A System of Midwifery

by Edward Rigby

We have already shown the effects which calomel possesses in large doses of rousing the different excretory organs into full action, and thus assisting to secrete or separate from the circulation any offending principle which may have been carried into it. We are also convinced that where calomel has been promptly given in this manner, the chances of the disease being prolonged or terminating in the adynamic form are considerably diminished. Dr. Hamilton, in speaking of the advantages derived from the use of purgative medicines in typhus fever states, “I am now thoroughly persuaded, that the full and regular evacuation of the bowels relieves the oppression of the stomach, cleans the loaded and parched tongue, and mitigates thirst, restlessness, and heat of surface; and that thus the later and more formidable impression on the nervous system is prevented, recovery more certainly and speedily promoted, and the danger of relapsing into the fever much diminished.” (Observations on the Utility and Administration of Purgative Medicines in several Diseases, by James Hamilton, M. D. p. 35.)

As the gastro-enteric form of puerperal fever which we have just described, is frequently observed in epidemics of the adynamic form, particularly at their commencement and going off, and frequently complicated with it, we would rather consider those local inflammations and deposites of puriform fluid in the muscles, joints, &c., which are occasionally seen after severe cases, to the disease being complicated with, or assuming the nature of, the malignant form.

If the symptoms have not yielded to the treatment which we have recommended, the alvine discharge becomes excessively unwholesome and fetid, the skin exhales a strong and unpleasant odour, the strength fails, the tongue is either dry and brown, or smooth and red like raw meat, the fever sometimes assumes the remittent character as described many years ago by Dr. Butter, of Derby; in others, the febrile symptoms subside, leaving the case one of chronic or subacute inflammation of the lining membrane of the bowels, with occasional attacks of irritative fever arising from it. In these cases mercurials, except in mild and guarded doses, appear to aggravate the irritation of the mucous membrane, and increase the disposition of it to ulcerate: five grains of Hydrarg. cum Cretâ and Dover’s powder may be given once, or at the utmost, twice, in the twenty-four hours; half a drachm of carbonate of ammonia neutralized by lemon juice, and rendered alkalescent by a little Spirit. Ammon. Arom., may be given in some aromatic water every three or four hours; injections of starch into the rectum with a few drops of Battley are also useful. In some cases, where there was continued flatulence, a small quantity of turpentine in some castor oil has had an excellent effect. Others, where every means had seemed to fail, have yielded under the use of copavia. Dr. Locock has found advantage from the occasional use of very small doses (eight to ten grains) of epsom salts with a few drops of laudanum in some aromatic water. The after treatment, as also, the rules for diet, are the same as in the other form.

The Contagious, or Adynamic, Puerperal Fever.

Although we have classed under the head of “puerperal fevers” a variety of affections connected with, and arising more or less from, the same cause with the dreadful malady which we are now about to describe, and although every form and modification of them is liable to assume its characters, still we must confess that the term puerperal fever belongs par excellence to this form, the adynamic, malignant, and, as we have upon a former occasion called it, the genuine puerperal fever.

It is in this form of disease that the vitiated state of the blood is shown with most distinctness, not only from the condition of the blood both during life, and after death, but also from the close connexion which exists between it and the plague, African typhus or yellow fever, and the other malignant fevers, both of the temperate as well as the tropical climates.

The interesting and daring researches of M. Bulard upon the pathology of the plague, tend to throw great light upon the nature of this formidable disease, and to confirm the views which we have long entertained of this and other diseases of the same class, that the essence of the disease consists in the vitiated condition of the blood.

Symptoms. The onset of this disease is almost invariably accompanied with a smart rigour, followed by intense headach, and rapid but generally powerless pulse. It seldom begins before the third day, although in some cases it seems to have commenced from the time of her delivery; whereas, in others the patient has gone on to recover favourably until the tenth or even the fourteenth day before being seized, and had already felt sufficiently well to leave her bed and sit up. The powers of the system seem prostrated at once; the shrunken features and dusky hue of the skin, the leaden colour of the lids, and circumscribed crimson or almost purple patches upon the cheeks, the short imperfect breathing and occasional deep sighing to relieve it, indicate but too surely the nature of the disease, and its depressing effects upon the whole system.

“The sensorium,” says Dr. Douglas in describing this form, “is seldom in any degree disturbed, whereas, in the others, it is so frequently, and even sometimes it is excited to high delirium. The pulse here is usually from the moment of the attack, soft, weak, and yielding, and in quickness often exceeds 150; whereas, in the first species it is full, bounding, and often incompressible; and in the second, small, hard, and contracted, and in both, moderately quick. The eye, instead of being suffused with a reddish or yellow tint, as in the others, is here generally pellucid with a dilated pupil. The countenance, instead of being flushed, as in the others, is here pale and shrunk with an indescribable expression of anxiety; an expression altogether so peculiar, that the disease could on many occasions be pronounced or inferred from the countenance alone. The surface of the body instead of being, as in others, dry and of pyrexial high heat, is here usually soft and clammy, and the heat not above the natural temperature; and not only is the skin cool with clammy exudation, but the muscles to the impression of the finger feel soft and flaccid, as if deprived of their vis vitæ by the influence of contagion. Indeed, there is such prostration of muscular strength and depression of vital principle from the very outset of the attack, that I must suppose the contagion to act through the medium of the nervous system in a manner analogous to that of the contagion of plague.” (Report on Puerperal Fever. Dub. Hosp. Rep. vol. iii.)

Where the powers of the system are not annihilated from the commencement of the attack by the depressing effects of the poison with which the circulation is impregnated, an effort at reaction is frequently made, and for some hours afterwards the surface of the body is hot and dry; but sooner or later, as the stage of collapse comes on, it then assumes the same cold death-like feel, as in the worst cases of malignant cholera. The character of the attack will be in great measure modified by the intensity of the poison, and the extent with which the circulation has been infected by it. The same effort to produce such a state of reaction as will raise the temperature of the skin, will probably assist nature in throwing it off under the form of peritonitic or gastro-enteric species of puerperal fever already described; whereas, where the circulation has been thoroughly impregnated with it in its concentrated form, the vital powers succomb at once, and a state of collapse exists from the very commencement of the disease. The course which the symptoms follow and the duration of the disease, will, therefore, depend not only on the severity of the attack, but also on the power of the particular constitution to resist the deadly effects of the morbid principle upon which the disease depends. When broken down by previous disease, intemperance, poverty, and depressing passions of the mind, the vital powers can make no stand against the powerful enemy by which they are attacked; “the blood is so much vitiated, even early in the disease, that it loses the power of stimulating the heart so as to keep up its healthy action; and, perhaps, also the vascular organs are early affected by the action of the poison, and lose the power of either feeling the stimulus, or reacting with force on the impression, which is communicated to their internal surface by the vitiated blood. In such cases, in place of increased excitement, there is frequently a want of action in the whole system.” (Stevens, op. cit. p. 188.) The patient sinks without pain or complaint, beyond that of debility, but in such cases with a rapidity which would almost claim for the disease the name of “plague.” The tongue becomes dry, red, and brown at the back part, the pulse weaker and more rapid, the debility and exhaustion more overpowering; still, even in this state, her mind usually remains clear, unconscious of the fate which awaits her, and occasionally even cheerful: a peculiar sickly odour exhales from the skin, and in many cases so distinctly, as to warn us the moment we enter the room of the patient’s condition. The dusky ashen hue of the skin becomes darker, the fingers are shrivelled, and the nails dark, or of a livid black as in cholera; diarrhœa frequently attends, the fæces are unhealthy, and of the same peculiar odour just noticed; during the first stage the lochia are generally present, although of an unhealthy character; the milk also continues in the milder cases, but as the stage of collapse approaches they both disappear, and the breasts become quite flaccid. In some cases there is vomiting from an early period, with more or less tympanitic distention; but these symptoms rather depend upon the disease being complicated with one of the other modifications. Livid purpurous blotches sometimes appear upon the legs, &c. and in some epidemics it is accompanied with dark or livid eruptions. The surface has now the cold wet feel in its greatest degree, and in some cases even the tongue feels cold to the finger; a drowsy state of insensibility generally follows and continues until death.