PUERPEEAL FEVER PUERPERAL MANIA 69 ting little more than inflammation of the con- nective cellular tissue of the pelvic cavity. It will therefore he seen that the subject is one of the most difficult and perplexing which writers on obstetrics have to meet. No system of clas- sification has been generally agreed upon, but several authorities, with the sanction of Sir James Y. Simpson and others, embrace within the term puerperal fever all those lesions of pelvic organs and tissues which in the puer- peral state, under favorable circumstances, are liable to engender and propagate septic poison. But it is asserted by many high authorities that there is a form of the disease which is charac- terized from the first by symptoms indicating the operation of a virulent poison, and which has received the name of malignant puerperal fever, or puerperal typhus. This may be re- garded as the true epidemic puerperal fever. Those who maintain these views also believe in the contagiousness of the disease, and in their classification they separate epidemic puer- peral fever from such affections as are specially named puerperal metritis, puerperal peritoni- tis, puerperal phlebitis, puerperal pelvic cellu- litis, and puerperal septicaemia and pyaemia. The symptoms of epidemic or malignant puer- peral fever usually commence with a chill be- tween the first and third days after delivery, rarely being deferred to the fifth day, although sometimes to the eighth or ninth ; but this is not one of the most important symptoms, for it is sometimes so slight as not to attract at- tention. In some cases, however, it is very se- vere and lasts 30 or 40 minutes or longer, and during the chill the pulse is small and quick ; afterward it becomes fuller but more compres- sible, ranging from 110 to 150. There is more or less delirium, and vomiting is quite common. Sometimes these symptoms are intensified, and the patient succumbs to the attack in 24 or 48 hours. In cases of the epidemic disease post- mortem examination will sometimes reveal not many pathological changes, but sometimes they are quite extensive and similar to those in sep- ticaemia and pyaemia. In cases of puerperal peritonitis, there may be nothing found except indications of inflammation of the peritoneum ; but in cases of septicaemia and pyaemia there will usually be found abscesses in different parts of the body. The uterus will be found cedematous, and its lymphatics are usually dis- tended with purulent contents, which are of- ten traced to ulcers on the neck of the womb. There are often dilatations in the lymphatics as large as a hazel nut, filled with pus; and there are frequently abscesses in the body of the uterus causing perforations into the peri- toneal cavity. The cellular connective tissue becomes inflamed and filled with serum, and often pelvic peritonitis follows this, and may extend to the general abdominal cavity, its contents becoming more or less adherent to each other from the formation of false mem- brane. Changes occur in other cavities besides that of the peritoneum ; extravasations of blood are often found beneath the lining membrane of the heart and the mucous membrane of the intestines. There is also often found pericar- ditis and inflammation of the joints, most fre- quently in the shoulder and knee, the pus un- dermining the surrounding parts, often to a great extent. Embolism of the blood vessels is common, especially in the lungs, the throm- bi which form in these organs breaking up and passing on into the circulation. Pneu- monia is frequent, with a great tendency to gangrene, caused by the presence of putrid emboli. The spleen is frequently enlarged, of a pulpy, greasy consistence and of a chocolate color; and the liver presents marks of fatty infiltration, embolism, and disintegration of liver cells. The treatment in all these puer- peral diseases depends upon the extent and in- tensity of the attack, and upon the organs in- volved, and consists to a great degree in pro- phylactic measures, such as cleanliness, inclu- ding the prevention of the reabsorption of sep- tic matter, and a bland but not innutritions diet. The medical attendant should exercise the most extreme care not to approach the lying-in chamber after attending cases of ery- sipelas or scarlet fever, or any other conta- gious disease. If he has recently attended a post-mortem dissection, he should bathe his person, use carbolic or salicylic acid gargles, and change his entire clothing. See "Clini- cal Lectures on Diseases of Women," by Sir James Y. Simpson, M. D. (Edinburgh, 1871); "A System of Midwifery," by William Leish- man, M. D. (Glasgow, 1873) ; " On the Nature, Signs, and Treatment of Childbed Fever," by Charles D. Meigs, M. D. (Philadelphia, 1872) ; " The Puerperal Diseases," by Fordyce Barker, M. D. (New York, 1874); "Erysipelas and Childbed Fever," by Thomas 0. Minor, M. D. (Cincinnati, 1874); and "A Manual of Mid- wifery," by Dr. Karl Schroeder (New York, 1875). PUERPERAL MANIA, a form of mental de- rangement which attacks women during the lying-in period. It is to be distinguished from the melancholia which occurs at the same pe- riod, although some authors treat both affec- tions under one head, either that of puerperal mania or puerperal insanity. It is also to be distinguished from the insanity of pregnancy and the insanity of lactation, affections which are liable to occur in the earlier stages of preg- nancy, or during lactation after the puerperal period has passed ; and it is also distinct from the delirium of labor. The insanity of preg- nancy, which generally occurs between the third and seventh months, may be caused by de- rangement of some of the bodily functions, usu- ally associated with an anaemic condition, and, according to Esquirol, dependent in more than one third of the number of cases upon hered- itary predisposition. The insanity of lactation generally occurs after the sixth month of that period, and therefore its principal cause, weak- ness from the exhaustion of nursing, is appa-
