A System of Midwifery

by 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.