“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.