PURULENT INFECTION.-PYEMIA.
Puerperal purulent infection is due to absolutely the same causes as surgical purulent infection, and the clinical phenomena and the patho logical lesions are the same in the one as in the other.
In general, pyemia developes late in the course of the puerperium, towards the eighth or tenth day, sometimes later still. The instances where the disease has appeared earlier are exceptional. We have seen a case beginning on the third day after delivery. Ordinarily, the early days of the puerperium are normal and regular, the health of the puer pera being perfect, and there being apparent no lesion of the genital organs, or else a cicatrizing wound of the perineum. Of a sudden, with out apparent cause, the woman has an intense chill, which may last from one half hour to a number of hours. Wunderlich has at times noted, immediately before the onset of the pyemic symptoms, a more or less great fall in temperature, and again he has seen slight rise of tempera ture. The chill, however, is followed by high temperature. The pulse rises to 130 and more pulsations in a few hours, and the temperature to 106° and even 107.5°. The temperature just as rapidly falls down even to 100°, and exceptionally below the normal. This chill and fever are followed by profuse perspiration, so that the bed-clothes are wringing wet, and this lasts until the temperature rises again. Sometimes a day or even two pass by with the woman in a fairly satisfactory condition, except that the pulse is rather rapid and the temperature slightly above the nor mal. Tben suddenly the woman is seized with another violent chill, fol lowed by the same rise in temperature and acceleration of the pulse. Similar attacks may follow for a number of days, and then the disease is pursuing its regular course.
Wunderlich thus describes the course of this disease: 1. Rapid rise of temperature, repeated without special regularity, even twice or thrice in the same day, the acme reached being nearly that of the first attack. Rapid fall of temperature immediately after each attack. Very seldom does the fever last for more than half the day at its maxi mum. The decline is to the normal or below, and exceptionally only to
102°.
2. Periods of apvrexia, lasting for twelve or even for twenty-four hours.
3. Usually, in the intervals of the febrile attacks, or else towards the end of the disease, there are periods of one or two days, where the tem perature is continuous or remittent, with a tendency upwards, or else with no definite tendency at all.
After the attacks have thus occurred for a number of times in more or less rapid succession, the fever becomes continuous with evening exacer bations, and we witness the unfolding of the following series of phe nomena..
The woman's skin becomes tinged yellow, which deepens shortly into the true jaundice hue; the uterus diminishes little by little in size; there is neither metritis, nor general nor circumscribed peritonitis; the lochial discharge is slightly suppressed, but at no time ftetid; and next appear the phenomena which are called metastatic.
Usually these metastases first affect the articulations. A vague, dull, and finally acute pain affects one or more joints. These swell, and run through the course of a purulent synovitis. At times the inflammatory process leaves one joint to affect another and definitively lodge there. Then abscesses are formed in the liver, the lungs, spleen, kidneys, rarely in the brain. At times the purulent collections are in the serous cavities, the pleura, the pericardium, the peritoneum. may occur.
The patients grow weaker, and die sooner or later from what may be termed a true purulent diathesis.
Here again the local affection seems insignificant. The uterine or peri uterine lesions are masked by the general phenomena. Yet, post-mortem, in the great majority of instances, the veins and the lymphatics are found filled with pus, at the insertion site of the tubes and the broad ligaments. There has existed, then, phlebitis and lymphangitis, and these are the prime causes of the pyemia.
It is apparent, of course, how serious an affection of this nature is, and how rare recovery.