PUTRID INFECTION.
We have stated that the puerperal affections, from a pathogenetic stand point, may be due either to auto- or to hetero-infection. To the deserip tionof the former we now pass.
Putrid infection manifests itself nearly always under special conditions, that is to say, after miscarriages, incomplete third stage of labor, trau matism—in a word, where there has occurred putrid decomposition of any thing which has become foreign to and yet is retained in the genital pas sages. Here the general condition predominates over the local manifesta tions. These latter, indeed, are very insignificant. We are dealing with a true poisoning from resorption of putrid material. It matters little clinically whether this absorption takes place from the uterine wound, or by the lymphatics or the veins. The gravity of the case is dependent less on the nature than on the fact of poisoning. This poisoning does not always take place under the same conditions. At times it is slow, pro gressive, by small doses, so to speak, and again rapid and in large dose. At times we are certain of the presence of an infecting body in the geni tal canal. Again this body may be wanting, yet the patient present iden tical symptoms of putrid infection, without our being able to discover the cause of the poisoning. Whence, then, certain differences in the symptoms and in the course of the disease. The varieties are, however, always typical of the disease.
The first phenomenon is the great alteration in the character of the lochial discharge. For several days the lochia remain normal and nothing foretells the disease. The discharge then is partially suppressed; it be comes brownish-black, filled with membranous &Iris, and the odor is more or less foetid. Occasionally the patients have profuse, persistent, hemorrhages composed of foul clots and portions of the placenta and membranes. Again, nothing is found in the lochia. They are simply horribly foetid. This fLetor may be so intense that not alone the bed, but also the room, the entire ward, or house is infected. It is particularly
in cases where remnants of the placenta or membranes have been left in the uterus, that the fcetor is so pronounced. The odor is characteristic and peculiar, and the accoucheur who has smelt it once will recognize it ever afterwards When he approaches the bed of the diseased puerpera. Disappearing at times for a few hours, after injections, it soon returns and thus persists until the foreign body has been expelled, or removed in tote.
In the above instances there is no room for error, but there are others where the diagnosis is very difficult. Here we find no tangible cause of infection. The third stage of labor was thoroughly completed; the labor itself was natural; there has been no hemorrhage; there exists no visible tear of perineum or of vagina. Yet, towards the fourth or the fifth day, the patient's condition becomes less satisfactory, the lochia are fcetid, although not intensely so, and the phenomena which characterize putrid infection set in. The abdomen, lungs, heart, give no explanation of the phenomena which seriously compromise the patient's life.
The next phenomena are chill and fever.
The chill varies in character, sometimes being intense and of long dura tion, and again there are a number of slight, frequently repeated chills, varying from simple coldness, to the true chill. There is often marked intermittency in these chills. They usually occur towards six or seven in the evening, either daily or every other day, and are always followed by an acceleration of the pulse, and of the temperature.
The temperature rise varies with the pulse rate, usually oscillating be tween 101° and 103°, but there is a constant evening rise. The fever in deed is continuous, but remittent. The pulse ranges between 96 and 120 a minute, and ordinarily does not exceed the latter figure, except just after the chill, when the temperature also may rise above There is never complete apyrexia, even when the patients feel better.