(especially peritonitis) has been established, we do not consider that the
lancet is required, merely because there is pain with a quick pulse. The
uterus may be hard, swollen, and painful, and yet there is not actual
inflammation present: we will not deny that inflammation will quickly
follow, if nothing be done to remove this state of uterine irritation. The
pulse is quick, but seldom hard; and even if it be at all sharp, it
produces but little resistance to the pressure of the finger. In these
cases we may bleed, but we seldom reduce the quickness of the pulse,
although it sinks still farther in point of strength. There is seldom much
buffy coat upon the blood when drawn at this stage; and if the pain be
relieved for a short time, it returns again as soon as the system has
recovered from the immediate effects of the syncope. We do not see that
striking relief follows a copious venesection in cases of this sort, which
is remarkable in inflammation of the abdominal viscera under other
circumstances; and we are more than ever convinced, not only from the fact
just mentioned, and from the results of our own experience, but from the
unfavourable results of the practice in which bleeding has been uniformly
and largely employed, that it is _not_ a remedy which is _always_ to be
premised before the employment of other treatment, as in cases of simple
inflammation of the viscera or serous membranes. The only circumstances we
apprehend, under which venesection ought to be employed in this affection
are, where the pain is constant, without intermission, and where, besides
its rapidity, the pulse betrays a degree of wiry resistance to the finger,
which can never be mistaken. In this case the blood drawn will show all
the usual marks of inflammation, and the relief procured will be
proportionally great. On the other hand, where the pain, although severe,
is not constant, but the patient experiences every now and then a slight
abatement in its severity, or a short intermission altogether; where the
pulse, although rapid, is soft, and resists the finger but feebly, we
shall seldom produce any permanent relief by bleeding; the pulse becomes
weaker, but its rapidity, so far from being diminished, is rather
increased. The pain may be relieved for a short time, but it almost always
returns as severely as before the venesection.
Under these circumstances, the pure antiphlogistic treatment seems to have
little or no control, either in removing the pain, or diminishing the
pulse, or in preventing the disease from running into that state of
tympanitic peritonitis, which is so fatal in its effects; and we are not
only losing time by employing an inefficacious mode of treatment, but are
exhausting the powers of the system, already more or less depressed.
"Large hæmorrhages," as Dr. Ferguson correctly observes, "favour
absorption," (_op. cit._ p. 108;) and it would seem that by thus reducing
the powers of the system, we diminish its capability of ridding itself by
the natural outlets of the virus which has been carried into the
circulation; nor do we see how this is to be assisted by bleeding. If a
state of actual hæmorrhage has been induced, bleeding, of course, must be
used with the greatest promptness; but in employing this remedy in the
above-mentioned form of puerperal fever, although we relieve the
inflammation for a time, the cause is not removed. It still continues to
act, and the symptoms return under much more formidable circumstances,
from the increased debility of the system confining our means of treatment
within still narrower limits.
According, therefore, to the views which we have taken of this form of
puerperal fever, the indications for treating it will be the following:
_first_, to subdue any inflammatory symptoms, if they be present; but it
must be remembered, that we have no positive proof of the existence of
inflammation, merely from the presence of pain and a rapid pulse, although
these two symptoms denote a state of irritation, advancing with rapid
strides into actual inflammation. The character of each must be carefully
ascertained before we are justified in deciding upon the necessity of
bleeding. As this operation is generally performed in the erect posture,
to favour a state of syncope, we are following a _second_ indication at
the same moment, and perhaps one of the most important, viz. placing the
patient in such a posture as will promote the escape of any coagula and
discharges which may have been stagnating in the uterus or vagina. To
effect this still more completely, a stream of warm water should be thrown
up briskly into the uterus, to dislodge any offensive irritating matter
which may have collected: the relief thus produced is sometimes quite
extraordinary, the pain abates, the uterus becomes less hard, the pulse
more natural, and the patient expresses herself greatly relieved. The rule
which we have made in our treatment of natural labour, viz. that if
possible, the patient should sit up to take her food, and suckle her
child, and especially that she should always kneel to pass water, should
never be neglected, for in many of these cases it will be found that the
patient has not stirred from the horizontal posture, and that the attack
had evidently followed the accumulation of stagnant lochia, &c., which
from the warmth of the adjacent parts, and free contact with the external
air, has rapidly become offensive; and, moreover, from her position, has
been prevented from being discharged. To ensure that the uterus has
expelled any coagula which may have lodged in it, is a powerful argument
in favour of applying the child to the breast as soon as possible after
labour; this refers particularly to those long slender coagula, which were
first noticed in the uterine veins by Dr. Burton, in 1751, as one of the
chief causes of after-pains; for by thus inducing firm uterine
contraction, the greater part of these will be generally expelled, and
access of air to the venous orifices prevented. "These coagula may be
distinctly perceived for several weeks after delivery, and both in their
form and colour they differ from those produced by inflammation." (R. Lee,
_op. cit._ p. 53.)
Our _third_ indication is to increase the action of all the excretory
functions, and thus, as far as possible, remove the virus, which may have
already entered the system. There is no remedy with which we are
acquainted that has such a power of producing a general erethism
throughout the whole excretory system, as calomel in large doses. The
secretions of the liver, the mucous membrane of the intestinal canal, of
the skin, and kidneys, are all very remarkably increased by the action of
a large dose of this medicine, and we cannot help attributing the return
of healthy lochia, which so frequently follows such a dose of colomel, to
a similar action on the vessels of the uterus and vagina. No effort of
nature can be so well directed for the removal of any noxious principle
from the circulating fluids as a general increased action of the excretory
system, and we have seldom or never seen calomel act with such success in
this form of puerperal fever, except where it had been given in a
sufficient dose to produce this effect. Salivation is by no means a
necessary object, nor have we seen it produced even by a scruple dose of
calomel. It is, however, seldom necessary to exceed ten grains at a time,
although this may occasionally be required to be repeated. It should
always be combined with some medicine which will assist its diaphoretic
action. For this purpose, in cases where the pain is constant, without any
remission, showing that a state of inflammation has been already induced,
it will be advisable to combine it with a little of James's or antimonial
powder. Where, on the other hand, the patient experiences evident
abatement or even remissions of pain, ten grains of calomel with an equal
quantity of Dover's powder, made up into pills, will be preferable; the
opium acts by relieving the pain, and contributing to induce a copious
perspiration. To assist this, and also to relieve pain still more, a hot
linseed-meal poultice, as above described, will be of great service; and
in a few hours (or the next morning, if the calomel has been given over
night,) a saline of sulphate and carbonate of magnesia should be given.
The vagina should be well syringed with warm water, and repeated from time
to time as occasion requires; in like manner, the poultice must be
continued until the pain has entirely ceased.
The general result of this treatment is, that in twelve or eighteen hours
the uterus loses its tenderness and hardness, the pulse becomes fuller
and softer, the tongue cleaner and more moist, the kidneys and bowels have
acted copiously, and the lochia and milk have returned.
_False Peritonitis._
Under this title, which we believe first originated at the General
Lying-in Hospital, and which has been adopted by Dr. Locock in his article
upon the subject, we propose to describe that peculiar species of
abdominable pain, which Dr. Ferguson has called the _transient_ form of
peritonitis. Strictly speaking, neither of these terms are exactly
appropriate, for the disease appears to depend upon a state of high
nervous irritability, perfectly independent of inflammation, or any other
affection of the peritoneum; still, however, as it has been most
frequently known and described under the former of these appellations, we
shall also continue to use it, merely warning our reader, that the
appellation of false peritonitis is more conventional than correct.
Properly speaking, it should be called _nervous abdominal pain_; for we
have reason to think that its real seat is in the muscular coat of the
intestines, and in the abdominal muscles themselves, much more than in any
portion of the peritoneum.
The disease chiefly attacks women of a delicate frame, and irritable habit
of body, with small features, fair complexion, and of a nervous hysterical
disposition, whose powers have but ill sustained them through the
processes of pregnancy and parturition, and are now beginning to fail
under that of lactation. Her mind is anxious and depressed, the sleep is
restless, the circulation irritable and feeble; she is pale, forebodes all
sorts of evils, and is unusually sensitive; complains inordinately of her
sufferings in trying to suckle the child, and of the severity of her
after-pains; not unfrequently she has severe headach, of that species
which affects the top of the head, and which is generally considered to
arise from a state of debility and anæmia. In many cases the pain has
evidently been produced by the action of a griping purge. The pain is of
the most intense character; indeed, in many cases, it is evidently too
severe for the ordinary suffering from abdominal inflammation. So
irritable are the abdominal muscles, that the slightest motion, even that
of respiration, will throw them into cramp-like contractions to the great
agony of the patient. The breathing is short and timid, like that of a
person under a severe attack of pleurodyne: the slightest touch of the
hand, or of a single finger, produces intolerable suffering, not so much
from the pain which its pressure produces, but from the sudden and
involuntary contraction to which the irritable muscles are thus excited.
The quickened breathing, from a dread of the abdomen being touched, is
frequently sufficient to bring on a paroxysm. If by soothing words and
promises of cautious proceeding we induce her to let us apply our hand
upon the abdomen so gently that it does not even rest with its weight upon
it, we shall find that we may now gradually increase the pressure, until
by degrees it becomes considerable, not only without her feeling any
increase of pain, but with complete relief--the pressure of the hand
appearing as it were, to benumb the pain. If we withdraw the hand in the
same gradual manner, no pain will be produced; but if we remove it
suddenly, a spasm of the muscles, with intense pain, is instantly excited.
The pulse is in an equally irritable state; after a few beats it rises in
rapidity as soon as the patient's mind is directed to it; in others it is
permanently quick. The tongue is sometimes slightly covered with a thin
fur; in others it is pale and flabby; and in others disposed to be glazed,
red, and dry.
The disease rarely exists long uncomplicated with any other form of
puerperal affection, but soon passes either into acute peritonitis, or
into the typhoid state of the malignant form, the latter transition being
almost certain, if the practitioner has considered it as an inflammatory
affection, and treated it antiphlogistically.
It is to the late Dr. Gooch that we are indebted for having first called
the attention of the profession to this disease, and pointed out its true
characters by the nature of the remedies which proved successful in
relieving it. "The effects of remedies on a disease, if accurately
observed, form the most important part of its history; they are like
chemical tests, frequently detecting important differences in objects
which were previously exactly similar. How many diseases are there in
which the symptoms are inadequate guides?" "The local pains and
constitutional disturbance which occur in feeble and bloodless persons,
and which are aggravated by bleeding and other evacuants, strikingly
resemble the local pains and constitutional disturbance which occur in
vigorous and plethoric persons, and which the lancet and other evacuants
relieve and ultimately cure; yet how many years is it before the young
practitioner learns that there are cases apparently so similar, yet really
so different, and how to distinguish them; and how many practitioners are
there who never learn it at all? Symptoms and dissections can never do
more than suggest probabilities about the nature of the disease, and the
effects of a remedy on it. A trial of the remedies themselves is the only
conclusive proof." (_Op. cit._ p. 37.)
In those cases which proved fatal, the post mortem appearances only tended
to confirm the nature of the disease. So far from marks of inflammation
being found, there was not a single trace to be discovered; in fact, an
entirely opposite condition existed; the peritoneum and viscera were pale
and bloodless.
_Treatment._ It is of the highest importance to distinguish these
affections from a state of inflammation; the treatment of the one will be
precisely the reverse of the other. The lancet is as little indicated in
this case, as it is in puerperal convulsions from anæmia, and the effects
produced will be scarcely less mischievous. The fatal cases which Dr.
Gooch has recorded, show that it was not the disease so much as the
treatment which destroyed the patients, and prove, as we have already
stated, that the presence of pain and a quick pulse do not surely indicate
a state of inflammation, without being confirmed by the general symptoms
of the patient's condition. "These cases taught me a new view of the
subject: they taught me that a lying-in woman might have permanent pain
and tenderness of the abdomen, with a rapid pulse, independent of acute
inflammation of the peritoneum or any other part; that these symptoms may
depend on a state which blood-letting does not relieve, and which, if this
remedy is carried as far as it requires to be carried in peritonitis, may
terminate fatally; and that the most effectual remedies are opiates and
fomentations. Most of the patients who were the subjects of these attacks,
were women, who, in their ordinary health, were delicate and sensitive;
the attack sometimes seems to originate in violent after-pains, gradually
passing into permanent pain and tenderness, resembling inflammation, or in
the painful operation of an active purgative; but it could sometimes be
traced to no satisfactory cause--the patient had had a common labour, and
had experienced no unusual cause of debility or irritation. The pulse in
all these cases, although quick, was soft and feeble: this, together with
the previous constitution of the patient, were my chief guides. When I
could trace it to any irritating cause, such as a griping purge, and when
blood had been already drawn without relief, and without being buffed, I
saw my way still clearer. When I doubted, I applied leeches to the
abdomen." (_Op. cit._ p. 72.)
In ordinary cases a dose of Liquor Opii Sedativus, or of Dover's powder,
repeated according to circumstances, will be sufficient to stop the
attack, taking care to clear the bowels of any irritating matter with
castor oil in some aromatic water, guarded by a few drops of Battley's
solution. In many of these cases, where the circulation is below the
natural standard in point of power, and the disease is more or less
complicated with hysteria, the opiates should be combined with a gentle
stimulant, of which camphor is by far the best. Five grains of powdered
camphor with half a grain of hydrochlorate of morphia and a sufficient
quantity of extract of henbane, to form two pills, may be repeated at
intervals, whenever the pain shows a disposition to return, and
constipation prevented by castor oil and Liq. Opii Sedativus as
before-mentioned, or a gentle draught of sulphate of potass, rhubarb, and
manna. In most cases, when the stomach and bowels are in a proper
condition, mild tonics will prove useful, as equal parts of extract of
gentian, henbane, with or without a grain or two of quinine or sulphate of
iron, at night; and, if necessary, the infusion of some vegetable tonic
during the day. The diet should be simple but nutritious, and a certain
quantity of malt liquor or wine allowed daily, if the condition of the
patient permit it. In some instances the low diet which is usually deemed
requisite for the first few days after labour, has appeared to have been
the cause of this highly irritable condition, especially in those who have
habitually accustomed themselves to pamper the appetite, and to use
fermented or spirituous liquors in excess: with spirit drinkers, the loss
of their daily stimulus is almost sure to be followed by a low, feeble,
irritable state of the system, much gastric and nervous derangement, and
the paroxysms of pain just described. It is astonishing how quickly every
symptom subsides, and the system returns to a natural condition, by the
daily allowance of a small quantity of their favourite beverage.
_Gastro-bilious Puerperal Fever._
This is the gastro-enteric species of Dr. Ferguson, and corresponds with
the "puerperal intestinal irritation" described by Dr. Locock. In its
simple uncomplicated form, this disease cannot be considered as a
dangerous affection; it occasionally passes into inflammation, but more
frequently it assumes after awhile the typhoid or malignant form,
especially where its true characters have not been recognised, and the
powers of the system have become much exhausted by its severity and long
continuance.
Like the false peritonitis it is frequently met with in cases where, from
unwholesome or intemperate living, the digestive organs are greatly
deranged, or where the bowels have been much neglected for some weeks
before labour. We cannot help thinking that the view which Dr. Ferguson
has taken of its cause, viz., a vitiated state of the fluids, as with the
case of puerperal peritonitis, is far too exclusive, inasmuch as it is
evidently produced in many instances by the direct irritation of matters
which are contained in the intestinal canal: in others, we fully agree
with him, that it is produced indirectly by the introduction of an animal
poison into the circulation, which spends its virulence upon the stomach,
liver, or intestines, or which, in other words, nature endeavours to
remove from the system by these outlets. In the early stage of uterine
irritation, or of phlebitis, from the absorption of putrid fluids, we have
shown that the cause at first, in most instances, acts directly, and not
through the medium of the circulation, otherwise the symptoms would not be
so instantly checked by washing out the uterus with warm water, and thus
removing the source of mischief; so in the gastro-bilious or enteric
form, the symptoms _at first_ are produced in most, if not all cases, by
the direct irritation of the unhealthy intestinal contents, upon the
removal of which they at once disappear; although at the same time, if the
source of irritation be not removed, we have no doubt but absorption will
take place sooner or later and vitiate the circulation. Thus, Dr. Kirkland
considers that retained fæces during a lying-in are capable of bringing on
symptoms which "may, properly enough, be called puerperal fever" (_op.
cit._ p. 87;) and Dr. John Clarke, in enumerating the different causes
entertained by "writers of good reputation," mentions, where fæces are
detained in the intestines, "the thin putrid parts of which are supposed
to be taken up into the blood." (_Practical Essay on the Management of
Pregnancy and Labour_, by J. Clarke, M. D., 1806, p. 53.)
There is, however, no reason to confine the source of the putrilage, which
infests the circulating current, in cases of gastro-bilious or intestinal
irritation, to unhealthy fæcal matter in the intestines; for in the
experiment made by Professor Tiedemann, to which we have already alluded,
viz. of injecting musk into the femoral vein of an animal, the poison
seemed to concentrate itself upon the mucous membrane of the intestinal
canal; and from the diarrhoea which had commenced shortly before death, it
is probable, if the dose had been smaller, that nature would have
succeeded in ridding the system of it by this means; we may, therefore,
conclude, in most of the cases of this affection, which are not the result
of direct enteric irritation, but an effort of nature to purify the
circulation by expelling the morbid matter, with which it had been
vitiated, through the medium of the mucous membrane of the bowels, that
the uterus had been the source of its origin, introduction, or absorption,
into the system.
_Symptoms._ This form of puerperal fever seldom commences so soon after
labour as any of the other species, and frequently the symptoms are so
trifling, at first, as scarcely to excite attention. There is an
indistinct uneasiness about the abdomen; the tongue is never quite
natural, being either slightly furred with a few prominent papillæ, or
pale and flabby; the appetite is irregular, or fails considerably; the
patient complains of weariness and lassitude; there is, perhaps, slight
headach across the eyes and forehead; the face has a sallow tinge, and if
her complexion be dark, there is a leaden-coloured ring beneath her eyes;
the sleep is unrefreshing; the spirits are unequal and anxious; she is
chilly at times, and at others, has considerable flushings of heat, with
increase of headach. The abdomen becomes full and doughy to the feel; it
is somewhat tender to the touch, but not distinctly so, as in peritonitis;
the motions are dark, sparing, and excessively offensive; sometimes hard
and scybalous; but more usually they assume the character of an irritable
diarrhoea, with much acrid slimy mucus, the evacuation of which, is
attended with much flatus, and for a time produces great relief,
although, at the moment of passing, it is frequently attended with a good
deal of forcing. The abdomen becomes more tender, with severe griping
flatulent pains at intervals; the diarrhoea assumes somewhat of the
characters of dysentery; the pulse becomes quick and irritable; the tongue
red and glossy at the tip and edges, with a patch of thin white fur in the
middle, or with a red centre between two parallel streaks of creamy
fur--the back part yellow, verging into brown; the breath is of a faint
disagreeable odour; the attacks of fever, from time to time, are more
distinct; and frequently, during the sweating stage, the skin throws out a
strong peculiar odour, which taints the air of the whole room. In some
cases there is frequent vomiting, either of watery fluid mixed with ropy
mucus, or of a greenish colour; the result probably of subacute
inflammation of the stomach. As the irritation of the intestinal canal
increases, she becomes more exhausted, and rapidly emaciates. The tongue
now becomes preternaturally red, its surface glossy smooth, the centre is
parched and brown, and sometimes traversed with fissures; the fever
assumes a low typhoid character, with delirium at night, and gradual
sinking. The appearance of the evacuations varies considerably; at times
they appear to consist of minute membranous shreds, floating in dark brown
water; in others, they are clay-coloured, slimy, adhesive, excessively
offensive, and even pungent; whereas, in others, they seem to consist
chiefly of dark unhealthy bile, mixed with water and mucus.
This form of disease is frequently met with in patients who have been
weakened by hæmorrhage, and necessarily tends to aggravate the state of
anæmia which is present. She has the intense pain at the summit of the
head, which characterizes this condition; she gets but little sleep, and
that is disturbed by restless and uneasy dreams; she lies with the eyelids
half closed, and the occasional twitchings of the muscles betray the
irritable condition of the system; exhaustion quickly supervenes, and is
usually attended either with low delirium, or the anæmic form of puerperal
mania.
_Appearances after death._ If the dysenteric affection has been very
severe, we shall probably find softened or even ulcerated spots in the
mucous membrane of the large intestine; but in other cases, there have
been no lesions of the kind; the intestines have been found a good deal
distended with gas, but pale and bloodless. Where the disease has passed
into the typhoid species, other appearances belonging to this form will be
observed: coagulable lymph will probably be effused, and those changes in
the structure of the uterus, which we shall mention when we come to the
consideration of this species.
_Treatment._ The treatment will, in great measure, depend upon whether the
disease is the result of irritation from loaded bowels, scybalous and
unhealthy contents, &c., or from that engorgement of the circulation
belonging to the chylopoietic viscera, with more or less fever, which
indicates the efforts nature is making to rid the circulation, by this
outlet, of any morbid principle with which it may have been infected.
In the first case it is simple enough, and, in most instances, the disease
is prevented, or, at any rate, checked in its very outset, by the dose of
castor oil which is customarily given on the second or third day after
labour. If the pulse be quick, the headach severe, with much fulness and
uneasiness of the abdomen, and more especially if the bowels have been
constipated, or in an unhealthy state before labour, five grains of
calomel and carbonate of soda, made up into two pills, with extract of
henbane, and followed in a few hours by a dose of castor oil, guarded with
some Liquor Opii Sedativus, as before recommended, will be required. We
combine a little soda with the calomel, to prevent it griping and acting
violently, which it is liable to do where there is much acidity of
stomach, from its being converted into the bichloride. We also think that
there will be less chance of vomiting, when the calomel is combined with
the soda, than with an antimonial, as recommended by Dr. Locock; a common
domestic enema of gruel and salt will assist the purgative, and bring away
much unhealthy fæculent matter. The medicines will generally require to be
repeated in twenty-four hours, to insure the removal of the irritating
cause from the bowels; the abdomen becomes softer and more free from
uneasiness; the pulse rises in strength and fulness, but diminishes in
rapidity, and the patient experiences general relief in her symptoms. She
may now take an ammoniated saline, with tincture of hop or henbane during
the day; five grains of Hydrarg. cum Cretâ with carbonate of soda and
henbane at night, instead of the calomel, and a draught of rhubarb and
magnesia with some aromatic confection the next morning, or of rhubarb and
manna with sulphate of potash, rendered warm by a little spirit of nutmeg.
If diarrhoea has come on spontaneously at an early period, the true nature
of the case is more liable to be mistaken; still, however, the evidences
of gastric and enteric irritation are quite sufficient to guide the
cautious and observant practitioner. The calomel here is not so desirable
as where there is constipation; eight or ten grains of Hydrarg. c. Cretâ
will produce less irritation, and act as effectually: it will require to
be followed by the same treatment as above-mentioned, and to be repeated
according to circumstances.
The diet should be chiefly farinaceous with milk; rice-milk, when the
bowels have been sufficiently cleared, is generally very useful; it is
slightly constipating, and soothes the irritable mucous membrane with its
bland consistence. Milk and soda-water, as mentioned by Dr. Locock, or
with lime-water, is very beneficial, especially where the tongue is
disposed to remain red, with a smooth glossy surface; as convalescence
proceeds, a tea-spoonful of the concentrated essence or decoction of
sarsaparilla may be added with advantage.
This form of puerperal affection is never epidemic; it is mere intestinal
irritation after labour from scybalous and other unhealthy contents; but
this is not the case with the "gastro-enteric form," described by Dr.
Ferguson; in the former, the febrile excitement of the circulation is but
trifling, and frequently can scarcely be said to exist; whereas, in the
latter, the disease rarely appears sporadically, but in conjunction with
numerous cases of the same character, or of the malignant adynamic form;
it is also, invariably accompanied with much febrile disturbance, and
usually of a low form, unless complicated with abdominal inflammation at
an early period.
"This form of puerperal fever," as Dr. Ferguson observes, "assumes the
general characters of a mild typhus, accompanied with intestinal
irritation." (_Op. cit._ p. 22.) The object of our treatment here is very
different to that of the other form just mentioned; it is to unload the
gorged circulation of the stomach, liver, and bowels, of the noxious and
excrementitious matters which nature has brought to these emunctories, in
order that they may be discharged from the system. It is in these cases
where, although little or no food has been taken for some time, and
without any evidences of fæcal accumulation, we find the exhibition of
certain purgatives, especially calomel, to be followed by such copious
fæculent evacuations, which we have every reason to believe have been
secreted by the liver and bowels under the action of this powerful remedy.
The treatment recommended by Dr. Ferguson, is so in accordance with our
own views, and so concisely expressed, that we may be allowed to quote it.
"The following," says he, "I have found the most suitable treatment. Get
rid of all local inflammations as soon as possible by leeching or by
moderate depletion, so as to reduce the malady into simple fever with
gastro-enteric irritation. When the skin is early dusky, and there is
nausea or vomiting, begin with an emetic. If there be no nausea nor
vomiting, but intestinal flux, with a red tongue smeared with suburra, a
large dose of calomel, from ten to fifteen grains should be given. Small
doses create purging, pain, and irritation, while the full dose produces
one to six large pultaceous stools, after which the tongue is cleaned,
rendered less red and more moist, and the pulse usually falls. These
stools, when examined, appear to contain the fæcal matter suspended in
large quantities of mucus and greenish bile, as if the turgid capillaries
of the irritated intestinal canal and liver had been freed from their
load. In some instances, a repetition only of the same dose is required to
efface the main features of the malady, and to leave nothing but debility
to support. In others, after a short respite, diarrhoea re-commences, and
soon is apt to become colliquative." (_Op. cit._ p. 158, 159.)
We have already shown the effects which calomel possesses in large doses
of rousing the different excretory organs into full action, and thus
assisting to secrete or separate from the circulation any offending
principle which may have been carried into it. We are also convinced that
where calomel has been promptly given in this manner, the chances of the
disease being prolonged or terminating in the adynamic form are
considerably diminished. Dr. Hamilton, in speaking of the advantages
derived from the use of purgative medicines in typhus fever states, "I am
now thoroughly persuaded, that the full and regular evacuation of the
bowels relieves the oppression of the stomach, cleans the loaded and
parched tongue, and mitigates thirst, restlessness, and heat of surface;
and that thus the later and more formidable impression on the nervous
system is prevented, recovery more certainly and speedily promoted, and
the danger of relapsing into the fever much diminished." (_Observations on
the Utility and Administration of Purgative Medicines in several
Diseases_, by James Hamilton, M. D. p. 35.)
As the gastro-enteric form of puerperal fever which we have just
described, is frequently observed in epidemics of the adynamic form,
particularly at their commencement and going off, and frequently
complicated with it, we would rather consider those local inflammations
and deposites of puriform fluid in the muscles, joints, &c., which are
occasionally seen after severe cases, to the disease being complicated
with, or assuming the nature of, the malignant form.
If the symptoms have not yielded to the treatment which we have
recommended, the alvine discharge becomes excessively unwholesome and
fetid, the skin exhales a strong and unpleasant odour, the strength fails,
the tongue is either dry and brown, or smooth and red like raw meat, the
fever sometimes assumes the remittent character as described many years
ago by Dr. Butter, of Derby; in others, the febrile symptoms subside,
leaving the case one of chronic or subacute inflammation of the lining
membrane of the bowels, with occasional attacks of irritative fever
arising from it. In these cases mercurials, except in mild and guarded
doses, appear to aggravate the irritation of the mucous membrane, and
increase the disposition of it to ulcerate: five grains of Hydrarg. cum
Cretâ and Dover's powder may be given once, or at the utmost, twice, in
the twenty-four hours; half a drachm of carbonate of ammonia neutralized
by lemon juice, and rendered alkalescent by a little Spirit. Ammon. Arom.,
may be given in some aromatic water every three or four hours; injections
of starch into the rectum with a few drops of Battley are also useful. In
some cases, where there was continued flatulence, a small quantity of
turpentine in some castor oil has had an excellent effect. Others, where
every means had seemed to fail, have yielded under the use of copavia. Dr.
Locock has found advantage from the occasional use of very small doses
(eight to ten grains) of epsom salts with a few drops of laudanum in some
aromatic water. The after treatment, as also, the rules for diet, are the
same as in the other form.
_The Contagious, or Adynamic, Puerperal Fever._
Although we have classed under the head of "puerperal fevers" a variety of
affections connected with, and arising more or less from, the same cause
with the dreadful malady which we are now about to describe, and although
every form and modification of them is liable to assume its characters,
still we must confess that the term _puerperal fever_ belongs _par
excellence_ to this form, the adynamic, malignant, and, as we have upon a
former occasion called it, the genuine puerperal fever.
It is in this form of disease that the vitiated state of the blood is
shown with most distinctness, not only from the condition of the blood
both during life, and after death, but also from the close connexion which
exists between it and the plague, African typhus or yellow fever, and the
other malignant fevers, both of the temperate as well as the tropical
climates.
The interesting and daring researches of M. Bulard upon the pathology of
the plague, tend to throw great light upon the nature of this formidable
disease, and to confirm the views which we have long entertained of this
and other diseases of the same class, that the essence of the disease
consists in the vitiated condition of the blood.
_Symptoms._ The onset of this disease is almost invariably accompanied
with a smart rigour, followed by intense headach, and rapid but generally
powerless pulse. It seldom begins before the third day, although in some
cases it seems to have commenced from the time of her delivery; whereas,
in others the patient has gone on to recover favourably until the tenth or
even the fourteenth day before being seized, and had already felt
sufficiently well to leave her bed and sit up. The powers of the system
seem prostrated at once; the shrunken features and dusky hue of the skin,
the leaden colour of the lids, and circumscribed crimson or almost purple
patches upon the cheeks, the short imperfect breathing and occasional deep
sighing to relieve it, indicate but too surely the nature of the disease,
and its depressing effects upon the whole system.
"The sensorium," says Dr. Douglas in describing this form, "is seldom in
any degree disturbed, whereas, in the others, it is so frequently, and
even sometimes it is excited to high delirium. The pulse here is usually
from the moment of the attack, soft, weak, and yielding, and in quickness
often exceeds 150; whereas, in the first species it is full, bounding, and
often incompressible; and in the second, small, hard, and contracted, and
in both, moderately quick. The eye, instead of being suffused with a
reddish or yellow tint, as in the others, is here generally pellucid with
a dilated pupil. The countenance, instead of being flushed, as in the
others, is here pale and shrunk with an indescribable expression of
anxiety; an expression altogether so peculiar, that the disease could on
many occasions be pronounced or inferred from the countenance alone. The
surface of the body instead of being, as in others, dry and of pyrexial
high heat, is here usually soft and clammy, and the heat not above the
natural temperature; and not only is the skin cool with clammy exudation,
but the muscles to the impression of the finger feel soft and flaccid, as
if deprived of their vis vitæ by the influence of contagion. Indeed, there
is such prostration of muscular strength and depression of vital principle
from the very outset of the attack, that I must suppose the contagion to
act through the medium of the nervous system in a manner analogous to that
of the contagion of plague." (_Report on Puerperal Fever._ _Dub. Hosp.
Rep._ vol. iii.)
Where the powers of the system are not annihilated from the commencement
of the attack by the depressing effects of the poison with which the
circulation is impregnated, an effort at reaction is frequently made, and
for some hours afterwards the surface of the body is hot and dry; but
sooner or later, as the stage of collapse comes on, it then assumes the
same cold death-like feel, as in the worst cases of malignant cholera. The
character of the attack will be in great measure modified by the intensity
of the poison, and the extent with which the circulation has been infected
by it. The same effort to produce such a state of reaction as will raise
the temperature of the skin, will probably assist nature in throwing it
off under the form of peritonitic or gastro-enteric species of puerperal
fever already described; whereas, where the circulation has been
thoroughly impregnated with it in its concentrated form, the vital powers
succomb at once, and a state of collapse exists from the very commencement
of the disease. The course which the symptoms follow and the duration of
the disease, will, therefore, depend not only on the severity of the
attack, but also on the power of the particular constitution to resist the
deadly effects of the morbid principle upon which the disease depends.
When broken down by previous disease, intemperance, poverty, and
depressing passions of the mind, the vital powers can make no stand
against the powerful enemy by which they are attacked; "the blood is so
much vitiated, even early in the disease, that it loses the power of
stimulating the heart so as to keep up its healthy action; and, perhaps,
also the vascular organs are early affected by the action of the poison,
and lose the power of either feeling the stimulus, or reacting with force
on the impression, which is communicated to their internal surface by the
vitiated blood. In such cases, in place of increased excitement, there is
frequently a want of action in the whole system." (Stevens, _op. cit._ p.
188.) The patient sinks without pain or complaint, beyond that of
debility, but in such cases with a rapidity which would almost claim for
the disease the name of "plague." The tongue becomes dry, red, and brown
at the back part, the pulse weaker and more rapid, the debility and
exhaustion more overpowering; still, even in this state, her mind usually
remains clear, unconscious of the fate which awaits her, and occasionally
even cheerful: a peculiar sickly odour exhales from the skin, and in many
cases so distinctly, as to warn us the moment we enter the room of the
patient's condition. The dusky ashen hue of the skin becomes darker, the
fingers are shrivelled, and the nails dark, or of a livid black as in
cholera; diarrhoea frequently attends, the fæces are unhealthy, and of the
same peculiar odour just noticed; during the first stage the lochia are
generally present, although of an unhealthy character; the milk also
continues in the milder cases, but as the stage of collapse approaches
they both disappear, and the breasts become quite flaccid. In some cases
there is vomiting from an early period, with more or less tympanitic
distention; but these symptoms rather depend upon the disease being
complicated with one of the other modifications. Livid purpurous blotches
sometimes appear upon the legs, &c. and in some epidemics it is
accompanied with dark or livid eruptions. The surface has now the cold wet
feel in its greatest degree, and in some cases even the tongue feels cold
to the finger; a drowsy state of insensibility generally follows and
continues until death.
The symptoms here enumerated present the characteristics of fever under
its different degrees of intensity. The peritonitic and gastro-enteric
forms may be compared with the ordinary fevers of temperate climates, and
which are attended with more or less inflammation of some organ. The
malignant adynamic form corresponds closely with the malignant typhus of
this, and the pestilential fevers of warm countries, more especially the
plague and the African typhus or yellow fever. In all of these diseases,
the vitiated state of the blood appears to be the essential condition of
their existence, quite independent of any inflammatory action; in fact, in
this form, so rapid and overpowering are the effects of the poison which
pervades the circulation, and so completely does it paralyze the whole
system, that there is neither time nor sufficient vis vitæ to make any
effort at reaction. Hence, as Mr. Moore has correctly observed, "when the
patient is rapidly destroyed by the violence of the disease, the morbid
changes bear no proportion to the severity of the previous symptoms; a
dubious trace of inflammation, a little serum, or a few feeble adhesions,
are all that dissection under such circumstances displays." (_Inquiry into
the Pathology, Causes, and Treatment, of Puerperal Fever_, p. 63.) In many
of the most rapidly fatal cases which we have witnessed, there have not
been even these questionable evidences of inflammation. The tissues have
been pale and bloodless, the uterus softened, its internal surface ragged,
and with a dark gangrenous appearance, extending to the os uteri, and dark
thin claret-like blood in all the larger vessels. The heart is flabby,
soft, and filled with dark blood; the lungs, liver, spleen, and kidneys
much softened; the spleen dark, sometimes enlarged and almost pulpy. If we
compare these appearances with those observed by M. Bulard in cases of
plague, we shall find a striking coincidence between the two diseases.
This intrepid pathologist remarks, that "the state of general turgescence
and dilatation of the venous system; the presence of inflammable gas in
eight cases in the cellular tissue, in the veins of the head, feet, and
abdomen; the presence of petechiæ, both internally and externally; the
general softening of the tissues; the enlargement, softening, and breaking
down of the spleen; the petechial state of the mucous membrane of the
stomach; the effusions of blood on the inner surface of that organ; the
passive hæmorrhages and boils, are symptoms which result from a change in
the condition of the blood. The symptoms connected with the state of the
nervous system, viz. the rigours, headach, and confusion of mind, the
quick and small pulse, the hurried respiration and vomiting, and also the
petechiæ, carbuncles, and buboes, are neither those of vascular nor
nervous inflammation. The blood has never shown the buffy coat; it was
found just as black in the arteries as in the veins, but in the former, in
much smaller quantity; it always had the appearance of being dissolved."
M. Bulard observes, that the decomposition of the blood is quite
independent of putrefaction being present before death takes place; and he
feels convinced that it is not only the sole cause of death, but must also
be looked upon as the origin of the various morbid phenomena during the
course of the disease. He considers "these phenomena to result from an
actual poisoning of the blood, similar appearances being observed in all
cases where putrid matter and morbid secretions have been introduced into
the system." With regard to the supposed inflammatory nature of the
plague, M. Bulard states, that in many cases not the slightest trace of
inflammation could be found. The changes in the spleen are of by far the
most invariable occurrence. In one hundred autopsies, this organ was found
only five times in a healthy state.
Where, on the other hand, the powers of the constitution, or the
diminished virulence of the disease, have enabled the system to withstand
the depressing action of its immediate effects, we find it considerably
modified, both in the symptoms which it presents during life, and the
appearances after death. Instead of being little else than a state of
collapse from the very outset of the disease, under which, not a single
attempt is made by the powers of the system to set up even the most feeble
effort of reaction, a variety of symptoms attend its commencement and
progress, indicating that the vis vitæ has not altogether succumbed
beneath the deadly effects of the malady. The very rigour itself, when
violent, the headach and flushing of the face, if severe, are rather
favourable than otherwise, and show that the system still possesses some
power of reaction. It is usually observed, that where the attack commences
with these precursory symptoms well marked, it is generally accompanied
with peritoneal pain, tympanitis, and other symptoms of inflammatory
action; whereas, in the worst cases, we have already stated, that from the
very commencement of the disease there is neither a symptom of
inflammation during life, nor a trace of it to be found afterwards. Dr.
Armstrong rightly observed, that inflammation is not an essential
constituent of typhus; and the same holds good in the strictest sense of
the word, with the typhoid or adynamic puerperal fever.
"Whatever the remote cause of fever may be, it is very evident that this
cause must invariably exist, not only at the moment of attack, but even
previous to that period. Now in the fevers from poison, the blood is
invariably diseased previous to the commencement of the cold stage. During
this period there are premonitory symptoms; but these are evidently the
effect of the diseased state of the vital fluid: and that these precursors
of fever are not the effect of any local inflammatory disease, is evident
from the fact, that frequently during this period there is no pain in any
of the organs, but a want of action, particularly in the extreme vessels,
and consequently a decrease of heat in the whole system.
"If inflammation in any of the organs were, in reality, the cause of
fever, then the disease ought to be fatal, exactly in proportion to the
violence of the local affection; but the very reverse of this is the
truth. Mere excitement can easily be reduced, and the inflammatory form of
fever is decidedly the most easily cured, though in it the excitement is
often so great that the organs are very liable to be injured; while the
malignant form of fever is by far the most fatal, though in this the
excitement is less, and the organs are seldom affected. This is
particularly the case in the worst form of the African typhus, and
probably other varieties of malignant fever, where the blood is under the
influence of an active poison, and where its vitality is diminished, and
its structure is injured even before the attack.
"Those who have seen most of the malignant diseases know well that
excitement in fever is invariably a good symptom; for this is a sure sign
that the blood has not yet undergone any fatal change, and independent of
this, mere increase of action is always at the mercy of the lancet. But
neither the lancet nor leeches, gum water, vitriolic emetics, calomel,
antimony, brandy, opium, or acids, can redden the colour of the black
blood, which we invariably meet with in pestilential diseases, or remedy
the diseased state of the vital current, so as to cure that fatal form of
fever where the malignant symptoms are produced, not by excitement, but by
the vitiated state of that mysterious fluid, which in health gives life
and nourishment to every solid of the system, and which, when diseased to
a certain extent, is by far the most frequent cause of death in all those
fevers that are produced by some deleterious poison acting, in the first
place, on the vital current, and then on the brain and the whole system
through the medium of the blood." (Stevens, _on the Blood_, p. 186.)
We have quoted thus largely from the observations of Dr. Stevens and M.
Bulard, to whose admirable researches we are so greatly indebted for our
present knowledge, respecting the nature of pestilential diseases both of
the East and West, for they tend not only to show the true pathology of
malignant puerperal fever, but also the class of diseases to which it
belongs.
_Appearances after death._ Where more or less inflammatory action has
accompanied the first part of the disease, the lesions observed after
death differ considerably from those of acute peritonitis: the effusions
of cogulable lymph, of serum, and sero-purulent fluid, are seldom met with
to such an extent where the case has been one of inflammation
uncomplicated with the adynamic form of puerperal fever, even although it
may have been exceedingly violent; whereas, in the present case, although
there has been scarcely sufficient power in the system to set up even a
moderate degree of inflammatory action, the intestines and uterine
appendages are found glued together, and thickly imbedded in immense
effusions of lymph. The ovaries, Fallopian tubes, and broad ligaments are
engorged with purple vascularity, softened, and, especially the ovaries,
quite disorganized, with numerous effusions of sero-purulent matter
beneath their peritoneal coverings, or into their parenchymatous tissue.
In others, their whole substance has been softened and pulpy, with little
cyst-like cavities filled with blood or pus, the remains of the Graafian
capsules. During the fatal epidemic which prevailed at the General
Lying-in Hospital, in the early part of 1838, we met with several cases
where the ovaries had entirely disappeared, their site being only
discoverable by an oval thickening of the broad ligament, something like
an empty cyst of peritoneum; this contained a small quantity of livid
pulpy débris of the ovary, and (on that side where conception had taken
place) a remarkably well marked or rather exaggerated corpus luteum. The
uterus is larger and its tissue much softer than under ordinary
peritonitis, so that, in many instances, the finger can be easily pushed
through its whole substance.
Where the constitution has borne the brunt of the attack without immediate
collapse, and the local mischief been controlled by appropriate means, we
find that fresh efforts are made to rid the circulation of the morbid
matter with which it is infected. The patient is suddenly seized with
severe pain, with heat, redness, and swelling of one of the large joints,
presenting all the appearances of arthritic or rheumatic inflammation, and
also of certain muscles, especially the supinators of the arm, the glutæi,
and gastrocnemii. The painful spot soon becomes hard, it is intensely
tender, and in two or three days the feeling of fluctuation indicates the
formation of an abscess, from which a large quantity of greenish coloured
pus mixed with blood and serum is discharged. The cellular tissue beneath
the skin and between the muscles is equally affected, and if examined when
the abscess is just beginning to form, will be found of a dirty brown
colour, softened, infiltrated, and here and there condensed with lymph or
pus, precisely as in cases of gangrenous erysipelas: the muscular tissue
has entirely lost its red colour, and closely resembles the appearance of
boiled meat, its structure so softened as to tear easily under the
fingers, and interspersed with deposites of immature lymph and purulent
fluid, the commencement of what would have been an abscess. Like
gangrenous erysipelas the extent of the abscess does not seem to be
limited by a surrounding wall of healthy lymph, as seen in a common
phlegmon, but if deep beneath the surface it continues to spread in all
directions until nearly the whole limb appears to be implicated in one
immense abscess: hence, in those patients who have recovered under these
attacks, the limb has frequently been rendered useless, the muscles being
atrophied and coherent.
Inflammation of a similarly arthritic or rheumatic nature occasionally
also attacks the eye, and presents all the usual characters of arthritic
iritis under ordinary circumstances: there is the same intolerance of
light, pain of the eye, dimness of vision, contracted pupil, and peculiar
white ring round the edge of the cornea, which distinguishes this
affection; but in the present case, the disease runs a far more rapid
course, and defies the remedies which in common cases would be sufficient
to check it; the inflammation soon extends to the deeper seated structures
of the eye, the pain is excrutiating, and, in two or three days,
disorganization takes place, followed by suppuration, staphyloma, and
bursting of the cornea. So rapid and destructive is its course, that,
although five or six cases have come under our notice, in only one
instance, with the greatest difficulty, was the eye saved, and, even then,
not before it had been considerably injured.
These attacks are attended by severe pains of a similar nature in
different parts of the body, more especially the joints and limbs; and,
from the arthritic character which they assume, tend, in our opinion,
still farther to elucidate the real condition of the system. The analogy
between gout or rheumatism, and those diseases which arise from a vitiated
state of the blood, is exceedingly close, nay, even identical, for in
both, a principal pervades the circulating fluids which requires to be
removed; and if this be not effected by any of the excretory organs,
nature endeavours to throw it off by some process of local inflammation.
The connexion between puerperal fever and typhus is very close, for it not
only assumes the characters of the typhus epidemics which may chance to be
prevailing at the time, but we have distinct evidence that the contagion
of typhus will, in a puerperal woman, manifest itself under the form of
puerperal fever. Dr. Collins has recorded a very interesting case of this
sort:--"A patient was admitted at a late hour at night into one of the
wards, labouring under a bad form of typhus fever, with petechial spots
over her body; when observed next morning, she was removed into a separate
apartment, where she died shortly after. The two females who occupied the
beds adjoining hers, while she remained in the large ward, were attacked
with puerperal fever, and died." (Collins, _op. cit._ p. 381.) During a
typhus epidemic which prevailed a few years ago in the poor districts of
the metropolis, a prominent feature of which were petechiæ and a livid
rubeoloid eruption, precisely the same appearances were observed among the
cases of adynamic puerperal fever at the General Lying-in Hospital.
The same has been observed with erysipelas; and, in one short but severe
epidemic, the child of every woman who had died of the disease perished
also from erysipelas, so severe that it ran its course in a few hours. Dr.
Gordon, of Aberdeen, remarks, that "with it and, at the same time,
epidemic erysipelas began, progressed with equal pace, arrived at its
acmé, and terminated together." He also says, that a very frequent crisis
of the disease was an external erysipelas. Mr. Hey remarks, that
infectious fevers were common at the time; and he does not recollect ever
having seen such malignant cases of erysipelas as then. Dr. Clark also
observes, that those inflammatory diseases which occurred were principally
erysipelatous. Dr. Armstrong states, "that in 1813 (the year of its
greatest prevalence throughout England) low fever, typhus, and acute
rheumatism also prevailed to an uncommon degree." (Moore, _on Puerp.
Fever_, p. 164.)
During the same epidemic, to which we just now alluded, the housemaid of
the hospital, a healthy young woman, was suddenly seized with sore-throat
and violent erysipelas of the head and face, from which she was saved with
great difficulty; her sister came and attended her, as the nurses were too
much occupied by the number of patients who were ill; just at the time
that she was pronounced out of danger, her sister, not feeling well, went
home, sickened, and died, in less than three days, of typhus fever.
The contagious nature of puerperal fever has long since ceased to be a
matter of doubt, and instances have repeatedly occurred of practitioners
and nurses communicating the disease to several patients in succession.
Dr. Gooch has recorded some striking instances of the kind, and we could
enumerate many others if necessary. Where a practitioner has been engaged
in the post mortem examination of a case of puerperal fever, we do not
hesitate to declare it highly unsafe for him to attend a case of labour
for some days afterwards. The peculiar smelling effluvia which arises from
the body of a patient during life is quite, in our opinion, sufficient to
infect the clothes; and every one who has made a minute dissection of the
abdominal viscera, especially in fatal cases of puerperal fever, knows
full well that it is almost impossible to remove the smell from the hands
for many hours, even with the aid of repeated washing; it must be,
therefore, self-evident, that, under such circumstances, it would be
almost criminal to expose a lying-in patient to such a risk.
That the discharges from a patient under puerperal fever are in the
highest degree contagious, we have abundant evidence in the history of
lying-in hospitals. The puerperal abscesses are also contagious, and may
be communicated to healthy lying-in women by washing with the same sponge:
this fact has been repeatedly proved at the Vienna hospital; but they are
equally communicable to women not pregnant; on more than one occasion the
women engaged in washing the soiled bed linen of the General Lying-in
Hospital have been attacked with abscesses in the fingers or hands,
attended with rapidly spreading inflammation of the cellular tissue.
We have stated that puerperal fever may arise from the effluvia which
exhales from the body of the patient, and from the various discharges; it
may also be produced by noxious exhalation from sewers, ditches, and other
sources of miasmata, the effects of which in producing typhus have been
long ascertained. "With regard to the General Lying-in Hospital, its
locality rather below the level of the river, and surrounded by a
mesh-work of open sewers fifteen hundred feet in extent, receiving the
filth of Lambeth, and some not thirty feet from the wards of the
institution, may account for its unhealthiness. It is only after repeated
remonstrances, that these sources of pollution have in part now begun to
be obliterated." (Dr. Ferguson, _op. cit._ p. 104.) The commissioners of
sewers refused the application of the hospital, to have the nearest of
these nuisances properly bricked over, and assigned this remarkable reason
for so doing, viz. that the hospital had come to them, not they to the
hospital. Consent was ultimately only obtained by the agreement, that a
large portion of the expense should be borne by the institution. On
completing the work they afforded us a striking instance of the effects of
effluvia on lying-in women; a large quantity of black pestilential mud had
been thrown out in making the necessary excavations, this they refused to
remove, and actually spread it upon the ground to a considerable extent;
the consequence was, that the first two cases of puerperal fever after the
re-opening of the hospital occurred within twenty-four hours of this
unjustifiable act.
_Treatment._ The fatal character of this disease and the varied form of
its epidemics will in part explain why so much discrepancy of opinion
should have existed among authors and practitioners respecting its
treatment. Where its remote cause has been but imperfectly known, it is
not to be wondered that practitioners, finding their efforts unsuccessful,
should lose their confidence in any one set of remedies or mode of
treatment, and try a variety, in the vain hope of hitting upon the right
one. But in a great measure this is to be attributed to the difference of
the affections which have been described by various authors under the same
head; each has described it as it occurred to himself; and in many
instances it has been only the description of a single epidemic, and,
therefore, has given to the world the treatment which his experience in
that particular form has proved successful. Thus, the lancet has been
looked upon as the only means of saving the patient by those who have
witnessed the inflammatory modification of the disease; whereas, in the
hands of those who had to treat it in its adynamic malignant form,
bleeding (as but too frequently every thing else) proved utterly
inefficacious.
A variety of plans have been tried in this last species, and their success
described by Dr. W. Hunter in his lectures, gives a fearful view of the
nature of the disease we have now to deal with. We continue the quotation
which we have already made from him. "In two months thirty-two patients
had the fever, and only one of them recovered. We tried various methods.
One woman we took from the beginning and bled her, and she died; to
another we gave cooling medicines, and she died: to a third we gave warm
medicines, such as Confect. Cardiac., cordial julep, Mithridate, &c., and
she died. In private practice it was the same, and at least three out of
four would die." (_MS. Lectures._)
There is no doubt that, wherever the state of the patient will permit it,
the lancet should be tried. Where the pulse is quick and small, with
little power, it is scarcely more than an experiment to ascertain how the
system will bear the bleeding: in the worst cases of the adynamic form,
uncomplicated by the slightest effort at reaction, the state of collapse
at once forbids such an attempt: but in many instances the circulation is
merely oppressed, the pulse rises in volume as the depletion proceeds; and
where from its feel before the operation we had little hopes of taking
away more than five or six ounces, we are often enabled to continue it
until a considerable quantity is lost. In other cases frightful exhaustion
is the immediate effect, and warn us instantly to discontinue it. The
capability of bearing bleeding may be always looked upon as a favourable
prognostic, not only because the patient's strength is better than we had
perhaps expected, and also because these are precisely the cases where
mercury can be used with decided benefit. Whether it be the bleeding,
which, in all probability, renders the system more easily brought under
the influence of this medicine, we will not stop to consider; at any rate,
its effects are not only more easily obtained, but they exert a more
decided control over the progress of the disease, the pain abates, the
tympanitic abdomen becomes less tense, the pulse slower, fuller, and
softer, the tongue moister, and there is a sense of general improvement in
the patient's feelings. But in the adynamic form, when present in its
greatest intensity, either there is not sufficient time to impregnate the
system, or it is less sensible to its effects; at any rate, even if we
succeed in producing salivation, little or no improvement follows.
In those cases where the inflammatory symptoms assume a metastatic
character, we must act according to the organ implicated. The attacks are
frequently of a very sudden nature, the patient being seized, without the
slightest warning, with severe pain and heat of head, throbbing of the
temples, intolerance of light and sound, and occasionally violent
delirium; the face is flushed, the carotids are seen strongly pulsating.
These signs denote a dangerous attack of cerebral congestion, which
requires the most prompt and active measures for its suppression. In these
cases the aberration of mind frequently continues for some time, even
after the symptoms of active inflammation have subsided, and form a
species of puerperal mania of a very dangerous character, which we shall
describe under its proper head. In other cases, effusion rapidly comes on,
followed by fatal coma or convulsions.
In some instances, the inflammatory action seems to fix itself upon the
chest: the patient is suddenly seized with great dyspnoea, oppression, and
pain, which latter is much increased by every effort at respiration, and
sometimes is so violent as to threaten suffocation, unless promptly
relieved by the lancet. These attacks sometimes return two or three times,
with the same degree of sudden violence, or change with equal rapidity
from one part to another.
So long as there are symptoms of local inflammation present, leeches and
hot poultices, &c., must be applied, as already mentioned; but it must
ever be borne in mind, that the local affection is _not_ the disease, but
one of its effects. We must, therefore, direct our energies to ridding the
system of the cause upon which it depends. In all cases we think it
desirable to begin the calomel in doses of five grains, at intervals of
two hours; and if properly guarded with Dover's powder, no disposition to
purging will be produced: by this means we not only gain time, but, which
is also of great importance, we premise a general increase of the
excretions, which tends not a little to relieve the system. After two such
doses, the calomel may be given at the ordinary rate of two grains every
two hours, with half a grain of opium, or, what is still better, a little
Dover's powder, until slight marks of salivation begin to appear. The
action should now be kept up by an occasional dose, but never allowed to
become at all severe, as considerable exhaustion may be the result. The
dark and offensive lochia should be constantly removed by the most
scrupulous attention to cleanliness, and by frequently washing out the
vagina and uterus with warm water.
If diarrhoea has set in to an exhausting degree, the opiates must be
increased, and the Hydrarg. cum Cretâ substituted for the calomel. Saline
draughts of citrate or acetate of ammonia, rendered alkaline in excess by
Sp. Ammon. Arom. may be given from time to time; they appear not only to
refresh the patient, but also to allay flatulence and vomiting, if
present. For her common drink we recommend a solution of carbonate of soda
in water, in the proportion of two drachms to a pint, slightly flavoured
with orange peel; and whenever she has taken this freely, we have observed
a considerable amelioration in her symptoms.
Although strongly inclined to advocate Dr. Stevens's views respecting the
action of salines in diseases of this character, we must confess that we
have been in great measure deterred from carrying them out to the full
extent that we could have wished, by the repugnance of the patient to
taking a draught so intensely salt as his celebrated mixture. On several
occasions we have seen the most beneficial effects from the use of
salines; and in two cases, during one of the most malignant epidemics,
where every thing seemed to be equally fruitless in arresting the progress
of the disease, the exhibition of repeated doses of soda, and encouraging
the patient to drink largely of the above-mentioned solution, was followed
by the happiest effects. We have again recently tried the common salt,
disguised as far as possible in the form of an effervescing draught, and
in two cases with very decided results.
The acid state of the mouth is a very constant symptom in this disease,
and the contents of the stomach after vomiting are frequently intensely
sour, so that in most instances the soda drink has been greedily longed
for, and by some patients even called lemonade. We have also tried still
more recently warm injections into the vagina, of a weak solution of salt
and water, but at present, can give no opinion from merely a case or two.
Ice has been lately recommended by Professor Michaelis, of Kiel, not only
internally but externally, by means of a large bladder. According to his
observations it diminished the pain and tympanitis, reduced the quickness
of the pulse, and relieved the patient considerably; this was followed by
a profuse diarrhoea of light coloured and offensive evacuations, under
which the pulse rose in power, followed by general improvement. We tried
it on one occasion; it was swallowed with avidity like barley-sugar; it
relieved the sense of inward heat and thirst, stopped the hiccough and
vomiting which had become very troublesome, and seemed to diminish the
tympanitis, but collapse followed as rapidly as in other cases; nor have
our subsequent observations been more favourable. It may be given with
advantage with other medicines to relieve several distressing symptoms,
but does not appear to us to exert any power in arresting the progress of
the disease.
The patient's diet should be mild but nutritious, much more so than in the
other forms of puerperal fever; and if there be symptoms of sinking, wine
and ammonia, &c., must be given with a liberal hand.
In reviewing what we have said upon the treatment of adynamic puerperal
fever, we repeat our conviction, that where the state of collapse has
precluded all antiphlogistic measures, and given us but little cause to
expect much relief from mercury, we know of no treatment which holds out
such rational hopes of success as the saline, based as it is upon the same
principles on which it has been employed by Dr. Stevens, in the malignant
fevers of warm climates, and by British physicians in the epidemic typhus
of this country.