The nature of this complaint appears to be a severe and sudden inflammation, commencing either in the womb or some of the neighboring parts, which, if not arrested, rapidly extends to all the organs of the pelvis and abdomen, and hastens to a fatal termination with fearful speed. The precise seat, and place of commencement, of the inflammation, varies in different cases, but this makes little difference either in the symptoms, consequences, or treatment of the disease, and it is of but little use to give a separate name to all these various forms. Uterine Phlebitis, Metro Peritonitis, Puerperal Metritis, and Puerperal Peritonitis, are all essentially the same complaint, and identical with what is called Puerperal, or Childbed fever.
The disease generally appears from the second to the fifth day after delivery, but may be delayed as late as the fifteenth or twentieth day, or commences as early as two or three hours after; and has even been known to show itself before labor came on.
It usually begins with headache, general debility, uneasy feelings, creeping of the flesh, and chills: then follow tremblings, numbness of the limbs, cold feet and hands, with a burning heat in the body. The abdomen gradually gets tender, so that it cannot bear the slightest pressure, sharp pains are felt in various parts of it, and the patient continually complains of twisting and burning within. She prefers to lie on her back, with the head raised and the knees drawn up, so as to relax the abdominal muscles. Very soon she complains of great thirst, and cries out repeatedly from the sharpness of the pain; the headache increases, and the breathing becomes laborious. Hiccough generally occurs at an early stage, and is usually accompanied or followed by vomiting and diarrhœa, but sometimes by obstinate constipation. The abdomen continues to swell, and becomes still more tender, the face is pale, bathed with cold perspiration, and indicates in every line the anxiety and suffering under which the patient labors. The features seem to be drawn upwards, and all together, or pinched up, and indeed the whole body seems to shrink. In general the lochial discharge either stops altogether or lessens very much, the breasts remain empty or nearly so, and the pulse is weak and irregular. In some few cases however, the lochia continues to flow, or even increases, and the breasts remain full up to the time of death. The urine is high colored and thick, and causes smarting and burning as it passes away. The tongue furs and becomes pointed, and pale colored. The eyes often seem much engorged, and the white part become yellow, as indeed the skin does over the whole body, owing to derangement of the bile, and alteration in the character of the blood. In most cases the mind retains its faculties nearly till dissolution, but there is frequently a vague sense of uneasiness and fear, with great depression of spirits and weeping. Some even feel assured, from the beginning, that they will never recover, and occasionally become delirious.
The duration of this disorder varies considerably, though in most cases it carries off the sufferer in a short time, frequently even in two or three days. It may however last five, ten, or twelve days, and has been known to do so fourteen.
The manner in which it terminates is also different in different cases. The fluid resulting from the inflammation may either be absorbed, or suppuration may ensue, and the matter be discharged, either from one of the natural passages or from an artificial opening; or it may not be discharged at all. Sometimes gangrene or mortification ensues, and sometimes the inflammation partly subsides and becomes chronic. When it terminates by resolution, which is the most favorable mode, the patient begins to improve about the fourth or fifth day; the pains become less acute, the swelling and tenderness become less, and the milk, lochia, and other secretions that were suppressed begin to reappear. The patient is also able to lie either on the back or sides, and soon feels conscious herself that she is improving. But even when a turn for the better has decidedly taken place, too much confidence should not be prematurely felt, nor should there be any relaxation of attention, for the slightest causes may bring back all the symptoms with more than their former severity. When suppuration ensues, which is most commonly the case, a mass of fluid forms in the womb or abdomen, and is plainly indicated, either by its moving about or by a portion escaping from the body. In this case also the pain and tenderness decreases, and the abdomen seems less hard, but the pulse becomes weaker, a sense of weight is felt about the womb, the extremities become cold, chills come on, and gradually the powers of the system seem to fail till complete exhaustion ensues. When gangrene or mortification ensues, the termination is nearly the same, but more rapid, and all the above symptoms are more marked. When it passes into the chronic form, there is but little permanent abatement in the severity of the symptoms for some time; they partially lessen at intervals, but return again, sometimes with renewed vigor, and it remains long a matter of doubt whether the disease has really passed the critical period or not. Recovery takes place occasionally in this form of the disease, but more frequently the patient becomes daily weaker and more emaciated, diarrhœa and slow fever set in, the vital powers steadily sink, and at last death ensues. This fatal termination may however be delayed for an indefinite period, and may ultimately result from Consumption or Dropsy, both of which frequently follow chronic puerperal fever.
In regard to the probable termination of this disease, but little hope can be entertained that it will be favorable. Nor are there many indications that can be relied upon with certainty, as to what course it is likely to take. In general it is favorable when the swelling subsides, and the pains abate in severity, and particularly if the milk and lochia begin to be secreted again. The indications are also good in proportion as the symptoms are mild, and when there is no great sympathetic disturbance of other parts of the system. It is regarded as unfavorable when the pain and tenderness extends over a large portion of the abdomen, and when the attack commences very suddenly. The danger is also considered greater in proportion as the disease begins nearer to delivery; and when its first symptoms exhibit themselves before labor it is always considered mortal. It is likewise more dangerous with twins than with a single birth, and with first children than afterwards. It is seldom possible however to come to any probable conclusion till between the fifth and tenth day, and even then it is in general a matter of great uncertainty.
The best treatment of this fearful disease is one of the greatest problems in medical science. So many different plans have been adopted, and with such various success, that the history of past cases affords but little reliable data to guide us in future ones. In general the most powerful antiphlogistic measures, or those thought most likely to reduce the inflammation at once, are immediately resorted to, such as bleeding, purgatives, and cold bathing. Bleeding is in particular the great agent depended upon, either from the arm, or by cups and leeches to the abdomen and vulva. Dr. Gordon, of Aberdeen in Scotland, who once met with a regular epidemic of puerperal fever in that city, assures us that nothing else succeeded in arresting the disorder but copious and frequent bleeding, at the very commencement. He carried it so far as to take twenty-four ounces at once, and he says that when he did so the patient was nearly sure to recover, but that at first, when he only abstracted about twelve ounces, she was as nearly sure to die. In about fifty cases to which he was called in time, he only lost five, and taking the average of all he attended the recoveries were about two-thirds of the whole number, which is above the usual proportion.
It appears however, from the experience of the most eminent practitioners, that the bleeding must commence early; that the first abstraction should not be omitted beyond twenty-four hours after the first symptoms of the disease, and should be as much earlier as possible. With very few exceptions they also think Gordon's standard of twenty-four ounces not too much. Indeed it is generally admitted that if the blood be not drawn at first and in large portions, it had better not be drawn at all. There may be of course many peculiar circumstances that will make bleeding improper, which nothing but experience and observation will teach a practitioner, but the number of such cases is thought to be small. The use of leeches meets with but few advocates, and certainly they seem to have had but partial success, compared with the lancet. Dr. Collins of Dublin depended chiefly upon leeches and Calomel, but he tells us that in eighty-eight cases fifty-six died when so treated, while in fifteen that were freely bled from the arm only eight died. In short it appears that the bleeding must be carried far enough, at the very beginning of the disease, to cut it short at once, or it will be of no avail, it being of little or no use merely to check it! In conjunction with the bleeding it is also usual to give enemas of starch and castor oil, or something similar, and to bathe the extremities in hot water.
I know that this practice of bleeding meets with strong opposition from many physicians, and that it is objected to by patients generally. I myself am as much opposed to it as any one reasonably can be, and I am well aware of the numerous evils which follow it, but still it cannot be denied that Dr. Gordon's plan has cured a greater number of cases of puerperal fever than any other yet tried. It is true that many of those thus cured may have afterwards died of dropsy, convulsions, typhus and other diseases produced by the bleeding, but then the risk they run of dying from these was less than that from the puerperal fever, and in a choice of evils we ought to choose the least. It should also be remembered that some eminent practitioners assert, if this plan be adopted promptly and fully, it will always cure, or at least with very few exceptions.
Several other modes of treatment have also been adopted to dispense with bleeding, some of which have been much more successful than others, though none so much so as we could desire. Thus some practitioners resort immediately to hot fomentations and sweating medicines, or a hot bath if convenient, together with brisk purgatives, and injections. Some depend upon Calomel in large doses, with leeches to the groins and vulva. Others again use cold fomentations, and cold injections both to the rectum and to the vagina. Others again use blisters over the abdomen, in conjunction with purgative enemas and moderate bleeding; but this mode seems to do but little good. Another plan is to give about six grains of ipecac, and to repeat the dose several times, at intervals of an hour or less, in conjunction with purgatives and warm fomentations. Turpentine has also been used internally and by enema, but seems to have accomplished little good. Perhaps the most frequent plan after bleeding, is to rub one or two drachms of Mercurial Ointment well on the skin, over the abdomen, every two or three hours, sometimes for several days regularly; eight or ten grains of Calomel being also given daily, at the same time. This brings on salivation, and in many cases the symptoms begin to abate in severity as soon as that commences. I am not aware however, that this treatment is any more successful than bleeding, nor do I think the consequences afterwards, in a case of recovery, are any less to be dreaded. It is difficult in fact to say what plan can be best recommended, even in the majority of cases, and certainly no one yet tried is applicable to all, on account of the peculiarities and varying circumstances of each. If the practitioner or patient is not decidedly opposed to the bleeding plan, that has undoubtedly the best recommendation, from former success. Next to that perhaps comes the mercurial treatment, which usually meets with as much opposition as the bleeding, but which certainly has been frequently found efficacious. The other plans have met with but little favor, though possibly they might sometimes succeed when the rest fail.