Such is the extreme pathological view of what fortunately takes place but seldom. The physiological condition, which we now proceed to describe, is that which occurs in other cases, in which the above described profound exhaustion does not obtain. Towards the one great end of sustaining the foetus in utero, all the vital energies of the mother’s system have been for months determined. In the fulfilment of this high use her own health may have been perfect, and her strength not overcome. And even through the last critical act of the drama, that of parturition, – in which all the muscles of her body and all the nobler powers of her system are called into action, – she may pass with comparative ease. True she is fatigued and weakened by such tremendous exertions. But a few days of rest would make ample amends for this, – if this were all. But it is not; for hitherto we have given but a superficial picture of the physiological reality. All the mother’s circulation and the entire economy of her nutrition have been made to assume one single direction, and the great currents of her life have but flown in unison with the lesser currents of the living form within her. At once all this is stopped; the vital union between the two is rudely served; and the living streams, flowing as before to supply the unborn babe, find in their place only the emptiness of desolation and are themselves wasted.
The whole physiological life of the mother receives a shock, which, is less fatally destructive than that already described as resulting from exhaustion of the vital forces, still profoundly disturbs her entire system. But a few brief hours before, all her vital energies moved on in vigorous harmony, as a fair ship moves on under the influence of a strong and favorable breeze. But now all is changed; the current of her life is suddenly arrested; and her entire system, so far as it had been engaged in supplying the young life within her, comes to a sudden stand- still, – in this respect resembling the condition of a ship taken aback in her course by failure of the wind, or rather when on the tack she loses the wind and the empty sails flap idly against the masts, leaving her helpless and at the mercy of any adverse influence. The “shock” from exhaustion is as if a vessel struck upon a rock; this “shock” form sudden arrest of the great function of nourishing the foetus in utero, is like that experienced by a vessel which, losing the wind and having no longer steerage way, drifts helplessly upon the waste of waters. In the former class of cases, sporadic child-bed fever may be spontaneously developed in the most malignant form of metritis and metro-phlebitis; in the latter, the slightest breath of epidemic peritonitis, erysipelas, or of any other of the animal poisons, may suffice to kindle at once the flames of puerperal fever.
Having thus at length shown how subject the puerperal woman is to influences from without, or form within her own body, which may develop child-bed fever, – it remains only to state what may already have been foreseen, that in her helpless, and peculiarly delicate period of transition, from the energetic performance of the great function of nourishing the foetus in utero, in which she is safe as a ship at anchor, to that other and equally safe condition in which she subsequently comes of nourishing her babe, as in lactation, – during the whole of this transition state she is liable to be thrown into a fever which may prove a malignant puerperal metro-peritonitis or assume any other of the various forms common to child-bed fever, – by any of the influences above enumerated. And the same result may also follow violent mental or moral emotions. This latter class of influences is especially apt to be efficient in unmarried females, and particularly in cases of abortion. In such cases either the violence of the means employed to bring about the abortion, or the unsuitable external conditions and attendant circumstances, or the profound disturbance of the moral sphere by fear and grief, or all these combined, very often lead to fatal uterine and peritoneal inflammation.
IV. SYMPTOMS. – These may be local or constitutional; and in most cases the latter are the first to make their appearance. And their general character will usually indicate either the one or the other of the three principal forms of child-bed fever; that in which the womb is principally affected; that in which the peritoneum seems to be the primary and chief seat of the disorder; or that which is known by the name of uterine phlebitis. In some cases however, the symptoms, from whichever source first arising, appear to involve all these structures as well as their adjacent organs nearly in an equal manner. And while the Homoeopathic physician will always seek to give the remedy which most faithfully represents the totality of the symptoms, still it will somewhat conduce to a clearer understanding of this frightful malady, if we arrange its more prominent symptoms with some reference to the three most common and often distinct forms of the disease in which they may be expected to appear, – taking note also of the order of their appearance as near as may be in the rapid development of the disease.
In puerperal metritis, or that form of child-bed fever in which the uterus is principally affected, the symptoms may vary in intensity and malignancy in the most remarkable manner; and the disease itself may rapidly involve also the uterine appendages and adjacent peritoneal tissues. The attack may begin before delivery, or almost immediately after; such attacks are usually exceedingly malignant in character and inclined to run with great rapidity to a fatal termination. Usually, however, the disease begins on the second, third, or fourth day; although it may occur still later. It may begin with distinct rigors; or there may be merely an imperfect and scarcely noticed chilliness. The pulse is very rapid, full and soft, – varying from 120 to 150, or even more. In some instances there is neither pain, distension nor tenderness of the abdomen; in others the pain is very acute- throughout, the distention enormous, and the tenderness exquisite. There may also be pain and tenderness at the epigastrium, with nausea and even vomiting. “Profuse sweating is a very common and distressing accompaniment of this disorder. In some cases this is so strongly marked and constitutes so large a part of the disease, that Dr. Blundell described it as a distinct form of puerperal fever, under the name of Hydrosis. The sweat and the breath are very often accompanied by a sweetish, pus-like odor. The sweating of puerperal fever does not diminish the secretion of urine, nor does it abate the quickness of the pulse. An intolerable thirst prevails, and the patient drinks immense quantities of whatever fluid she may be allowed. Dark spots or ecchymoses appear upon the wrists or other parts of the body. At first the lochia may be unaffected, they may even be increased in quantity; but more commonly t hey are entirely suppressed. The tongue is flabby, broad and slimy, and covered with perspiration. As the disease advances, usually about the third day, diarrhoea may supervene. The patient is nervous, depressed and fearful; the pulse is soft, small and increasing in rapidity; the respiration quick, hurried, high and often panting. And where this latter symptom occurs in connection with excessive distention of the bowels, it must be regarded as a very bad indication; since the impossibility of properly oxygenating the blood where the lungs have so little play, and they very rapidity of their movement, attempting to compensate by the number of the respiratory motions what they lack in amount, – combine to degenerate the physical organization and exhaust the vital forces with the greatest speed. The abdomen in many cases is swollen, tympanitic and painful; sometimes, from the extension of the inflammation to the peritoneum, it is universally tender, – sometimes tender in a particular part only. The lochia, if not entirely arrested, are generally, after a day or two, changed in quality and become fetid. The flow of milk is almost invariably checked; in the worst cases, sometimes it is entirely prevented; in other cases it is repressed after the secretion has taken place.
In an epidemic of puerperal fever described by Dr. Gooch, the cases began a a few days after delivery; and the leading symptoms were, “diffused pain and tenderness with some swelling of the abdomen, a quick pulse, which was generally at first full and vibrating. Sometimes it was small, but still hard and incompressible; the skin was hot, though not so hot as in other fevers; the tongue was white and moist and the milk suppressed. As the disease advanced, the belly became less painful, but more swelled, and the breathing short; towards the end the pulse was very frequent and tremulous, and the skin covered with a clammy sweat; even in this state the tongue continued moist and the mind clear, and death took place abut the fifth day. In a subsequent epidemic which appeared in Paris, the symptoms assumed the typhoid form from the first; beginning with a long and severe rigor, often a few hours after delivery; pain very intense over the whole abdomen, which rapidly became swollen; pulse feeble, compressible, undulating, often 150; respiration hurried, anxiety extreme, severe frontal headache; countenance sunk, pale, and covered with clammy sweat; constant vomiting of green matters; purging, stools fetid. The patients sunk rapidly at the end of a few days or even hours. There was no regularity in either lochia or milk. In the commencement of this form of child-bed fever, the nervous system of organic life and the blood* (“In some f the worst examples, pathology has found no other change than fluidity and altered color of the blood. – T. Smith.) appear to be suddenly and seriously affected, as shown by the general loss of vascular tone and of nervous power; by the disturbance of all the vital functions; by the rapid exhaustion of the powers of life; by the sudden death which often ensues, and by the accompanying softening and putrescence of the womb, as shown by post-mortem examinations. “Inflammation of the muscular tissue and lining membrane of the uterus is characterized by great disturbance of the nervous system, distressing cephalalgia, and is attended by fever of low type. Occasionally the cerebral symptoms are so intense as entirely to mask the uterine disease. It is ushered in by the same symptoms, as regards rigors, acceleration of the pulse, and state of the tongue, as those which attend the other varieties of puerperal inflammation. Its tendency is to produce softening, suppuration, and gangrene of the substance of the uterus, and it is one of the most fatal of all the puerperal inflammations. – T. Smith.
