PATHOLOGICAL ANATOMY.
it is granted to-day that puerperal accidents are the result of the penetration into the organism of an infectious germ, in other words that they are due to a true sepsis, it is not necessary any longer to de scribe in detail the different lesions which may be met with post-mortem. Such lesions always exist, are so to speak innumerable, and there is not a single one which may not be met with. Although cases have been re ported where no lesion whatsoever was found, these instances daily be come more and more exceptional, and, as Playfair well says: " In such cases even the olden-time rough methods of examination will reveal some alteration in the blood, and ecchymoses in the lungs, the spleen, the kid neys, etc. Recently it has been shown that, besides beginning inflam mation in most of the tissues, such as cloudy swelling, there exists granu lar infiltration and disorganization of the cellular elements. This is proof that the blood, impregnated strongly with septic material, has car ried everywhere the morbid germ, which had not the time to develop before the patient's death." This morbid germ, we have seen, has been demonstrated by Mayrhofer, Waldeyer, Recklinghausen, Heiberg, Orth, Birsch-Hirschfeld, Spillmann, Kehrer, Miller, Hausmann, Quinquaud, Despine, etc., but to Pasteur and his pupils belongs the honor of isolating this germ, of cultivating it, of reproducing it, according to the manner of culture, in determinate forms; of establishing, in a word, in puerperal septicaemia, germ-varieties and shapes corresponding to the degree of development of the germ.
According to Pasteur and Doleris, two sorts of organisms preside over infection : 1. The cylindrical septic bacteria, which induces rapid septicemia.
2. The micrococcus which begins as a point and then is harmless; later forms in couples and determines suppuration; later still assumes the form of chapelet de grain, and causes the attenuated variety of septicemia.
One capital point, according to them, dominates the entire pathologi cal anatomy of puerperal fever: " This is the constant presence of microbes with a determinate pathological transformation." The microbe exists, a number of routes are open by which it may pene trate into the organism, and once it has gained access, we witness the development of the most varied and complex pathological manifestations. All the necessary conditions for the production of puerperal accidents are present: vulvar, perineal, vaginal lesions, uterine wound, on the surface of which open the lymphatics and veins in great number, each forming a route by which the infectious germ may reach the organism and thence be spread by the blood and the lymph to produce the varied secondary lesions which are observed in these patients.
We must hence study in succession, even as do Doleris and Raymond: 1. The lesions which may be met within the utero-vagino-vulvar canal.
2. The lesions in the veins, lymphatics, cellular tissue, the channels of diffusion.
3. The resultant secondary lesions.
4. The vehicles of the poison (blood and lymph.) 1. Almost all authorities seek the source of infection in the uterine wound (placental site.) We believe with Schroeder, Spiegelberg, and others, that the wounds of the vulva, of the vagina, and especially those of the cervix, are at least as often the starting-point of infection, and this explains the unquestionable greater frequency of puerperal septicaemia in primiparEe over multiparEe.
The wounds, in case of puerperal infection, usually have an unhealthy look, and are often transformed, especially at the introitus vaginEe, into a species of ulceration which the Germans call puerperal ulceration. The margins are tumefied, the base covered with a dirty yellow deposit, which separates only at the end of a number of days. In certain instances these ulcerations have a tendency to spread, at times having a true gangrenous appearance, and they are associated with much edematous infiltration of the neighboring tissues. When they are extensive, the labia majora are livid-red, tumefied, edematous, and it is not rare to wane& true gan grene of the vulva and vagina, extending to the cervix, and even within the uterus. Virchow has given these appearances the name of malignant internal puerperal erysipelas, but we are not dealing with a true erysipelas, there being simply inflammation of the neighboring cellular tissue. In other instances, the wound looks diphtheritic, or at least it has the same appearance as that seen in surgical diphtheritic. When the lesion invades the vagina, we have puerperal vaginitis; higher still, and we have puer peral metritis. Occasionally, only the mucous membrane is affected, and then there exists an endometritis, the organ being soft, slightly infiltrated, sub-involuted, although its muscularis remains sound. The inflamma tion may thence extend to the tubes and give rise to a salpingitis, which in turn may set up puerperal peritonitis. But this form, as we will see, is more frequently determined by another process.