A System of Midwifery

by Edward Rigby

The pulse is in an equally irritable state; after a few beats it rises in rapidity as soon as the patient’s mind is directed to it; in others it is permanently quick. The tongue is sometimes slightly covered with a thin fur; in others it is pale and flabby; and in others disposed to be glazed, red, and dry.

The disease rarely exists long uncomplicated with any other form of puerperal affection, but soon passes either into acute peritonitis, or into the typhoid state of the malignant form, the latter transition being almost certain, if the practitioner has considered it as an inflammatory affection, and treated it antiphlogistically.

It is to the late Dr. Gooch that we are indebted for having first called the attention of the profession to this disease, and pointed out its true characters by the nature of the remedies which proved successful in relieving it. “The effects of remedies on a disease, if accurately observed, form the most important part of its history; they are like chemical tests, frequently detecting important differences in objects which were previously exactly similar. How many diseases are there in which the symptoms are inadequate guides?” “The local pains and constitutional disturbance which occur in feeble and bloodless persons, and which are aggravated by bleeding and other evacuants, strikingly resemble the local pains and constitutional disturbance which occur in vigorous and plethoric persons, and which the lancet and other evacuants relieve and ultimately cure; yet how many years is it before the young practitioner learns that there are cases apparently so similar, yet really so different, and how to distinguish them; and how many practitioners are there who never learn it at all? Symptoms and dissections can never do more than suggest probabilities about the nature of the disease, and the effects of a remedy on it. A trial of the remedies themselves is the only conclusive proof.” (Op. cit. p. 37.)

In those cases which proved fatal, the post mortem appearances only tended to confirm the nature of the disease. So far from marks of inflammation being found, there was not a single trace to be discovered; in fact, an entirely opposite condition existed; the peritoneum and viscera were pale and bloodless.

Treatment. It is of the highest importance to distinguish these affections from a state of inflammation; the treatment of the one will be precisely the reverse of the other. The lancet is as little indicated in this case, as it is in puerperal convulsions from anæmia, and the effects produced will be scarcely less mischievous. The fatal cases which Dr. Gooch has recorded, show that it was not the disease so much as the treatment which destroyed the patients, and prove, as we have already stated, that the presence of pain and a quick pulse do not surely indicate a state of inflammation, without being confirmed by the general symptoms of the patient’s condition. “These cases taught me a new view of the subject: they taught me that a lying-in woman might have permanent pain and tenderness of the abdomen, with a rapid pulse, independent of acute inflammation of the peritoneum or any other part; that these symptoms may depend on a state which blood-letting does not relieve, and which, if this remedy is carried as far as it requires to be carried in peritonitis, may terminate fatally; and that the most effectual remedies are opiates and fomentations. Most of the patients who were the subjects of these attacks, were women, who, in their ordinary health, were delicate and sensitive; the attack sometimes seems to originate in violent after-pains, gradually passing into permanent pain and tenderness, resembling inflammation, or in the painful operation of an active purgative; but it could sometimes be traced to no satisfactory cause—the patient had had a common labour, and had experienced no unusual cause of debility or irritation. The pulse in all these cases, although quick, was soft and feeble: this, together with the previous constitution of the patient, were my chief guides. When I could trace it to any irritating cause, such as a griping purge, and when blood had been already drawn without relief, and without being buffed, I saw my way still clearer. When I doubted, I applied leeches to the abdomen.” (Op. cit. p. 72.)

In ordinary cases a dose of Liquor Opii Sedativus, or of Dover’s powder, repeated according to circumstances, will be sufficient to stop the attack, taking care to clear the bowels of any irritating matter with castor oil in some aromatic water, guarded by a few drops of Battley’s solution. In many of these cases, where the circulation is below the natural standard in point of power, and the disease is more or less complicated with hysteria, the opiates should be combined with a gentle stimulant, of which camphor is by far the best. Five grains of powdered camphor with half a grain of hydrochlorate of morphia and a sufficient quantity of extract of henbane, to form two pills, may be repeated at intervals, whenever the pain shows a disposition to return, and constipation prevented by castor oil and Liq. Opii Sedativus as before-mentioned, or a gentle draught of sulphate of potass, rhubarb, and manna. In most cases, when the stomach and bowels are in a proper condition, mild tonics will prove useful, as equal parts of extract of gentian, henbane, with or without a grain or two of quinine or sulphate of iron, at night; and, if necessary, the infusion of some vegetable tonic during the day. The diet should be simple but nutritious, and a certain quantity of malt liquor or wine allowed daily, if the condition of the patient permit it. In some instances the low diet which is usually deemed requisite for the first few days after labour, has appeared to have been the cause of this highly irritable condition, especially in those who have habitually accustomed themselves to pamper the appetite, and to use fermented or spirituous liquors in excess: with spirit drinkers, the loss of their daily stimulus is almost sure to be followed by a low, feeble, irritable state of the system, much gastric and nervous derangement, and the paroxysms of pain just described. It is astonishing how quickly every symptom subsides, and the system returns to a natural condition, by the daily allowance of a small quantity of their favourite beverage.

Gastro-bilious Puerperal Fever.

This is the gastro-enteric species of Dr. Ferguson, and corresponds with the “puerperal intestinal irritation” described by Dr. Locock. In its simple uncomplicated form, this disease cannot be considered as a dangerous affection; it occasionally passes into inflammation, but more frequently it assumes after awhile the typhoid or malignant form, especially where its true characters have not been recognised, and the powers of the system have become much exhausted by its severity and long continuance.

Like the false peritonitis it is frequently met with in cases where, from unwholesome or intemperate living, the digestive organs are greatly deranged, or where the bowels have been much neglected for some weeks before labour. We cannot help thinking that the view which Dr. Ferguson has taken of its cause, viz., a vitiated state of the fluids, as with the case of puerperal peritonitis, is far too exclusive, inasmuch as it is evidently produced in many instances by the direct irritation of matters which are contained in the intestinal canal: in others, we fully agree with him, that it is produced indirectly by the introduction of an animal poison into the circulation, which spends its virulence upon the stomach, liver, or intestines, or which, in other words, nature endeavours to remove from the system by these outlets. In the early stage of uterine irritation, or of phlebitis, from the absorption of putrid fluids, we have shown that the cause at first, in most instances, acts directly, and not through the medium of the circulation, otherwise the symptoms would not be so instantly checked by washing out the uterus with warm water, and thus removing the source of mischief; so in the gastro-bilious or enteric form, the symptoms at first are produced in most, if not all cases, by the direct irritation of the unhealthy intestinal contents, upon the removal of which they at once disappear; although at the same time, if the source of irritation be not removed, we have no doubt but absorption will take place sooner or later and vitiate the circulation. Thus, Dr. Kirkland considers that retained fæces during a lying-in are capable of bringing on symptoms which “may, properly enough, be called puerperal fever” (op. cit. p. 87;) and Dr. John Clarke, in enumerating the different causes entertained by “writers of good reputation,” mentions, where fæces are detained in the intestines, “the thin putrid parts of which are supposed to be taken up into the blood.” (Practical Essay on the Management of Pregnancy and Labour, by J. Clarke, M. D., 1806, p. 53.)

There is, however, no reason to confine the source of the putrilage, which infests the circulating current, in cases of gastro-bilious or intestinal irritation, to unhealthy fæcal matter in the intestines; for in the experiment made by Professor Tiedemann, to which we have already alluded, viz. of injecting musk into the femoral vein of an animal, the poison seemed to concentrate itself upon the mucous membrane of the intestinal canal; and from the diarrhœa which had commenced shortly before death, it is probable, if the dose had been smaller, that nature would have succeeded in ridding the system of it by this means; we may, therefore, conclude, in most of the cases of this affection, which are not the result of direct enteric irritation, but an effort of nature to purify the circulation by expelling the morbid matter, with which it had been vitiated, through the medium of the mucous membrane of the bowels, that the uterus had been the source of its origin, introduction, or absorption, into the system.