A System of Midwifery

by Edward Rigby

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. Assafœtidæ, &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 pharmacopœia,—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.