13. Accidents almost always fatal. —The first variety under this heading, is usually the result of putrid infection from decomposition of placental debris, shreds of membranes, clots retained in the uterus, gangrenous eschars in the vagina or the uterus. Infection of this nature is usually seen after incomplete miscarriage, or when a dead putrid fcetus is in the uterus. Its progress is slower, and when the foreign body is removed, it may terminate in recovery, and it is possibly the morbid form where our therapeutics avail the most. But, unhappily, this removal of the infec tions mass is not always possible, or does not occur spontaneously, and the patients, poisoned by the detritus, die at the end of a variable time, usually after a somewhat prolonged interval. [See Vol. II., under Mis carriage, for remarks bearing on this point.—Ed.] The second variety is purulent infection, identical to that in case of major wounds, beginning, in general, more slowly than the preceding, and accompanied by the same local and general phenomena as in case of purulent surgical infection, and also with metastatic abscesses, internal or external, emboli, etc. Cure is absolutely exceptional.
The third variety constitutes what we call puerperal septicemia. Here there is no proper localization, but all the organs of the economy may be invaded simultaneously or successively, and thus the patients present, alternately, morbid phenomena from the side of the abdomen, pleura, heart, brain, lungs, joints, skin, etc., without our being able to say what in reality was the cause of death. It is in these instances that the special alterations of the blood are found on which Depaul, Dubois and Hervieux, based the theory of essentiality.
Such are the chief varieties of affections which dominate, we may say, the pathology of the puerperal state. We must add two more which belong to the puerperal period, although they differ notably from the pre ceding. The one is puerperal mania, which we studied in connection
with the psychical disorders of pregnancy; the other is a late accident of the puerperium, since it rarely appears before the tenth to the twelfth day, often later, and this is phlegmasia alba dolens.
Finally, we would mention the worst accident of all, sudden death, which occurs unfortunately too frequently without any premonitory symptoms.
It will be noticed that we do not use the terms phlebitis, lymphangitis, adeno-lymphitis, and that we make no attempt to differentiate them. Whether the poison, the germ, the infectious microbe, enters the econo my by the veins or the lymphatics, the effects at the bedside are such as to enable us to classify the case under one or another of the varieties mentioned. The diagnosis of lymphangitis or phlebitis can only be con firmed at the post-mortem, and such a diagnosis made at the bedside is entirely too subtile, and devoid of practical interest. Such a distinction is certainly of importance theoretically, but in practice it is not. We will describe clinically only the following varieties: 1. Inflammatory affections localized in the uterus or its adnexa.
2. Puerperal peritonitis.
3. Putrid infection.
4. Purulent infection.
5. True puerperal septicaemia.
6. Phlegmasia alba dolens.
7. Sudden death in the puerperal state.
Before entering upon a description of these different forms, we would mention that when puerperal fever becomes epidemic: 1. The same affections occur in all the diseased puerpera, peritonitis, pleurisy, phlebitis, lymphangitis, and the same lesions are found in all the women.
2. Epidemics are always preceded in Maternities by diseases of the children, enteritis, ophthalmitis, etc.
3. The surgical wards are the seat of erysipelas, purulent infection, hospital gangrene, etc.