In puerperal peritonitis, or that form of child-bed fever in which the peritoneum appears to be primarily and principally involved, the disease may commence before delivery; but it is more apt to arise in from twenty hours to three days afterwards. Sudden rigors usually constitute the first obvious symptom; or there may be instead severe pain, but rising of the pulse generally precedes them both; then follow heat of the skin, thirst, flushed face, and hurried respiration. Next there may be nausea, vomiting, – which, by its spasmodic contraction of the abdominal muscles, greatly heightens the sufferings of the patient, – pain in the head, and increased sensibility of the uterus. In some cases the tenderness of the uterus is contemporary with the rigors, or immediately succeeds them. The abdomen becomes tender; the weight of the clothes is insupportable, and the least movement of the body attended with exquisite suffering. Sometimes there are pains, either slight or severe, continuous or paroxysmal, which beginning in the hypogastrium, or in one of the iliac regions, gradually extend over the whole abdomen. But while the excessive sensibility of the abdomen, aggravated by pressure and motion, is characteristic of the peritoneal form of child-bed fever, – the other distinct pains are not so constantly present. As the disease advances the abdomen becomes still more tender and sensitive to movement or pressure; not only is the weight of the lightest covering intolerable, but the patient lies on her back with her knees drawn up, in order as much as possible to avoid tension and pressure of the abdominal parietes. As the disease makes still further progress, the abdomen becomes tumid and tympanitic. This may be followed by effusion into the cavity of the peritoneum indicated by a peculiar doughy feeling.
The lochia are variously affected; in many cases this discharge continues undisturbed; or it may become fetid; or diminished in quantity; or entirely suppressed. The secretion of milk is much more positively affected; if the attack begins before the flow is established, it is prevented; if afterwards, the secretion is suspended and the breasts become flaccid: and the patient may at the same time become entirely indifferent to the fate of her infant. Rapidity of pulse is characteristic of this disorder; its range varies from 120 to 160; and the severity of the attack will be well measured by this symptoms; – since as the disease advances the pulse becomes contracted, thready, intermittent, and towards the last almost imperceptible. The tongue generally has a whitish coating in the centre, with red around the edges; sometimes it is dry and brown in the centre, with yellowish or white fur at the edges. There may be nausea and vomiting, of the ingesta, of bilious, green, brown, or black fluids; and there may also be diarrhoea, – with dejections dark and fetid towards the close of bad cases. The urine is generally turbid, or high colored, scanty and in some cases passed with difficulty. The heat of the skin may often be not much more than is natural; but towards the last, the skin may become cold and clammy. The countenance will usually mark the advance of the disorder, by features drawn up and expressive of great distress. The dark areola surrounding the eyes, the dilated pupil, the glassy surface and bloodless conjunctiva, give a lustrous and unearthly appearance to the eyes in all cases of puerperal fever, whatever the special complication, whenever the disease is fully formed. The intellectual faculties often remain unaffected to the last.
Such are some of the most prominent symptoms, which will appear in different cases of this disorder, in different forms and combinations; for while their variety is so great that all do not appear in any single case, scarcely any are constant, if we except the rapidity of the pulse and the abdominal tenderness. In this as in the form of child-bed fever more immediately affecting the uterus, the disorder runs a rapid course, and the vital forces are manifested very weak, even in cases which do not appear to assume the lowest or typhoid symptoms. In some cases, as already stated, this disorder is transferred or extends to the pleural sac; still more rarely does it involve the serous membranes of the brain; in either case the invasion of the inflammation will be marked by sharp, lancinating pains, worse on motion.
In uterine phlebitis, or at least in its earlier stages, the symptoms do not seem to vary remarkably from those common to other forms of puerperal metritis; in some cases there may be greater freedom from pain; the pulse alone, ranging from one hundred and ten to one hundred and fifty, indicating the great danger. This form of disease, in the common and gross pathology of the schools, has been attributed to reabsorption of purulent matter from the utero-placental surface. But, even if this is possible, it is probable that the mischief lies farther back and still deeper, in a primary disordered state of the blood itself. Puerperal fever, as described in its more malignant form under the head of Puerperal Metritis, may destroy patients in a few hours, even before there has been sufficient time for the occurrence of phlebitic inflammation; and in such cases, as already stated, no pathological changes are met with beyond a diseased state of the blood. And it is to this morbid condition of the blood in a milder form, and not to reabsorption, that we should look for the real cause of uterine phlebitis.
Before this form of disease is so far advanced as to be indicated by objective symptoms, by external suppuration, it may be recognized according to the following observations of Dr. Meigs by the (subjective) moral symptoms. “In peritonitis, pure and simple, the mind is clear, the nervous system not being disturbed by the presence of pus-corpuscles in the blood; the woman recovers, or dies, without those hysterical, or rather hysteroidal and even maniacal symptoms that invariably mark a purulent infection of the blood. The alarm I wish to awaken in your mind is one connected with the very great probability that hysterical or hysteroidal affections, in women recently delivered, and assailed with fever, are really the exhibitions of that curious influence that pus in the blood, or pyaemia, exerts upon the nervous system. In all the individuals, male or female, that I have attended in mortal illness, from wounds of veins in venesection, I have invariably noted this kind of hysterical intoxication, caused by purulent infection of the blood. As the diseases advances the more palpable phenomena attendant upon the formation of pus in the veins are developed by the deposit of purulent matter in various parts of the boy, especially in the vicinity of the large joints. We find in such cases, swellings in the neighborhood of the articulations; erysipelatous blushes; and large suppurations in the vicinity of the joints, or patches of slough or gangrene form at the sides of the erysipelatous blushes.
V. DIAGNOSIS. – There can be little real difficulty in distinguishing child-bed fever, in any of its various forms, from any other disease. Its occurrence soon after delivery, the gravity of the symptoms and their rapid progress present a tout ensemble found in no other malady. And while the Homoeopathic physician will always prescribe according to the symptoms and conditions present, without depending upon the name by which the affection may be characterized; still it is of the highest importance that he should recognize a case of child-bed fever at the earliest possible moment. And to this he will be impelled by the gravest considerations, that he may from the very first afford to his patient that devoted and intelligent attention which such a case requires, perhaps more than any other; that he may make sure of not himself becoming the medium of transfer of the puerperal poison form one patient to another; and that he may secure himself from suspicion of ignorance and incompetency.
In most cases of child-bed fever, as shown in the preceding pages, the disease will be ushered in either by rigors more or less distinct, or by serious acceleration of the pulse. For the appearance of either of these symptoms the physician should therefore be on his guard, – especially if he has reason to suspect the possible presence of the epidemic influence of puerperal peritonitis, of erysipelas, or of any other of those influences already described as capable to developing fever in the puerperal state. He should make sure that the nurse is intelligent enough to inform him at once if rigors, or even chilliness appear; and he should himself carefully observe the pulse at every visit. As long as this is below one hundred the patient is comparatively safe; but when it suddenly rises above one hundred, there is serious reason to apprehend the onset of child-bed fever, it it be not already insidiously at work within the pelvis. And in fact any severe symptoms arising in the puerperal woman should at once command the most careful attention. The pains of peritonitis may be distinguished from the after-pains, by observing that the latter are attended by a perceptible contraction of the uterus; and that the after-pains are diminishing about the time, – the third day, – when the pains of puerperal peritonitis make their appearance; and that they become more and more severe. In like manner it will be observed that in child-bed fever the constitutional disturbance and hypogastric tenderness and even the acceleration of the pulse constantly increase day by day; instead of subsiding as would be the case were these symptoms dependent upon after-pains or hysteralgia alone.
