A System of Midwifery Part 32

"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 quant.i.ty 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 p.r.o.ne 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 cra.s.samentum; the coagulum is so soft that it can easily be separated with the fingers, and during its formation, a large quant.i.ty 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 cla.s.s of fevers, the cra.s.samentum of the blood, instead of forming a firm coagulum, is loose, small in proportion to the quant.i.ty 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. Ill.u.s.t. 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 h.o.m.ogeneous semi-gelatinous ma.s.s, with little or no separation of serum from the cra.s.samentum. 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 cra.s.samentum is small, the alb.u.minous 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 a.s.sume; 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 a.s.sume the character of synochus, or low malignant typhus. It varies a good deal according to the cla.s.s of patients attacked, being more frequently of the inflammatory character among the middling and higher cla.s.ses, 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 a.s.sumes 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 a.s.sumes 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 a.s.sumed 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 circ.u.mstance 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 pract.i.tioner 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 pract.i.tioner 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. Loc.o.c.k 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. Loc.o.c.k, 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 a.s.sume 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 pa.s.s 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 quant.i.ties, 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 a.s.sumes 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 a.s.sume 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 quant.i.ty 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 a.s.sumed 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 a.s.sist 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 diaph.o.r.etic: 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 ma.s.s; 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 ma.s.s, 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 repet.i.tion, 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 a.s.sume 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 subst.i.tute 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 quant.i.ty 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 quant.i.ty 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 versa_: 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 quant.i.ty 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 repet.i.tion 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 ca.n.a.l, 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 a.s.sisted 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 rea.s.sumed its former condition; if the action of the purgatives has not taken place, or has been at most unsatisfactory, even with a repet.i.tion 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. Loc.o.c.k, "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 pract.i.tioners: 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.

Loc.o.c.k, that calomel is by far the best form in which it can be used, where we wish to obtain its specific effects. The Hydrargyrum c.u.m Creta, 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 quant.i.ty will be sufficient: in order to save time we usually begin with five grains of calomel, and an equal quant.i.ty 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 circ.u.mstances. 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 v.a.g.i.n.a 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 pa.s.sages 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 a.s.sists 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. Loc.o.c.k; but we have not met with the success which he mentions, probably from the disease having already a.s.sumed 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. a.s.safoetidae, &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 circ.u.mstances 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 a.s.suming 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 t.i.tle 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 a.s.sume 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 circ.u.mstance 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 ma.s.s, 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 s.p.a.ce with pus, and their ca.n.a.l 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 circ.u.mstances; 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 circ.u.mstances 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 circ.u.mstances, 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 haemorrhages," 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 a.s.sisted by bleeding. If a state of actual haemorrhage 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 circ.u.mstances, 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 v.a.g.i.n.a. 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 pa.s.s 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 acc.u.mulation 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 ca.n.a.l, 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 v.a.g.i.n.a. 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 a.s.sist its diaph.o.r.etic 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 quant.i.ty 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 a.s.sist 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 v.a.g.i.n.a 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 t.i.tle, which we believe first originated at the General Lying-in Hospital, and which has been adopted by Dr. Loc.o.c.k 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.