not very uniform in its duration. It is, however, in general short. It
may last for a number of days—for many days, if we reckon the
convalescence a part of the disease. On the other hand, it may, like the
plague itself carry the patient off within the first twenty-four hours
of the attack. Three or four days is reckoned to be the average duration
of childbed fever, when it occurs in the epidemic form.
Professor Meigs has well explained why it is that childbed or peritoneal
fever is so serious and dangerous a malady as it is. He observes:
“The peritoneum (the lining, membrane of the abdomen), a serous
membrane, known for ages as one of the tissues most ready to take on
inflammation, undergoes in labor, and during lying-in, changes of the
greatest importance. Its great extent may be known by computing the
superficial contents of that portion of the serous membrane which
invests the alimentary canal. This canal is about forty feet in length,
and its outer coat is composed of peritoneum. If cut up by the
enterotome, it would be at least four inches wide and forty feet long,
affording a superficies of more than thirteen feet, to which should be
added the superficial contents of the remainder of the membrane, where
it invests the liver, the epiploon, the mesentery and mesocolon, besides
the ligamenta lata, and all the other parts which derive from it their
serous covering. This vast surface inflames rapidly and totally, and
passes through the stage of inflammation with extraordinary speed. It
cannot happen that it shall ever be extensively inflamed without a
coincident exhibition of the greatest disorder in the functions of the
nervous organs directly implicated in its structure, or possessing with
it physiological relations that could not be safely disturbed. The
peritoneum is the investiture of the abdominal organs; the peritoneal
coat of the stomach is as truly a part of the organ as its muscular or
mucous coat; the same is true as to the peritoneum that invests the
liver, that of the spleen, and the same truth is of the utmost import
when it is stated with regard to the peritoneal coat of the whole
alimentary apparatus. It is clear that extensive or universal
inflammation of the peritoneal membrane is inflammation of all or many
of the organs contained within the cavity of the abdomen. A great
puerperal peritonitis, therefore, may be properly regarded as a complex
inflammation of a vast number of organs indispensable to existence. Why
should we be astonished, then, to see the power of the nervous mass sink
under the invasion of causes of destruction so great and so pervading?
“Seeing that the superficies of the peritoneum is equal, probably, to
thirteen or fourteen feet, we should have abundant reason to dread so
extensive an inflammation from the constitutional irritation which it
alone would produce; but when, in addition to that consideration, we
take into view the great affusions which may ensue, the suppurations,
the interruption of the intestinal functions, the depravation of the
actions of the liver, etc., which are occasioned by it, we have still
greater reason to deprecate its attack, and to seek for the justest
views of its nature, and of the remedies most appropriate for its cure.”
Professor Meigs elsewhere judiciously remarks, that, considering the
changes that take place in the reproductive tissues at childbirth,
“there is, in fact, greater reason for surprise, when we find it not
followed by inflammation, than when we meet with the most violent and
destructive cases of that affection.”
_Treatment._—In the year 1846, I treated (in connection with a
missionary friend and physician, who is now in Siam) a premature case of
childbirth, which, to say the least, threatened to become one of severe
puerperal fever. The case was an important one, and as such I here
present it to the reader. It was written out with great care and
accuracy at the time by the medical friend referred to. I give it in his
own words:
“_March 19, 1846._—Desirous of availing myself of an opportunity which
Dr. Shew kindly afforded me of witnessing the hydropathic treatment of
cases of labor, I accompanied him to No. — Second Street, where he had
been summoned a few minutes before, to attend Mrs. S., who was then in
need of his services.
“We found the patient an intelligent woman, of the nervous temperament,
with her constitution much broken down—though she was but thirty-one
years of age—by the results of severe previous labors, the last a
miscarriage. After some of her former confinements, she had been weeks
and months in recovering. In one case, when, she was treated for
puerperal fever, her husband paid in one year not less than one hundred
and fifty dollars—no trifling sum out of the earnings of a working man
with a large family—to the apothecary alone, for leeches and medicines.
The patient had always been in the habit of using strong tea and coffee;
drank the _mineral_ water of the city wells; for some months had
relished nothing but the little delicacies sent in by her friends, and
throughout the winter had been able to do little or nothing at home.
“In consequence of excessive fatigue, a few days before, in
‘house-hunting,’ as she called it, she had been seized on Tuesday, the
17th, at 10 A. M., at the close of the fifth month of her pregnancy,
with the pains of labor—her former miscarriage having, of course,
induced a predisposition to another. These pains increased in frequency
and severity till they caused the greatest suffering, and prevented all
sleep on Wednesday night and Thursday, up to the hour (3 P. M.) when she
sent for Dr. Shew.”
Here, then, was a patient, whose previous history, impaired
constitution, loss of sleep, and exhaustion from intense and almost
incessant suffering, protracted now for more than two days, seemed to
promise any thing but a _speedy_ recovery, even should delivery be
safely effected. It should be added that, _up to the time_, she was an
_utter stranger_ even to the hydropathic treatment.
“Her bowels having been moved the day before, all that was deemed
necessary was to render the condition of the patient more comfortable,
by resorting to sedative frictions along the spine with a towel wrung
out of cold water, and to the tepid hip-bath, with sponging and rubbing
the whole surface of the body. After this, less complaint was made, till
soon after 6 P. M., when there was a sudden aggravation of the
bearing-down pains, resulting in the delivery of a well-formed but
still-born male child, of apparently five months.
“In about fifteen minutes the after-birth was detached, and taken away.
Not even the usual amount of hemorrhage occurred. A bandage was applied
to the abdomen, as the patient expressed a wish for it; and after
resting awhile, a little panada was given her as nourishment.
“Mrs. S. continued very comfortable through the evening; no excess of
the natural discharge; complained only of exhaustion, and slight
difficulty of passing urine. As there was some heat of the surface—the
pulse being from 90 to 100—tepid sponging was resorted to, which proved
very grateful to the patient.
“_Second Day (Friday), Seven, A. M._—Found the patient had obtained
considerable sleep at intervals during the night; felt very comfortable,
though occasionally had slight pains in the abdomen; tongue moist; pulse
81; had passed a little water during the night, but with difficulty; had
a strong desire for a cup of coffee, but persuaded her to take a little
panada in its place; had not much appetite; was permitted to sit up for
a few minutes while her bed was made.
“_Half-past Eleven, A. M._—Mrs. S. still very comfortable; found her
sitting up in the rocking-chair, the very picture of convalescence.
Sponging enjoined, if any feverishness should arise.
“_Three, P. M._—Dr. S. sent for, as the patient had been seized a few
minutes before, rather suddenly, with a sharp pain in the left side. Had
been drinking a tumbler of cold lemonade. Had a natural movement of the
bowels that morning, and passed a little water. The tepid sponging of
the surface had been neglected. Pain fixed, severe, pretty constant,
remitting only for a moment or so. No corresponding contractions of the
uterine tumor observed. Some pain also complained of in the hip, with
which she had, on a former occasion, been troubled. Up to that time had
had no chill. Warm fomentations were applied, but with little relief.
“_Half-past Four, P. M._—A chilliness felt, then shivering, prolonged,
with increase of the fixed pain of the side; pulse 112, weak; patient
restless, anxious, desponding; knitting of the brows, involuntary
weeping. A bottle of warm water was applied to the feet, and soon after,
the chills ceased.
“A large warm enema was now administered; this brought away considerable
fecal matter; and fomentations were applied to the abdomen. Next, the
patient was seated in the hip-bath, at a temperature of 95°, for fifteen
minutes, when water was passed more freely than before, and a slight
nausea experienced. The result of this was complete abatement, for the
time, of the pain in the uterine region, the diminution of the frequency
of the pulse to 90, and great comfort. The bandage to the abdomen having
been removed, to allow of the bath, was not replaced. If need be,
fomentations to be kept up.
“At 7 P. M. found the patient in a profuse perspiration; pain in the
abdomen had lost its acuteness; _soreness_ there was all now complained
of—soreness in the head, ‘in the bones, and all over.’ Abdomen swollen,
and tender on pressure; breathing shallow; pulse 110–12; discharge from
the womb (the lochial discharge) arrested. Patient is to be kept quiet;
to take no nourishment; no fire to be in the room.
“At 9¼ P. M., the perspiration still continues; complains of pain in the
hip, but chiefly in the left side, as before, and shooting across the
abdomen; pain now very severe, increased by coughing; breathing thoracic
(shallow), and 28 in the minute; pulse 98; is thirsty; tongue moistish,
with a slight milky coat. Fomentations as usual.
“_Half-past Ten, P. M._—Pain increasing in the abdomen and hip;
tenderness increasing; can scarce bear slight pressure on the abdomen;
knees drawn up; restless, discouraged; pulse 100, though not very full
or strong; skin still slightly moist.
“In this critical state of things, when nearly every symptom of that
fearful disease, puerperal fever, was invading the system, and when,
according to the prescribed rules of practice, the most vigorous
antiphlogistic measures would be called for, a plan of treatment was
adopted that was, as it seemed to me, far more likely to _kill_ than to
_cure_, and which I could not but protest against at the time, but
which, as the result proved, was eminently calculated to turn back the
tide of disease so rapidly setting in. It certainly afforded striking
evidence of the resources of hydropathy, and its promptness and
efficiency in relieving pain, and extinguishing inflammation.
“Mrs. S. was carefully lifted from her bed, and after being placed in
her chair, was transferred to a hip-bath, containing about one pail of
water fresh from the Croton hydrant near by, of the temperature of 42°
Fah. A towel, wrung out of cold water, was applied to the forehead at
the same time. Of course she was well covered with blankets. She had
been seated there but a few minutes, when she expressed herself as
feeling _very comfortable indeed_. The severe pain in her abdomen and
thigh _had left her as if by magic_, and so complete was the relief,
that she fell into a gentle doze, from which, awakened by nodding, she
observed, ‘There, I feel so easy now, I lost myself, I believe.’
“While in the bath, her pulse was lowered several beats in the minute;
the unimmersed parts of the body remained warm; the hips were to her of
a refreshing coolness. After remaining thus seated in the water about
twenty-five minutes—a slight addition of more cold water, by gradual
pouring, having been made during this time—she was lifted back to the
bed. Her pain had now entirely vanished; the natural lochial discharge
was soon restored; the pulse reduced to 94; and, warm and comfortable,
she had a prospect of a good night’s rest.
“_Third Day (Saturday), Seven A. M._—Found patient looking comfortable
and happy. No pain now in the abdomen, slight soreness only; tympanitis
(swelling) gone; tongue moist, and hardly coated; pulse 79; had had no
sensation of chilliness after her bath, but slept from 12½ to 4 A. M.,
without waking, and another doze after that; window had been a little
raised all night, and no fire in the room, though it was cool. Now was
able to pass water without difficulty. Was directed to take for
breakfast some coarse wheaten bread, toasted, and softened with milk,
and a little scraped apple, if she wished.
“_Eleven, A. M._—Mrs. S. appears very comfortable. With the aid of a
friend has been up and changed her clothing. Pulse 84; complains of no
pain of any consequence in the abdomen.
“_Half-past One, P. M._—Had been under the necessity of getting up
without assistance, and fatigued herself, and thus induced a return of
very severe pain in the uterine region. Dr. S. was sent for, when resort
was had again to the hip-bath, filled with cold water from the hydrant,
which had with such wonderful promptitude averted the danger of
puerperal fever, with which she was threatened on the evening of the
second day; as on that occasion, in less than five minutes, the pain and
feverishness was completely quelled. She was allowed to remain in the
bath half an hour, and requested to abstain from food till evening.
“_Five, P. M._—Patient doing remarkably well; cheerful; free from pains
in the abdomen, save now and then a very slight one; some soreness on
pressure; pulse 84, compressible.
“_Ten, P. M._—Had slept during evening; had taken a little nourishment.
Has some difficulty in passing water, and as occasional slight pains and
soreness still continues in the abdomen, the cold hip-bath, at 42° Fah.,
was again resorted to for about thirty minutes. During this time the
pulse was lowered from 80 beats in a minute to 70; water was passed
freely, and pains put to flight.
“After the bath, the patient continuing warm and comfortable, was
directed, should there be any return of pains during the night, to seat
herself in the hip-bath, which was left in the room.
“_Fourth Day (Sunday), Half-past Seven, A. M._—Patient had slept most of
the night; looks bright; feels ‘very comfortable;’ pulse 72, soft and
natural; had raised herself in bed without difficulty, and washed. On
account of some difficulty in passing water, the hip-bath was used for
about fifteen minutes, when the urine flowed more copiously and freely
than at any previous time. Left seated in the rocking-chair; sitting up
occasionally; she says it has rested and refreshed her from the first.
“Appetite good; thinks even the plainest food would be relished.
Breakfast to be as before; the toasted coarse bread, soaked in milk,
with a little scraped apple. Directed to take no nourishment at any
time, unless a decided appetite, nor then oftener than three times in a
day. Is to take an enema and another hip-bath in the course of the
morning.
“_Six, P. M._—Had continued to gain during the day till toward evening.
It most unfortunately happened that an intoxicated man, mistaking the
house, strayed into the room where she was lying, with no attendant but
a young girl; seating himself, without any ceremony, in the
rocking-chair, with a lighted cigar in his mouth, he smoked away to his
satisfaction, and then very deliberately composed himself for a nap.
This strange visitor, and the fumes of the tobacco, had given poor Mrs.
S. a severe headache, the first with which she had been troubled;
considerable nausea, with paleness of the face, cold feet, etc. A towel
wet with cold water was applied to the head, and a hip-bath ordered.
“_Half-past Nine, P. M._—Was rapidly recovering from the effects of the
afternoon’s unexpected visit; sat up awhile.
“_Fifth Day (Monday)._—At 7½ A. M., found Mrs. S. sitting up in bed
sewing; pulse 75; had rested well; has a good appetite. Breakfast to be
as before; may safely take a hip-bath at any time when suffering from
pains and is not made very chilly by sitting in it.
“Was able this morning to rise and walk about the room unsupported.
Required no assistance in getting to the bath; bowels moved naturally;
sat up several hours to-day; appears bright, pleasant, and cheerful.
“_Sixth Day (Tuesday)._—Mrs. S. feels to-day as much better than she did
yesterday, as she did yesterday better than the day before. Sat up, and
was about the room nearly all day; continues the practice of daily
sponging the whole surface, and the use of the hip-bath. At night,
retention having ensued from over-distention of the bladder, in
consequence of an untimely and protracted visit from some of patient’s
friends, Dr. S. was sent for, and deemed it advisable to resort to the
catheter, which she had frequently been compelled to use on former
occasions, sometimes for months together.
“_Seventh Day (Wednesday)._—Mrs. S. appeared to be better in the
morning; able to rise without assistance, to walk about, and even to
sweep the room; catheter again required.
“_Eighth Day (Thursday)._—During the night, of her own accord, took two
or three or four cool hip-baths, and found them refreshing, and of
service in promoting easy evacuation of the bladder. At one time dropped
asleep, and remained so an hour or more—sitting in the water. Pulse in
the morning. Dressed the children and arranged the room herself to-day;
and though a week had hardly elapsed since her confinement, felt _strong
enough in the morning to go down stairs_, and to do a half day’s work in
sewing, etc., from which she appeared to experience no injury. A few
days after she ventured to ride down to the lower part of the city, and
having since continued to improve, save an occasional return of an old
difficulty—retention—is most gratefully sensible, under Heaven, to her
physician and hydropathy, for a far more speedy and pleasant
convalescence than she ever experienced after any of her former
confinements.”
Professor Gilman, of this city (New York), in his edition of the Dublin
Practice of Midwifery, gives us the following account of a method of
treatment which was adopted with remarkable success in the old country:
“In an epidemic (puerperal fever), which raged at Keil in 1834, ’35, and
’36,” says Professor G., “Michælis used ice, both externally and
internally, with excellent effect. The cases in which he gave it with
success were marked by burning pain and heat in the bowels, thirst,
painful eructations, and tenderness of the epigastrium. The brain was
clear; no delirium. The ice was given by the mouth, in bits the size of
the finger, every half hour or oftener; it was also applied over the
abdomen in a large bullock’s bladder, extending from the epigastrium to
the pelvis, in a layer half an inch thick. This application was in some
cases continued for three days, the bladder being changed as soon as the
ice melted. It was very grateful to the patient, and Michælis thought it
had cured some cases where affusion had actually taken place into the
peritoneal cavity. The use of ice was not persisted in unless it was
grateful to the patient. The symptoms of amendment were a sudden and
very great fall in the frequency of the pulse, a peaceful sleep, relief
from the painful eructations, and diminished distention of the bowels. A
profuse watery diarrhea occurring with these favorable changes, seemed
to him to be critical.”
This treatment of Michælis is certainly a very bold one. Those who are
well acquainted with the water-treatment will be able at once to
comprehend the fact, that the applications mentioned were sufficient to
cause “a sudden and very great fall in the frequency of the pulse, a
peaceful sleep, relief from the painful eructations, and diminished
distention of the bowels.” Nor is it incredible that a cure might thus
take place, even in some cases where affusion into the peritoneal cavity
had actually taken place, since the effort of nature tends always, so
long as life lasts, necessarily to that end. It is well worthy of
remark, that the treatment of Michælis was persisted in only so long as
it was grateful to the patient. This is an important rule to remember.
Nor do I regard it necessary, absolutely, to use ice in the treatment of
this or any other inflammatory affection. Water—even at the temperature
of rivers at this latitude in the summer—which is usually, I believe, at
about 70° Fah., may be made very effectual in the cure of inflammatory
diseases. Thus, if we wrap one or more wet sheets about a patient,
having him, at the same time, on a cool straw bed, and neither the bed
or wet sheets having any covering whatever, we, through the natural
processes of evaporation and refrigeration, abstract in a short time a
great amount of animal heat. We may likewise change these applications
as often as we desire, or pour water upon the sheets frequently, and
thus cool the patient to any desirable extent, without the use of ice or
water that is extremely cold. It should be understood, also, that
general applications—applications over the whole or a large part of the
body’s surface—are far more effectual in reducing the inflammation of a
local part, than applications locally made can be. This fact is not
generally understood.
_Is Childbed Fever a Contagion?_—This disease is believed by many to be
at times contagious. It would, doubtless, be a difficult undertaking to
prove positively that such is the fact. It is the opinion of some able
writers on medicine, “that there is unquestionably an epidemic
influence, or atmospheric constitution, which sometimes, in extensive
districts of country, in villages, in towns, and cities, and especially
in crowded lying-in hospitals, determines, by an unknown force, the
attack of childbed fever, and so modifies the pathognomonic conditions
as to hurry numerous victims to the grave, and this, notwithstanding the
most reasonable methods of cure.”
But that the disease is really communicable from one patient to another,
is not so palpable. One author—Professor Meigs—a man whose good
character and long experience entitle his opinions to much weight, tells
us that a great experience—and few have enjoyed greater—has not enabled
him to perceive that he has been the means of disseminating this malady
among lying-in women, to whom he had given professional aid while
attending upon dangerous and fatal attacks of it, or after making or
witnessing autopsic examinations of the bodies of the dead. On the other
hand, Dr. Gooch, an author whose opinions are probably equally deserving
of respect, tells us in reference to puerperal fever, that it is not
uncommon for the greater number of cases to occur in the practice of one
man, while the practitioners of the neighborhood, who are not more
skillful or busy, meet with few or none. A practitioner opened the body
of a woman who had died of puerperal fever, and continued to wear the
same clothes. A lady whom he delivered a few days afterward was attacked
with, and died of a similar disease; two more of his lying-in patients,
in rapid succession, met with the same fate. Struck by the thought that
he might have carried the contagion in his clothes, he instantly changed
them, and met with no more cases of the kind.