A System of Midwifery

by Edward Rigby

The symptoms here enumerated present the characteristics of fever under its different degrees of intensity. The peritonitic and gastro-enteric forms may be compared with the ordinary fevers of temperate climates, and which are attended with more or less inflammation of some organ. The malignant adynamic form corresponds closely with the malignant typhus of this, and the pestilential fevers of warm countries, more especially the plague and the African typhus or yellow fever. In all of these diseases, the vitiated state of the blood appears to be the essential condition of their existence, quite independent of any inflammatory action; in fact, in this form, so rapid and overpowering are the effects of the poison which pervades the circulation, and so completely does it paralyze the whole system, that there is neither time nor sufficient vis vitæ to make any effort at reaction. Hence, as Mr. Moore has correctly observed, “when the patient is rapidly destroyed by the violence of the disease, the morbid changes bear no proportion to the severity of the previous symptoms; a dubious trace of inflammation, a little serum, or a few feeble adhesions, are all that dissection under such circumstances displays.” (Inquiry into the Pathology, Causes, and Treatment, of Puerperal Fever, p. 63.) In many of the most rapidly fatal cases which we have witnessed, there have not been even these questionable evidences of inflammation. The tissues have been pale and bloodless, the uterus softened, its internal surface ragged, and with a dark gangrenous appearance, extending to the os uteri, and dark thin claret-like blood in all the larger vessels. The heart is flabby, soft, and filled with dark blood; the lungs, liver, spleen, and kidneys much softened; the spleen dark, sometimes enlarged and almost pulpy. If we compare these appearances with those observed by M. Bulard in cases of plague, we shall find a striking coincidence between the two diseases. This intrepid pathologist remarks, that “the state of general turgescence and dilatation of the venous system; the presence of inflammable gas in eight cases in the cellular tissue, in the veins of the head, feet, and abdomen; the presence of petechiæ, both internally and externally; the general softening of the tissues; the enlargement, softening, and breaking down of the spleen; the petechial state of the mucous membrane of the stomach; the effusions of blood on the inner surface of that organ; the passive hæmorrhages and boils, are symptoms which result from a change in the condition of the blood. The symptoms connected with the state of the nervous system, viz. the rigours, headach, and confusion of mind, the quick and small pulse, the hurried respiration and vomiting, and also the petechiæ, carbuncles, and buboes, are neither those of vascular nor nervous inflammation. The blood has never shown the buffy coat; it was found just as black in the arteries as in the veins, but in the former, in much smaller quantity; it always had the appearance of being dissolved.” M. Bulard observes, that the decomposition of the blood is quite independent of putrefaction being present before death takes place; and he feels convinced that it is not only the sole cause of death, but must also be looked upon as the origin of the various morbid phenomena during the course of the disease. He considers “these phenomena to result from an actual poisoning of the blood, similar appearances being observed in all cases where putrid matter and morbid secretions have been introduced into the system.” With regard to the supposed inflammatory nature of the plague, M. Bulard states, that in many cases not the slightest trace of inflammation could be found. The changes in the spleen are of by far the most invariable occurrence. In one hundred autopsies, this organ was found only five times in a healthy state.

Where, on the other hand, the powers of the constitution, or the diminished virulence of the disease, have enabled the system to withstand the depressing action of its immediate effects, we find it considerably modified, both in the symptoms which it presents during life, and the appearances after death. Instead of being little else than a state of collapse from the very outset of the disease, under which, not a single attempt is made by the powers of the system to set up even the most feeble effort of reaction, a variety of symptoms attend its commencement and progress, indicating that the vis vitæ has not altogether succumbed beneath the deadly effects of the malady. The very rigour itself, when violent, the headach and flushing of the face, if severe, are rather favourable than otherwise, and show that the system still possesses some power of reaction. It is usually observed, that where the attack commences with these precursory symptoms well marked, it is generally accompanied with peritoneal pain, tympanitis, and other symptoms of inflammatory action; whereas, in the worst cases, we have already stated, that from the very commencement of the disease there is neither a symptom of inflammation during life, nor a trace of it to be found afterwards. Dr. Armstrong rightly observed, that inflammation is not an essential constituent of typhus; and the same holds good in the strictest sense of the word, with the typhoid or adynamic puerperal fever.

“Whatever the remote cause of fever may be, it is very evident that this cause must invariably exist, not only at the moment of attack, but even previous to that period. Now in the fevers from poison, the blood is invariably diseased previous to the commencement of the cold stage. During this period there are premonitory symptoms; but these are evidently the effect of the diseased state of the vital fluid: and that these precursors of fever are not the effect of any local inflammatory disease, is evident from the fact, that frequently during this period there is no pain in any of the organs, but a want of action, particularly in the extreme vessels, and consequently a decrease of heat in the whole system.

“If inflammation in any of the organs were, in reality, the cause of fever, then the disease ought to be fatal, exactly in proportion to the violence of the local affection; but the very reverse of this is the truth. Mere excitement can easily be reduced, and the inflammatory form of fever is decidedly the most easily cured, though in it the excitement is often so great that the organs are very liable to be injured; while the malignant form of fever is by far the most fatal, though in this the excitement is less, and the organs are seldom affected. This is particularly the case in the worst form of the African typhus, and probably other varieties of malignant fever, where the blood is under the influence of an active poison, and where its vitality is diminished, and its structure is injured even before the attack.

“Those who have seen most of the malignant diseases know well that excitement in fever is invariably a good symptom; for this is a sure sign that the blood has not yet undergone any fatal change, and independent of this, mere increase of action is always at the mercy of the lancet. But neither the lancet nor leeches, gum water, vitriolic emetics, calomel, antimony, brandy, opium, or acids, can redden the colour of the black blood, which we invariably meet with in pestilential diseases, or remedy the diseased state of the vital current, so as to cure that fatal form of fever where the malignant symptoms are produced, not by excitement, but by the vitiated state of that mysterious fluid, which in health gives life and nourishment to every solid of the system, and which, when diseased to a certain extent, is by far the most frequent cause of death in all those fevers that are produced by some deleterious poison acting, in the first place, on the vital current, and then on the brain and the whole system through the medium of the blood.” (Stevens, on the Blood, p. 186.)

We have quoted thus largely from the observations of Dr. Stevens and M. Bulard, to whose admirable researches we are so greatly indebted for our present knowledge, respecting the nature of pestilential diseases both of the East and West, for they tend not only to show the true pathology of malignant puerperal fever, but also the class of diseases to which it belongs.

Appearances after death. Where more or less inflammatory action has accompanied the first part of the disease, the lesions observed after death differ considerably from those of acute peritonitis: the effusions of cogulable lymph, of serum, and sero-purulent fluid, are seldom met with to such an extent where the case has been one of inflammation uncomplicated with the adynamic form of puerperal fever, even although it may have been exceedingly violent; whereas, in the present case, although there has been scarcely sufficient power in the system to set up even a moderate degree of inflammatory action, the intestines and uterine appendages are found glued together, and thickly imbedded in immense effusions of lymph. The ovaries, Fallopian tubes, and broad ligaments are engorged with purple vascularity, softened, and, especially the ovaries, quite disorganized, with numerous effusions of sero-purulent matter beneath their peritoneal coverings, or into their parenchymatous tissue. In others, their whole substance has been softened and pulpy, with little cyst-like cavities filled with blood or pus, the remains of the Graafian capsules. During the fatal epidemic which prevailed at the General Lying-in Hospital, in the early part of 1838, we met with several cases where the ovaries had entirely disappeared, their site being only discoverable by an oval thickening of the broad ligament, something like an empty cyst of peritoneum; this contained a small quantity of livid pulpy débris of the ovary, and (on that side where conception had taken place) a remarkably well marked or rather exaggerated corpus luteum. The uterus is larger and its tissue much softer than under ordinary peritonitis, so that, in many instances, the finger can be easily pushed through its whole substance.

Where the constitution has borne the brunt of the attack without immediate collapse, and the local mischief been controlled by appropriate means, we find that fresh efforts are made to rid the circulation of the morbid matter with which it is infected. The patient is suddenly seized with severe pain, with heat, redness, and swelling of one of the large joints, presenting all the appearances of arthritic or rheumatic inflammation, and also of certain muscles, especially the supinators of the arm, the glutæi, and gastrocnemii. The painful spot soon becomes hard, it is intensely tender, and in two or three days the feeling of fluctuation indicates the formation of an abscess, from which a large quantity of greenish coloured pus mixed with blood and serum is discharged. The cellular tissue beneath the skin and between the muscles is equally affected, and if examined when the abscess is just beginning to form, will be found of a dirty brown colour, softened, infiltrated, and here and there condensed with lymph or pus, precisely as in cases of gangrenous erysipelas: the muscular tissue has entirely lost its red colour, and closely resembles the appearance of boiled meat, its structure so softened as to tear easily under the fingers, and interspersed with deposites of immature lymph and purulent fluid, the commencement of what would have been an abscess. Like gangrenous erysipelas the extent of the abscess does not seem to be limited by a surrounding wall of healthy lymph, as seen in a common phlegmon, but if deep beneath the surface it continues to spread in all directions until nearly the whole limb appears to be implicated in one immense abscess: hence, in those patients who have recovered under these attacks, the limb has frequently been rendered useless, the muscles being atrophied and coherent.

Inflammation of a similarly arthritic or rheumatic nature occasionally also attacks the eye, and presents all the usual characters of arthritic iritis under ordinary circumstances: there is the same intolerance of light, pain of the eye, dimness of vision, contracted pupil, and peculiar white ring round the edge of the cornea, which distinguishes this affection; but in the present case, the disease runs a far more rapid course, and defies the remedies which in common cases would be sufficient to check it; the inflammation soon extends to the deeper seated structures of the eye, the pain is excrutiating, and, in two or three days, disorganization takes place, followed by suppuration, staphyloma, and bursting of the cornea. So rapid and destructive is its course, that, although five or six cases have come under our notice, in only one instance, with the greatest difficulty, was the eye saved, and, even then, not before it had been considerably injured.

These attacks are attended by severe pains of a similar nature in different parts of the body, more especially the joints and limbs; and, from the arthritic character which they assume, tend, in our opinion, still farther to elucidate the real condition of the system. The analogy between gout or rheumatism, and those diseases which arise from a vitiated state of the blood, is exceedingly close, nay, even identical, for in both, a principal pervades the circulating fluids which requires to be removed; and if this be not effected by any of the excretory organs, nature endeavours to throw it off by some process of local inflammation. The connexion between puerperal fever and typhus is very close, for it not only assumes the characters of the typhus epidemics which may chance to be prevailing at the time, but we have distinct evidence that the contagion of typhus will, in a puerperal woman, manifest itself under the form of puerperal fever. Dr. Collins has recorded a very interesting case of this sort:—“A patient was admitted at a late hour at night into one of the wards, labouring under a bad form of typhus fever, with petechial spots over her body; when observed next morning, she was removed into a separate apartment, where she died shortly after. The two females who occupied the beds adjoining hers, while she remained in the large ward, were attacked with puerperal fever, and died.” (Collins, op. cit. p. 381.) During a typhus epidemic which prevailed a few years ago in the poor districts of the metropolis, a prominent feature of which were petechiæ and a livid rubeoloid eruption, precisely the same appearances were observed among the cases of adynamic puerperal fever at the General Lying-in Hospital.