A System of Midwifery

by Edward Rigby

The same has been observed with erysipelas; and, in one short but severe epidemic, the child of every woman who had died of the disease perished also from erysipelas, so severe that it ran its course in a few hours. Dr. Gordon, of Aberdeen, remarks, that “with it and, at the same time, epidemic erysipelas began, progressed with equal pace, arrived at its acmé, and terminated together.” He also says, that a very frequent crisis of the disease was an external erysipelas. Mr. Hey remarks, that infectious fevers were common at the time; and he does not recollect ever having seen such malignant cases of erysipelas as then. Dr. Clark also observes, that those inflammatory diseases which occurred were principally erysipelatous. Dr. Armstrong states, “that in 1813 (the year of its greatest prevalence throughout England) low fever, typhus, and acute rheumatism also prevailed to an uncommon degree.” (Moore, on Puerp. Fever, p. 164.)

During the same epidemic, to which we just now alluded, the housemaid of the hospital, a healthy young woman, was suddenly seized with sore-throat and violent erysipelas of the head and face, from which she was saved with great difficulty; her sister came and attended her, as the nurses were too much occupied by the number of patients who were ill; just at the time that she was pronounced out of danger, her sister, not feeling well, went home, sickened, and died, in less than three days, of typhus fever.

The contagious nature of puerperal fever has long since ceased to be a matter of doubt, and instances have repeatedly occurred of practitioners and nurses communicating the disease to several patients in succession. Dr. Gooch has recorded some striking instances of the kind, and we could enumerate many others if necessary. Where a practitioner has been engaged in the post mortem examination of a case of puerperal fever, we do not hesitate to declare it highly unsafe for him to attend a case of labour for some days afterwards. The peculiar smelling effluvia which arises from the body of a patient during life is quite, in our opinion, sufficient to infect the clothes; and every one who has made a minute dissection of the abdominal viscera, especially in fatal cases of puerperal fever, knows full well that it is almost impossible to remove the smell from the hands for many hours, even with the aid of repeated washing; it must be, therefore, self-evident, that, under such circumstances, it would be almost criminal to expose a lying-in patient to such a risk.

That the discharges from a patient under puerperal fever are in the highest degree contagious, we have abundant evidence in the history of lying-in hospitals. The puerperal abscesses are also contagious, and may be communicated to healthy lying-in women by washing with the same sponge: this fact has been repeatedly proved at the Vienna hospital; but they are equally communicable to women not pregnant; on more than one occasion the women engaged in washing the soiled bed linen of the General Lying-in Hospital have been attacked with abscesses in the fingers or hands, attended with rapidly spreading inflammation of the cellular tissue.

We have stated that puerperal fever may arise from the effluvia which exhales from the body of the patient, and from the various discharges; it may also be produced by noxious exhalation from sewers, ditches, and other sources of miasmata, the effects of which in producing typhus have been long ascertained. “With regard to the General Lying-in Hospital, its locality rather below the level of the river, and surrounded by a mesh-work of open sewers fifteen hundred feet in extent, receiving the filth of Lambeth, and some not thirty feet from the wards of the institution, may account for its unhealthiness. It is only after repeated remonstrances, that these sources of pollution have in part now begun to be obliterated.” (Dr. Ferguson, op. cit. p. 104.) The commissioners of sewers refused the application of the hospital, to have the nearest of these nuisances properly bricked over, and assigned this remarkable reason for so doing, viz. that the hospital had come to them, not they to the hospital. Consent was ultimately only obtained by the agreement, that a large portion of the expense should be borne by the institution. On completing the work they afforded us a striking instance of the effects of effluvia on lying-in women; a large quantity of black pestilential mud had been thrown out in making the necessary excavations, this they refused to remove, and actually spread it upon the ground to a considerable extent; the consequence was, that the first two cases of puerperal fever after the re-opening of the hospital occurred within twenty-four hours of this unjustifiable act.

Treatment. The fatal character of this disease and the varied form of its epidemics will in part explain why so much discrepancy of opinion should have existed among authors and practitioners respecting its treatment. Where its remote cause has been but imperfectly known, it is not to be wondered that practitioners, finding their efforts unsuccessful, should lose their confidence in any one set of remedies or mode of treatment, and try a variety, in the vain hope of hitting upon the right one. But in a great measure this is to be attributed to the difference of the affections which have been described by various authors under the same head; each has described it as it occurred to himself; and in many instances it has been only the description of a single epidemic, and, therefore, has given to the world the treatment which his experience in that particular form has proved successful. Thus, the lancet has been looked upon as the only means of saving the patient by those who have witnessed the inflammatory modification of the disease; whereas, in the hands of those who had to treat it in its adynamic malignant form, bleeding (as but too frequently every thing else) proved utterly inefficacious.

A variety of plans have been tried in this last species, and their success described by Dr. W. Hunter in his lectures, gives a fearful view of the nature of the disease we have now to deal with. We continue the quotation which we have already made from him. “In two months thirty-two patients had the fever, and only one of them recovered. We tried various methods. One woman we took from the beginning and bled her, and she died; to another we gave cooling medicines, and she died: to a third we gave warm medicines, such as Confect. Cardiac., cordial julep, Mithridate, &c., and she died. In private practice it was the same, and at least three out of four would die.” (MS. Lectures.)

There is no doubt that, wherever the state of the patient will permit it, the lancet should be tried. Where the pulse is quick and small, with little power, it is scarcely more than an experiment to ascertain how the system will bear the bleeding: in the worst cases of the adynamic form, uncomplicated by the slightest effort at reaction, the state of collapse at once forbids such an attempt: but in many instances the circulation is merely oppressed, the pulse rises in volume as the depletion proceeds; and where from its feel before the operation we had little hopes of taking away more than five or six ounces, we are often enabled to continue it until a considerable quantity is lost. In other cases frightful exhaustion is the immediate effect, and warn us instantly to discontinue it. The capability of bearing bleeding may be always looked upon as a favourable prognostic, not only because the patient’s strength is better than we had perhaps expected, and also because these are precisely the cases where mercury can be used with decided benefit. Whether it be the bleeding, which, in all probability, renders the system more easily brought under the influence of this medicine, we will not stop to consider; at any rate, its effects are not only more easily obtained, but they exert a more decided control over the progress of the disease, the pain abates, the tympanitic abdomen becomes less tense, the pulse slower, fuller, and softer, the tongue moister, and there is a sense of general improvement in the patient’s feelings. But in the adynamic form, when present in its greatest intensity, either there is not sufficient time to impregnate the system, or it is less sensible to its effects; at any rate, even if we succeed in producing salivation, little or no improvement follows.

In those cases where the inflammatory symptoms assume a metastatic character, we must act according to the organ implicated. The attacks are frequently of a very sudden nature, the patient being seized, without the slightest warning, with severe pain and heat of head, throbbing of the temples, intolerance of light and sound, and occasionally violent delirium; the face is flushed, the carotids are seen strongly pulsating. These signs denote a dangerous attack of cerebral congestion, which requires the most prompt and active measures for its suppression. In these cases the aberration of mind frequently continues for some time, even after the symptoms of active inflammation have subsided, and form a species of puerperal mania of a very dangerous character, which we shall describe under its proper head. In other cases, effusion rapidly comes on, followed by fatal coma or convulsions.

In some instances, the inflammatory action seems to fix itself upon the chest: the patient is suddenly seized with great dyspnœa, oppression, and pain, which latter is much increased by every effort at respiration, and sometimes is so violent as to threaten suffocation, unless promptly relieved by the lancet. These attacks sometimes return two or three times, with the same degree of sudden violence, or change with equal rapidity from one part to another.