FORMS OF THE DISEASE.
They are as numerous as they are varied, as is apparent from consulting the descriptions of different epidemics of puerperal fever. Whence the divisions into metritis, metro-peritonitis, peritonitis, phlebitis, lymphan gitis, purulent infection, pleurisies, endocartitis, etc. Whence also those numerous diseases described by Hervieux in his work, and which, from our standpoint, are only manifestations of general infection, of puerperal septicaemia. We propose here simply to study the clinical side of puer peral affections without entering into elaborate detail. We will mention purely the most marked forms of what was formerly called puerperal fever, and to-day is known as puerperal septicemia.
At the outset, as has been so well shown by Pajot, there is a vast differ ence between the lesser puerperal state, that is to say, the modifications in the organism during pregnancy and lactation, and the greater puer peral state, that is to say, the modifications which occur in the puerpera.
" Let us examine," says Pajot, "the organs on trial, and in no respect do the physiology and the pathology of the puerperal state resemble the physiology and pathology of pregnancy. All tends to hypertrophy during pregnancy; after delivery, it is atrophy which is the predominating factor. The nosological line of demarcation is just as striking." And Raymond, after having quoted the above words of Pajot, adds with justice: " If we consider the general modifications impressed on the economy by preg nancy and the puerperium, we find marked differences. In the first state, the equilibrium is with difficulty preserved, seeing that it is disturbed day by day; the mother must look after her own nourishment, and that of her child; the co-efficient of distribution varies each hour so to speak. In the puerperal state the inverse obtains: the alimentary decline pro duced by lactation is lowered after a certain time; if it increases occa sionally, it is never with the same regularity and the same continuity. as during pregnancy. In the gravida, the alteration of the fluids of the body is qualitative; there are never foreign elements. in the economy. In the puerpera it is very different. Nutrition tends to become normal, and per contra, the blood may contain septic products. There exists then a
difference between the physiological and the pathological processes, which precede and follow delivery." During the puerperal state, indeed, what changes in the circulation, the temperature, what variations in the secretions and the excretions; what modifications and transformations in the genital organs. and, in consequence, what transitory or persistent accidents, what diverse and multiple diseases ! Leaving aside all theory, and basing ourselves purely on clinical data, we may divide puerperal accidents into two great classes: 1. Those which are almost always recovered from. 2. Those which almost certainly kill. The first are frankly inflammatory, with a tendency towards localization, and retaining the characters of a simple inflammation; the others are strikingly infectious in character, reacting on the entire economy, and accompanied by diverse manifestations in organs more or less remote from the starting•point of the infection.
A. Accidents which are almost always recovered from.—Such are me tritis, peri-metritis, pelvic peritonitis, abscesses in the broad ligaments, etc. These remain, as it were, local, and are dangerous purely from the fact of their presence. Being essentially inflammatory in nature, they follow the ordinary course of an acute inflammation, lasting in the acute state for a few days, to terminate in suppuration, or, as is the rule, in resolution, convalescence being tardy. These forms, however, may really be due to infection, and then we see them in the shape of gangrene, diphtheria, croup, of the Germans. They become then exceptionally grave, and instead of cure, it is death which is the rule, death occurring quickly, the disease approaching in type what Peter calls the " typhus of the puerperium." The most grave expression of these semi-inflammatory and semi-infec tious forms, and which may be considered the connecting link between the purely inflammatory and the deadly forms, is peritonitis, puerperal metro-peritonitis, and this is ordinarily the result of true infection. Sometimes primitive, and again secondary, that is to say, complicating metritis, its progress is rapid, sometimes lightning-like, it is accompanied by serous and sero-purulent exudations, and it usually ends in death.