A System of Midwifery

by Edward Rigby

Symptoms. This form of puerperal fever seldom commences so soon after labour as any of the other species, and frequently the symptoms are so trifling, at first, as scarcely to excite attention. There is an indistinct uneasiness about the abdomen; the tongue is never quite natural, being either slightly furred with a few prominent papillæ, or pale and flabby; the appetite is irregular, or fails considerably; the patient complains of weariness and lassitude; there is, perhaps, slight headach across the eyes and forehead; the face has a sallow tinge, and if her complexion be dark, there is a leaden-coloured ring beneath her eyes; the sleep is unrefreshing; the spirits are unequal and anxious; she is chilly at times, and at others, has considerable flushings of heat, with increase of headach. The abdomen becomes full and doughy to the feel; it is somewhat tender to the touch, but not distinctly so, as in peritonitis; the motions are dark, sparing, and excessively offensive; sometimes hard and scybalous; but more usually they assume the character of an irritable diarrhœa, with much acrid slimy mucus, the evacuation of which, is attended with much flatus, and for a time produces great relief, although, at the moment of passing, it is frequently attended with a good deal of forcing. The abdomen becomes more tender, with severe griping flatulent pains at intervals; the diarrhœa assumes somewhat of the characters of dysentery; the pulse becomes quick and irritable; the tongue red and glossy at the tip and edges, with a patch of thin white fur in the middle, or with a red centre between two parallel streaks of creamy fur—the back part yellow, verging into brown; the breath is of a faint disagreeable odour; the attacks of fever, from time to time, are more distinct; and frequently, during the sweating stage, the skin throws out a strong peculiar odour, which taints the air of the whole room. In some cases there is frequent vomiting, either of watery fluid mixed with ropy mucus, or of a greenish colour; the result probably of subacute inflammation of the stomach. As the irritation of the intestinal canal increases, she becomes more exhausted, and rapidly emaciates. The tongue now becomes preternaturally red, its surface glossy smooth, the centre is parched and brown, and sometimes traversed with fissures; the fever assumes a low typhoid character, with delirium at night, and gradual sinking. The appearance of the evacuations varies considerably; at times they appear to consist of minute membranous shreds, floating in dark brown water; in others, they are clay-coloured, slimy, adhesive, excessively offensive, and even pungent; whereas, in others, they seem to consist chiefly of dark unhealthy bile, mixed with water and mucus.

This form of disease is frequently met with in patients who have been weakened by hæmorrhage, and necessarily tends to aggravate the state of anæmia which is present. She has the intense pain at the summit of the head, which characterizes this condition; she gets but little sleep, and that is disturbed by restless and uneasy dreams; she lies with the eyelids half closed, and the occasional twitchings of the muscles betray the irritable condition of the system; exhaustion quickly supervenes, and is usually attended either with low delirium, or the anæmic form of puerperal mania.

Appearances after death. If the dysenteric affection has been very severe, we shall probably find softened or even ulcerated spots in the mucous membrane of the large intestine; but in other cases, there have been no lesions of the kind; the intestines have been found a good deal distended with gas, but pale and bloodless. Where the disease has passed into the typhoid species, other appearances belonging to this form will be observed: coagulable lymph will probably be effused, and those changes in the structure of the uterus, which we shall mention when we come to the consideration of this species.

Treatment. The treatment will, in great measure, depend upon whether the disease is the result of irritation from loaded bowels, scybalous and unhealthy contents, &c., or from that engorgement of the circulation belonging to the chylopoietic viscera, with more or less fever, which indicates the efforts nature is making to rid the circulation, by this outlet, of any morbid principle with which it may have been infected.

In the first case it is simple enough, and, in most instances, the disease is prevented, or, at any rate, checked in its very outset, by the dose of castor oil which is customarily given on the second or third day after labour. If the pulse be quick, the headach severe, with much fulness and uneasiness of the abdomen, and more especially if the bowels have been constipated, or in an unhealthy state before labour, five grains of calomel and carbonate of soda, made up into two pills, with extract of henbane, and followed in a few hours by a dose of castor oil, guarded with some Liquor Opii Sedativus, as before recommended, will be required. We combine a little soda with the calomel, to prevent it griping and acting violently, which it is liable to do where there is much acidity of stomach, from its being converted into the bichloride. We also think that there will be less chance of vomiting, when the calomel is combined with the soda, than with an antimonial, as recommended by Dr. Locock; a common domestic enema of gruel and salt will assist the purgative, and bring away much unhealthy fæculent matter. The medicines will generally require to be repeated in twenty-four hours, to insure the removal of the irritating cause from the bowels; the abdomen becomes softer and more free from uneasiness; the pulse rises in strength and fulness, but diminishes in rapidity, and the patient experiences general relief in her symptoms. She may now take an ammoniated saline, with tincture of hop or henbane during the day; five grains of Hydrarg. cum Cretâ with carbonate of soda and henbane at night, instead of the calomel, and a draught of rhubarb and magnesia with some aromatic confection the next morning, or of rhubarb and manna with sulphate of potash, rendered warm by a little spirit of nutmeg.

If diarrhœa has come on spontaneously at an early period, the true nature of the case is more liable to be mistaken; still, however, the evidences of gastric and enteric irritation are quite sufficient to guide the cautious and observant practitioner. The calomel here is not so desirable as where there is constipation; eight or ten grains of Hydrarg. c. Cretâ will produce less irritation, and act as effectually: it will require to be followed by the same treatment as above-mentioned, and to be repeated according to circumstances.

The diet should be chiefly farinaceous with milk; rice-milk, when the bowels have been sufficiently cleared, is generally very useful; it is slightly constipating, and soothes the irritable mucous membrane with its bland consistence. Milk and soda-water, as mentioned by Dr. Locock, or with lime-water, is very beneficial, especially where the tongue is disposed to remain red, with a smooth glossy surface; as convalescence proceeds, a tea-spoonful of the concentrated essence or decoction of sarsaparilla may be added with advantage.

This form of puerperal affection is never epidemic; it is mere intestinal irritation after labour from scybalous and other unhealthy contents; but this is not the case with the “gastro-enteric form,” described by Dr. Ferguson; in the former, the febrile excitement of the circulation is but trifling, and frequently can scarcely be said to exist; whereas, in the latter, the disease rarely appears sporadically, but in conjunction with numerous cases of the same character, or of the malignant adynamic form; it is also, invariably accompanied with much febrile disturbance, and usually of a low form, unless complicated with abdominal inflammation at an early period.

“This form of puerperal fever,” as Dr. Ferguson observes, “assumes the general characters of a mild typhus, accompanied with intestinal irritation.” (Op. cit. p. 22.) The object of our treatment here is very different to that of the other form just mentioned; it is to unload the gorged circulation of the stomach, liver, and bowels, of the noxious and excrementitious matters which nature has brought to these emunctories, in order that they may be discharged from the system. It is in these cases where, although little or no food has been taken for some time, and without any evidences of fæcal accumulation, we find the exhibition of certain purgatives, especially calomel, to be followed by such copious fæculent evacuations, which we have every reason to believe have been secreted by the liver and bowels under the action of this powerful remedy. The treatment recommended by Dr. Ferguson, is so in accordance with our own views, and so concisely expressed, that we may be allowed to quote it.

“The following,” says he, “I have found the most suitable treatment. Get rid of all local inflammations as soon as possible by leeching or by moderate depletion, so as to reduce the malady into simple fever with gastro-enteric irritation. When the skin is early dusky, and there is nausea or vomiting, begin with an emetic. If there be no nausea nor vomiting, but intestinal flux, with a red tongue smeared with suburra, a large dose of calomel, from ten to fifteen grains should be given. Small doses create purging, pain, and irritation, while the full dose produces one to six large pultaceous stools, after which the tongue is cleaned, rendered less red and more moist, and the pulse usually falls. These stools, when examined, appear to contain the fæcal matter suspended in large quantities of mucus and greenish bile, as if the turgid capillaries of the irritated intestinal canal and liver had been freed from their load. In some instances, a repetition only of the same dose is required to efface the main features of the malady, and to leave nothing but debility to support. In others, after a short respite, diarrhœa re-commences, and soon is apt to become colliquative.” (Op. cit. p. 158, 159.)