A System of Midwifery

by Edward Rigby

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.