As shown in a previous chapter, all the various forms of constitutional dyscrasia may develop themselves during pregnancy; so also may they, – till then held as it were in reverse, – finally ultimate themselves in still more dangerous manifestations of disease immediately after parturition. There are cases in which these morbid influences establish themselves, even before the full term, in the form of febris gravidarum, fever of pregnant women, which by its continuance after delivery becomes entitled to the additional designation of et parturientium, and of those lying in. Sometimes these morbid influences terminate the pregnancy before term; and thus destroy the child at the same time that they threaten the life of the mother. The influence which epidemic, traumatic and gangrenous erysipelas, and the peculiar miasms of typhus and scarlatina, may exert in causing fever of lying-in women has already been sufficiently indicated in the examples previously adduced. And the epidemic influence of puerperal fever itself in extending its ravages is but too well understood. And all that is meant by contagion, by the personal transmission of the poisonous effluvia of child-bed fever by physicians and nurses from one patient to another, is but a more direct and perhaps more highly concentrated development of what in its diffused form corresponds to the same epidemic influence. Every animal poison of a putrid nature, like that form post-mortem examinations of persons who have died from puerperal fever as well as that form dissections in general, seems equally capable of establishing this peculiar fever in lying-in women.
In some cases it is evident that the direct application of such poisons to the genitalia of parturient females by means of the hands of accoucheurs, or event he presence of such infected persons in the lying-in room has been followed in a very few hours by the most malignant attacks of puerperal metritis and metro-phlebitis. Not less fatal were those cases of puerperal disease which resulted form receiving the infection of this malady imparted through the respiration of persons who had indeed been exposed to the influence of this disorders, – but had not visited such cases for days, or months, or even years, – as in the case of Dr. Rutter, and in the instances above quoted form Drs. Merriman and Gooch. In these cases, certain individuals are shown to have been endowed with the most unfortunate faculty of retaining and perpetuating in their own persons a sort of concentrated miasm exactly corresponding to the general epidemic influence in this disease. And even as the raw utero-placental surface possesses a wonderful faculty of absorbing the subtle poison locally approximated to it; so the tissues of the peritoneum in the puerperal state seem endowed with a remarkable susceptibility of becoming specifically inflamed by means of the absorption into the general system of the epidemic influence of the same particular poison, or of its personal influence as imparted by the respiration of a person whose system has once been charged with it.
Suppression of the lochia has been regarded as one of the most frequent causes of child-bed fever. But of the two most distinct and most common forms of this disorder, metritis and peritonitis, the former alone appears to be any more than incidentally connected with such suppression. In cases of pure puerperal peritonitis, the lochial discharge will sometimes continue undisturbed; while in cases of inflammation of the uterus, – either in that of its interior surface, or of its muscular tissue, or of both, the lochia may be much diminished or even entirely suppressed. And yet in these latter cases, the young physician will be most woefully deceived who allows himself to believe there is no child-bed fever because he finds no particular swelling or tenderness of the abdomen. Still suppression of the lochia by cold applications or by styptic injections administered in cases of uterine hemorrhage, may very rapidly bring on phlebitis and even gangrene of the uterus. It would scarcely seem possible that styptic or even cold injections could fail to produce such a repulsion of the lochial discharge as would in effect be equivalent to its reabsorption. In damp, moist weather puerperal fever is found to be much more prevalent, – in part perhaps from the more ready and penetrating diffusibility of the poison, and in part no doubt from the general debilitating influence of such weather upon the lying-in women themselves. Over-distention of the bladder; long-continued pressure of the foetal head against the particular parts of the interior of the pelvis, in difficult labors; and compression and even rupture or laceration of the uterus itself, have been mentioned by different authors as capable to producing child-bed fever. “The presence of inflammatory ulceration of the cervix during the first stage of the puerperal period, has appeared to me powerfully to predispose the patient to puerperal fever. The uterus seems to retain a predisposition to inflammation in the puerperal state; even in the cases in which ulceration, having existed during pregnancy, has been cured (allopathically) before parturition occurred. I have met with repeated instances of puerperal fever under these circumstances. (*J.H. Bennett, Inflammation of the Uterus, 1864, p.169. ) But such a result can hardly ever arise from these accidents, unless there is present some additional miasmatic influence.
Fragments of the placenta, still adhering to the uterine parietes and there decomposing, may occasion metro-phlebitis. In like manner the open mouths of the uterine sinuses may become the receptacles of poisonous matters originating in the uterus itself; or even the form of adhesive inflammation by which these sinuses are naturally closed may, under certain conditions presently to be mentioned, lead also to phlebitis and even to gangrene of the uterus. But since in many cases the influences exist without producing such results, – since even the decomposition of portions of the membranes and of the placenta, occasioning an offensive lochial discharge, is not always followed by inflammation of the womb, or any other form of child- bed fever, and since, as already abundantly shown, this disorder will spring up apparently from the slightest cause, or from no obvious cause at all – the question arises, how are these discrepancies to be accounted for?
With regard to those cases which arise from epidemic influence, or from any form of poisonous effluvia from without, nothing here needs to be said; since evidently the puerperal state is one which renders the patient remarkably susceptible to all these influences. But do we not even here approach the solution of the mystery of the sporadic origin of this disease? That condition of a mass which requires but the addition of a little external warmth in order to set it on fire, is in no very remarkable manner different from that which presently leads to spontaneous combustion. The exhaustion of the vital forces, that which in surgical language is technically termed “shock, affords the real clue to much that is obscure and anomalous in puerperal fever. Nature always puts her best foot foremost, – especially in this matter of gestation and parturition, – the former a long- continued and all-absorbing function, of which the latter may be an equally exhausting crisis. In some of these cases, where child-bed fever arises from no external cause, and proves rapidly fatal, we see reason to believe in such profound exhaustion of the vital forces as may lead to ramollissement, putrescence and gangrene of the womb, when such fatal degeneration has been only developed within a very few hours after delivery! To this final act of the grand function of reproduction are summoned all the remaining energies of the entire system; the work is indeed accomplished; but the instrument is destroyed; and the worker is no more! That poor womb has been compelled to expend an amount of vital force in a few short hours which originally might have supplied the whole system for years. Or is it that these vital forces bear so near a relation to electricity, that their excessive development, through the nerves and muscles and blood- vessels of the womb, is followed by a disposition to putridity similar to that which is seen to take place when lightning strikes the whole body* (*In the most rapidly fatal cases, nothing has been met with beyond non-coagulability, thinness, and blackness of the blood. The blood in these cases resembles that of persons killed by lighting or by hydrocyanic acid. – T. Smith.) Such are the ideas associated with the shock of lightning; and not unlike are the consequences which follow such nervous “shock” as we have attempted to portray. What is most remarkable of all is that in some of these cases nature gives no signal of distress till she thus hauls down her colors in sudden despair. Similar indeed is the case in some instances of paralytic shock, in which the apparently strong man is struck down in an instant and without a moment’s warning.
