PUERPERAL SEPTIC/EMIA.
In this affection there is nothing fixed or precise. Sometimes purely inflammatory accidents open the scene, and it looks as though we were dealing with one of the classic forms. The woman has a metritis, or a peritonitis, or is under purulent infection, and these affections apparently follow their ordinary course. Again, on the other hand, general phe nomena predominate, the local troubles being relatively benign. But what characterizes this variety of puerperal infection, is particularly the peculiar mobility, so to speak, the variety and the multiplicity of the local manifestations. Sometimes the abdomen seems most affected, then the lungs, then the heart, then the brain, etc. Sonietimes there will be no special,local manfestation,and these organs in succession will be affected, and the morbid phenomena will predominate more in one or in another, when, of a sudden, the disease will seem to affect still another organ hitherto untouched. In a word, it looks as though morbid raids were being made on all the organs without particular localization on any one. Elevation of temperature, however, is constant, and is proof that these local manifestations are not at all illusory, and that the entire body is profoundly affected. In case of septicaemia, indeed, we are no longer dealing with the particular forms we have passed in review. The evil is much greater if possible. Here the infection has attained its climax. Alteration in the blood is the capital phenomenon, and the various mani festations are purely outward signs of this true poisoning of the puerpera. The patients nearly always die, without our being able to say which of the morbid local manifestations was the cause of death.
[In his description of the different varieties of puerperal fever, Char pentier follows the example of nearly all ancient and modern writers, in making no reference to puerperal diphtheria as a special variety. The majority of clinical observers have indeed never seen a case of what they could term diphtheria of the genital .passages of the puerpera, and we must rank ourselves with this great majority. Garrigues, of New York, however, is a firm believer in the existence of this special variety, and, having been fortunate enough to witness twenty-seven cases, he has given us a thorough description of the disease. He claims that there exists a variety of puerperal fever " distinctly limited by the appearance of a diphtheritic infiltration somewhere in the genital canal of puerperal women, seriously threatening the patient's life, tolerably well marked by other symptoms, and calling for the most energetic special treatment." The peculiar infiltration is thus described by him: " Of a light pearl-grey color, more exceptionally milk-white or sulphur-yellow, it makes its first appearance as discrete spots not larger than a millet-seed, but soon these spots extend in all directions and melt together, so as to form one or more large thick plates firmly adherent to, imbedded in, and, as it were, dove tailed with the subjacent tissue. The patches have commonly round
contours, measure from one-eighth to one inch in diameter, and about one-eighth of an inch in thickness. All torn and abraded surfaces be come more easily a prey to the diphtheritic infiltration, but I have re peatedly seen entirely healthy parts of the mucous membrane of the vagina, yet covered with epidermis and separated by intervening tissue from all tears and abrasions, become the seat of the affection. The parts surrounding the patches are more or less swollen, dark red, brown, or dirty green." The symptomatology is not specially peculiar, but the signs of infection of the system precede the appearance of the infiltration for several days.
In one of Garrigues's cases where there existed "an unusual length of the period of formation of new patches, the same affection appeared sim ultaneously on the tongue." This he takes as strong corroboration of his opinion, that "this disease is identical with diphtheria as occurring on non-puerperal wounds, or as a primary disease without any wound, and most commonly localized in the throat, but found on all other mucous membranes." Such is Garrigues's statement in regard to puerperal diphtheria. Com ing as it does from such an eminently conscientious observer it is to be hoped that obstetricians generally will watch their cases, in order to cor roborate what at the present day is still scarcely admitted as a justifiable addition to the varieties of puerperal fever. Lusk states the prevalent opinion as follows: " Whether these so-called diphtheritic patches are identical with those which appear in the throat is an open question. Morphologically they are so, but in hospitals, epidemics of puerperal diph theritis are not associated with throat diphtheritis. Diphtheritic patches indicate an unwholesome atmospheric condition, and are somewhat rare outside of public institutions. Orth and Heiberg noticed the same gen eral post-mortem changes in those cases in which the patches were absent as in those in which they were present. My own observations show that they are rarely developed in the early stages of a hospital epidemic of puerperal fever, nor are they to be found in all cases when such an epi demic is at its height." It is noteworthy that all of Garrigues's cases occurred in a hospital, and in all of them the symptomatology was no different from that which we aro accustomed to find in other varieties of puerperal fever. It is the local lesion, the patch, which constitutes the differential factor, and we do not think that either he or other observers have proved the identity of this patch with that which is found in the pharynx of patients suffer ing from diphtheria.
As to whether then there exists a variety of puerperal fever to which the distinctive name puerperal diphtheria may be applied, must still re main an open question.—Ed.]