Edward Rigby

PUERPERAL FEVERS.

Nature and varieties of puerperal fever.—Vitiation of the blood.—Different species of puerperal fever.—Puerperal peritonitis.—Symptoms.—Appearances after death.—Treatment.—Uterine phlebitis.—Symptoms.—Appearances after death.—Treatment.—Indications.—False peritonitis.—Treatment.—Gastro-bilious puerperal fevers.—Symptoms.—Appearances after death.—Treatment.—Contagious, or adynamic, puerperal fevers.—Symptoms.—Appearances after death.—Treatment.

In enumerating the different species of Dystocia, we have mentioned a long list of causes, by which the process of labour might be rendered one of considerable danger either to the mother or her child; but, for the most part, they are not of very common occurrence, those only which are of trifling import being met with most frequently. Even under the most dangerous forms of dystocia, as for instance, convulsions, and the different forms of hÆmorrhage, the danger, although great, is capable of being averted, from the mother at least, in the majority of instances by timely and skilful assistance; the means of treatment which art and experience have supplied us with, being generally capable of affording both certain and effective relief, if used according to the rules which we have given when treating of these subjects; but we now come to a source of danger which follows the most favourable as well as unfavourable labours—which is extremely varied in its nature, fatal in its effects, and (what renders it so peculiarly formidable) by no means uncommon in its occurrence.

Of all the dangers to which a lying-in woman is exposed, puerperal fever is by far the most to be dreaded: there are few or no difficulties during parturition which the practitioner has to contend with that can be compared to it; there are none in which he is frequently made to feel so helpless, and his various means of treatment so utterly inefficacious; certain it is that puerperal fever in its worst forms has occasionally committed such ravages among patients of this class as to rival in destructiveness the most malignant pestilences with which the human race has been afflicted.One of the greatest improvements in our knowledge of puerperal fever which has taken place in modern times, is the having ascertained that it is not one specific disease, but occurs under different forms, each of which is subject to a good deal of variety, depending upon individual peculiarity, season of the year, and numberless other circumstances. The chief error into which authors have fallen when treating of this difficult subject, is their having merely described the peculiar form of disease which had come under their own notice, and to which they have exclusively awarded the name of puerperal fever—an error in judgment which has led to still greater errors in practice, and which has certainly tended to prevent the subject being so clearly understood as it might have been. The mode also in which it has been investigated by modern authors has been but of little assistance in disclosing the true features of the disease; they have indeed rather tended to mislead than to guide us, they have directed our attention to certain effects of it, which they have considered to be the disease itself, and thus rather conceal than disclose the real natura morbi.

In our printed lectures on puerperal fever we have taken a similar view. “I am not sure if the present fashionable morbid anatomy of the day, misnamed pathology, has assisted so much in developing the real nature of the disease as has been supposed: it appears to me rather to have withdrawn the attention of practitioners from a close observation of the phenomena presented during life, to the inspection of those changes which are to be found after death. They have rather sought to examine the effects of the disease at a time when it had attained such an extent as to be incompatible with life, than to investigate upon correct and physiological grounds the series of changes which were taking place during the earlier periods.” (London Med. and Surg. Journ. June 27, 1835.) Dr. Alison, of Edinburgh, in his dissertation on the state of medical science (Cyc. Prac. Med.) has taken a similar view of this prevailing mode of investigating the nature of disease; he considers that it is “an important practical error to fix the attention, particularly of students of the profession, too much on those characters of disease which are drawn from changes of structure already effected, and to trust too exclusively to these as the diagnostics of different diseases, because in many instances these characters are not clearly perceptible until the latest and least remediable stage of diseases—the very object of the most important practice is to prevent the occurrence of the changes on which they depend. Accordingly, when this department of pathology is too exclusively cultivated, the attention of students is often found to be fixed on the lesions to be expected after death, much more than on the power and application of remedies either to control the diseased actions, or relieve the symptoms during life.”“Pathological anatomy (says Dr. Stevens) is but one of the many ‘points of view in which we may consider the science of disease,’ and notwithstanding all that has been said about ‘la mÉdicine eclarireÉ par les ouvertures des cadavres,’ I have a firm belief that morbid anatomy has done little good, particularly in the hands of those who do not understand its real value; for those who are constantly mistaking the effect for the cause, or confounding the immediate cause of death with the cause of the disease, and forming theories on this foundation, not only deceive themselves, but unfortunately, particularly for the inhabitants of hot climates, they have deceived others.” (Obs. on the Healthy and Diseased Properties of the Blood, p. 182.)

We have made our last quotation from one of the most valuable and original works of the present day upon the subject of fevers, and which has tended in great measure to unveil the mysterious nature of these diseases. Dr. Steven’s researches have been conducted in the truest spirit of pathological inquiry, and form a striking contrast with the modern morbid anatomy of puerperal fevers.

We use the term puerperal fevers precisely with the same meaning as Dr. Locock has done in his valuable essay on this subject (Library of Pract. Med. vol i.,) requesting our readers to bear in mind his observation, “that they vary in their nature and treatment as much as other kinds of fevers;” that whether occurring sporadically or in epidemics, they rarely, appear twice alike, but vary with the season of the year and the type of the prevailing fevers of the place; they are influenced by the rank, habits, and constitution of the patient, as well as by the nature and locality of her residence.

Although we cannot quite coincide with the views of Dr. Ferguson to their fullest extent, respecting the exclusive cause of the various forms of puerperal fever, viz. the vitiation of the fluids, still, in great measure, we consider them as correct, having not only taught them for many years, but published them in our lectures on this subject in 1835. Much praise is due to the last two mentioned authors for the able manner in which they have handled this difficult subject, they have carefully sifted the mass of jarring opinions, and tested them by their own great experience; and have not only reduced the subject to a simpler form, but have succeeded, we trust, in removing the very erroneous views of some modern authors respecting the supposed identity of certain forms of local inflammation with this disease.

Having drawn our information upon puerperal fevers from the same ample source, we willingly bear testimony to the accuracy with which they have described the different forms; and trust that in giving a detail of our own opinions and observations, it will be found that so far from differing from them, we have tended to confirm, reconcile, and carry out their views.Nature and varieties of puerperal fever. The history of puerperal fevers at the General Lying-in Hospital, would of itself afford an excellent monograph on this class of diseases in all their varied forms. When we resided at the hospital in 1826, the cases were all of the inflammatory character; they appeared to occur sporadically, among the out as well as the in-patients; and were successfully relieved by bleeding, hot poultices, and a mercurial purge, and occasionally leeches. During the following years, an epidemic of a highly malignant character spread destruction rapidly among the patients, setting at defiance the treatment previously employed. Still more remarkable was the sudden change in the character of the disease noticed by Dr. Locock in 1822. “In the spring of 1822, puerperal fever existed in the lying-in hospital in two very different and well-marked forms, at an interval of about six weeks between the last case of the first epidemic and first case of the second. The early cases were of an active inflammatory character; the peritoneal covering of the uterus and intestines was chiefly affected; the albuminous and serous effusions in the fatal cases showed a sthenic state of the system, that is, the serum was clear, the coagulable lymph firm and white; the patients bore blood-letting, and other active treatment to a great extent, fairly, and with much advantage; the blood drawn was strongly cupped and highly buffed, and the fatal cases were few. Six weeks afterwards a very different epidemic was found to exist. The same remedies which had been so beneficial a few weeks before, were naturally at first tried, but their bad success confirmed the sagacious remark of Gooch, that ‘the effects of remedies form not only an essential but an important part of their history.’ (Gooch on Peritoneal Fevers, p. 35.) The fever was attended with marked oppression and debility; the local pain was comparatively slight; the pulse was extremely rapid from the first, with no force, and easily compressible. In many of the cases, purulent deposites took place in the joints and in the calves of the legs, and in one case there was destructive inflammation of the eye.” (Locock, op. cit. p. 349.)

The various forms and modifications under which puerperal fevers have appeared at different times, have produced an equal variety of arrangement in the classifications of authors. Thus, some who have attributed the disease to inflammation, have merely distinguished its varieties according to the different organs which have exhibited after death appearances of congested or injected vessels, or have been covered and imbedded in effusions of coagulable lymph, &c., or have had their structure more or less broken down and disorganized. Thus, for instance, Dr. R. Lee is of opinion, that “inflammation of the uterus and its appendages must be considered as essentially the cause of all the destructive febrile affections which follow parturition; and that the various forms they assume, inflammatory, congestive, and typhoid, will in great measure be found to depend on whether the serous, the muscular, or the venous, tissue of the organ has become affected.” (Med. Chir. Trans. vol. xv. part ii. p. 405, 1829.) He accordingly arranges “the principal varieties of inflammation of the uterus in puerperal women under the following heads, viz. 1. Inflammation of the peritoneal covering of the uterus, and of the peritoneal sac; 2. Inflammation of the uterine appendages, ovaria, fallopian tubes, and broad ligaments; 3. Inflammation of the muscular and mucous tissues of the uterus; 4. Inflammation and suppuration of the absorbent vessels and veins of the uterine organs.” (Cyc. Pract. Med. art. Puerperal Fever.) This arrangement is manifestly incorrect, and by giving so partial a view of puerperal fevers, must, if adopted, necessarily lead to serious errors in practice. “That these forms of inflammation are the proximate cause of the various febrile affections is most completely refuted by the detail of his own (Dr. Lee’s) experience, as relates to the varieties occurring under similar circumstances.” (Moore, on Puerp. Fever.) We may also add, that, according to our own experience, and that of our colleagues at the General Lying-in Hospital, in the worst forms of puerperal fever, the fewest traces of inflammation have been observed; and that in the severest and most rapidly fatal cases it has frequently happened, that not a single vestige of inflammation could be detected. In our review of Mr. Moore’s able work in the Brit. and For. Med. Rev. Oct. 1836, p. 483, we have made a similar remark, and quoted a striking passage from Dr. Stevens, when speaking of contagious fevers, that “there is not one symptom of inflammation during the fatal progress of the disease, nor one inflammatory spot to be seen after death, to mark its existence, or to induce us to believe that any thing but functional disease had existed in any of the solids; yet these are the very cases of all others which are the most fatal.” (On the blood, p. 179.)

In many of the worst cases which have come under our notice, there has neither been time nor power sufficient to produce either a symptom or a trace of inflammation; the powers of life have from the very commencement sunk under the deadly influence of the disease, without a single effort to establish even a temporary reaction in the system: hence, in most instances, we are led to the necessary conclusion, that inflammation, when it does appear, is the result of disease, not the disease of inflammation. “For,” as Dr. Ferguson observes, “if any or more of these (phlebitis, peritonitis, &c.) be assumed as constituting the essence of puerperal fever, abundant examples may be found of puerperal fever, in which the cause fixed on is absent. Thus to believers in the identity of peritonitis and puerperal fever, we can show puerperal fever with a perfect healthy peritoneum. To those who insist on inflammation of the uterine veins, as constituting puerperal fever, we can show the genuine disease without this condition.” (Essays on the most important Diseases of Women, part i. Puerperal Fever, p. 81.)

The vitiation of the blood has long been a subject which has excited our deepest interest, and the admirable researches of Dr. Stevens upon the condition of this fluid under the effects of malignant fevers, have tended to disclose the real nature of the diseases under consideration. We have long been convinced that one of the causes of puerperal fever is the absorption of putrid matters furnished by the coagula and discharges which are apt to be retained in the uterus and passages after parturition,—a view which has been adopted by Kirkland, C. White, and other older authors. It is with sincere pleasure that we now find ourselves supported by the able author, from whom we have just quoted, in this opinion. Dr. Ferguson’s three positions respecting “the source and nature of puerperal fever” are highly valuable, for they have been deduced from careful physiological experiments, and not less sound physiological reasoning; they are as follows:—

1. The phenomena of puerperal fever originate in a vitiation of the fluids.

2. The causes which are capable of vitiating the fluids are particularly rife after childbirth.

3. The various forms of puerperal fever depend on this one cause, and may readily be deduced from it.

We do not agree with him in supposing that every form of puerperal inflammation is produced by vitiation of the circulating fluids, because in one species of uterine phlebitis, which occurred sporadically, and prevailed a good deal from 1829 to 1832, it was, in our opinion, evidently produced directly by the absorption of putrid matter into the uterine veins and lymphatics, exciting inflammation in these vessels: the same cause, when only carried to a certain extent, produces a local inflammation, which, when affecting the general circulation, is followed by fever. Thus, then, we may have in the same case uterine phlebitis followed by the typhoid malignant puerperal fever—the local and constitutional disturbance arising from the same cause, imbibition or absorption of putrid matter; the one being the local, the other the general effect, but not the one resulting from the other. The doctrine of the vitiation of the blood from its admixture with pus secreted by the lining membrane of an inflamed vein, though very plausible, still requires farther confirmation, for it is doubtful if the introduction of pure healthy pus into the circulation produces any of those dangerous effects which result from the absorption of putrid matters, whether purulent, sanious, mucous, &c. It is the introduction into the circulation of an animal poison generated by putrefaction, which destroys the vitality of the blood, and renders it unfit for maintaining the vital powers.Few have expressed this opinion more strikingly than Dr. Kirkland, although so long ago as 1774; and it has often created our surprise, that amid all the numerous writings on this subject, which have excited attention during later years, so little notice should have been taken of his observations. We consider that Dr. Kirkland is one of the earliest authors who has shown that puerperal fever is not the result of inflammation, but that it may be produced by the introduction of an animal poison into the circulation. “There are other causes beside inflammation which bring on a puerperal fever; for it sometimes happens that coagulated blood lodges in the uterus after delivery, and putrefying from access of air, forms a most active poison, is in part absorbed, and brings on a putrid fever. In this case the discharge which should immediately follow delivery is not sufficiently large, making allowance for the difference which happens to different women in this respect: small clots of blood make part of the lochia, which are less in quantity than they ought to be; but the patient has not any other sort of complaint for three or four days till the retained blood begins to putrefy. A fever then first makes its appearance, followed by a quick weak pulse, thirst, pain in the head, want of sleep, sighing, load at the prÆcordia, restlessness, great weakness, dejection of spirits, either wildness or despair in the countenance, and the white of the eyes is often a little inflamed.” (A Treatise on Childbed Fevers, by Thos. Kirkland, M. D. p. 70.)

The late Mr. Charles White, of Manchester, adopted a similar opinion, and in our published lectures we have quoted largely from these two authors in support of the opinions which we have there advanced.

Dr. Ferguson’s opinion, that the different modes in which the poison infecting the circulation manifests itself, give rise to the different forms of puerperal fever, is highly interesting, and deserves great attention. He conceives that in some instances it spends its virulence upon the peritoneum, producing the inflammatory peritoneal form of puerperal fever. He considers that the gastro-enteric form arises “from the action of the poison being directed to the liver, the organ through which, as the experiments of Gaspard and Fontana, and the admission of all physiologists show, most poisons received into the system endeavour to escape.” (Op. cit. p. 85.) These views have been proved by injecting putrilage, &c., into the veins of animals, and the effects of which, both as seen in the symptoms during life and the appearances after death, tend strongly to confirm these opinions; still we cannot feel justified in excluding inflammatory forms which have not been indirectly produced by the vitiation of the circulation, but which are the more direct effects of labour itself, or, as we have before observed, from the immediate absorption of putrilage, &c., into the veins and lymphatics, and production of inflammation in them. The production of inflammation in that part of a vein or absorbent, with which putrid matter has come in immediate contact, is an important fact, for it is by this means that nature prevents the poison being carried into the general system, and thus, instead of generating a malignant fever, she limits the injury to a local inflammation, by which farther mischief is confined by the effusion of coaguable lymph, tumefaction, and other means for rendering the vessels impervious. In making these remarks we wish it to be distinctly understood, that we by no means under-value the views brought forward by Dr. Ferguson, that “the introduction of a poison into the circulation is capable of producing local inflammation, varying according to the strength and qualities of the agent,” &c.

The results of Professor Tiedemann’s experiments, of which we have given an abstract in the Brit. and For. Med. Rev. vol. i. p. 241, contain some facts which throw much light as to the modus operandi of certain agents when mingled with the circulation, and tend still farther to prove the correctness of Dr. Ferguson’s views. In the experiments where musk was injected into the femoral vein of a small bitch, the effects of the poison upon the abdominal viscera were remarkable; the veins of the abdomen were distended with dark coloured blood, the whole intestinal canal was very red, the mucous membrane of the stomach had a reddish tinge; that of the whole intestinal canal was of a dark red, it was swollen, turgid, and in the highest state of engorgement—the canal also contained a quantity of effused dark blood in its lower part; the vessels of the liver and spleen were gorged with dark blood.

We are anxious to impress upon the minds of our readers the physiological fact, that most, if not all, vegetable and animal poisons do not act primarily on the nervous system, but indirectly through the medium of the circulation. “The physiological researches (as we have observed elsewhere) especially during the last thirty years, both in this country and the continent, have satisfactorily proved that most, if not all, of the agents which exert such destructive energies on the nervous system, do it through the medium of the circulation: this has been shown by the experiments of Christison and Coindet, of Brodie, Emmert, Viborg, and many others. Those of Sir B. Brodie on the action of the Woorara poison are well known. Emmert showed this to be the case in a still more striking manner, by amputating the leg of an animal, and leaving it connected to the body only by means of the nerves; poisonous substances introduced into the foot produced no effects, not even when applied to the trunk of the nerve; and Viborg even applied one drachm of concentrated prussic acid to the brain of a horse, which had been exposed by trepanning, without producing any effect.” (Brit. and For. Med. Rev. vol. i. p. 559.)We cannot agree with the opinion, “that the vitiated state of the blood is the secondary and not the primary link in the chain of phenomena,” and “that the nervous system is the main instrument by which this change in the blood takes place.” (Locock, op. cit. p. 353.) “We believe that is not the deficiency of nervous influence which primarily tends to deteriorate this fluid (although it may possibly react in this way afterwards,) but the deteriorated condition of this fluid, which renders it incapable of supplying the brain and nervous system with their due degree of energy.” (Brit. and For. Med. Rev. vol. ii. p. 483, 1836.)

In considering the phenomena of fever, Dr. Stevens has well observed, that we must not look upon them “as the result of either a nervous impression, or local inflammation, for even in the beginning of fever its symptoms are universal and peculiar to itself. It is not, therefore, a local affection; and in all the idiopathic fevers, but particularly in those that are produced by the aerial poisons, there is but one thing which is never absent, namely, the diseased condition of the whole circulating current, and, therefore, this alone can be fairly considered as essential to the disease. This morbid condition of the blood is decidedly the first link in the chain of those phenomena which constitute fever, for even before the attack every drop of the vital currant is changed in its properties; and wherever this deranged blood can circulate, there fever extends its empire: for the cause which produces this disease is not confined to a part, but acts on every fibre, and in every tissue of the living system; it disturbs every function in the body, and deranges every faculty of the mind. All the excretions are in a diseased state, and every one of the secreted fluids is changed both in its quantity and quality. The blood is the medium that conveys the poison, while the impression on the nerves is merely the effect of the diseased condition of its natural stimulus.” (On the Blood, p. 273.)

These observations just quoted, apply strictly to the causes as well as to the phenomena of puerperal fever, more especially of the adynamic kind; and show that, particularly in this form, we must not merely refer the cause to the absorption of putrid matters by the uterine veins and lymphatics, or to the commixture of the blood with pus secreted from the coats of an inflamed vein, but to the still more pervading and truly epidemic and contagious action of miasmata, with which the air that surrounds the patient is charged. The lungs afford a ready and ample means by which effluvia may be conveyed into the circulating current, and enables us to account for the fact adduced by Dr. Stevens, that in situations favourable to the production of fevers, the blood is frequently found in a very unhealthy state, even before the outbreak of the disease itself. Dr. Kirkland has nearly anticipated the discoveries of later years upon this subject; and considering the time at which he wrote, we think that his observations are both interesting as well as valuable.“Seeing then that an absorption of putrid matter will bring on a puerperal fever, with common symptoms, may we not conclude that the putrid miasms of lying-in hospitals will produce the same effect? Is it not reasonable to suppose, that the puerperal fever which has been observed in hospitals, is owing to some cause peculiar to hospitals? otherwise, would it not be equally frequent in other places? Dr. Pringle informs us that the foul air occasioned by one mortified limb brought on a malignant fever in the military hospital. Peu also seems to have proved, that the putrid effluvia exhaling from wounded men brought on a fever which killed a great many child-bed women who lay in the same hospital; and are not the putrid effluvia arising from the lochial discharge in lying-in hospitals capable of producing the same disease? I have sometimes been called to women in child-bed, where the offensive effluvia arising from this kind of evacuation, pent up in a small close room, at once evinced to what cause their fever was owing; and though I have not any doubt, but in lying-in hospitals every attempt is made to preserve the air pure and the patient in a state of cleanliness, yet where many women lie in the same ward, it is perhaps impossible to obtain these advantages in the perfection to be wished.” (Op. cit. p. 73.)

Van Swieten compared the state of the inner surface of the uterus with that of a large wound,—“Something of a like nature seems to be affected in the womb, but in a slighter manner, because the injury is here superficial, but on a broad surface.” (Comment. on Boerhaave, § 1329.) He quotes also an interesting description from Moschion of the changes which are observed in the evacuations after delivery,—“Primo sanguis, secundo fÆculentus et paucus, ultimo purulentus.” “It hence appears,” he observes, “that that fever in lying-in women, which is called the milk fever, does not spring solely from the milk brought into the breasts, but also from the purifying of the womb by that gentle and superficial suppuration. But, as even the best pus when retained too long becomes acrid and putrefies, the same thing will hold with regard to the purulent evacuations after delivery, if they should be kept back.” “But if that purulent matter does not come out, but being sucked back should be mixed with the humours, it may, being brought to the viscera by a bad metastasis of the morbid matter, give occasion to dangerous disorders.”

This comparison by Van Swieten and Dr. Kirkland, of the state of the uterus with that of an open wound, has been recently brought into notice by Cruveilhier, and quoted by Dr. Ferguson, in his work. “All the uterine veins and arteries have been torn from the placenta, and they form a part of a large wound, and are, therefore bathed in all the secretions which necessarily take place while this wound is healing. In this respect the uterus presents an exact analogy to the surface of an amputated stump; and it is, therefore, not surprising, that the secondary evils of amputation should be so similar to those of the puerperal state.” (Op. cit. p. 75.) Professor SchÖnlein also considers that the contagion of puerperal fever has the greatest similarity with hospital gangrene.

The causes of puerperal disease which have been enumerated by Cruveilhier, apply almost solely to those inflammatory affections of the puerperal state which do not depend upon a vitiated state of the circulation, but “are derived from the changes induced by parturition, and are dependent on,

“1. The organic changes induced by pregnancy.

“2. Those induced by the act of labour.

“3. Those consecutive of labour.

“1. Pregnancy:—the hyperthrophy of the uterus; the enlargement of the ligamenta lata; the traction on the peritoneum of the neighbouring organs; the extraordinary development of the arteries, veins, and lymphatics.

“2. Changes induced by labour:—bruising of all the soft parts—they appear raw.

“3. Changes after labour:—the woman presents the faithful picture of one who has undergone a serious surgical operation. The internal surface of the womb may be compared to a vast solution of continuity; the whole of the mucous membrane has been altered by the inflammation, of which it has been the seat; the gaping veins are like the open mouthed vessels of an amputated limb.

“Except just at the inner surface of the cervix uteri, there is no mucous membrane at all; but the muscular tissue of the uterus is every where exposed. This, therefore, like the stump, is to be covered by a new membrane.

“This process of reparation is accompanied by a traumatic fever, called milk fever. Like the fever from wounds, it has its period of incubation, varying in various individuals: it lasts about twenty-four hours, and vanishes on the third day.

“As in amputation, a false membrane covers the stump, and precedes cicatrisation, so the inner surface of the womb is first covered with a false membrane before it is cicatrised. If there be no lochial discharge, there is union by the first intention, as in the stump where there is no discharge: this is the rarest of all cases.

“Ordinarily, this false membrane is thrown off with a purulent discharge, which is the lochia. At first it is sanious, i. e. mixed with blood, and fetid; then less fetid and more purulent; then thin and serous. The quality and quantity of the discharge are, as in amputations, an index of the state of the wound.” (Cruveilhier, quoted by Dr. Ferguson, p. 76.)

The comparison between the inner surface of the uterus shortly after parturition and that of a stump, does not hold good in every respect: in the one, the open mouths of the vessels are pretty firmly compressed by the contracted state of the surrounding uterine tissue, whereas, in the other they are uncontracted beyond the mere effects of the traumatic inflammation upon their cut extremities, and they are surrounded by the flaccid surface of divided muscles: still, however, it is quite sufficient to show, that the inner surface of the uterus must be for some days bathed in mucous, sanious, and purulent fluids, highly prone to decomposition; and that, in this state, absorption is peculiarly liable to take place.

The vehement exertions of the uterus and abdominal muscles during labour, and the violent pressure to which the abdominal circulation has been subjected at this time, are sources of inflammation, which, although not noticed by Cruveilhier, are frequently met with quite independent of puerperal fever, although, from what we have already stated, it will be evident that the disposition to absorption and consequent vitiation of the blood will be still farther increased by the excited state of the circulation.

Where blood has been vitiated by the action of aerial poisons, or introduction of putrid matter into its current, changes are quickly produced in its condition, which not only unfit it for the varied functions which it has to perform, especially in maintaining the activity of the brain and nervous system, but which may be perceived, as already shown, before the disease itself appears. It is dark, and of an unhealthy tinge. In severer forms of typhus, “when first drawn, it has a peculiar smell, and coagulates almost invariably without any crust. There are black spots on the surface of the crassamentum; the coagulum is so soft that it can easily be separated with the fingers, and during its formation, a large quantity of the black colouring matter falls to the bottom of the cup. When the serum separates, it has generally a yellow, and in some cases even a deep orange colour.” (Stevens, op. cit. p. 219.)

Dr. Tweedie has observed similar conditions of blood in the common typhus of the metropolis, and remarks, “that in this class of fevers, the crassamentum of the blood, instead of forming a firm coagulum, is loose, small in proportion to the quantity of serum, and so soft that it breaks readily on attempting to raise it, resembling in consistence half-boiled currant jelly, and that in some instances, when abstracted late in the disease, it is scarcely coagulated at all.” (Tweedie, Clin. Illust. of Fever, quoted by Dr. Stephens.)

This accords closely with the appearances of blood drawn from patients under puerperal fever, especially of the adynamic form. The blood is of a dark muddy colour, in some cases resembling even thin treacle in consistence: in this state the coagulation is very imperfect, so that after a time it merely forms a homogeneous semi-gelatinous mass, with little or no separation of serum from the crassamentum. After death the blood is found perfectly fluid, readily infiltrating and staining the coats of the vessels which contain it, and resembling thin watery claret, both in colour and consistence. In the other forms, which are of a more inflammatory character, it is highly buffed and cupped; the crassamentum is small, the albuminous layer upon it is of a muddy yellow colour; and the serum, which is frequently large in proportion, is of a similar colour, or even of a slight bilious tinge; in some, there has been occasionally observed a white cloudy appearance, as if from the admixture of milk.

The mortality of puerperal fevers depends in great measure upon the form they assume; and, as we have already stated, this will vary in great measure according to the period of the year, the nature of the season, and the type of the prevailing epidemic fevers in the neighbourhood, whether they assume the character of synochus, or low malignant typhus. It varies a good deal according to the class of patients attacked, being more frequently of the inflammatory character among the middling and higher classes, whereas, among the lower orders, who are exposed to the depressing effects of cold, damp, and ill-ventilated dwellings, of insufficient clothing and food, of an atmosphere poisoned with the noxious effluvia arising from a dirty and thickly inhabited suburb, and habitual intemperance, it generally assumes the adynamic or contagious form. This is the reason that puerperal fever is not only seen less frequently among the middling and upper ranks, but even when it does appear, from being usually of the inflammatory form, it is more tractable. It is in lying-in hospitals, where it appears in all its terrors, and occasionally assumes such a degree of malignity as almost to equal the plague or yellow fever, in the frightful rapidity of its course, and in the almost certain fatality of its termination. Few have witnessed it in a more destructive form than the late Dr. W. Hunter at the British Lying-in Hospital. He observes in his lectures that he had seen a great many cases of it in the hospital, “and particularly in one year, when it was so remarkably prevalent there. It was so bad, that not only every gentleman belonging to the hospital, but all our friends in town, had a consultation to think whether we should shut up the house. In two months thirty-two patients had the fever, and only one of them recovered.” (MS. Lectures.)

Although puerperal fever has never yet attained the frightful degree of mortality at the General Lying-in Hospital, nevertheless, it has appeared repeatedly with such malignity, as to commit fearful ravages among the patients. In these epidemics, the first few cases are generally comparatively mild, being of the peritonitic or gastro-bilious form (Douglas:) but as it advances, the malignant adynamic form, which is so destructive, prevails. In some epidemics, as is seen in common fevers, after a short time the disease has become more tractable, it has assumed a milder character, and ultimately has again disappeared. This corresponds with the admirable remarks of Dr. Gooch, to whose graphic pen we are indebted for much valuable information on the subject of puerperal fevers. “Another remarkable circumstance about this disease is, that, when it is most prevalent, it is most dangerous. Each case is more difficult of cure than when it occurs seldomer. The practitioner finds, that, although the group of symptoms resembles what he was formerly accustomed to, he has now to deal with a disease far more obstinate and destructive, and his usual remedies are not so successful as formerly; he loses case after case in spite of his best efforts. When it has been thus raging for a considerable time, it at length subsides; the case becomes less frequent and less severe; the practitioner finds his treatment becoming more successful, partly because experience has taught him to detect it earlier, and to treat it better, but probably also because the disease has itself become milder.” (Gooch on Peritoneal Fevers, p. 3.)

The table of the cases at the General Lying-in Hospital and their mortality, which Dr. Ferguson has calculated during the twelve years, from March 1827, to April 1838, is highly important, and points out the period of the year in which puerperal fever, prevails most, and the contrary. The last two and the first seven months of the year are those in which the greatest mortality occurred; whereas, in the month of July, during this whole period, not a single patient died; in August only one; in September two; and again, none in October, although several were attacked. “Puerperal fever was epidemic in the years 1828, 1829, 1835, 1836. 1838; in the other years it was only sporadic. The greatest mortality was in the years 1835 and 1838, in the last of which 20 in 26 died. The malady commenced in January, in which month Dr. Rigby saved only 1 out of 9. The hospital was closed for a month, and opened again in March, when he succeeded in rescuing only 2 in 8. Thinking that another mode of treatment might be more successful, I determined to bleed largely, and to salivate. This plan was fairly tried under the constant attendance of Dr. Cape, and with my supervision, but 3 only in 9 lived. Seeing that no treatment was of avail, the hospital was closed from May till November.” (Ferguson, op. cit. p. 277.)

Different species of puerperal fever. Having premised these general observations on puerperal fevers, we now proceed to consider them separately, according to the various forms which they exhibit; and in doing so, shall adopt the arrangement of the subject made by Dr. Douglas, viz. under the three heads of inflammatory gastro-bilious, and the contagious or adynamic form. It is not only one of the earliest, but in our opinion, one of the most correct; nor do the arrangements adopted by Drs. Locock and Ferguson differ essentially from it. We hope by this means to combine the advantages which each affords, while we hold ourselves free to differ or coincide with either, as our opinions lead us, trusting that we shall thus be able to render this complex and difficult subject more complete.

Under the inflammatory form we shall not only consider the acute peritonitis, so ably described by Dr. Locock, which is chiefly produced by the effects of labour, to which we have already alluded in the quotation from Cruveilhier, but also that form which, according to Dr. Ferguson, arises from vitiation of the blood, by the introduction of putrid matter into the circulation; a form which has not only a great disposition to assume a typhoid character, but also to become epidemic. Under this head we must also bring the uterine inflammation and phlebitis, which we have described, as resulting from a direct action of putrid matters contained in the uterus, a form which is very liable to pass into uterine, and afterwards general peritonitis; lastly, there remains that species of nervous abdominable pain, which has received the name of false peritonitis.

Puerperal Peritonitis.

Symptoms. The acute peritonitis, which has been produced by the effects of labour, generally makes its appearance at an early period after. The labour has probably been either tedious or severe, the efforts of the uterus and abdominal muscles have been violent, especially during the last stage; and from the moment of the child’s birth, the patient has complained of considerable soreness over the lower part of the abdomen, amounting to much pain and tenderness when touched. At first she is tolerably easy, so long as she lies still, and keeps the abdominal muscles in complete repose; but, by degrees, fits of pain come on, they become more frequent, and the intervals between them shorter and shorter, until the pain is constant; she now complains of much tension and fulness of the abdomen; the tenderness is greatly increased, both in severity and extent, and is often attended with the painful sense of twisting about the umbilicus, which is observed in ordinary forms of peritonitis. The pain and tension are now so severe that she is constrained to lie wholly upon her back, with the knees drawn up, in order to relax the abdominal muscles, and thus, if possible, alleviate her sufferings. The abdomen itself is evidently fuller to the feel, and is beginning to be tympanitic; the breathing is quick and anxious; the tongue has a thin coating of white fur, which is browner and thicker at the back; the pulse is quick and hard, sometimes small and wiry, occasionally full and strong; the lochia and milk have either never appeared, or only in small quantities, to be quickly suppressed again. As the tympanitis increases, the breathing becomes more anxious and painful; for every effort of the diaphragm in inspiration is followed by severe pain, from the movement which it produces in the abdominal contents. After awhile, the flatulent distention of the intestines, particularly of the stomach, renders the diaphragm irritable, and provokes hiccough, which is excessively painful from the involuntary jerk which it gives to the abdomen; or, what is still worse, retching and efforts to vomit frequently come on, which greatly aggravate her sufferings. She now lies upon her back, perfectly helpless and immoveable, for the slightest attempt to touch her is insupportable; even the jar of a person walking heavily across the room excites pain. The abdomen is now even larger than it was before labour, her anxiety and restlessness increase, and she rapidly becomes exhausted from suffering and want of sleep. The face becomes sallow, the features fallen, the tongue dry and brown, and sordes collect upon the teeth; she falls into an uneasy slumber, during which, the eyelids remain partly open, or she mutters incoherently with low delirium. The abdomen is less painful, but not diminished in size; the pulse is small, hurried, and feeble; subsultus tendinum and picking of the bed-clothes follow, with all the other symptoms of approaching dissolution.

Where the attack has risen from the introduction of putrid matter into the circulating current, it usually appears somewhat later, seldom before the third day after labour: it is almost invariably preceded by a severe rigour, followed by intense headach, and darting pain about the lower part of the abdomen, which gradually becomes constant. There is a nearer approach to the adynamic form, or rather, it is frequently attended, or at least followed, by this disease; hence the inflammatory stage is shorter, the pulse is even more rapid, and loses its strength sooner than in the other form; the milk and lochia have usually not only been established, but continue, we think, longer afterwards than in the other case; the pain is perhaps less in many instances, but in other respects, the first part of the attack does not differ essentially from the form above described; but as the disease advances, it gradually assumes the adynamic form; the inflammatory symptoms of the early part of the attack are merged in the general collapse which now exists, the same cause which had produced the peritoneal inflammation now acting on the whole system.

Peritonitis occurring by itself, is, as Dr. Ferguson observes, of comparatively rare occurrence in puerperal women, the condition of the system during childbed, disposing it quickly to assume more or less of the adynamic character.

Appearances after death. On examining cases of fatal puerperal peritonitis, we shall find marks of inflammation, or its consequences, over a large extent of the peritoneum; large portions of it are highly congested, and more or less thickened; considerable effusions of serum or sero-purulent fluid, mixed with flakes of coagulable lymph, into the abdominal cavity: the omentum adhering to the intestines, and also the intestines to each other, by means of coagulable lymph, in which they are occasionally completely imbedded; the broad ligaments and ovaries are frequently much inflamed, covered with lymph, and the latter more or less softened; the Fallopian tubes engorged and adhering to the neighbouring parts; the uterus is covered at its fundus with a coating of coagulable lymph, as if it had been smeared with a quantity of dirty white paint, and this extends more or less in patches over the various reflexions of the peritoneum, in the upper parts of the abdominal cavity.

Treatment. We may take it as a rule, that the earlier we see the patient in the disease, the less active will be the treatment required. At first, when the pain has not yet assumed its full intensity, and only occurs in paroxysms, when little or no traces of abdominal tension and fulness are to be perceived from incipient tympanitis, we may frequently succeed in cutting short the disease by a full dose of calomel and James’s powder, with some morphia or Dover’s powder, to allay irritation and assist in producing a general determination to the skin; this must be followed by some castor oil, and if the pain is no longer constant, with the addition of a few drops of Liquor Opii Sedativus. Where the pain has already become severe, a draught of sulphate and carbonate of magnesia in peppermint water, with a little antimonial wine and henbane, will be preferable. We have long since been convinced, that common black draught, or any form of purge which acts violently or gripes, is objectionable, having frequently seen a return of pain brought on by its action. A hot poultice of linseed-meal, large enough to cover the whole abdomen, and as hot as the patient can bear it, must be applied; this, if made properly, will prove a great relief, for it not only allays the pain, but quickly acts as a powerful diaphoretic: there is a little art in making this, and unless it be done properly, it is apt to produce much discomfort, and do more harm than good. The water should be poured boiling hot on the linseed-meal, and the mixture well beaten with a large spoon, until it forms a nearly gelatinous mass; it should then be spread upon a large piece of linen, so as to be between a quarter and half an inch in thickness; there is now only one layer of cloth between the poultice and the patient’s abdomen, and it can be applied or removed with perfect facility: without these precautions it is apt to form a pudding-like mass, which greatly annoys the patient from its weight, and from being applied directly to the abdomen, smears about, and is not easily changed. A poultice made in the manner now described, will keep hot for three hours at least, and is by far the most effective form of fomentation which can be employed. Common fomentations of sponges, or flannels wrung out of hot water, are by no means desirable, as from the constant exposure, which is required for their frequent repetition, the patient has little benefit from the temporary heat, and is very liable to catch cold.

If the symptoms do not yield to this treatment, but assume a more formidable aspect, or if the attack has not commenced in this gradual manner, but has come on much more suddenly and with greater violence, recourse must be had immediately to the lancet. Leeches are seldom proper as a substitute for bleeding, although they frequently prove of great value afterwards. A certain effect is required to be produced upon the general circulation, before leeches are capable of affording even a temporary relief; and so far from economizing the patient’s powers by using leeches instead of the lancet, we shall find that in order to overcome the inflammation by this means, the patient will require to lose a far greater quantity of blood than if it had been suddenly removed from the circulation by bleeding. Upon the same principle, therefore, we must take care, that the blood shall be drawn pleno rivo from an ample orifice: we thus spare the patient an unnecessary loss of power, for the required effect upon the circulation is produced in a much shorter time and with less expenditure of blood, than if the blood had been slowly dribbled from a small opening.

“In the treatment of acute inflammation in the vital organs, the customary practice is to consider local bleeding as a milder means of effecting the same object as general bleeding, and to postpone it till the stage for the latter is over. To me it appears that they are calculated to effect two different objects, both of which are necessary at the beginning of the treatment; the one to reduce the violence of the general circulation, the other to empty the distended capillaries of the part. As long as the pulse is quick, full, and hard, it is in vain to take blood from the affected part; if we could completely empty its gorged capillary vessels, they would be instantly gorged again, whilst the heart and large arteries are injecting them with so much violence. On the other hand, after having reduced the force of the general circulation, the capillary vessels of the part often remain preternaturally injected: this, I conclude, from the fact that the patient is often not relieved till local blood-letting has been used, and then is relieved immediately. Hence, as soon as the patient has recovered from the faintness occasioned by bleeding from the arm, leeches ought to be applied without delay.” (Gooch, on Peritoneal Fevers, p. 47.)

It is impossible to fix what quantity of blood is to be drawn; nor is it easy, either from the patient’s appearance or the feel of her pulse, to foretell how much she will require to lose: a certain effect is to be produced on the circulation in order to bring it under such control as will moderate the state of inflammation. No two patients are alike in this respect; and it frequently happens, that where, from external appearances, we might have expected to find most strength, faintness is quickly produced, and vice versÂ: on the whole, we think that where the patient has a small, quick, and oppressed pulse, we may expect she will require to lose a large quantity of blood, for in these cases the pulse rises in volume and strength as the bleeding proceeds; hence, as before observed, we must “carry the bleeding to its proper limits, which is the approach to, or actual state of, syncope.” So far from removing the pillows, and letting her lie with the head low, so as to recover from her faintness as quickly as possible, it will be much better to support her in a sitting posture, and thus prolong the state of faintness for some while; the dilated vessels have now time to contract, the heart returns to a more moderate and healthy action, the effects of the bleeding are much more permanent, and the chances of its repetition being required considerably diminished. From this state of relaxation and temporary collapse being prolonged, we find that the secretion of the skin, and particularly the intestinal canal, are more easily re-established, the operation of a purgative being now much quicker and more effective.

As soon after the bleeding as possible, a smart dose of calomel and James’s powder, followed by an active saline laxative, must be given; and the combination of sulphate and carbonate of magnesia with antimonial wine and Tinct. Hyosc. already recommended, is preferred by us: it is better given in divided doses, as then the effects of the antimonial is prolonged. The action of the bowels may also be assisted by a domestic enema: and if there are no signs of action in the bowels after two hours, the purgative should be repeated. The results of the leeches, fomentation, and purging, will guide us as to the necessity of repeating the bleeding. Dr. Gooch’s truly practical remarks on these points are well worthy of attention:—“I waited till the purgatives had operated fully, that I might know what impression the combined operation of general and local blood-letting had produced on the disease, before deliberating on the employment of a second blood-letting. The common effect, of these remedies was this, as long as the faintness lasted in the slightest degree, the pulse remained soft and often slower, and the pain was much less, or ceased altogether; but an hour or two after the bleeding, when the circulation had recovered, the pain returned more or less, and the pulse regained much of its hardness or incompressibility. This state continued till the leeches had bled freely, and the purgatives had acted repeatedly and copiously.” (Op. cit. p. 48.)

If, however, the pain has experienced but little abatement, or has returned as severely as before; if the pulse has quickly reassumed its former condition; if the action of the purgatives has not taken place, or has been at most unsatisfactory, even with a repetition of the saline, we are justified in having recourse to a second bleeding; the faintness this time will probably be more complete; the effect upon the disease more decided; and, in all probability, it will be quickly followed by free evacuations from the bowels, which produce great relief. In some cases the bleeding requires to be repeated again and again before the disease can be subdued: this, however, usually arises not so much from the obstinacy of the attack, as from the first bleedings not having been performed in an effective manner. “The pulse,” says Dr. Locock, “is the best guide, for the pain after the first full relief from the bleeding is often of a mixed character, partly inflammatory, partly nervous, to be detected only by watching closely the other symptoms. The tenderness is a less certain guide, for few will bear pressure for a considerable time after the inflammatory symptoms have been entirely relieved. Many patients also from fear shrink from the pressure of the hand, although by drawing off the attention, it will be found that they bear firm and steady pressure very well.” (Op. cit. p. 355.)

Throughout the whole process of treatment, the linseed-meal poultices must be continued, and, if not made too heavy, can be borne when there is a considerable degree of abdominal tenderness.

In all cases where the disease has not been completely checked in the very outset, but has shown a disposition to return, the treatment above-mentioned should now be followed by a mild mercurial course. The effects of mercury in allaying inflammation at a certain stage, which does not appear to be fully under the control of mere antiphlogistic remedies, have been amply proved by British practitioners: this applies particularly to inflammation of serous membranes: mercury not only tends to prevent the effusions of serum and coagulable lymph, but, where they have taken place, it is of great value in promoting their absorption. We agree with Dr. Locock, that calomel is by far the best form in which it can be used, where we wish to obtain its specific effects. The Hydrargyrum cum CretÂ, which we have occasionally found useful in the gastro-bilious or enteric form to restore a depraved state of intestinal secretions, has failed us in the other forms where we wished to produce salivation. The purgative dose of calomel, which we have advised to be given after the bleeding, ought not to be less than six to eight grains; but now, as the dose is to be repeated every two or three hours, a smaller quantity will be sufficient: in order to save time we usually begin with five grains of calomel, and an equal quantity of Dover’s powder, and repeat this in an hour’s time, after which, we proceed with doses of two or three grains every second or third hour according to circumstances. The sooner the system can be brought under the influence of mercury the better, the pulse becomes softer and less frequent, the pain and tension of the abdomen diminish, the tongue becomes moist and natural at the edges, and general improvement follows. Throughout the whole attack the vagina should be occasionally washed out with warm water, more especially if we have reason to suspect that the disease has arisen from the imbibition or absorption of putrid matter. The smell of the patient will frequently guide us in this respect, and point out the condition of the passages and their contents; even if there be no putrid matter lodging there, the application of warm water will always act as a comfortable fomentation to the patient, and assists not a little in favouring a return of the lochia.

If the pain and swelling of the abdomen still continue, and the case is evidently becoming more unfavourable, we have occasionally sprinkled the abdomen with spirit of wine or oil of turpentine, and then covered it with a fresh poultice: this has acted as a powerful rubefacient, and has in some cases relieved the patient at a very advanced stage. We have also tried blistering the abdomen, and dressing the vesicated surface with strong mercurial ointment, as recommended by Dr. Locock; but we have not met with the success which he mentions, probably from the disease having already assumed the malignant characters of the adynamic form, and, in some instances, because the patient could not endure the intense smarting which it produced. We have occasionally covered the abdomen with camphorated mercurial ointment without previous blistering, and with good effect. The internal use of turpentine, circular friction upon the abdomen, and enemata of Mist. AssafoetidÆ, &c., which we have sometimes found useful in removing the tympanites of the adynamic puerperal fever, and which does not depend on an acute form of inflammation, are scarcely applicable in the present case.

When the powers are beginning to fail, as a last hope we must have recourse to stimulants combined with nourishment: the Mist. Spiritus Vini Gallici of the last London pharmacopoeia,—anglice, “egg and brandy,”—has for many years been used at the Lying-in Hospital to support the system at this last stage, and sometimes even under the most unfavourable circumstances with marked success; powerful doses of ammonia will be required at frequent intervals, and an occasional opiate, to procure the still farther refreshment of sleep. Even where the face is assuming a Hippocratic appearance, the pulse so feeble and rapid as scarcely to be counted, where the abdomen is immensely distended, with cessation of pain and cold clammy state of the skin, we ought not to despair; no case, however bad, is entirely hopeless; and although the majority of such cases perish in spite of the greatest care and activity, still we are justified in persevering till the last, knowing from experience that we every now and then succeed even at this late hour in rescuing our patient.[145]

Uterine Phlebitis.

In describing the other species of inflammatory puerperal affection, which we have designated by the title of uterine inflammation or phlebitis, and which we conceive arises in most instances, from the presence and absorption of putrid matter in the uterus, we shall merely confine our description to the early part of the disease, because, as it invariably terminates in peritotinis if not stopped at an early period, it will be unnecessary to go over this part of our subject again.

Symptoms. This affection generally makes its appearance on the second, third, or fourth day after labour, and varies considerably in its mode of attack. In some cases it will be observed to come on suddenly, with scarcely any premonitory symptoms. The patient is suddenly seized with severe griping pain in the lower part of her abdomen, generally extending more or less to one side, and usually preceded by a smart shivering fit, which is followed by intense headach. On examining the abdomen, the uterus is hard, larger than natural, and excessively painful to the touch; the pulse quick and usually small; the tongue covered with a thin white fur, becoming brown and thicker towards the back part; the countenance anxious. With all this, the abdomen is neither hard nor painful upon moderate pressure; not even over the uterus itself do we produce pain, until we begin to press so hard, that the organ becomes plainly distinguishable to the hand through the soft integuments. The lochia has either not appeared at all, or has been suddenly suppressed; and in all probability, the secretion of milk has followed a similar course.

Or the disease may commence in a much more gradual manner. The after-pains are observed to increase in severity and duration, producing a considerable degree of pain over the whole abdomen, but especially the uterus, which, during the paroxysms, is harder than in the intervals. The pains are increased by the slightest pressure, if suddenly applied; but, if gradually increased, the patient will bear a considerable degree of pressure, not only without complaining, but will even remark that the pain is, as it were, benumbed by it; if the hand be now suddenly removed, very severe suffering is produced. The pains become more and more constant, until they assume the uniform character of inflammation of the uterus, as already described, when the disease makes its attack suddenly. If the disease be not checked in its progress, the pain becomes more intense, and gradually extends over the whole surface of the peritoneum; the abdomen swells from tympanitis, and is followed by the other symptoms of acute peritonitis already described. The latter stages of the attack are almost invariably mingled with symptoms of the malignant form of puerperal fever,—a circumstance which, when we consider the probable source of the disease is not to be wondered at. Indeed, we may say, that by the time the peritonitis is fairly established, the introduction of putrid virus into the circulation has been of sufficient duration and extent to render the production of adynamic symptoms almost unavoidable.

Appearances after death. Examination after death shows that the uterus and its appendages have been the chief seat of the inflammation, its whole peritoneal surface thickly covered with exudations of coagulable lymph; the broad ligaments vascular; the Fallopian tubes livid, swollen, and softened; the ovaries greatly altered in appearance and structure, being generally more or less swollen and much softened,—at times the natural tissue of the gland completely broken down into a pulpy semi-purulent mass, at others the external surface only has been red or gorged with dark-coloured vessels; the whole uterine appendages thickly imbedded in cogulable lymph. The uterus is large and soft, deposites of pus have been found beneath its peritoneal covering, or in the proper muscular tissue of the organ; and in many cases, on cutting into its substance, pus has appeared in numerous little points, oozing from the veins or absorbents which have been divided. In those veins which are large enough to be traced by dissection, their coats have been found vascular, thickened, and in many places lined with lymph, so that the vessel has become completely impervious: in others, they have been filled for a space with pus, and their canal then obliterated, either by swelling, effusion of lymph, or by plugs of fibrine from coagulated blood. These changes in ordinary cases do not extend beyond the substance of the uterus; but where the disease has been of some duration, as well as severity, they become much more extensive, affecting the neighbouring veins to some distance. “Inflammation,” says Dr. R. Lee, who has examined this subject with great care, “having once begun, it is liable, as I have before stated, to spread continuously to the veins of the whole uterine system, to those of the ovaria, of the Fallopian tubes, and broad ligaments. The vena cava itself does not always escape, the inflammation spreading to it from the iliac, or from the spermatic veins.” (Researches on the Pathology and Treatment of some of the more important Diseases of Women, p. 54.)

The surrounding structures are generally implicated in the inflammation; the muscular tissue of the uterus becomes soft and of a dark red, or even dirty black colour, and, as before stated, the peritoneum which covers the organ is particularly affected. The appearances after death in this species of puerperal fever are those most commonly observed, for puerperal peritonitis is rarely met with in its uncomplicated form, being usually more or less mixed up with it; on the other hand, the majority of cases which belong to the adynamic form of puerperal fever (except the most malignant) are generally preceded to a certain extent and attended by this disease.

Treatment. In the early stage of the disease, before inflammation (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 Cret 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. Cret 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 Cret 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 Cret 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.