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.