior and posterior vaginal wall. 
Before operation urine was normal and no bladder symptoms were 
present. After operation temporary retention, single introduction 
of entirely new catheter; moderate or partial suppression ; the third 
day after the operation, smarting and burning in urination, in- 
creasing pain in bladder, vesical tenesmus after urination. Hypo- 
dermic injection of morphine, followed by relief of bladder symptoms, 
but then followed a dragging pain in the left groin, extending by the 
seventh day to the neighborhood of the kidney, which was extremely 
sensitive to pressure. The next day the pain was somewhat less, 
but the urine was cloudy and acid; specific gravity, 1020, precipitating 
flocculi of albumen ; under the microscope, pus, epithelium of blad- 
der in cohering flakes; small obovate cells, probably from the ure- 
ters ; in larger quantity elongated and spindle-shaped shrunken cells 
from the pelvis of the kidney. The patient gradually recovered. 
In the two first cases we have acute erysipelatous inflamma- 
tion travelling rapidly upward along the inner surface of the 
urinary passages to the kidney, setting up acute nephritis, 
marked by acute imemia, producing coma and death, solely as Urinary Organa to Puerperal Diseases. 
9 
a consequence of tlie kidney disease. In the third case we 
have traumatic inflammation exciting at first moderate cystitis, 
which was subdued, then travelling along the external surface 
of the urinary passages to the capsule of the kidney, as shown 
by the great sensitiveness to pressure, thence through the corti- 
cal to the tubular portion, as shown by the late appearance of 
the urinary disturbance and the proportions of different epi- 
thelia. 
T\\q predisposition of the parturient woman just stated, con- 
sists in that circle of changes by which she departs from the 
noil-pregnant state and returns to it in a period occupying 
about eleven months. 
In the following brief statement I shall sometimes use the 
statements of Dr. Barnes and sometimes those which were pre- 
pared before I had seen his language on the same subject. 
First are to be noted the changes in the blood. 
“ These probably begin very early. Convulsions with albu- 
minuria have been seen as early as the fifth month, before the 
uterus is large enough to exert any material pressure. The 
circulating fluid, the circulatory and the excretory apparatus, 
have a double work to do. They must suffice for two organ- 
isms. The blood must nourish both; it must purify itself of 
the degraded materials resulting from the molecular changes 
going on in both. 
For two reasons the rapidity of the circulation is increased. 
First, thevquality of the blood being lowered, it must be sent 
round more quickly in order to compensate for its lesser value. 
Secondly, there is the increased demand caused by the new 
organism. There is every reason to suppose that so powerful 
a local action cannot go on without affecting the chemical 
properties as well as the volume and the circulation of the 
blood. The pulse is quickened; the heart has to labor harder 
to maintain this increased rate of circulation. 
There is a physiological hypertrophy of the heart in preg- 
nancy, analogous to the physiological hypertrophy of the gravid 
womb.” (Larcher, Guillot, and others.) 
There are two other causes for hypertrophy of the heart; 
namely, the increased difficulty of circulating an impoverished 
fluid, which we see illustrated in the palpitations and cardiac 
tumult of so-called anaemia; and the increased power required 10 
Chambeelain : Relation of the 
on account of mechanical obstruction from intra-abdominal 
pressure. These two causes equally, though not in precisely 
the same form, subsist in chronic Bright’s disease, and serve 
to constitute a more or less remote parallel between the two 
conditions. 
Andral and Gavarret, quoted by Leishman (System of Mid- 
wifery, p. 221), state that at term the tibrine of the blood is 
increased by sixty-two per cent, of its normal amount, the 
water and phosphorized fat to an undetermined extent. The 
white corpuscles are also largely increased, while the red cor- 
puscles are diminished about nine per cent., and the albumen 
to a variable and undetermined extent. 
Thus the maternal blood is in a condition of imperfect oxida- 
tion. IIow this may occur, we can see when we consider that, 
in the first place, the mother’s respiratory capacity is decreased 
by the encroachment of the abdomen on the thorax; and, in 
the second, that, in the comparative quiet and seclusion which 
the civilized woman observes in the later months of gestation, 
the respiratory process is not quickened by exercise; and the 
air respired, being in-door air, is itself in a condition of suboxy- 
genation. At the same time the red corpuscles give up oxygen 
in the placenta to supply the aeration of the foetal blood. Thus, 
by diminished receipt and increased expenditure, the quota of 
oxygen is drawn down. 
Here also the measure of divergence from the normal state is 
to be found in the sum of the opposite departures. Thus, if 
there be an equation between the red and the white corpuscles 
in the normal state, the inequality of the disturbed state is found 
by adding together the deficiency of the red and the excess of 
the white; and the vitality of any particular quantum of the 
blood will be further lownred by the addition of several equiva- 
lents of water. The red corpuscles, or their haemoglobin, are 
the only carriers of oxygen, which is the factor of normal met- 
amorphosis by combustion ; and in the insufficient supply of it 
the carbonaceous elements in circulation and in tissue are prone 
to that rearrangement which we call fatty degeneration, for fat 
is one form of hydrocarbon. 
It is understood that in all zymotic processes there is an 
indefinite multiplication of parasitic life in all the tissues. And 
it is the opinion of some that the mischief of the microphytes Urinary Organs to Puerperal Diseases. 
11 
or mycrozymes consists in the energy with which these evolving 
forms, in their nascent stage, abstract oxygen from the weak- 
ening vitality of the organism which harbors them. 
Have we here a solution of the rapidity with which fatty 
metamorphosis invades the organs of the parturient woman ? 
I-t will be seen that the changes of the kidney, of which we are 
about to speak, fall in this line. 
Furthermore, as all retrogressive changes end in solution, 
so they begin in infiltration1—a condition to which the plethora 
and liydrsemia above noted alike conduce. The attenuated 
quality and the increased quantity alike favor capillary trans- 
udation. Again, the increased amount of fibrin not only 
favors coagnlation in the transuded fiuid, but within the vessels 
large and small. 
Thus these three states of hyperinosis, hydraemia and oligo- 
erythrohsemia, or deficiency of haemoglobin, condition a cloud 
of accidents more or less imminent over the parturient woman. 
These are: heart clot; capillary infarction; subserous he- 
morrhages ; general oedema ; specially cerebral oedema, embar- 
rassing the nutrition of the brain by compression of intracranial 
vessels; and infiltration of those complex excretory organs, the 
liver and the kidneys. 
This hepatic and renal oedema further increases the tendency 
to fatty metamorphosis, not only by solution, but by extrusion 
of blood from compression, as in the brain. 
It is not in place now to notice how all these blood changes 
have for a final cause the development of the ovum, nor to 
remark how seldom the cloud breaks in a rain of accidents. 
More pertinent is it to note how closely these conditions corre- 
spond with those of Bright’s disease, and how, in the excep- 
tional puerperal cases, they conduce, as they do in Bright’s 
disease, to headache, amaurosis, eclampsia, pericarditis, pleu- 
risy, and pneumonia. 
If, now, to these causes of disease we add another in the shape 
of direct pressure from the distended uterus upon the emulgent 
veins of the kidney, we have the cumulative effect on the cir- 
culation of the organ in venous hypersemia of the Malpighian 
tufts, capillary distention and stasis, effusion of liquor san- 
guinis and fibrine into the inter-tubular structure, and into the 
1 llindlleisch, Pathological Histology, §§ 7-16, passim. 12 
Chamberlain : Relation of the 
tubules themselves, forming within them a fibrinous coagnlmn, 
a hyaline cast. Upon its surface the loosened epithelium, de- 
tached by a still continuous transudation, may cohere, making 
it an epithelial cast. If it be awhile retarded in its progress 
through the convoluted tubule, the devitalized and sodden epithe- 
lium breaks up into its germinal granular matter, and we have 
a granular cast. If it be still longer delayed, the retrograde 
process in the epithelium goes still further, and the granular 
matter is resolved into fat globules, giving us a fatty cast. If 
upon this train, so prepared, there fall a spark of peripheric 
irritation, of septic or specific poison, we have a fulminant 
eclampsia or icterus. Otherwise, nature attempts her own 
relief by setting up premature delivery, and, subsequent to 
delivery, unloads infarcted liver, kidneys, and intestinal glands 
by an excretory uraemic fever. Such a case I have fully 
reported in the sixth volume of the Medical Record, p. 265, 
and will here add other illustrations: 
Case IV.*— Mrs. H., aged 35, was admitted to hospital in the sixth 
month of her fifth pregnancy, moribund. Was in good health until 
a fortnight before admission. Thence symptoms developed as follows: 
Mental depression, gastric oppression, vomiting, progressive jaundice, 
constipation, hsematemesis, stupor alternating with violent delirium, 
premature delivery of twins, coma, death. Autopsy thirty-one hours 
after. Skin and viscera icterized. Lungs moderately congested and 
cedematous. Many small ecchymoses beneath pericardium, and cap- 
sules of liver and spleen, and through the substance of liver, which 
was very much reduced in size. On scraping the surface of section 
a large amount of fatty matter remained on the knife. The cells on 
the periphery of the lobules were almost completely broken down; 
towards the interior were enlarged, filled, some with oil globules, some 
with fatty matter. Kidneys : A very copious exudation occupied the 
uriniferous tubules, and the epithelium was affected in the same way, 
as were some of the cells of the liver, i. e., some of the cells were 
swelled, dense, opaque, granular; some extremely fatty; some had 
broken down and disappeared. 
Case V.—Mrs. M., set. 22, near the end of first pregnancy ; was 
always in good health. Became suddenly ill on the 20th of October, 
with symptoms at first referred to the uterus. Admitted to hospital 
on the evening of the 22d, premature labor on the morning of the 
24th ; death on the same evening; illness three and one-lialf days. 
At the autopsy : Uterus appendages and peritoneum were found to be 
all normal for the parturient state, and no morbid anatomy was found 
anywhere except in the liver and kidneys. In the latter the tubules 
* From Grainger Stewart on Bright’s Diseases. Urinary Organs to Puerperal Diseases. 
13 
were distended, opaque, gorged ; their epithelial cells full of granular 
matter and fatty matter, very easily breaking down; the pressure of 
a light-covering glass sufficing to reduce the tube casts to a fine 
debris. The stroma also contained numerous fatty granules, arranged 
in tubes and lines, as if situated in the connective-tissue corpuscles. 
Similar changes in the liver were less advanced. 
Case VI. (Abridged from report by Dr. Oppenheimer, of Charity 
Hospital.)—Ellen O’Brien, set. 29. Delivered Decentber 23d, after 
natural labor of nine hours. Uterus contracted well. Immediately 
after delivery lost control over sphincters—an almost continuous flow 
from the urethra and anus. Urine acid, sp. gr. 1016, abundantly 
laden with pus, casts and epithelium from bladder, pelves and tubules. 
Urine after filtration showed one-fourth albumen. Temperature 
103|- on the second day, thenceforward 99—101-J-; in articulo, 102. 
Diarrhoea incontrollable; tongue moist and slightly furred. Abdo- 
men never tympanitic or painful; lochia normal. Conscious and 
uncomplaining until three days before death, when she became stupid. 
Pulse and heart action very feeble. Death, from heart failure, seven- 
teen days after delivery. 
JBy autopsy.—Viscera of thorax all normal; uterus, appendages, 
vagina, cervix, and peritoneum normal. 
Liver large, flabby, pale yellow ; section showed several infarcti in 
yellow stage. 
Kidneys large, soft capsule loosened ; both pelves showed pyelitis— 
most marked in right, parenchymatous nephritis; bladder normal; 
small intestines normal; colon in state of catarrhal inflammation 
throughout—most marked at the caecum, where were small superficial 
ulcerations. 
A fourth case speaks for the hyperinosis of the parturient 
woman. v 
Case VII.—Lizzie O’Neill, set. 32, was delivered December 19, 
1875, after a short and easy labor of an hour and a half. All the 
sequelae were apparently normal, and she was up and dressed on the 
sixth day for Christmas. On the morning of the 2d of January she 
went to the water-closet and returned gasping, cyanotic; expiring in 
a few moments. 
The heart was found to be somewhat fatty. In the first divisions 
of the left pulmonary artery was an old and partially decolorized clot, 
overlapped by a soft recent clot two and one-half inches long in the 
main trunk, in diameter as large as a wooden pencil. The liver was 
soft and friable, weighing 6 lbs. 7 oz. Kidneys somewhat increased 
in size, cortex swollen, tubules yellowish. Both pelves and ureters 
contained puriform fluid ; left ureter was dilated, and there was 
marked cystitis. Uterus and appendages all normal. 
I regard these cases as not less interesting by their dissimi- 
larity than by their essential identity. 14 
Chamberlain' : Relation of the 
Four women, so far as known, previously healthy, succumbing 
to the blood changes of pregnancy, without symptom or lesion 
of the uterine organs; one by acute fatty metamorphosis (I use 
this word rather than “ degenerationsince the latter would 
seem to imply a slower process) of the liver, plus a minor grade 
of the same process in the kidneys; another by acute fatty 
metamorphosis of the kidney, plus a minor grade of the same 
process in the liver; a third by recent cedematous infiltration 
of the kidney and fatty metamorphosis of: the same, plus similar 
oedema and catarrh of the overlying intestine; and the fourth 
hv a morbidly coagulable blood, plus a fatty heart, liver and 
kidneys. Like the aspect of the old Parcse, “Facies non una, 
nec diversa tamen, sed quales dec.et esse sororum ” 
According to Frerichs and Murchison, more than half of the 
cases of acute yellow atrophy of the liver occur in women in the 
later months of pregnancy—almost always inducing miscar- 
riage. 
The cases thus far cited were free from every uterine com- 
plication ; they were in nowise influenced by accidents of the 
puerperal process, and they therefore show the organic pre- 
disposition in the pregnant woman to diseases of the lddne}7. 
This predisposition is farther increased by changes in the 
tissues corresponding to those in the blood. 
The 11011-pregnant uterus with its appendages weighs perhaps 
five ounces; the same, containing the matured ovum, not less 
than fifteen pounds ; the same, four weeks later, from seven to 
ten ounces. To provide for the evolution of the uterus, the 
extrusion of the ovum and the involution of the uterus, requires 
a very signal development of the muscular and vascular tissues. 
The plates of Cruveilhier and Mascagni demonstrate a mass 
of venous convolutions enveloping the uterus in such abundance 
that, when fully injected, they constitute a nearly complete 
sheath. The same description may apply to the lymphatic 
vessels in the subserous connective tissue. Clusters of lympha- 
tic ganglia, previously unrecognizable, encircle the cervical zone 
of the uterus and the inner portion of the Fallopian tubes. 
So fully equipped, and so apt for its coming work is the ab- 
sorbent system that women near term are especially liable to all 
infectious diseases. Dr. Braxton Hicks, in the 12th volume of 
the Obstetrical Society’s Transactions, publishes 37 cases of Urinary Organs to Puerperal Diseases. 
15 
puerperal scarlet fever (27 fatal), commencing either shortly 
before labor or within five days after, thus showing either ex- 
traordinarily shortened incubation or ante-parturient absorp- 
tion. Also similar observations with regard to diphtheria and 
erysipelas. Dr. Barnes says it is not uncommon for pregnant 
women to have a second attack of scarlatina. Dr. Haussmann, 
whose studies in this direction have for a long time been in high 
esteem, in the last number of the Berlin Obstetrical Journal 
says that the vaginal secretions of at least 11 per cent, of 
women near term show the presence of bacteria. 
We may now consider how the process of parturition affects 
the urinary organs. By this process, in the course of a few 
hours the woman suffers a loss of substance, and a diversion of 
the circulation about equal to that involved in the amputation 
of the thigh at its middle third, often also combined with an 
equivalent amount of pain and nervous shock, and in addition 
a degree of muscular effort without a parallel. 
The tense contractions of all the abdominal muscles, includ- 
ing the diaphragm, the closed glottis, the compressed but ex- 
cited heart, and the maximum pressure on the emulgent veins, 
are all factors in inducing a marked—fortunately, for the most 
part—a transient congestion of the kidney. 
But, at this stage, the lower portion of the urinary organs 
becomes exposed to great hazard. For days before labor, the 
low lying head often so flattens the bladder against the pubic 
arch as to prevent its full evacuation, and the residual urine be- 
coming alkaline, disorganizes the mucous membrane. During 
labor, the contusion and stretching of the anterior wall of the 
vagina, determine all grades of accidents from sphacelus to 
catarrh. Some degree of morbid action from these causes is 
seen in the majority of cases. A single case may serve as an 
illustration. 
Case YIII.—A lady, the patient of a medical friend, believed to 
be at the end of her term, and suffering from pains in the hypogas- 
trium, with frequent micturition, summoned her physician. He found 
the head low down, the cervix obliterated, the os distensible. For 
a week he waited on a labor which did not begin. Then, being 
obliged to leave, he passed the case to me. I saw her first when 
labor was in progress. It was normal and easy. Eight hours after, 
I found her suffering from retention with much tenesmus. The urine 
drawn by catheter contained abundantly epithelium of the bladder 16 
Chamberlain : Relation of the 
and pus. Acute cystitis was developed, but in a few days yielded to 
washings of warm salt water and anodynes. 
This form of cystitis is very common, usually slight in its 
symptoms and tending to spontaneous recovery. 1 believe that 
I have very often overlooked it; confounding its subjective 
symptoms with after-pains; its tender hypogastric tumor with 
a sensitive uterus ; its troubled urine with urine contaminated 
by lochial admixture or vaginal secretions. Karely is there a 
vesical paralysis permitting a painless hyperdistention of the 
bladder, to such an extent that we might suppose meteorism 
was present, did not the fluctuating tumor, soft but dull on per- 
cussion, and the stillicidium urinse, but especially the catheter, 
readily conduct us to the true diagnosis. 
It is the opinion of the Germans, as stated by Kaltenbach 
and Olshausen, that bladder-catarrh or cystitis is often caused, 
where it would not otherwise exist, by the introduction of the 
catheter. They declare that danger from this source is three- 
fold : 1st. The irritation caused by forcing a catheter through 
the swollen urethra. 2d. The carrying of infectious matter, 
s.c. lochial discharge, vaginal secretion, puis from vaginal lace- 
ration, or unclean matter accidentally remaining in the cathe- 
ter, into the bladder; and 3d, The introduction of air too often 
charged with parasitic spores. 
To guard against these contingencies, which they declare 
they have occasionally seen to be very mischievous, they have 
made the rule, in some of their maternity hospitals, that the 
catheter shall never be introduced under cover ; that the orifice 
of the urethra shall be fully exposed to view, and previously 
wiped with a lock of cotton wetted in some mild antiseptic 
solution; and that only an instrument, new or capable of being 
disinfected by fire, shall be used. For lack of these precau- 
tions they declare that a benign catarrh may become or be made 
an erysipelatous or a diphtheritic cystitis, occupying the entire 
bladder, ascending the ureters, and invading the kidney with 
fatal results. The following case, which fell under my own 
observation, supports, in part, this declaration. 
Case VIII.—M. M., 28 years of age, an habitue of the Island and 
a hard character, was delivered by me with forceps of her child, weigh- 
ing eleven and one-half pounds, naked ! It was dead, very much de- Urinary Organs to Puerperal Diseases. 
17 
composed, the skin of the arms and hack being wiped off by the towel 
used in drying it. The discharge which followed extrication of pla- 
centa was foetid, no hemorrhage. The perineum was lacerated'nearly 
to the sphincter, not involving it. 
The following day—Pulse 120; temp. 101-2-°-103°. Much tym- 
panitis ; no tenderness of abdomen; lochia offensive; water drawn 
and vagina syringed, ter-in-die, with carbolic solution. 
Second day—Temp. 103°-103^°; pulse 120. Dark slough, forming 
on the perineal wound. Constant disinfection employed. 
Third day, morning—Pulse 94; temp. 101°. Abdomen softer; 
patient says she is better. Evening, temp. 102°; pulse 130. 
Fourth day—Pulse 126; temp. 101°. Patient is much worse. 
Abdomen very much distended, but there is no pain in it, and it may 
be freely manipulated without tenderness. Patient grew rapidly 
worse, and died exactly four days after deliver}7. 
Autopsy, twelve hours after death.—Abdomen, upper portion, 
tympanitic ; dull on percussion over pubis ; perineal wound sloughy, 
covered with a fetid discharge. Thorax: Recent pleurisy, with 
slight amount of fibrinous exudation in lower third of right lung. 
Also a patch on the outer surface of left lung, about midway. 
Underlying this pleuritis was a thin stratum of acute pneumonia, 
averaging six lines in depth. Remainder of lung somewhat congested, 
with some muco-pus in bronchi. Heart shows a few small superfi- 
cial hemorrhages ; walls contracted, cavities empty, valves and vessels 
normal. Abdomen: Cavity of pelvis contained a little thin serous 
and purulent fluid with fiocculi of fibrine. Surface of peritoneum : 
transparency lost; no adhesions; a yellowish substance may be 
scraped from the surface. Intestines distended with gas; uterus 
reaches fully to umbilicus. Liver: Much enlarged (5 lbs. 10 ounces), 
flabby, very friable, deeply congested and oedematous; a moderate 
amount of old cirrhosis ; spleen enlarged, diffluent. Kidneys : Much 
enlarged; onfe weighing thirteen ounces, the other ten and one-half 
ounces, or nearly two and one-half times their normal weight; capsule 
loose and marked with inflammatory mottling. Surface of kidney 
shows lobulated swellings (Malpighian bodies), sulci depressed and pale 
yellow (fatty degeneration of intertubular connective tissue) ; the 
whole surface shows minute puriform points, scattered miliary hemor- 
rhages, deep redness of the swollen and prominent portions of surface. 
By section: Tissue soft, cortical substance twice as thick as normal, 
and, with the pyramids, is the seat of an almost general, acute, suppur- 
ative nephritis. The whole mucous membrane of renal pelves shows 
intense pyelitis with large patches of hemorrhage in substance of mem- 
brane. Ureters: Moderately thickened and dilated; the mucous 
membrane in the same condition as that of pelves. Bladder : Its walls 
hypertrophied, capacity much increased; mucous membrane much 
thickened, rough, villous, at fundus filled with miliary hemorrhages ; 
prominences of trabeculae covered with diphtheritic membrane. Ute- 
rus and appendages : Womb, twelve inches long, eight inches across 
fundus ; walls, three-quarters of an inch thick and flabby ; in poste- 18 
Chamberlain : Relation of the 
rior wall several small subperitoneal fibroids ; surface of cavity cov- 
ered with shaggy coagula, at placental site; and throughout with a 
thick diphtheritic membrane, which superficially is disorganized and 
gangrenous, and extends into the substance of the uterine wall and 
sinuses. The cervix is slightly nicked at the right lip of os. Summits 
of vaginal rugae, covered with diphtheritic membrane, still intact and 
firmly united with structure of mucous membrane. Stomach and 
intestines were normal. (Maxwell.) 
This unfortunate woman, containing a putrid foetus, and 
therefore septicsemic ante-partum, might have died if all her 
urinary organs had been sound, but, as I read the autopsy, it 
seems that the morbid process was farther advanced in the urin- 
ary organs than elsewhere, that the thoracic lesions were prob- 
ably consecutive to the renal trouble, and that death, when it 
occurred, was determined by the condition of the kidneys. 
Diplitlieritis may have extended to the bladder by contiguity 
from the anterior wall of the vagina, or it may have been trans- 
ferred by vaginal secretions adhering to the catheter. 
In view of the fact that although the secretions of the diph- 
theritic fauces are constantly falling through the oesophagus, yet, 
so far as I know, we rarely have diphtherite of the stomach, 
it would appear more probable that the extension was by 
contiguity rather than by transfer. 
It will be noted that the diphtherite extended through the 
entire genital track as far as the oviducts, aud through the 
entire urinary tract as far as the ureters. Beyond these points 
we have suppurative salpingitis and ovaritis ; suppurative 
ureteritis and nephritis. That, in both cases, this was due to 
the same proximate cause, i.e., swelling of the muscular coat of 
uterus and bladder, which occluded the distal orifices of these 
tubes, appears probable from the immense oedema of both kid- 
neys and ovaries, both more than double their normal size, and 
the dilated ureters and loosened capsule. 
At this point the observations of Zalesky become very 
interesting. lie removed the kidneys from a certain num- 
ber of animals, and in an equal number of the same animals 
he tied the ureters, at their entrance to the bladder. The 
latter died promptly from uraemic coma, and from the sur- 
face of the peritoneum and pleura he could “ scrape a yel- 
lowish substance which proved to be salts of urea ; ” an appar- 
ently similar deposit was (as above stated) found upon the Urinary Organs to Puerperal Diseases. 
19 
peritoneum in this case. On the other hand, the animals, 
from which the kidneys were removed, lived a much longer 
time, becoming uraemic very slowly. These experiments having 
been repeated and confirmed by Oppler, Schottin, and Peris, 
have been accepted as showing that the urea is not secreted 
by the kidney from the blood, but formed in the kidney. The 
observations of Cyon and Meissner show that it is also formed 
in the liver. 
The two cases last cited may be taken respectively for ex- 
amples, if not types, of inflammation of the mucous and of the 
muscular coats of the bladder. I have a third observation which 
I wfill not cite at length, in which a cellulitis of the right broad 
ligament, swelling largely, slowly developed albuminuria; cells 
supposed to represent the ureter being first observed ; the hvpo- 
gastrium then became very sensitive to pressure, and finally 
vesical epithelium and pus appeared abundantly in the urine. 
Inferentially, we have in this case, periuteritis, followed by 
pericystitis striking through all the coats, and becoming a 
general cystitis, enduring until the cellulitis terminated in re- 
covery. 
This matter of the occlusion of the ureters, whether by 
thickening of the muscularis of the bladder, or by lymphan- 
gitic swellings, seems to me of much interest in view of 
our recent discussion of lacerations of the cervix. By every 
such laceration, and particularly by such as extend into vaginal 
tissue, the web of greatly developed lymph spaces and lymph 
canals is opened, and freer entry of whatever is morbid in 
vaginal secretions, and of the products of suppuration, is pro- 
moted. If now we remember that the cervix is in apposition 
with the middle portion of the base line of the triangle of 
Lieutard, connecting the vesical orifices of the two ureters, we can 
see how readily traumatic swelling, in proportion to its amount, 
will infringe on the calibre of the ureter. 
Having thus considered the conditions subsisting before 
birth, and the contingencies connected with birth, we may now 
look at those which arise after birth. After the middle of 
pregnancy the uterus escapes from the true pelvis, and expands 
under only such moderate pressure as exists in the large cavity 
of the abdomen. That this expansion sometimes effects a mis- 
chievous coarctation of the renal emulgent veins, is on all sides 20 
Chamberlain : Relation of the 
conceded, bnt the blood and lymph-moving canals of the uterus 
itself are in good measure shielded. After birth the conditions 
are somewhat changed. The uterus descends into the true 
pelvis as far and as fast as its reduced size will allow. In all 
the autopsies of women dying in the first week after delivery, 
the transverse diameter of the fundus is greater than the trans- 
verse diameter of the pelvic brim, and the longitudinal di- 
ameter is largely in excess of the depth of the true pelvis. 
Thus the womb remains resting upon the promontory of the 
sacrum, and the efferent trunks of its blood and lymph vessels 
occupy the half-enclosed canal between the promontory and 
the inner border of the psoas muscle (see Hunter’s plate). In 
the condition of tonic contraction, the globo-cylindrical form 
of the womb wdll leave this not essentially constricted. But 
the condition of firm contraction is not persistent, and is inter- 
rupted by many physiological causes, and by all morbid pro- 
cesses. When flaccid, the uterus must overlie this canal, and at 
least, by its weight, oppress the efferent vessels, and the ureters, 
which lie parallel with them, and in the same web of connec- 
tive tissue. Thus, the pelvic circulation and urination will be 
correspondingly impeded. Doubtless, this condition is often 
very much aggravated by the injudicious employment of com- 
presses and binders, by which, with the purpose of preventing 
concealed hemorrhage, we crowd the womb hard down on the 
pelvic brim. Thus, ordinarily, for three days the collapsed 
rectum cannot deliver the contents of the colon, and the hamp- 
ered bladder must make partial and unsymmetrical efforts to 
expel its contents—limited in amount by the coarctation of 
the ureters. I have repeatedly observed in the reports of 
autopsies that, accurately at the margin of the brim, the 
ureter, of normal size below, was upward to the pelvis of the 
kidney, dilated to twice or three times its normal calibre. 
Kaltenbach makes also this observation : 
Case IX.—S. B., twenty years; primipara. Urine, in pregnancy, 
normal; after delivery, endometritis ; diphtheritis of slight lacerations 
in mucous membrane of vulva, followed by diffuse parametritis and 
peritonitis ; died at the fifteenth day post-partum. In the last three 
days of life, the urine, which up to that time had been normal, be- 
came fetid, turbid; reaction alkaline. It contained albumen in large 
quantity ; and of elementary forms—pus, epithelium of the various 
passages; various detritus; ammoniaco-magnesian phosphates. Post- TJrinary Organs to Puerperal Diseases. 
21 
mortem gave extensive peritonitis, diphtheritis of the placental site, 
patches of diphtheritic membrane as large as a bean upon the mucous 
membrane; the diphtheritis of external genitals was retiring. In the 
parametrium, to left of the uterus, cloudy swelling of the connective 
tissue ; the left ureter dilated to double its size ; left kidney enlarged ; 
after removal of its capsule, the cortical substance in some places 
yellow, in some gray, marked by reddened streaks and many super- 
ficial hemorrhagic infarctions, also numerous small patches of soften- 
ing on the periphery, which on section were seen to penetrate like 
wedges. In the almost normal right kidney only a solitary group of 
puriform points ; mucous membrane of the bladder strongly injected, 
ecehymosed in several places, and upon it patches of false membrane, 
which, when removed, showed loss of substance beneath. 
Here we have, as a consequence of diphtheritis about the 
vulva and in the endometrium, the pelvic lymph spaces laid 
open to the entrance of septic fluid ; lymphangitis of the left 
side causing occlusion of left ureter, which, in turn, produced 
oedema and rapid fatty metamorphosis of left kidney; the right 
side remaining exempt. 
Case X.—The same observer also reports a very interesting case 
in which, after difficult labor from contracted pelvic outlet, perime- 
tritis and peritonitis followed, which, by the tenth day post-partum, 
had set up a secondary nephritis; the causal phlegmasia then 
seemed to decline and pass away, but the nephritis continued, and in 
the fifth week post-partum, the patient died from uraemic coma. 
Autopsy showed of the early changes in perimetrium and peritone- 
um, only a slight swelling in the right parametrium remaining; ab- 
scesses in both ovaries; both kidneys enlarged; cortical substance 
thickened and discolored, and in the right kidney upon surface and 
through the substance numerous little abscesses, from the size of a 
pin’s head to that of a pea. This case is clearly to be interpreted as 
metastatic suppurative nephritis—the fatal out-put of a transient 
peritonitis and cellulitis. 
A case from the IIosj3ital Records, in which, unfortunately, 
no determination of the quantity and quality of the urine 
seems to have been made for several days after labor, appears 
nevertheless very fully to illustrate the same process of uraemia 
from occluded ureters. 
Case XI.—D. G., 20 years, pvimipara; labor normal; thirteen 
hours ; living child ; sequelae normal ; forty-eight hours after, pulse 
82, temperature, 101 ; twelve hours later, tenderness in liypogas- 
trium and left iliac fossa; variable fever; pulse, 118. Tempera- 
ture, 104R Chamberlain : Relation of the 
22 
4th day.—Same symptoms ; weakness ; deafness (in this case the 
first symptoms of uraemia). Details of urine lacking. 
5th day.—Epigastric pain; later, general abdominal pain. 
6th day.—Vomiting; weakness ; epigastric pain. 
7th day.—General abdominal pain; great weakness; excitement. 
8th day.—Less pain ; great weakness. 
9th day.—Less pain; great weakness; bowels regular to date; 
urine not noted. 
10th day.—Less pain; great weakness; urination scanty, albumi- 
nous. 
11th day.—Became suddenly delirious; comatose; suppression; 
four ounces of densely albuminous urine in bladder; convulsive 
twitching. 
12tli day.—Coma, Death. 
Autopsy.—Brain, lungs, heart, liver, spleen, nearly normal. Kid- 
neys large ; capsule loose ; cortex thickened, swollen. Acute paren- 
chymatous and tubular nephritis. Both pelves dilated. Both ure- 
ters dilated ; right five times normal size. Both contain pus (ma- 
croscopic), probably tubular epithelium. 
Localized peritonitis, agglutinating the fundus of the uterus, a 
few loops of intestine, the fundus of the bladder, the broad liga- 
ments, and retro-peritoneal connective tissue, and muscular coat of 
bladder. The interior of bladder and uterus, the cervix and vagina 
nearly normal. 
This patient clearly died of uraemia. By the great weak- 
ness, the disturbance of the senses, the constant nausea, deliri- 
um, convulsions and coma, the case is distinguished from simple 
puerperal peritonitis, and from puerperal septicaemia. 
This uraemia was consecutive to a localized inflammation, 
involving fundus of uterus, bladder, etc., and by swelling oc- 
cluding the ureters. Hence the kidneys became cedematous, 
and nephritis with suppression followed. 
I am entirely of opinion that the converse relation also exists 
—that is, that the renal disease sometimes stands as the cause of 
the peritonitis, for I have a recollection of two young primi- 
parous women, seen for the first time when in labor, both very 
anasarcous, both in convulsions (which continued with de- 
creasing frequency for some days after labor), and both, when 
apparently convalescent from the uraemia, developing an un- 
expected peritonitis. 
Compare the facts that peritonitis rather often arises in the 
course of Bright’s disease, and the observation of Zalesky, 
before quoted, that after tying the ureters, the salts of urea 
accumulate on the surface of the peritoneum. Urinary Organs to Puerperal Diseases. 
23 
I have thus presented cases of simple erysipelatous, diphthe- 
ritic, lyinpliangitic, pytemic, metastatic cystitis and nephritis. 
It may be thought that from a wide search, only such as suited 
my present purpose have been collated. Such is not the case. 
I have carefully reviewed the history of obstetrics in Charity 
Hospital for several years, and endeavored to trace the autopsies 
of women who died within six wreeks after delivery, with an 
increasing conviction that the urinary organs in fatal puerperal 
cases are almost uniformly diseased, and in many cases much 
more significantly than the uterine organs. 
The autopsies of the Hospital are made by the curators ap- 
pointed for that purpose, and the custom is to summarize the lead- 
ing facts in the caption or heading of the record. Many of these 
records in recent years have been made by Dr. Maxwell, whose 
pathological attainments and discriminate modes of statement 
are highly appreciated by all who know him. From these re- 
cords I have obtained a series of cases standing nearly consecutive 
in the autopsies of puerperal women. These headings of casesj 
with occasionally a word of explanation from the text, read— 
Case I.—Pelvic abscess ; acute endometritis ; acute suppura- 
tive nephritis; thrombosis of uterine veins. 
Case II.—Diphtheritic endometritis ; dilated ureters and 
pelves; pyelitis; acute interstitial suppurative nephritis; cystitis. 
Case III.—Puerperal septicaemia; advanced parenchymatous 
degeneration of kidneys. 
Case IY^—Uraemia seventh month of pregnancy; parenchy- 
matous degeneration of kidneys. 
Case Y.—Puerperal convulsions; parenchymatous nephritis. 
Case YI.—Diphtheritic cystitis, endometritis; ureteritis and 
pyelitis; acute suppurative interstitial nephritis; pleuritis ; and 
pleurogenous pneumonia. 
Case YI1.—Puerperal metritis; gangrene of cervix; kidneys 
enlarged, pale, fatty. 
Case Yill.—Pelvic cellulitis and peritonitis; kidneys normal 
size, generally congested ; pelves and ureters somewhat dilated. 
Case IX.—Puerperal pyelo-nephritis; iobular pneumonia; 
kidneys slightly enlarged ; capsule easily stripped over the sur- 
face of each ; several swollen prominences dotted with yellow 
points ; acute interstitial nephritis; ureters above pelvic brim 
distended to 2£ times normal size, and are the seat of intense 24 
Chamberlain : Relation of the 
ureteritis. The tissues surrounding them are oedematous; uterus, 
ovaries and appendages normal. 
Case X.—Pyelo-nephritis, ureteritis and cystitis; dilated pel- 
ves and ureters ; cysts of ovary. 
Case XI.-—Diphtheritic endometritis ; pelvic abscess ; hemor- 
rhagic cystitis and pyelitis; suppurative interstitial nephritis of 
left kidney ; acute parenchymatous nephritis of right kidney ; 
entero-colitis; emboli infarcti of spleen and left kidney. 
Case XII.—Puerperal peritonitis ; double circumscribed 
pleuritis. This patient died in urjemic coma, convulsions con- 
tinuing after delivery ; suppression of urine ; symptoms of pe- 
ritonitis developing twenty-four hours before death; no abnor- 
mal appearances in any portion of the urinary organs recognized 
at autopsy. 
Case XIII.—Double pleuritis; double hypostatic pneumo- 
nia; perimetritis; localized diphtheritic puerperal endometritis; 
diphtheritic cystitis ; dilated pelvis and ureter of right kidney. 
Case XIV.—Puerperal peritonitis; acute interstitial nephritis; 
diphtheritic cystitis, ureteritis and pyelitis ; double pleuritis. 
Case XV.—Puerperal peritonitis; double pleuritis; parenchy- 
matous degeneration of kidneys; pyelitis; ureters markedly 
dilated, that of the right side about seven times the normal size. 
Case XVI.—Puerperal endometritis ; slight lobular pneumo- 
nia ; suppurative interstitial nephritis. 
Case XVII.—Puerperal metritis ; abscesses in uterine wall; 
peritonitis; cystitis; hemorrhagic pyelitis; localized acute in- 
terstitial nephritis; suppurative arthritis of knee-joint; pyaemia. 
CaseXVIII.—Acute parenchymatous nephritis; cystitis ; cer- 
vical endometritis, puerperal. 
Case XIX.—Localized pelvic peritonitis ; pelvic abscess ; pa- 
renchymatous nephritis. 
Case XX.—Thrombosis and embolism of left pulmonary 
artery. 
Case XXI.—Puerperal peritonitis; acute interstitial nephritis. 
Of these twenty-one cases, nineteen showed distinct morbid 
process in the kidneys, eight showed distinct morbid process in 
the bladder, eleven showed distinct morbid process in the 
interior of uterus. In nine, who had distinct lesions of the 
kidneys, no distinct lesion of the uterus was recorded. In all 
who had distinct lesions of the uterus, distinct lesions of the Urinary Organs to Puerperal Diseases. 
25 
kidneys were also recorded. Wherever there was diphtheritic 
inflammation of the bladder or intense lymphangitis there was 
dilatation of the ureters. The average age of the patients was 
between twenty-three and twenty-four, and therefore the pre- 
sumption of Bright’s disease preceding pregnancy was small. 
During my last term of service, which continued for six 
months, and comprised about 275 deliveries, I made a diag- 
nosis of greater or less kidney disease in thirteen cases which 
terminated in recovery. The diagnosis was based upon pain 
in the lumbar region, increased by pressure, accompanied by 
pus, epithelium or casts in the urine. In most of these cases 
there was also a degree of cystitis, sometimes apparently con- 
secutive to the nephritis, descending along the ureters to the 
bladder, and sometimes primary and followed by nephritis 
ascendens. 
Finally, I venture to formulate the following conclusions: 
1. Acute erysipelatous inflammation of the external genitals 
may ascend to the kidney, sometimes by the inner and some- 
times by the outer surface of the urinary tract. 
2. The blood of the parturient woman, saturated with fibrine 
and poor in haemoglobin, predisposes her to disease of the 
excretory organs—the kidneys and liver. With a sufficient 
exciting cause acute fatty metamorphosis takes place. Fatal 
cases only are demonstrable, but minor grades of the process 
are probably not unfrequent. 
3. Lymphangitis limited (cellulitis), and lymphangitis diffuse 
may mechanically induce acute oedema of the kidney in the 
puerperal woman by obstruction of the ureter. 
Diphtheritic or other inflammation involving the muscular 
coat of the bladder produces the same result. 
However excited, oedema of the kidney tends to rapid de- 
generation both of the tubular and inter-tubular structure. 
4. Diffuse lymphangitis, commonly attending septic pro- 
cesses, by rapid destruction of the haemoglobin, tends to the 
same result, while ulcerative endometritis, suppurative me- 
trophlebitis and cellulitis, tending to pyaemia, not unfrequently 
are productive of metastatic suppurative nephritis. 
5. The condition known as uraemia tends to develop perito- 
nitis in parturient women. 
Should the profession confirm and extend these observations, 26 
Ciiambeklahst: Relation of the 
important inferences as to prognosis, and as to the hygiene of 
the pregnant, and the management of the parturient woman, 
may follow from them. 
68 W. 40th Stbeet, Feb. 20th, 1877. 
[With the consent of the various parties concerned, we append the 
following remarks, made after the reading of the paper : 
The President called upon Dr. Fordyce Barker, who spoke as 
follows : 
Mr. President and Gentlemen:—I have listened with interest to 
the paper read by Dr. Chamberlain, and regard it as one character- 
ized by a most thorough and careful research, and also by a very close 
and extensive observation. I do not propose, in any sense of the 
word, to criticize the paper; that would be impossible, from merely 
listening to it, and indeed, I should not wish to, because it states in 
a full and clear manner most important facts, which should be borne 
in mind, and in most respects I should agree with the author in his 
pathological views. 
There are, however, some deductions not mentioned in the paper, 
and it is to those that I shall chiefly allude. In the first place, I will 
briefly refer to the fact that all these various lesions of the kidneys 
and liver, to which especial attention has been drawn, are found asso- 
ciated mainly with puerperal diseases, when they exist in an epidemic 
or endemic form. The tendency of a certain class of observers and 
writers has been invariably to give prominence and significant impor- 
tance to local lesions, to regard such manifestations as purely local 
diseases. For instance, as we all know, in former times, able writers 
have endeavored to explain puerperal fever by referring it to a purely 
local inflammation. Now, I am aware that I stand in a very small 
minority in the professional world, a minority much larger than it 
was a few years ago, who hold to the view that puerperal fever is an 
essential, constitutional disease, having its peculiar local manifestations 
in different types in different epidemics and in different localities; 
that it is a specific disease, properly speaking, without special charac- 
teristic, anatomical lesions. 1 am well aware that we find in epidemic 
and endemic puerperal fever, lesions of the kidneys and liver, vary- 
ing in severity from a mere hypereemia to extreme inflammation, 
with its terminal results. I simply wish to call attention, in connec- 
tion with this point, to this fact, that these various lesions are gener- 
ally associated with the epidemic and endemic forms of puerperal 
fever, as I consider it. It is not my intention, however, to discuss 
the subject of puerperal fever, but simply throw out these suggestions 
because I feel that the deductions might remain, that such special 
lesions of the liver and kidney are purely local forms of disease, and 
are to be studied as such. 
I will add, by way of supplement to the paper, not in the light of a 
criticism, but to make our discussion broader, what my own clinical 
experience may contribute to the knowledge already obtained upon Urinary Organs to Puerperal Diseases. 
27 
the general subject, and I do this simply because it is well to take in 
the entire scope of the subject, involved in the announcement of the 
paper. 
I will allude to one practical point suggested in the paper, and I 
mention it because I believe that nothing should be accepted as 
authority unless it can be demonstrated. The author of the paper 
referred to Olshausen and other German writers, who object to 
the use of the catheter for certain reasons which he mentioned. I 
refer to this because I believe that the catheter is not too frequently 
\ised in puerperal cases, but because my experience would lead me to 
the conclusion that the use of the catheter is too often neglected. I 
very rarely see cases in which the catheter has produced harm, but I 
frequently see cases in which its neglect has resulted most hazardously. 
Not long since I saw for the first time a case of secondary hemor- 
rhage, caused by a distended bladder. The attending physician had 
been deceived by the statement of both the patient and the nurse 
that the urine had been frequently evacuated, and he regarded the 
tumor over the pubis, which was very distinct, to be the large uterus. 
But on palpating the abdomen, I found the tumor to be more smooth 
on its surface, more regularly ovoid in its form, and that it was 
characterized by a more fluctuating kind of elasticity than should 
belong to the uterus, and I therefore suspected it to be due to a dis- 
tended bladder. The patient at this time was in a condition of col- 
lapse from hemorrhage, which occurred fifty-two hours after labor 
was completed. A catheter was introduced, and nearly two quarts of 
urine was drawn off. 
The results which follow retention of the urine in puerperal cases, 
I have repeatedly seen, and one of these is an incomplete evacuation 
of the bladder, and the effects on the general system of residual urine. 
I take this occasion to give a description, which I know to be clini- 
cally true, of a condition which I regard as practically important, 
but which I htive been as yet unable to find mentioned in any obstet- 
rical work. It is not unfrequently the case that a woman after her 
confinement suffers from retention of urine, or, at least, difficulty in 
evacuating the bladder. This may arise from long pressure upon the 
urethra, or some portion of the bladder, during the processes of par- 
turition, or from long retention of urine and paralysis or paresis of 
the urethra or bladder. Subsequently the bladder gets relief to a 
great extent, but not completely. 
Now there is an affection which I am sure results from this condi- 
tion of affairs, and which has well-marked and characteristic phenom- 
ena that I will describe, and which I feel certain many who have been 
long in the practice of medicine have met. I am certain that the 
affection exists, and the process by which I reached this conclusion 
is something as follows : 
The first case, in which the symptoms which I am to detail were 
developed, was that of a woman who had relaxation of the symphysis 
pubis to such an extent that she fell upon the carpet aiid was unaole 
to walk afterwards. She was subsequently confined, and had a per- 28 
Chamberlain : Relation of the 
fectly natural and quick labor. She was unable to walk for a long 
time after her confinement. For three or four weeks she did well, 
as regards her general condition, but there had been more or less 
trouble in passing water, and she began to develop symptoms which 
were like those seen in the case of a gentleman whom I was attending 
at the same time. He was paraplegic during a certain period in the 
progress of his case, which I now know to have been one of locomotor 
ataxy—a disease which had at that time not been described. He 
suffered from painful and frequent micturition and the following con- 
stitutional symptoms. There were great gastric irritability, nausea, 
vomiting, and loss of appetite, loaded tongue, general muscular weak- 
ness, and great mental depression. Subsequently the man had com- 
plete paralysis of the bladder and I was compelled to use the catheter. 
From the time I began its use there was a rapid subsidence of all 
these symptoms mentioned. His general condition improved, his 
appetite was restored, and his countenance looked quite healthy, and 
the frequent urgent desire to micturate subsided. About five or six 
weeks after my patient with relaxed symphysis pubis was confined, 
she began to manifest similar symptoms and suffered from an almost 
incessant desire to empty her bladder. Finally, a catheter was in- 
troduced, just after she had passed all the water she could, and nearly 
two ounces of exceedingly foetid urine were withdrawn. That quan- 
tity had remained in the bladder after the most complete effort to 
empty it. The thought at once struck me that it was the decompo- 
sition of the urine remaining in the bladder that gave rise to the 
constitutional symptoms from which my patient was suffering. From 
that time forward I used the catheter three times every twenty-four 
hours, and with the most striking and rapid improvement. These 
cases occurred in my practice more than thirty years ago, and since 
that time I have seen a considerable number of like cases, although 
rarely developed, to such a high degree as the two just mentioned. 
They have, however, manifested the same general constitutional 
disturbance, and presented the same phenomena. I have often 
been called in consultation at the expiration of three or four weeks 
after delivery, and found the condition I have just described. 
The patient has gone on very well for three or four weeks, some- 
times longer, after her confinement, when it is noticed that she begins 
to lose her appetite, to complain of nausea, and sometimes vomit, 
there is increasing muscular weakness, a sunken, haggard counte- 
nance, a coated tongue, offensive breath, and great mental depression, 
accompanied by vesical tenesmus, and a frequent, most troublesome 
desire to evacuate the bladder. When I have suggested that these 
symptoms might be due to residual urine in the bladder, it has been 
objected that she is too frequently called upon to pass water. 
Insisting, however, that there might be a residual amount of urine in 
the bladder, the patient has been directed to void all that she possi- 
bly could, and then the catheter has been introduced with the result 
of drawing off a certain quantity of exceedingly offensive water. The 
catheter is then used every six or eight hours, and the patients have TJrinary Organs to Puerperal Diseases. 
29 
been relieved of the constant vesical irritation and the attendant 
symptoms. Other treatment has been employed, according to the re- 
quirements of each case, but no radical measures have been employed, 
except the use of the catheter. 
(Several illustrative cases were related.) 
In two clinical lectures, which I have given at Bellevue Hos- 
pital, 1 have ventured to denominate this affection, Puerperal Am- 
monhemia. 
In connection with the subject of the paper read, there is one other 
point to which I will call attention, and that is, the occurrence of 
peri nephritis as a puerperal disease. An important monograph upon 
this affection has been written by Bowditcli of Boston, and an excel- 
lent clinical lecture upon the same disease has been given by Trous- 
seau, but I refer to it as a puerperal affection. It is not of frequent 
occurrence, but I have met with it several times in connection with 
epidemics of puerperal fever, and I have seen three sporadic cases. 
I will not stop to describe the symptoms or discuss the pathology 
of this affection, but will briefly relate the three sporadic cases, to 
which I have alluded. 
The first was a woman who entered Bellevue Hospital in my ser- 
vice three weeks after her confinement. As she gave her liistoi'y, 
four days after the birth of her child, she was up and engaged in 
washing clothes, when she was suddenly obliged to cease her work 
on account of a most severe pain in her side. The next day she had 
complete retention of urine, and a doctor was called in who gave her 
medicine which cured this trouble in two or three days. After this 
she was able to do her house-work for a week or two, but she always 
suffered from pain in the side. The day before she entered the 
hospital, she again sent for the doctor, who told her husband that 
her case was bad and that she must go to the hospital. She had 
fever, chills of irregular recurrence, but not severe, constant pain over 
the left kidney,"where there was great tenderness, and a circum- 
scribed tumor in which I thought I could detect fluctuation. I 
called my obstetrical colleagues of the hospital in consultation, but 
we could not settle upon a diagnosis. Three days afterwards I passed 
an exploring needle into the tumor and found pus. I then made a 
free incision over the kidney and gave exit to about six ounces of 
pus. After its discharge a portion of the kidney could be easily seen. 
This patient made a good recovery. 
The second case was a patient of the late Dr. Stillwell, whom I saw 
for the first time six weeks after her confinement. A few days after- 
wards, I evacuated a large amount of pus by an incision, and this 
lady eventually got well. 
The third case was a patient of Dr. Purple, whom I saw, I think, 
about the fourth week after her confinement, and I then expressed 
the belief that a peri-nephritic abscess might be forming. 
This lady had a peculiar temperament, she was very difficult to 
manage and she had a great horror of an operation. Some time after- 
wards, I again saw her with Dr. Purple and Dr. Buck. It was then 30 
Chamberlain : Relation of the 
evident that the pus had worked its way down to the iliac fossa. 
Dr. Buck subsequently evacuated the pus by an operation, but I be- 
lieve that she afterwards died from exhaustion. 
Dr. Mary Putnam-Jacobi remarked that in regard to the alleged 
anaemia of pregnancy, it was much to be regretted that no other data 
were appealed to than those established so long ago by Andral and 
Gavarret. She was not herself acquainted with any more recent in- 
vestigations than theirs, but the present method of direct numera- 
tion of the blood corpuscles was so much more exact than the method 
of weighing the clot—adopted by Andral and Gavarret—that 
these early experiments decidedly needed control. Moreover, it 
seemed to her that there must be a certain illusion on this point, 
wherever, at least, the number of blood corpuscles for a given volume 
of blood was calculated; since an increase of plasmatic fluid, relative 
to the blood corpuscles, would occasion an apparent diminution in 
the latter, as effectively as if, the plasma remaining the same, the 
amount of corpuscles were really diminished, we should expect that 
the plasma would be increased, to meet the demand for plastic mate- 
rial made by the embryo ; and the diminution of muscular activity 
on the part of the mother, must diminish her demand for the corpus- 
cles whose oxygen would be required during muscular contractions. 
Hence again, even if the absolute amount of corpuscles were dimin- 
ished, it should not imply a normal diminution below the real needs 
of the economy. 
We have no assurance to what extent Andral and Gavarret’s sub- 
jects, hospital patients, were in a normal condition. With regard to 
the fatty infiltration of the liver found in many of Dr. Chamberlain’s 
cases, it is certain that this is found in a large number of pregnant 
women, where the pregnancy has been perfectly normal, and death 
has occurred, sometimes before parturition, from accidental causes, 
or intercurrent disease. Cornil—to mention no other pathologist— 
considered such fatty infiltration—to be distinguished of course from 
fatty degeneration—as a normal circumstance of pregnancy—and it 
is certain that, whenever the oxidation of fats is diminished, these 
became stored up, first in the adipose tissue, afterwards in the liver. 
The liver is the internal store-house of fat. Infiltration of the kid- 
neys was less frequent, but even that might occur under the same 
circumstances. It is known to be normal in dogs. 
It was evident from Dr. Chamberlain’s histories, that in many 
cases no symptom of hepatic or renal lesion, no albuminuria existed 
before parturition, and he himself shows how nephritis has devel- 
oped as a consequence of the local lesions of metro-peritonitis. In 
these cases, therefore, at least, of course the kidneys could not be held 
responsible for the predisposition to the puerperal accidents. Where 
nephritis did exist, however, during pregnancy, it seemed very 
plausible to suppose that interference with excretion of nitrogenous 
substances would favor septicsemic accidents in the same way that, 
according to Murchison, chronic renal disease extraordinarily aggra- 
vates the prognosis in continued fevers. Urinary Organs to Puerperal Diseases. 
31 
The very interesting experiments quoted by Dr. Chamberlain upon 
ligature of the ureters, and the excretion of urea by the peritoneum, 
have been already invoked to explain the dependence of general peri- 
tonitis upon acute nephritis. Bauer admits that the latter disease is 
sometimes the only cause of the former, and the speaker had recently 
seen a case where a woman was attacked by general peritonitis, three 
months after confinement, the health in the interval having been 
good, and whose urine, at the time, contained forty per cent, of albu- 
men. After death, no uterine or other local disease was found to 
explain the origin of the peritonitis, but the kidneys showed all the 
signs of an acute parenchymatous nephritis. 
Dr. Chamberlain remarked that these lesions of the urinary sys- 
tem in general were very largely the effects of the general processes 
of puerperal fever, and that it was not to represent them as exclu- 
sively local lesions that he brought them forward in his paper. It 
was rather to show that as we reckoned metritis, phlebitis, and cellu- 
litis, so we must also consider nephritis and fatty metamorphosis of 
the kidneys as varieties of the morbid puerperium, more frequent 
and more grave than commonly represented. 
In a certain number of cases the patient recovered entirely from 
the metritis, peritonitis, lymphangitis, cellulitis, etc., yet had more 
permanent renal lesions, as evidenced by careful examination of the 
urine. 
Regarding the catheter, he wished to be understood as maintaining 
that it was not necessarily its use that was detrimental, but that the 
use of an impure instrument, or the blind and rude use of a clean 
one, might be a frequent cause of puerperal difficulties. The use of 
the catheter for the purpose of removing decomposing urine from the 
bladder, was not only justifiable, but imperative. 
With reference to hydrsemia, the points made were, that the woman 
was shown to be in that condition, because, by absolute measure, the 
water of the blood tvas increased, and by absolute count the red cor- 
puscles were diminished; the albumen was diminished, and the fibrin 
and white corpuscles were increased. It was the appreciation of the 
total change, as indicated by actual measure, that gave rise to the 
condition. 
With regard to the haemoglobin, the doctor regarded it as the oxy- 
gen carrier, and as such, it was the agent of normal combustion, and 
that normal combustion was the natural method of consuming the 
residual excretory elements in the blood, and that in the absence or 
diminution of that element in the blood, there was an accumulation 
of carbonaceous matter, which required only a slight change to take 
the form of fatty degeneration, both in the blood and the tissues. 
The statements of Andral and Gavarret were old, it is true, but he did 
not understand Dr. Jacobi to say that they had been invalidated. 
If not, age argued authenticity.—Ed.]