PUERPERAL FEVERS.
_Nature and varieties of puerperal fever.--Vitiation of the blood.--
Different species of puerperal fever.--Puerperal peritonitis.--
Symptoms.--Appearances after death.--Treatment.--Uterine phlebitis.--
Symptoms.--Appearances after death.--Treatment.--Indications.--False
peritonitis.--Treatment.--Gastro-bilious puerperal fevers.--
Symptoms.--Appearances after death.--Treatment.--Contagious, or
adynamic, puerperal fevers.--Symptoms.--Appearances after death.--
Treatment._
In enumerating the different species of Dystocia, we have mentioned a long
list of causes, by which the process of labour might be rendered one of
considerable danger either to the mother or her child; but, for the most
part, they are not of very common occurrence, those only which are of
trifling import being met with most frequently. Even under the most
dangerous forms of dystocia, as for instance, convulsions, and the
different forms of hæmorrhage, the danger, although great, is capable of
being averted, from the mother at least, in the majority of instances by
timely and skilful assistance; the means of treatment which art and
experience have supplied us with, being generally capable of affording
both certain and effective relief, if used according to the rules which we
have given when treating of these subjects; but we now come to a source of
danger which follows the most favourable as well as unfavourable
labours--which is extremely varied in its nature, fatal in its effects,
and (what renders it so peculiarly formidable) by no means uncommon in its
occurrence.
Of all the dangers to which a lying-in woman is exposed, puerperal fever
is by far the most to be dreaded: there are few or no difficulties during
parturition which the practitioner has to contend with that can be
compared to it; there are none in which he is frequently made to feel so
helpless, and his various means of treatment so utterly inefficacious;
certain it is that puerperal fever in its worst forms has occasionally
committed such ravages among patients of this class as to rival in
destructiveness the most malignant pestilences with which the human race
has been afflicted.
One of the greatest improvements in our knowledge of puerperal fever which
has taken place in modern times, is the having ascertained that it is not
one specific disease, but occurs under different forms, each of which is
subject to a good deal of variety, depending upon individual peculiarity,
season of the year, and numberless other circumstances. The chief error
into which authors have fallen when treating of this difficult subject, is
their having merely described the peculiar form of disease which had come
under their own notice, and to which they have exclusively awarded the
name of puerperal fever--an error in judgment which has led to still
greater errors in practice, and which has certainly tended to prevent the
subject being so clearly understood as it might have been. The mode also
in which it has been investigated by modern authors has been but of little
assistance in disclosing the true features of the disease; they have
indeed rather tended to mislead than to guide us, they have directed our
attention to certain effects of it, which they have considered to be the
disease itself, and thus rather conceal than disclose the real _natura
morbi_.
In our printed lectures on puerperal fever we have taken a similar view.
"I am not sure if the present fashionable morbid anatomy of the day,
misnamed pathology, has assisted so much in developing the real nature of
the disease as has been supposed: it appears to me rather to have
withdrawn the attention of practitioners from a close observation of the
phenomena presented during life, to the inspection of those changes which
are to be found after death. They have rather sought to examine the
_effects_ of the disease at a time when it had attained such an extent as
to be incompatible with life, than to investigate upon correct and
physiological grounds the series of changes which were taking place during
the earlier periods." (_London Med. and Surg. Journ._ June 27, 1835.) Dr.
Alison, of Edinburgh, in his dissertation on the state of medical science
(_Cyc. Prac. Med._) has taken a similar view of this prevailing mode of
investigating the nature of disease; he considers that it is "an important
practical error to fix the attention, particularly of students of the
profession, too much on those characters of disease which are drawn from
changes of structure _already effected_, and to trust too exclusively to
these as the diagnostics of different diseases, because in many instances
these characters are not clearly perceptible until the latest and least
remediable stage of diseases--the very object of the most important
practice is to _prevent_ the occurrence of the changes on which they
depend. Accordingly, when this department of pathology is too exclusively
cultivated, the attention of students is often found to be fixed on the
lesions to be expected after death, much more than on the power and
application of remedies either to control the diseased actions, or relieve
the symptoms during life."
"Pathological anatomy (says Dr. Stevens) is but one of the many 'points of
view in which we may consider the science of disease,' and notwithstanding
all that has been said about 'la médicine eclarireé par les ouvertures des
cadavres,' I have a firm belief that morbid anatomy has done little good,
particularly in the hands of those who do not understand its real value;
for those who are constantly mistaking the effect for the cause, or
confounding the immediate cause of death with the cause of the disease,
and forming theories on this foundation, not only deceive themselves, but
unfortunately, particularly for the inhabitants of hot climates, they have
deceived others." (_Obs. on the Healthy and Diseased Properties of the
Blood_, p. 182.)
We have made our last quotation from one of the most valuable and original
works of the present day upon the subject of fevers, and which has tended
in great measure to unveil the mysterious nature of these diseases. Dr.
Steven's researches have been conducted in the truest spirit of
pathological inquiry, and form a striking contrast with the modern morbid
anatomy of puerperal fevers.
We use the term _puerperal fevers_ precisely with the same meaning as Dr.
Locock has done in his valuable essay on this subject (_Library of Pract.
Med._ vol i.,) requesting our readers to bear in mind his observation,
"that they vary in their nature and treatment as much as other kinds of
fevers;" that whether occurring sporadically or in epidemics, they rarely,
appear twice alike, but vary with the season of the year and the type of
the prevailing fevers of the place; they are influenced by the rank,
habits, and constitution of the patient, as well as by the nature and
locality of her residence.
Although we cannot quite coincide with the views of Dr. Ferguson to their
fullest extent, respecting the exclusive cause of the various forms of
puerperal fever, viz. the vitiation of the fluids, still, in great
measure, we consider them as correct, having not only taught them for many
years, but published them in our lectures on this subject in 1835. Much
praise is due to the last two mentioned authors for the able manner in
which they have handled this difficult subject, they have carefully sifted
the mass of jarring opinions, and tested them by their own great
experience; and have not only reduced the subject to a simpler form, but
have succeeded, we trust, in removing the very erroneous views of some
modern authors respecting the supposed identity of certain forms of local
inflammation with this disease.
Having drawn our information upon puerperal fevers from the same ample
source, we willingly bear testimony to the accuracy with which they have
described the different forms; and trust that in giving a detail of our
own opinions and observations, it will be found that so far from differing
from them, we have tended to confirm, reconcile, and carry out their
views.
_Nature and varieties of puerperal fever._ The history of puerperal fevers
at the General Lying-in Hospital, would of itself afford an excellent
monograph on this class of diseases in all their varied forms. When we
resided at the hospital in 1826, the cases were all of the inflammatory
character; they appeared to occur sporadically, among the out as well as
the in-patients; and were successfully relieved by bleeding, hot
poultices, and a mercurial purge, and occasionally leeches. During the
following years, an epidemic of a highly malignant character spread
destruction rapidly among the patients, setting at defiance the treatment
previously employed. Still more remarkable was the sudden change in the
character of the disease noticed by Dr. Locock in 1822. "In the spring of
1822, puerperal fever existed in the lying-in hospital in two very
different and well-marked forms, at an interval of about six weeks between
the last case of the first epidemic and first case of the second. The
early cases were of an active inflammatory character; the peritoneal
covering of the uterus and intestines was chiefly affected; the albuminous
and serous effusions in the fatal cases showed a sthenic state of the
system, that is, the serum was clear, the coagulable lymph firm and white;
the patients bore blood-letting, and other active treatment to a great
extent, fairly, and with much advantage; the blood drawn was strongly
cupped and highly buffed, and the fatal cases were few. Six weeks
afterwards a very different epidemic was found to exist. The same remedies
which had been so beneficial a few weeks before, were naturally at first
tried, but their bad success confirmed the sagacious remark of Gooch, that
'the effects of remedies form not only an essential but an important part
of their history.' (Gooch _on Peritoneal Fevers_, p. 35.) The fever was
attended with marked oppression and debility; the local pain was
comparatively slight; the pulse was extremely rapid from the first, with
no force, and easily compressible. In many of the cases, purulent
deposites took place in the joints and in the calves of the legs, and in
one case there was destructive inflammation of the eye." (Locock, _op.
cit._ p. 349.)
The various forms and modifications under which puerperal fevers have
appeared at different times, have produced an equal variety of arrangement
in the classifications of authors. Thus, some who have attributed the
disease to inflammation, have merely distinguished its varieties according
to the different organs which have exhibited after death appearances of
congested or injected vessels, or have been covered and imbedded in
effusions of coagulable lymph, &c., or have had their structure more or
less broken down and disorganized. Thus, for instance, Dr. R. Lee is of
opinion, that "inflammation of the uterus and its appendages must be
considered as essentially the cause of all the destructive febrile
affections which follow parturition; and that the various forms they
assume, inflammatory, congestive, and typhoid, will in great measure be
found to depend on whether the serous, the muscular, or the venous, tissue
of the organ has become affected." (_Med. Chir. Trans._ vol. xv. part ii.
p. 405, 1829.) He accordingly arranges "the principal varieties of
inflammation of the uterus in puerperal women under the following heads,
viz. 1. Inflammation of the peritoneal covering of the uterus, and of the
peritoneal sac; 2. Inflammation of the uterine appendages, ovaria,
fallopian tubes, and broad ligaments; 3. Inflammation of the muscular and
mucous tissues of the uterus; 4. Inflammation and suppuration of the
absorbent vessels and veins of the uterine organs." (_Cyc. Pract. Med._
art. PUERPERAL FEVER.) This arrangement is manifestly incorrect, and by
giving so partial a view of puerperal fevers, must, if adopted,
necessarily lead to serious errors in practice. "That these forms of
inflammation are the proximate cause of the various febrile affections is
most completely refuted by the detail of his own (Dr. Lee's) experience,
as relates to the varieties occurring under similar circumstances."
(Moore, _on Puerp. Fever_.) We may also add, that, according to our own
experience, and that of our colleagues at the General Lying-in Hospital,
in the worst forms of puerperal fever, the fewest traces of inflammation
have been observed; and that in the severest and most rapidly fatal cases
it has frequently happened, that not a single vestige of inflammation
could be detected. In our review of Mr. Moore's able work in the _Brit.
and For. Med. Rev._ Oct. 1836, p. 483, we have made a similar remark, and
quoted a striking passage from Dr. Stevens, when speaking of contagious
fevers, that "there is not one symptom of inflammation during the fatal
progress of the disease, nor one inflammatory spot to be seen after death,
to mark its existence, or to induce us to believe that any thing but
functional disease had existed in any of the solids; yet these are the
very cases of all others which are the most fatal." (_On the blood_, p.
179.)
In many of the worst cases which have come under our notice, there has
neither been time nor power sufficient to produce either a symptom or a
trace of inflammation; the powers of life have from the very commencement
sunk under the deadly influence of the disease, without a single effort to
establish even a temporary reaction in the system: hence, in most
instances, we are led to the necessary conclusion, that inflammation, when
it does appear, is the result of disease, not the disease of inflammation.
"For," as Dr. Ferguson observes, "if any or more of these (phlebitis,
peritonitis, &c.) be assumed as constituting the essence of puerperal
fever, abundant examples may be found of puerperal fever, in which the
cause fixed on is absent. Thus to believers in the identity of peritonitis
and puerperal fever, we can show puerperal fever with a perfect healthy
peritoneum. To those who insist on inflammation of the uterine veins, as
constituting puerperal fever, we can show the genuine disease without
this condition." (_Essays on the most important Diseases of Women_, part
i. PUERPERAL FEVER, p. 81.)
The _vitiation of the blood_ has long been a subject which has excited our
deepest interest, and the admirable researches of Dr. Stevens upon the
condition of this fluid under the effects of malignant fevers, have tended
to disclose the real nature of the diseases under consideration. We have
long been convinced that one of the causes of puerperal fever is the
absorption of putrid matters furnished by the coagula and discharges which
are apt to be retained in the uterus and passages after parturition,--a
view which has been adopted by Kirkland, C. White, and other older
authors. It is with sincere pleasure that we now find ourselves supported
by the able author, from whom we have just quoted, in this opinion. Dr.
Ferguson's three positions respecting "the source and nature of puerperal
fever" are highly valuable, for they have been deduced from careful
physiological experiments, and not less sound physiological reasoning;
they are as follows:--
1. The phenomena of puerperal fever originate in a vitiation of the
fluids.
2. The causes which are capable of vitiating the fluids are particularly
rife after childbirth.
3. The various forms of puerperal fever depend on this one cause, and may
readily be deduced from it.
We do not agree with him in supposing that every form of puerperal
inflammation is produced by vitiation of the circulating fluids, because
in one species of uterine phlebitis, which occurred sporadically, and
prevailed a good deal from 1829 to 1832, it was, in our opinion, evidently
produced _directly_ by the absorption of putrid matter into the uterine
veins and lymphatics, exciting inflammation in these vessels: the same
cause, when only carried to a certain extent, produces a local
inflammation, which, when affecting the general circulation, is followed
by fever. Thus, then, we may have in the same case uterine phlebitis
followed by the typhoid malignant puerperal fever--the local and
constitutional disturbance arising from the same cause, imbibition or
absorption of putrid matter; the one being the local, the other the
general effect, but not the one resulting from the other. The doctrine of
the vitiation of the blood from its admixture with pus secreted by the
lining membrane of an inflamed vein, though very plausible, still requires
farther confirmation, for it is doubtful if the introduction of pure
healthy pus into the circulation produces any of those dangerous effects
which result from the absorption of putrid matters, whether purulent,
sanious, mucous, &c. It is the introduction into the circulation of an
animal poison generated by putrefaction, which destroys the vitality of
the blood, and renders it unfit for maintaining the vital powers.
Few have expressed this opinion more strikingly than Dr. Kirkland,
although so long ago as 1774; and it has often created our surprise, that
amid all the numerous writings on this subject, which have excited
attention during later years, so little notice should have been taken of
his observations. We consider that Dr. Kirkland is one of the earliest
authors who has shown that puerperal fever is not the result of
inflammation, but that it may be produced by the introduction of an animal
poison into the circulation. "There are other causes beside inflammation
which bring on a puerperal fever; for it sometimes happens that coagulated
blood lodges in the uterus after delivery, and putrefying from access of
air, forms a most active poison, is in part absorbed, and brings on a
putrid fever. In this case the discharge which should immediately follow
delivery is not sufficiently large, making allowance for the difference
which happens to different women in this respect: small clots of blood
make part of the lochia, which are less in quantity than they ought to be;
but the patient has not any other sort of complaint for three or four days
till the retained blood begins to putrefy. A fever then first makes its
appearance, followed by a quick weak pulse, thirst, pain in the head, want
of sleep, sighing, load at the præcordia, restlessness, great weakness,
dejection of spirits, either wildness or despair in the countenance, and
the white of the eyes is often a little inflamed." (_A Treatise on
Childbed Fevers_, by Thos. Kirkland, M. D. p. 70.)
The late Mr. Charles White, of Manchester, adopted a similar opinion, and
in our published lectures we have quoted largely from these two authors in
support of the opinions which we have there advanced.
Dr. Ferguson's opinion, that the different modes in which the poison
infecting the circulation manifests itself, give rise to the different
forms of puerperal fever, is highly interesting, and deserves great
attention. He conceives that in some instances it spends its virulence
upon the peritoneum, producing the inflammatory peritoneal form of
puerperal fever. He considers that the gastro-enteric form arises "from
the action of the poison being directed to the liver, the organ through
which, as the experiments of Gaspard and Fontana, and the admission of all
physiologists show, most poisons received into the system endeavour to
escape." (_Op. cit._ p. 85.) These views have been proved by injecting
putrilage, &c., into the veins of animals, and the effects of which, both
as seen in the symptoms during life and the appearances after death, tend
strongly to confirm these opinions; still we cannot feel justified in
excluding inflammatory forms which have not been indirectly produced by
the vitiation of the circulation, but which are the more direct effects of
labour itself, or, as we have before observed, from the immediate
absorption of putrilage, &c., into the veins and lymphatics, and
production of inflammation in them. The production of inflammation in
that part of a vein or absorbent, with which putrid matter has come in
immediate contact, is an important fact, for it is by this means that
nature prevents the poison being carried into the general system, and
thus, instead of generating a malignant fever, she limits the injury to a
local inflammation, by which farther mischief is confined by the effusion
of coaguable lymph, tumefaction, and other means for rendering the vessels
impervious. In making these remarks we wish it to be distinctly
understood, that we by no means under-value the views brought forward by
Dr. Ferguson, that "the introduction of a poison into the circulation is
capable of producing local inflammation, varying according to the strength
and qualities of the agent," &c.
The results of Professor Tiedemann's experiments, of which we have given
an abstract in the _Brit. and For. Med. Rev._ vol. i. p. 241, contain some
facts which throw much light as to the modus operandi of certain agents
when mingled with the circulation, and tend still farther to prove the
correctness of Dr. Ferguson's views. In the experiments where musk was
injected into the femoral vein of a small bitch, the effects of the poison
upon the abdominal viscera were remarkable; the veins of the abdomen were
distended with dark coloured blood, the whole intestinal canal was very
red, the mucous membrane of the stomach had a reddish tinge; that of the
whole intestinal canal was of a dark red, it was swollen, turgid, and in
the highest state of engorgement--the canal also contained a quantity of
effused dark blood in its lower part; the vessels of the liver and spleen
were gorged with dark blood.
We are anxious to impress upon the minds of our readers the physiological
fact, that most, if not all, vegetable and animal poisons do not act
_primarily_ on the nervous system, but indirectly through the medium of
the circulation. "The physiological researches (as we have observed
elsewhere) especially during the last thirty years, both in this country
and the continent, have satisfactorily proved that most, if not all, of
the agents which exert such destructive energies on the nervous system, do
it through the medium of the circulation: this has been shown by the
experiments of Christison and Coindet, of Brodie, Emmert, Viborg, and many
others. Those of Sir B. Brodie on the action of the Woorara poison are
well known. Emmert showed this to be the case in a still more striking
manner, by amputating the leg of an animal, and leaving it connected to
the body only by means of the nerves; poisonous substances introduced into
the foot produced no effects, not even when applied to the trunk of the
nerve; and Viborg even applied one drachm of concentrated prussic acid to
the brain of a horse, which had been exposed by trepanning, without
producing any effect." (_Brit. and For. Med. Rev._ vol. i. p. 559.)
We cannot agree with the opinion, "that the vitiated state of the blood is
the secondary and not the primary link in the chain of phenomena," and
"that the nervous system is the main instrument by which this change in
the blood takes place." (Locock, _op. cit._ p. 353.) "We believe that is
_not_ the deficiency of nervous influence which primarily tends to
deteriorate this fluid (although it may possibly react in this way
afterwards,) but the deteriorated condition of this fluid, which renders
it incapable of supplying the brain and nervous system with their due
degree of energy." (_Brit. and For. Med. Rev._ vol. ii. p. 483, 1836.)
In considering the phenomena of fever, Dr. Stevens has well observed, that
we must not look upon them "as the result of either a nervous impression,
or local inflammation, for even in the beginning of fever its symptoms are
universal and peculiar to itself. It is not, therefore, a local affection;
and in all the idiopathic fevers, but particularly in those that are
produced by the aerial poisons, there is but one thing which is never
absent, namely, the diseased condition of the whole circulating current,
and, therefore, this alone can be fairly considered as essential to the
disease. This morbid condition of the blood is decidedly the first link in
the chain of those phenomena which constitute fever, for even before the
attack every drop of the vital currant is changed in its properties; and
wherever this deranged blood can circulate, there fever extends its
empire: for the cause which produces this disease is not confined to a
part, but acts on every fibre, and in every tissue of the living system;
it disturbs every function in the body, and deranges every faculty of the
mind. All the excretions are in a diseased state, and every one of the
secreted fluids is changed both in its quantity and quality. The blood is
the medium that conveys the poison, while the impression on the nerves is
merely the effect of the diseased condition of its natural stimulus." (_On
the Blood_, p. 273.)
These observations just quoted, apply strictly to the causes as well as to
the phenomena of puerperal fever, more especially of the adynamic kind;
and show that, particularly in this form, we must not merely refer the
cause to the absorption of putrid matters by the uterine veins and
lymphatics, or to the commixture of the blood with pus secreted from the
coats of an inflamed vein, but to the still more pervading and truly
epidemic and contagious action of miasmata, with which the air that
surrounds the patient is charged. The lungs afford a ready and ample means
by which effluvia may be conveyed into the circulating current, and
enables us to account for the fact adduced by Dr. Stevens, that in
situations favourable to the production of fevers, the blood is frequently
found in a very unhealthy state, even before the outbreak of the disease
itself. Dr. Kirkland has nearly anticipated the discoveries of later years
upon this subject; and considering the time at which he wrote, we think
that his observations are both interesting as well as valuable.
"Seeing then that an absorption of putrid matter will bring on a
_puerperal fever_, with common symptoms, may we not conclude that the
putrid miasms of lying-in hospitals will produce the same effect? Is it
not reasonable to suppose, that the _puerperal fever_ which has been
observed in hospitals, is owing to some cause peculiar to hospitals?
otherwise, would it not be equally frequent in other places? Dr. Pringle
informs us that the foul air occasioned by one mortified limb brought on a
malignant fever in the military hospital. Peu also seems to have proved,
that the putrid _effluvia_ exhaling from wounded men brought on a fever
which killed a great many child-bed women who lay in the same hospital;
and are not the putrid _effluvia_ arising from the lochial discharge in
lying-in hospitals capable of producing the same disease? I have sometimes
been called to women in child-bed, where the offensive _effluvia_ arising
from this kind of evacuation, pent up in a small close room, at once
evinced to what cause their fever was owing; and though I have not any
doubt, but in lying-in hospitals every attempt is made to preserve the air
pure and the patient in a state of cleanliness, yet where many women lie
in the same ward, it is perhaps impossible to obtain these advantages in
the perfection to be wished." (_Op. cit._ p. 73.)
Van Swieten compared the state of the inner surface of the uterus with
that of a large wound,--"Something of a like nature seems to be affected
in the womb, but in a slighter manner, because the injury is here
superficial, but on a broad surface." (_Comment. on Boerhaave_, § 1329.)
He quotes also an interesting description from Moschion of the changes
which are observed in the evacuations after delivery,--"_Primo sanguis,
secundo fæculentus et paucus, ultimo purulentus_." "It hence appears," he
observes, "that that fever in lying-in women, which is called the milk
fever, does not spring solely from the milk brought into the breasts, but
also from the purifying of the womb by that gentle and superficial
suppuration. But, as even the best pus when retained too long becomes
acrid and putrefies, the same thing will hold with regard to the purulent
evacuations after delivery, if they should be kept back." "But if that
purulent matter does not come out, but being sucked back should be mixed
with the humours, it may, being brought to the viscera by a bad metastasis
of the morbid matter, give occasion to dangerous disorders."
This comparison by Van Swieten and Dr. Kirkland, of the state of the
uterus with that of an open wound, has been recently brought into notice
by Cruveilhier, and quoted by Dr. Ferguson, in his work. "All the uterine
veins and arteries have been torn from the placenta, and they form a part
of a large wound, and are, therefore bathed in all the secretions which
necessarily take place while this wound is healing. In this respect the
uterus presents an exact analogy to the surface of an amputated stump; and
it is, therefore, not surprising, that the secondary evils of amputation
should be so similar to those of the puerperal state." (_Op. cit._ p. 75.)
Professor Schönlein also considers that the contagion of puerperal fever
has the greatest similarity with hospital gangrene.
The causes of puerperal disease which have been enumerated by Cruveilhier,
apply almost solely to those inflammatory affections of the puerperal
state which do not depend upon a vitiated state of the circulation, but
"are derived from the changes induced by parturition, and are dependent
on,
"1. The organic changes induced by pregnancy.
"2. Those induced by the act of labour.
"3. Those consecutive of labour.
"1. Pregnancy:--the hyperthrophy of the uterus; the enlargement of the
ligamenta lata; the traction on the peritoneum of the neighbouring organs;
the extraordinary development of the arteries, veins, and lymphatics.
"2. Changes induced by labour:--bruising of all the soft parts--they
appear raw.
"3. Changes after labour:--the woman presents the faithful picture of one
who has undergone a serious surgical operation. The internal surface of
the womb may be compared to a vast solution of continuity; the whole of
the mucous membrane has been altered by the inflammation, of which it has
been the seat; the gaping veins are like the open mouthed vessels of an
amputated limb.
"Except just at the inner surface of the cervix uteri, there is no mucous
membrane at all; but the muscular tissue of the uterus is every where
exposed. This, therefore, like the stump, is to be covered by a new
membrane.
"This process of reparation is accompanied by a traumatic fever, called
milk fever. Like the fever from wounds, it has its period of incubation,
varying in various individuals: it lasts about twenty-four hours, and
vanishes on the third day.
"As in amputation, a false membrane covers the stump, and precedes
cicatrisation, so the inner surface of the womb is first covered with a
false membrane before it is cicatrised. If there be no lochial discharge,
there is union by the first intention, as in the stump where there is no
discharge: this is the rarest of all cases.
"Ordinarily, this false membrane is thrown off with a purulent discharge,
which is the lochia. At first it is sanious, _i. e._ mixed with blood, and
fetid; then less fetid and more purulent; then thin and serous. The
quality and quantity of the discharge are, as in amputations, an index of
the state of the wound." (_Cruveilhier_, quoted by Dr. Ferguson, p. 76.)
The comparison between the inner surface of the uterus shortly after
parturition and that of a stump, does not hold good in every respect: in
the one, the open mouths of the vessels are pretty firmly compressed by
the contracted state of the surrounding uterine tissue, whereas, in the
other they are uncontracted beyond the mere effects of the traumatic
inflammation upon their cut extremities, and they are surrounded by the
flaccid surface of divided muscles: still, however, it is quite sufficient
to show, that the inner surface of the uterus must be for some days bathed
in mucous, sanious, and purulent fluids, highly prone to decomposition;
and that, in this state, absorption is peculiarly liable to take place.
The vehement exertions of the uterus and abdominal muscles during labour,
and the violent pressure to which the abdominal circulation has been
subjected at this time, are sources of inflammation, which, although not
noticed by Cruveilhier, are frequently met with quite independent of
puerperal fever, although, from what we have already stated, it will be
evident that the disposition to absorption and consequent vitiation of the
blood will be still farther increased by the excited state of the
circulation.
Where blood has been vitiated by the action of aerial poisons, or
introduction of putrid matter into its current, changes are quickly
produced in its condition, which not only unfit it for the varied
functions which it has to perform, especially in maintaining the activity
of the brain and nervous system, but which may be perceived, as already
shown, before the disease itself appears. It is dark, and of an unhealthy
tinge. In severer forms of typhus, "when first drawn, it has a peculiar
smell, and coagulates _almost invariably_ without any crust. There are
black spots on the surface of the crassamentum; the coagulum is so soft
that it can easily be separated with the fingers, and during its
formation, a large quantity of the black colouring matter falls to the
bottom of the cup. When the serum separates, it has generally a _yellow_,
and in some cases even a _deep orange_ colour." (Stevens, _op. cit._ p.
219.)
Dr. Tweedie has observed similar conditions of blood in the common typhus
of the metropolis, and remarks, "that in this class of fevers, the
crassamentum of the blood, instead of forming a firm coagulum, is loose,
small in proportion to the quantity of serum, and so soft that it breaks
readily on attempting to raise it, resembling in consistence half-boiled
currant jelly, and that in some instances, when abstracted late in the
disease, it is scarcely coagulated at all." (Tweedie, _Clin. Illust. of
Fever_, quoted by Dr. Stephens.)
This accords closely with the appearances of blood drawn from patients
under puerperal fever, especially of the adynamic form. The blood is of a
dark muddy colour, in some cases resembling even thin treacle in
consistence: in this state the coagulation is very imperfect, so that
after a time it merely forms a homogeneous semi-gelatinous mass, with
little or no separation of serum from the crassamentum. After death the
blood is found perfectly fluid, readily infiltrating and staining the
coats of the vessels which contain it, and resembling thin watery claret,
both in colour and consistence. In the other forms, which are of a more
inflammatory character, it is highly buffed and cupped; the crassamentum
is small, the albuminous layer upon it is of a muddy yellow colour; and
the serum, which is frequently large in proportion, is of a similar
colour, or even of a slight bilious tinge; in some, there has been
occasionally observed a white cloudy appearance, as if from the admixture
of milk.
The mortality of puerperal fevers depends in great measure upon the form
they assume; and, as we have already stated, this will vary in great
measure according to the period of the year, the nature of the season, and
the type of the prevailing epidemic fevers in the neighbourhood, whether
they assume the character of synochus, or low malignant typhus. It varies
a good deal according to the class of patients attacked, being more
frequently of the inflammatory character among the middling and higher
classes, whereas, among the lower orders, who are exposed to the
depressing effects of cold, damp, and ill-ventilated dwellings, of
insufficient clothing and food, of an atmosphere poisoned with the noxious
effluvia arising from a dirty and thickly inhabited suburb, and habitual
intemperance, it generally assumes the adynamic or contagious form. This
is the reason that puerperal fever is not only seen less frequently among
the middling and upper ranks, but even when it does appear, from being
usually of the inflammatory form, it is more tractable. It is in lying-in
hospitals, where it appears in all its terrors, and occasionally assumes
such a degree of malignity as almost to equal the plague or yellow fever,
in the frightful rapidity of its course, and in the almost certain
fatality of its termination. Few have witnessed it in a more destructive
form than the late Dr. W. Hunter at the British Lying-in Hospital. He
observes in his lectures that he had seen a great many cases of it in the
hospital, "and particularly in one year, when it was so remarkably
prevalent there. It was so bad, that not only every gentleman belonging to
the hospital, but all our friends in town, had a consultation to think
whether we should shut up the house. _In two months thirty-two patients
had the fever, and only one of them recovered._" (_MS. Lectures._)
Although puerperal fever has never yet attained the frightful degree of
mortality at the General Lying-in Hospital, nevertheless, it has appeared
repeatedly with such malignity, as to commit fearful ravages among the
patients. In these epidemics, the first few cases are generally
comparatively mild, being of the peritonitic or gastro-bilious form
(_Douglas_:) but as it advances, the malignant adynamic form, which is so
destructive, prevails. In some epidemics, as is seen in common fevers,
after a short time the disease has become more tractable, it has assumed a
milder character, and ultimately has again disappeared. This corresponds
with the admirable remarks of Dr. Gooch, to whose graphic pen we are
indebted for much valuable information on the subject of puerperal fevers.
"Another remarkable circumstance about this disease is, that, when it is
most prevalent, it is most dangerous. Each case is more difficult of cure
than when it occurs seldomer. The practitioner finds, that, although the
group of symptoms resembles what he was formerly accustomed to, he has now
to deal with a disease far more obstinate and destructive, and his usual
remedies are not so successful as formerly; he loses case after case in
spite of his best efforts. When it has been thus raging for a considerable
time, it at length subsides; the case becomes less frequent and less
severe; the practitioner finds his treatment becoming more successful,
partly because experience has taught him to detect it earlier, and to
treat it better, but probably also because the disease has itself become
milder." (Gooch _on Peritoneal Fevers_, p. 3.)
The table of the cases at the General Lying-in Hospital and their
mortality, which Dr. Ferguson has calculated during the twelve years, from
March 1827, to April 1838, is highly important, and points out the period
of the year in which puerperal fever, prevails most, and the contrary. The
last two and the first seven months of the year are those in which the
greatest mortality occurred; whereas, in the month of July, during this
whole period, not a single patient died; in August only one; in September
two; and again, none in October, although several were attacked.
"Puerperal fever was _epidemic_ in the years 1828, 1829, 1835, 1836. 1838;
in the other years it was only sporadic. The greatest mortality was in the
years 1835 and 1838, in the last of which 20 in 26 died. The malady
commenced in January, in which month Dr. Rigby saved only 1 out of 9. The
hospital was closed for a month, and opened again in March, when he
succeeded in rescuing only 2 in 8. Thinking that another mode of treatment
might be more successful, I determined to bleed largely, and to salivate.
This plan was fairly tried under the constant attendance of Dr. Cape, and
with my supervision, but 3 only in 9 lived. Seeing that no treatment was
of avail, the hospital was closed from May till November." (Ferguson, _op.
cit._ p. 277.)
_Different species of puerperal fever._ Having premised these general
observations on puerperal fevers, we now proceed to consider them
separately, according to the various forms which they exhibit; and in
doing so, shall adopt the arrangement of the subject made by Dr. Douglas,
viz. under the three heads of inflammatory gastro-bilious, and the
contagious or adynamic form. It is not only one of the earliest, but in
our opinion, one of the most correct; nor do the arrangements adopted by
Drs. Locock and Ferguson differ essentially from it. We hope by this means
to combine the advantages which each affords, while we hold ourselves free
to differ or coincide with either, as our opinions lead us, trusting that
we shall thus be able to render this complex and difficult subject more
complete.
Under the inflammatory form we shall not only consider the acute
peritonitis, so ably described by Dr. Locock, which is chiefly produced by
the effects of labour, to which we have already alluded in the quotation
from Cruveilhier, but also that form which, according to Dr. Ferguson,
arises from vitiation of the blood, by the introduction of putrid matter
into the circulation; a form which has not only a great disposition to
assume a typhoid character, but also to become epidemic. Under this head
we must also bring the uterine inflammation and phlebitis, which we have
described, as resulting from a direct action of putrid matters contained
in the uterus, a form which is very liable to pass into uterine, and
afterwards general peritonitis; lastly, there remains that species of
nervous abdominable pain, which has received the name of false
peritonitis.
_Puerperal Peritonitis._
_Symptoms._ The acute peritonitis, which has been produced by the effects
of labour, generally makes its appearance at an early period after. The
labour has probably been either tedious or severe, the efforts of the
uterus and abdominal muscles have been violent, especially during the last
stage; and from the moment of the child's birth, the patient has
complained of considerable soreness over the lower part of the abdomen,
amounting to much pain and tenderness when touched. At first she is
tolerably easy, so long as she lies still, and keeps the abdominal muscles
in complete repose; but, by degrees, fits of pain come on, they become
more frequent, and the intervals between them shorter and shorter, until
the pain is constant; she now complains of much tension and fulness of the
abdomen; the tenderness is greatly increased, both in severity and extent,
and is often attended with the painful sense of twisting about the
umbilicus, which is observed in ordinary forms of peritonitis. The pain
and tension are now so severe that she is constrained to lie wholly upon
her back, with the knees drawn up, in order to relax the abdominal
muscles, and thus, if possible, alleviate her sufferings. The abdomen
itself is evidently fuller to the feel, and is beginning to be tympanitic;
the breathing is quick and anxious; the tongue has a thin coating of white
fur, which is browner and thicker at the back; the pulse is quick and
hard, sometimes small and wiry, occasionally full and strong; the lochia
and milk have either never appeared, or only in small quantities, to be
quickly suppressed again. As the tympanitis increases, the breathing
becomes more anxious and painful; for every effort of the diaphragm in
inspiration is followed by severe pain, from the movement which it
produces in the abdominal contents. After awhile, the flatulent distention
of the intestines, particularly of the stomach, renders the diaphragm
irritable, and provokes hiccough, which is excessively painful from the
involuntary jerk which it gives to the abdomen; or, what is still worse,
retching and efforts to vomit frequently come on, which greatly aggravate
her sufferings. She now lies upon her back, perfectly helpless and
immoveable, for the slightest attempt to touch her is insupportable; even
the jar of a person walking heavily across the room excites pain. The
abdomen is now even larger than it was before labour, her anxiety and
restlessness increase, and she rapidly becomes exhausted from suffering
and want of sleep. The face becomes sallow, the features fallen, the
tongue dry and brown, and sordes collect upon the teeth; she falls into an
uneasy slumber, during which, the eyelids remain partly open, or she
mutters incoherently with low delirium. The abdomen is less painful, but
not diminished in size; the pulse is small, hurried, and feeble; subsultus
tendinum and picking of the bed-clothes follow, with all the other
symptoms of approaching dissolution.
Where the attack has risen from the introduction of putrid matter into the
circulating current, it usually appears somewhat later, seldom before the
third day after labour: it is almost invariably preceded by a severe
rigour, followed by intense headach, and darting pain about the lower part
of the abdomen, which gradually becomes constant. There is a nearer
approach to the adynamic form, or rather, it is frequently attended, or at
least followed, by this disease; hence the inflammatory stage is shorter,
the pulse is even more rapid, and loses its strength sooner than in the
other form; the milk and lochia have usually not only been established,
but continue, we think, longer afterwards than in the other case; the pain
is perhaps less in many instances, but in other respects, the first part
of the attack does not differ essentially from the form above described;
but as the disease advances, it gradually assumes the adynamic form; the
inflammatory symptoms of the early part of the attack are merged in the
general collapse which now exists, the same cause which had produced the
peritoneal inflammation now acting on the whole system.
Peritonitis occurring by itself, is, as Dr. Ferguson observes, of
comparatively rare occurrence in puerperal women, the condition of the
system during childbed, disposing it quickly to assume more or less of the
adynamic character.
_Appearances after death._ On examining cases of fatal puerperal
peritonitis, we shall find marks of inflammation, or its consequences,
over a large extent of the peritoneum; large portions of it are highly
congested, and more or less thickened; considerable effusions of serum or
sero-purulent fluid, mixed with flakes of coagulable lymph, into the
abdominal cavity: the omentum adhering to the intestines, and also the
intestines to each other, by means of coagulable lymph, in which they are
occasionally completely imbedded; the broad ligaments and ovaries are
frequently much inflamed, covered with lymph, and the latter more or less
softened; the Fallopian tubes engorged and adhering to the neighbouring
parts; the uterus is covered at its fundus with a coating of coagulable
lymph, as if it had been smeared with a quantity of dirty white paint, and
this extends more or less in patches over the various reflexions of the
peritoneum, in the upper parts of the abdominal cavity.
_Treatment._ We may take it as a rule, that the earlier we see the patient
in the disease, the less active will be the treatment required. At first,
when the pain has not yet assumed its full intensity, and only occurs in
paroxysms, when little or no traces of abdominal tension and fulness are
to be perceived from incipient tympanitis, we may frequently succeed in
cutting short the disease by a full dose of calomel and James's powder,
with some morphia or Dover's powder, to allay irritation and assist in
producing a general determination to the skin; this must be followed by
some castor oil, and if the pain is no longer constant, with the addition
of a few drops of Liquor Opii Sedativus. Where the pain has already become
severe, a draught of sulphate and carbonate of magnesia in peppermint
water, with a little antimonial wine and henbane, will be preferable. We
have long since been convinced, that common black draught, or any form of
purge which acts violently or gripes, is objectionable, having frequently
seen a return of pain brought on by its action. A hot poultice of
linseed-meal, large enough to cover the whole abdomen, and as hot as the
patient can bear it, must be applied; this, if made properly, will prove a
great relief, for it not only allays the pain, but quickly acts as a
powerful diaphoretic: there is a little art in making this, and unless it
be done properly, it is apt to produce much discomfort, and do more harm
than good. The water should be poured boiling hot on the linseed-meal, and
the mixture well beaten with a large spoon, until it forms a nearly
gelatinous mass; it should then be spread upon a large piece of linen, so
as to be between a quarter and half an inch in thickness; there is now
only one layer of cloth between the poultice and the patient's abdomen,
and it can be applied or removed with perfect facility: without these
precautions it is apt to form a pudding-like mass, which greatly annoys
the patient from its weight, and from being applied directly to the
abdomen, smears about, and is not easily changed. A poultice made in the
manner now described, will keep hot for three hours at least, and is by
far the most effective form of fomentation which can be employed. Common
fomentations of sponges, or flannels wrung out of hot water, are by no
means desirable, as from the constant exposure, which is required for
their frequent repetition, the patient has little benefit from the
temporary heat, and is very liable to catch cold.
If the symptoms do not yield to this treatment, but assume a more
formidable aspect, or if the attack has not commenced in this gradual
manner, but has come on much more suddenly and with greater violence,
recourse must be had immediately to the lancet. Leeches are seldom proper
as a substitute for bleeding, although they frequently prove of great
value afterwards. A certain effect is required to be produced upon the
general circulation, before leeches are capable of affording even a
temporary relief; and so far from economizing the patient's powers by
using leeches instead of the lancet, we shall find that in order to
overcome the inflammation by this means, the patient will require to lose
a far greater quantity of blood than if it had been suddenly removed from
the circulation by bleeding. Upon the same principle, therefore, we must
take care, that the blood shall be drawn _pleno rivo_ from an ample
orifice: we thus spare the patient an unnecessary loss of power, for the
required effect upon the circulation is produced in a much shorter time
and with less expenditure of blood, than if the blood had been slowly
dribbled from a small opening.
"In the treatment of acute inflammation in the vital organs, the customary
practice is to consider local bleeding as a milder means of effecting the
same object as general bleeding, and to postpone it till the stage for the
latter is over. To me it appears that they are calculated to effect two
different objects, both of which are necessary at the beginning of the
treatment; the one to reduce the violence of the general circulation, the
other to empty the distended capillaries of the part. As long as the pulse
is quick, full, and hard, it is in vain to take blood from the affected
part; if we could completely empty its gorged capillary vessels, they
would be instantly gorged again, whilst the heart and large arteries are
injecting them with so much violence. On the other hand, after having
reduced the force of the general circulation, the capillary vessels of the
part often remain preternaturally injected: this, I conclude, from the
fact that the patient is often not relieved till local blood-letting has
been used, and then is relieved immediately. Hence, as soon as the patient
has recovered from the faintness occasioned by bleeding from the arm,
leeches ought to be applied without delay." (Gooch, _on Peritoneal
Fevers_, p. 47.)
It is impossible to fix what quantity of blood is to be drawn; nor is it
easy, either from the patient's appearance or the feel of her pulse, to
foretell how much she will require to lose: a certain effect is to be
produced on the circulation in order to bring it under such control as
will moderate the state of inflammation. No two patients are alike in this
respect; and it frequently happens, that where, from external appearances,
we might have expected to find most strength, faintness is quickly
produced, and _vice versâ_: on the whole, we think that where the patient
has a small, quick, and oppressed pulse, we may expect she will require to
lose a large quantity of blood, for in these cases the pulse rises in
volume and strength as the bleeding proceeds; hence, as before observed,
we must "carry the bleeding to its proper limits, which is the approach
to, or actual state of, syncope." So far from removing the pillows, and
letting her lie with the head low, so as to recover from her faintness as
quickly as possible, it will be much better to support her in a sitting
posture, and thus prolong the state of faintness for some while; the
dilated vessels have now time to contract, the heart returns to a more
moderate and healthy action, the effects of the bleeding are much more
permanent, and the chances of its repetition being required considerably
diminished. From this state of relaxation and temporary collapse being
prolonged, we find that the secretion of the skin, and particularly the
intestinal canal, are more easily re-established, the operation of a
purgative being now much quicker and more effective.
As soon after the bleeding as possible, a smart dose of calomel and
James's powder, followed by an active saline laxative, must be given; and
the combination of sulphate and carbonate of magnesia with antimonial wine
and Tinct. Hyosc. already recommended, is preferred by us: it is better
given in divided doses, as then the effects of the antimonial is
prolonged. The action of the bowels may also be assisted by a domestic
enema: and if there are no signs of action in the bowels after two hours,
the purgative should be repeated. The results of the leeches, fomentation,
and purging, will guide us as to the necessity of repeating the bleeding.
Dr. Gooch's truly practical remarks on these points are well worthy of
attention:--"I waited till the purgatives had operated fully, that I might
know what impression the combined operation of general and local
blood-letting had produced on the disease, before deliberating on the
employment of a second blood-letting. The common effect, of these remedies
was this, as long as the faintness lasted in the slightest degree, the
pulse remained soft and often slower, and the pain was much less, or
ceased altogether; but an hour or two after the bleeding, when the
circulation had recovered, the pain returned more or less, and the pulse
regained much of its hardness or incompressibility. This state continued
till the leeches had bled freely, and the purgatives had acted repeatedly
and copiously." (_Op. cit._ p. 48.)
If, however, the pain has experienced but little abatement, or has
returned as severely as before; if the pulse has quickly reassumed its
former condition; if the action of the purgatives has not taken place, or
has been at most unsatisfactory, even with a repetition of the saline, we
are justified in having recourse to a second bleeding; the faintness this
time will probably be more complete; the effect upon the disease more
decided; and, in all probability, it will be quickly followed by free
evacuations from the bowels, which produce great relief. In some cases the
bleeding requires to be repeated again and again before the disease can be
subdued: this, however, usually arises not so much from the obstinacy of
the attack, as from the first bleedings not having been performed in an
effective manner. "The pulse," says Dr. Locock, "is the best guide, for
the pain after the first full relief from the bleeding is often of a mixed
character, partly inflammatory, partly nervous, to be detected only by
watching closely the other symptoms. The tenderness is a less certain
guide, for few will bear pressure for a considerable time after the
inflammatory symptoms have been entirely relieved. Many patients also from
fear shrink from the pressure of the hand, although by drawing off the
attention, it will be found that they bear firm and steady pressure very
well." (_Op. cit._ p. 355.)
Throughout the whole process of treatment, the linseed-meal poultices must
be continued, and, if not made too heavy, can be borne when there is a
considerable degree of abdominal tenderness.
In all cases where the disease has not been completely checked in the very
outset, but has shown a disposition to return, the treatment
above-mentioned should now be followed by a mild mercurial course. The
effects of mercury in allaying inflammation at a certain stage, which does
not appear to be fully under the control of mere antiphlogistic remedies,
have been amply proved by British practitioners: this applies particularly
to inflammation of serous membranes: mercury not only tends to prevent the
effusions of serum and coagulable lymph, but, where they have taken place,
it is of great value in promoting their absorption. We agree with Dr.
Locock, that calomel is by far the best form in which it can be used,
where we wish to obtain its specific effects. The Hydrargyrum cum Cretâ,
which we have occasionally found useful in the gastro-bilious or enteric
form to restore a depraved state of intestinal secretions, has failed us
in the other forms where we wished to produce salivation. The purgative
dose of calomel, which we have advised to be given after the bleeding,
ought not to be less than six to eight grains; but now, as the dose is to
be repeated every two or three hours, a smaller quantity will be
sufficient: in order to save time we usually begin with five grains of
calomel, and an equal quantity of Dover's powder, and repeat this in an
hour's time, after which, we proceed with doses of two or three grains
every second or third hour according to circumstances. The sooner the
system can be brought under the influence of mercury the better, the pulse
becomes softer and less frequent, the pain and tension of the abdomen
diminish, the tongue becomes moist and natural at the edges, and general
improvement follows. Throughout the whole attack the vagina should be
occasionally washed out with warm water, more especially if we have reason
to suspect that the disease has arisen from the imbibition or absorption
of putrid matter. The smell of the patient will frequently guide us in
this respect, and point out the condition of the passages and their
contents; even if there be no putrid matter lodging there, the application
of warm water will always act as a comfortable fomentation to the patient,
and assists not a little in favouring a return of the lochia.
If the pain and swelling of the abdomen still continue, and the case is
evidently becoming more unfavourable, we have occasionally sprinkled the
abdomen with spirit of wine or oil of turpentine, and then covered it with
a fresh poultice: this has acted as a powerful rubefacient, and has in
some cases relieved the patient at a very advanced stage. We have also
tried blistering the abdomen, and dressing the vesicated surface with
strong mercurial ointment, as recommended by Dr. Locock; but we have not
met with the success which he mentions, probably from the disease having
already assumed the malignant characters of the adynamic form, and, in
some instances, because the patient could not endure the intense smarting
which it produced. We have occasionally covered the abdomen with
camphorated mercurial ointment without previous blistering, and with good
effect. The internal use of turpentine, circular friction upon the
abdomen, and enemata of Mist. Assafoetidæ, &c., which we have sometimes
found useful in removing the tympanites of the adynamic puerperal fever,
and which does not depend on an acute form of inflammation, are scarcely
applicable in the present case.
When the powers are beginning to fail, as a last hope we must have
recourse to stimulants combined with nourishment: the Mist. Spiritus Vini
Gallici of the last London pharmacopoeia,--anglice, "egg and brandy,"--has
for many years been used at the Lying-in Hospital to support the system at
this last stage, and sometimes even under the most unfavourable
circumstances with marked success; powerful doses of ammonia will be
required at frequent intervals, and an occasional opiate, to procure the
still farther refreshment of sleep. Even where the face is assuming a
Hippocratic appearance, the pulse so feeble and rapid as scarcely to be
counted, where the abdomen is immensely distended, with cessation of pain
and cold clammy state of the skin, we ought not to despair; no case,
however bad, is entirely hopeless; and although the majority of such cases
perish in spite of the greatest care and activity, still we are justified
in persevering till the last, knowing from experience that we every now
and then succeed even at this late hour in rescuing our patient.[145]
_Uterine Phlebitis._
In describing the other species of inflammatory puerperal affection, which
we have designated by the title of uterine inflammation or phlebitis, and
which we conceive arises in most instances, from the presence and
absorption of putrid matter in the uterus, we shall merely confine our
description to the early part of the disease, because, as it invariably
terminates in peritotinis if not stopped at an early period, it will be
unnecessary to go over this part of our subject again.
_Symptoms._ This affection generally makes its appearance on the second,
third, or fourth day after labour, and varies considerably in its mode of
attack. In some cases it will be observed to come on suddenly, with
scarcely any premonitory symptoms. The patient is suddenly seized with
severe griping pain in the lower part of her abdomen, generally extending
more or less to one side, and usually preceded by a smart shivering fit,
which is followed by intense headach. On examining the abdomen, the uterus
is hard, larger than natural, and excessively painful to the touch; the
pulse quick and usually small; the tongue covered with a thin white fur,
becoming brown and thicker towards the back part; the countenance anxious.
With all this, the abdomen is neither hard nor painful upon moderate
pressure; not even over the uterus itself do we produce pain, until we
begin to press so hard, that the organ becomes plainly distinguishable to
the hand through the soft integuments. The lochia has either not appeared
at all, or has been suddenly suppressed; and in all probability, the
secretion of milk has followed a similar course.
Or the disease may commence in a much more gradual manner. The after-pains
are observed to increase in severity and duration, producing a
considerable degree of pain over the whole abdomen, but especially the
uterus, which, during the paroxysms, is harder than in the intervals. The
pains are increased by the slightest pressure, if _suddenly_ applied; but,
if gradually increased, the patient will bear a considerable degree of
pressure, not only without complaining, but will even remark that the pain
is, as it were, benumbed by it; if the hand be now suddenly removed, very
severe suffering is produced. The pains become more and more constant,
until they assume the uniform character of inflammation of the uterus, as
already described, when the disease makes its attack suddenly. If the
disease be not checked in its progress, the pain becomes more intense,
and gradually extends over the whole surface of the peritoneum; the
abdomen swells from tympanitis, and is followed by the other symptoms of
acute peritonitis already described. The latter stages of the attack are
almost invariably mingled with symptoms of the malignant form of puerperal
fever,--a circumstance which, when we consider the probable source of the
disease is not to be wondered at. Indeed, we may say, that by the time the
peritonitis is fairly established, the introduction of putrid virus into
the circulation has been of sufficient duration and extent to render the
production of adynamic symptoms almost unavoidable.
_Appearances after death._ Examination after death shows that the uterus
and its appendages have been the chief seat of the inflammation, its whole
peritoneal surface thickly covered with exudations of coagulable lymph;
the broad ligaments vascular; the Fallopian tubes livid, swollen, and
softened; the ovaries greatly altered in appearance and structure, being
generally more or less swollen and much softened,--at times the natural
tissue of the gland completely broken down into a pulpy semi-purulent
mass, at others the external surface only has been red or gorged with
dark-coloured vessels; the whole uterine appendages thickly imbedded in
cogulable lymph. The uterus is large and soft, deposites of pus have been
found beneath its peritoneal covering, or in the proper muscular tissue of
the organ; and in many cases, on cutting into its substance, pus has
appeared in numerous little points, oozing from the veins or absorbents
which have been divided. In those veins which are large enough to be
traced by dissection, their coats have been found vascular, thickened, and
in many places lined with lymph, so that the vessel has become completely
impervious: in others, they have been filled for a space with pus, and
their canal then obliterated, either by swelling, effusion of lymph, or by
plugs of fibrine from coagulated blood. These changes in ordinary cases do
not extend beyond the substance of the uterus; but where the disease has
been of some duration, as well as severity, they become much more
extensive, affecting the neighbouring veins to some distance.
"Inflammation," says Dr. R. Lee, who has examined this subject with great
care, "having once begun, it is liable, as I have before stated, to spread
continuously to the veins of the whole uterine system, to those of the
ovaria, of the Fallopian tubes, and broad ligaments. The vena cava itself
does not always escape, the inflammation spreading to it from the iliac,
or from the spermatic veins." (_Researches on the Pathology and Treatment
of some of the more important Diseases of Women_, p. 54.)
The surrounding structures are generally implicated in the inflammation;
the muscular tissue of the uterus becomes soft and of a dark red, or even
dirty black colour, and, as before stated, the peritoneum which covers the
organ is particularly affected. The appearances after death in this
species of puerperal fever are those most commonly observed, for puerperal
peritonitis is rarely met with in its uncomplicated form, being usually
more or less mixed up with it; on the other hand, the majority of cases
which belong to the adynamic form of puerperal fever (except the most
malignant) are generally preceded to a certain extent and attended by this
disease.