2. The second microbe differs only from the first in volume, being three to four times larger, and also more brilliant. It unites in pairs, in triplets, and does not constitute true chaplets. Doleris believes that it belongs to a very deadly variety. The more abundant it is, the greater the danger of septicaemia. (Fig. 183.) 3. In the first portion of the vaginal canal is found, sometimes from the sixth to the seventh day, a little aerobic vibrio. It is of little im portance from a pathological standpoint. (Fig. 184.) 4. Finally, in true septicaemia, the kind which prostrates from the very beginning, there are found no living organisms in the blood until just before death or even after. The variety of organism is multiple, and is formed of long, thin, cylindrical elements, which are movable and burrow into the tissues, the lymphatics, the peritoneum. Only at a late stage do they reach the blood. These bacteria.may assume many shapes. (Fig. 185.) The blood containing them is thick, at times black when death has supervened quickly. The blood globules are much altered, deformed, deprived of hEemoglobulin, but the leucocytes are not particu larly increased. (Fig. 186.) In a milder form of septicaemia the blood always contains microbes, and this is in the common suppurative form. The micrococcus in chains is the active organism. (Fig. 186.) But in the phlebitic form, with thrombi, these micrococci in chains are not common. The nature of the organism differs with the case. When the lymphatic lesion coexists and developes progressively, cultivation of the micrococcus of the blood gives rise almost constantly to long chaplets of grains similar to those con tained in the lymphatics, and sometimes cylindrical. When the hematic lesion alone exists, culture gives rise only to colonies of micrococci in irregular groups or in couples, but these are never sufficiently organized to form chains.
When the hematic lesion is accompanied by phlebitis and thrombus, the almost constant form is the point in couples. Culture produces it at once in large numbers, to such a degree, that it seems as though we had, made artificial pus.
After delivery, everything favors rapid absorption by the lymphatics. When the uterus contracts, the intra-parietal branches, true enough, are • closed, but those in the sub-peritoneal layer are widely open. In the sub-serous reticulum the organisms collect and develop, and they spread rapidly to distant parts. No law presides over the distribution of the microbes, whence the varied resulting lesions, abscesses, peritonitis, pleurisy, meningitis, arthritis. Infection by the lymphatics is always the first in order. The blood is only reached secondarily through the thora cic duct, and from a clinical standpoint cases may be divided as follows: 1. Those rare but actual cases of rapid septicemia characterized by the early introduction into the blood of the long septic bacteria, isolated or united with the micrococcus.
2. Those more common cases of puerperal infection, characterized in particular by the presence of the micrococcus in the lymphatics, the ten dency to suppuration, and the occurrence of true septictemia ultimately, that is to say, the invasion by the septic bacteria, which are sometimes found in the lymph or the blood just before the agony. This is the sup purative lymphatic, serous, purulent form.
3. Cases of pyemia with phlebitis and thrombosis, answering to surgical purulent infection.
4. Finally, the slow, progressive pyemic forms, 9f long duration, fre quently characterized by the presence of puerperal pernicious anemia, or of abscess, or of chronic metritis.
To resume then: While we might confound all the varieties of puer peral infection under the name septicaemia, with variable forms and vari able pathological products, still I believe myself authorized, following Pasteur exactly, and considering the organism from the standpoint of specialization of its product and not from that of its probable origin, in separating morbid infectious germs into two great categories 1. Cylindrical septic bacteria (rapid septicemia.)
2. Micrococci in chains (attenuated septicaemia); under the shape of couplets; under the shape of dots or points.
I admit, therefore, that the micrococcus is always characterized by an attenuation of the septic nature of the products, and that the double dot or point is the true pyogenic element." (Doleris.) These researches of Pasteur, then, seem to throw great light on the nature and the method of the production of puerperal affections. Ray mond has resumed the question as follows: " When the lochia of a healthy puerpera are examined under the microscope, either none at all or else a few micro-organisms are found. If, on the other hand, the lochia of a woman on the point of having some puerperal affection be examined, we are struck by the large number of organisms present; and if she dies, in the pus of the peritoneum, in the uterine lymphatics, in the exudations of the pleurae, in the metastatic abscesses, etc., the same organisms exist as were found before death in the lochia. By means of those valuable and delicate culture processes which were devised by Pasteur, he has been able to demonstrate in the blood before death microscopic organ isms, touching, as it were, with the finger, the cause of the risoning. Further still, Pasteur, in the services of Hervieux and of Championniere, has been able, by the simple microscopic examination of the lochia, to predict the appearance of affections before the clinician even suspected them. During the discussion before the Academy of Medicine, Pasteur showed an organism in chaplets of many grains which he had frequently found in the lochia of women dying from infection, and he has seen them in myriads. He has found this little organism, under such circumstances, everywhere in the body. Is this the only organism met with in the course of puerperal fever? Must we attribute the disease to it? Pasteur thinks not. Puerperal fever has not its special microbe, but there are many which may affect the puerpera in one or in another way, accord ing to its number. Indeed the micro-organism which kills the woman may even not have any infectious property. Injected subcutaneously it may produce no symptom. It is thence to the special conditions of the uterine wounded surface that the puerperal accidents are due. The organism developes rapidly and in abundance in the lochia within the uterine cavity. It penetrates readily to the neighboring peritoneum, and there, by the fact of rapid multiplication, produces peritonitis with pus full of the micro-organisms which Pasteur has shown us. In case the peritoneal cavity does not afford conditions favorable for development the affection will be more limited, and instead of intense general peritonitis, we will have localized pelvic peritonitis, which is less acute. It is equally easy to understand the development of cases of phlebitis and of pelvic peritonitis. It is the situation of the wound, the connections of the which increase the danger, and this is what is peculiar to the puerpera. If the infectious microbe reaches her by any one of the many open routes, then infectious and rapid septicaemia develop, and those sud den deaths may occur which have so frequently swept out maternity hos pitals. The blood then offers the characteristics of the typhoidal diseases, a fact on which the essentialists lay great stress in behalf of their theory.