342 
F. L. STEVENS. 
We thus see puerperal fever under three distinct forms in 
which the streptococcus is always found. It sometimes takes 
the form of a true septicaemia, quickly leading to death. At 
other times the patient succumbs with an abscess of the large 
ligaments and generalization of streptococcus without occasion¬ 
ing new abscesses, and finally the disease sometimes evolves 
comparatively slowly, assuming the character of pyaemia, with 
multiple streptococcus abscesses. 
That the genital tract, and especially the uterus, immedi¬ 
ately after parturition, forms an excellent location for the mul¬ 
tiplication of the microbes of putrefaction is self-evident and 
needs no argument. Frohner and Friedberger in their excellent 
work have covered the whole ground, but there is one impor¬ 
tant fact which I have observed in each of the three cases that I 
have carefully examined during the past few months and which 
I do not see mentioned by any of the works on the subject, or if 
mentioned no stress is laid upon the point. I refer to the fact 
that while the uterus is not usually contracted, and the os 
not always closed tightly, yet in every case of puerperal 
septicaemia that I have examined the os uteri was absolutely 
occluded by a gelatinous exudate which required considerable 
labor to remove before an entrance to the womb could be 
effected. 
Now, as most of the germs producing septicaemia are 
anaerobic, especially the streptococcus pyogenes aureus, which 
according to Mosselmann and Fienaux is the microbe producing 
puerperal septicaemia and cannot multiply in the presence of 
oxygen this would appear to be a condition absolutely essen¬ 
tial to the production of puerperal septicaemia. 
Without this occlusion of the os it might be urged that the 
uterus could not be the seat of septic infection or intoxication 
from the fact that the microbe producing it, being anaerobic, 
could not exist and undergo proliferation under such conditions. 
Whether this occlusion of the os is constant in cases of this 
kind, I am unable to say, but, so far as I have observed, this 
condition is always present. 
