What, therefore, we must consider as peculiarly characteristic and dan gerous in infected wounds, is the great tendency of the inflammation to extend by continuity to other parts. In the puerpera, the state of the cellular tissue around the uterus is an indication as to whether the in flammation of the vulva or cervix is local or progressive. Exudation in this tissue, in our experience, always depends on infection of the puerpera, or the non-puerpera. If, during delivery, there occurs a tear of the upper part of the vagina, when there is no infection, it is always the parts immediately in contact with the borders of the wound which inflame. The sides of the uterus are neither tumefied nor sensitive, while, even in case of simple erosion of the vaginal mucous membrane, if there be in fection, we may usually determine the fact that the inflammatory process has spread into the cellular tissue which exists to the sides of the uterus." If we have thus detailed Schroeder's views, it is because they represent absolutely our own, and because with him we grant in puerperal diseases only two varieties. Every labor, however normal, is necessarily accom panied by erosions, wounds, fissures, of the vulvo-vaginal mucous mem brane and of that of the uterus, possibly deep lesions to the side of the cervix and the uterus. Finally, the placental site, with its thrombosed vessels, represents itself a vast wound. If these wounds remain simple, there arise no symptoms, or else these remain purely local; but if the wounds are infected, there result poisoning of the woman, and that en tire series of phenomena to which the name of puerperal fever has been and is still given.
We would, however, go still further than Schroeder, and maintain that even these wounds and abrasions are not indispensable for infection. Do we not indeed often see true phenomena of poisoning appear in physicians who are frequently brought in contact with cadavers, or are busied with the preparation of anatomical specimens? Here the infection unques tionably occurs through the respiratory and digestive tracts. There is true septicaemia, and the same holds true, we believe, during the puer perium.. The wound is not necessary, but only the presence of the in fecting agent. We will see shortly what the nature of this agent is.
Doli.ris thus expresses himself: " To-day all authorities are in accord in considering puerperal fever as a species of poisoning. The most resolute 'oculists have long since renounced the view that the disease resides in the lesion itself. This lesion is, according to them, purely a necessary phenomenon, necessary when it is primitive, as the uterine wound, and gives access to the poison or furnishes a site for its development; necessary, again, when it is secondary even as are organic metastases, which are only a result of the introduction of the poison into the economy; necessary, further still, when it is intermediate, so to speak, as is phlebitis, lym phangitis, which are only the traces of the passage of the toxic element, the septic element, whatever it be, and which serve as entrance-gates into the organism. The question, therefore, for them is limited to the infec tion of the wound. The sine qua non condition of toxemia is a raw sur face, a surgical wound. No wound, no infection. Both phlebitis and
lymphangitis, in surgery as well as in obstetrics, exist from the same causes. Lesions of the uterine lymphatics are in intimate connection with lesions of the neighboring serous membrane and the glands, even as the septic wound, however slight it be, is in absolute connection with the lymphangitis, the erysipelas, the diffuse phlegmon, which are often the consequences. Phlebitis introduces into the blood morbid elements, which carry further on the germs of what are known as metastatic affec tions, and which, customarily, are found in the viscera. Such is the case both in puerperal metritis and in the surgical wound." The recent investigations of Lucas Championniere, Siredey, Quinquaud, Fiouppe, Despine, Boa., plead in favor of the absolute similarity of puerperal and of surgical infection. This is the doctrine uniformly ad mitted in France, and the one stated by Winckel in 1878. It is the doc trine admitted almost uniformly throughout the world.
[In the United States, the belief of almost all accoucheurs is certainly in accord with the statements made by Charpentier. Puerperal fever is septicaemia, differing only from surgical septicaemia in that, superadded to infection, is the puerperal state. The most distinguished exception is Fordyce Barker. He still clings tenaciously to the views promulgated by him years ago, and with an ardor which, if it does not carry complete con viction, certainly tends to make every thoughtful man hesitate a trifle in propounding the absolute statement that puerperal fever is always sim ply puerperal septicaemia. In the memorable discussion before the New York Acad3my of Medicine, in 1884, when Thomas, with all his elo quence, plead for the entire identity of this fever with septicaemia, Barker alone protested against such a broad view, and stated that " his creed to day is fully avowed in his book on the Puerperal Diseases, and unless in the future he learned new facts and new arguments to change his faith, he should die impenitent." In reference to Thomas's argument, he stated that its pathological doctrines were misleading and dangerous, because they were "supersaturated with septic infection." Barker's creed to-day, even as yesterday, is that there does exist an epidemic disease differing in all characteristic points from what is known as septicaemia; differing in its origin, its modes of attack, its symptoms, its anatomical lesions. These symptoms are frequently manifested a day or two before, or even during labor, even when the child is subsequently born alive. In septi caemia, the symptoms are never observed before or during labor, except when the faetus is putrid. The former disease, puerperal fever, originates froth epidemic causes, and from contagion and infection; the latter from nosocomial malaria, from autogenetic infection, and from direct inocula tion. Barker's conviction, therefore, is still that there is such a disease as puerperal fever eui yeneris, and that outside of hospitals less than two per cent, of the puerperal diseases, and not half of one per cent, of the deaths after child-birth, are due to septicaemia.