Part 32 (1/2)

”3. Changes after labour:--the woman presents the faithful picture of one who has undergone a serious surgical operation. The internal surface of the womb may be compared to a vast solution of continuity; the whole of the mucous membrane has been altered by the inflammation, of which it has been the seat; the gaping veins are like the open mouthed vessels of an amputated limb.

”Except just at the inner surface of the cervix uteri, there is no mucous membrane at all; but the muscular tissue of the uterus is every where exposed. This, therefore, like the stump, is to be covered by a new membrane.

”This process of reparation is accompanied by a traumatic fever, called milk fever. Like the fever from wounds, it has its period of incubation, varying in various individuals: it lasts about twenty-four hours, and vanishes on the third day.

”As in amputation, a false membrane covers the stump, and precedes cicatrisation, so the inner surface of the womb is first covered with a false membrane before it is cicatrised. If there be no lochial discharge, there is union by the first intention, as in the stump where there is no discharge: this is the rarest of all cases.

”Ordinarily, this false membrane is thrown off with a purulent discharge, which is the lochia. At first it is sanious, _i. e._ mixed with blood, and fetid; then less fetid and more purulent; then thin and serous. The quality and quant.i.ty of the discharge are, as in amputations, an index of the state of the wound.” (_Cruveilhier_, quoted by Dr. Ferguson, p. 76.)

The comparison between the inner surface of the uterus shortly after parturition and that of a stump, does not hold good in every respect: in the one, the open mouths of the vessels are pretty firmly compressed by the contracted state of the surrounding uterine tissue, whereas, in the other they are uncontracted beyond the mere effects of the traumatic inflammation upon their cut extremities, and they are surrounded by the flaccid surface of divided muscles: still, however, it is quite sufficient to show, that the inner surface of the uterus must be for some days bathed in mucous, sanious, and purulent fluids, highly p.r.o.ne to decomposition; and that, in this state, absorption is peculiarly liable to take place.

The vehement exertions of the uterus and abdominal muscles during labour, and the violent pressure to which the abdominal circulation has been subjected at this time, are sources of inflammation, which, although not noticed by Cruveilhier, are frequently met with quite independent of puerperal fever, although, from what we have already stated, it will be evident that the disposition to absorption and consequent vitiation of the blood will be still farther increased by the excited state of the circulation.

Where blood has been vitiated by the action of aerial poisons, or introduction of putrid matter into its current, changes are quickly produced in its condition, which not only unfit it for the varied functions which it has to perform, especially in maintaining the activity of the brain and nervous system, but which may be perceived, as already shown, before the disease itself appears. It is dark, and of an unhealthy tinge. In severer forms of typhus, ”when first drawn, it has a peculiar smell, and coagulates _almost invariably_ without any crust. There are black spots on the surface of the cra.s.samentum; the coagulum is so soft that it can easily be separated with the fingers, and during its formation, a large quant.i.ty of the black colouring matter falls to the bottom of the cup. When the serum separates, it has generally a _yellow_, and in some cases even a _deep orange_ colour.” (Stevens, _op. cit._ p.

219.)

Dr. Tweedie has observed similar conditions of blood in the common typhus of the metropolis, and remarks, ”that in this cla.s.s of fevers, the cra.s.samentum of the blood, instead of forming a firm coagulum, is loose, small in proportion to the quant.i.ty of serum, and so soft that it breaks readily on attempting to raise it, resembling in consistence half-boiled currant jelly, and that in some instances, when abstracted late in the disease, it is scarcely coagulated at all.” (Tweedie, _Clin. Ill.u.s.t. of Fever_, quoted by Dr. Stephens.)

This accords closely with the appearances of blood drawn from patients under puerperal fever, especially of the adynamic form. The blood is of a dark muddy colour, in some cases resembling even thin treacle in consistence: in this state the coagulation is very imperfect, so that after a time it merely forms a h.o.m.ogeneous semi-gelatinous ma.s.s, with little or no separation of serum from the cra.s.samentum. After death the blood is found perfectly fluid, readily infiltrating and staining the coats of the vessels which contain it, and resembling thin watery claret, both in colour and consistence. In the other forms, which are of a more inflammatory character, it is highly buffed and cupped; the cra.s.samentum is small, the alb.u.minous layer upon it is of a muddy yellow colour; and the serum, which is frequently large in proportion, is of a similar colour, or even of a slight bilious tinge; in some, there has been occasionally observed a white cloudy appearance, as if from the admixture of milk.

The mortality of puerperal fevers depends in great measure upon the form they a.s.sume; and, as we have already stated, this will vary in great measure according to the period of the year, the nature of the season, and the type of the prevailing epidemic fevers in the neighbourhood, whether they a.s.sume the character of synochus, or low malignant typhus. It varies a good deal according to the cla.s.s of patients attacked, being more frequently of the inflammatory character among the middling and higher cla.s.ses, whereas, among the lower orders, who are exposed to the depressing effects of cold, damp, and ill-ventilated dwellings, of insufficient clothing and food, of an atmosphere poisoned with the noxious effluvia arising from a dirty and thickly inhabited suburb, and habitual intemperance, it generally a.s.sumes the adynamic or contagious form. This is the reason that puerperal fever is not only seen less frequently among the middling and upper ranks, but even when it does appear, from being usually of the inflammatory form, it is more tractable. It is in lying-in hospitals, where it appears in all its terrors, and occasionally a.s.sumes such a degree of malignity as almost to equal the plague or yellow fever, in the frightful rapidity of its course, and in the almost certain fatality of its termination. Few have witnessed it in a more destructive form than the late Dr. W. Hunter at the British Lying-in Hospital. He observes in his lectures that he had seen a great many cases of it in the hospital, ”and particularly in one year, when it was so remarkably prevalent there. It was so bad, that not only every gentleman belonging to the hospital, but all our friends in town, had a consultation to think whether we should shut up the house. _In two months thirty-two patients had the fever, and only one of them recovered._” (_MS. Lectures._)

Although puerperal fever has never yet attained the frightful degree of mortality at the General Lying-in Hospital, nevertheless, it has appeared repeatedly with such malignity, as to commit fearful ravages among the patients. In these epidemics, the first few cases are generally comparatively mild, being of the peritonitic or gastro-bilious form (_Douglas_:) but as it advances, the malignant adynamic form, which is so destructive, prevails. In some epidemics, as is seen in common fevers, after a short time the disease has become more tractable, it has a.s.sumed a milder character, and ultimately has again disappeared. This corresponds with the admirable remarks of Dr. Gooch, to whose graphic pen we are indebted for much valuable information on the subject of puerperal fevers.

”Another remarkable circ.u.mstance about this disease is, that, when it is most prevalent, it is most dangerous. Each case is more difficult of cure than when it occurs seldomer. The pract.i.tioner finds, that, although the group of symptoms resembles what he was formerly accustomed to, he has now to deal with a disease far more obstinate and destructive, and his usual remedies are not so successful as formerly; he loses case after case in spite of his best efforts. When it has been thus raging for a considerable time, it at length subsides; the case becomes less frequent and less severe; the pract.i.tioner finds his treatment becoming more successful, partly because experience has taught him to detect it earlier, and to treat it better, but probably also because the disease has itself become milder.” (Gooch _on Peritoneal Fevers_, p. 3.)

The table of the cases at the General Lying-in Hospital and their mortality, which Dr. Ferguson has calculated during the twelve years, from March 1827, to April 1838, is highly important, and points out the period of the year in which puerperal fever, prevails most, and the contrary. The last two and the first seven months of the year are those in which the greatest mortality occurred; whereas, in the month of July, during this whole period, not a single patient died; in August only one; in September two; and again, none in October, although several were attacked.

”Puerperal fever was _epidemic_ in the years 1828, 1829, 1835, 1836. 1838; in the other years it was only sporadic. The greatest mortality was in the years 1835 and 1838, in the last of which 20 in 26 died. The malady commenced in January, in which month Dr. Rigby saved only 1 out of 9. The hospital was closed for a month, and opened again in March, when he succeeded in rescuing only 2 in 8. Thinking that another mode of treatment might be more successful, I determined to bleed largely, and to salivate.

This plan was fairly tried under the constant attendance of Dr. Cape, and with my supervision, but 3 only in 9 lived. Seeing that no treatment was of avail, the hospital was closed from May till November.” (Ferguson, _op.

cit._ p. 277.)

_Different species of puerperal fever._ Having premised these general observations on puerperal fevers, we now proceed to consider them separately, according to the various forms which they exhibit; and in doing so, shall adopt the arrangement of the subject made by Dr. Douglas, viz. under the three heads of inflammatory gastro-bilious, and the contagious or adynamic form. It is not only one of the earliest, but in our opinion, one of the most correct; nor do the arrangements adopted by Drs. Loc.o.c.k and Ferguson differ essentially from it. We hope by this means to combine the advantages which each affords, while we hold ourselves free to differ or coincide with either, as our opinions lead us, trusting that we shall thus be able to render this complex and difficult subject more complete.

Under the inflammatory form we shall not only consider the acute peritonitis, so ably described by Dr. Loc.o.c.k, which is chiefly produced by the effects of labour, to which we have already alluded in the quotation from Cruveilhier, but also that form which, according to Dr. Ferguson, arises from vitiation of the blood, by the introduction of putrid matter into the circulation; a form which has not only a great disposition to a.s.sume a typhoid character, but also to become epidemic. Under this head we must also bring the uterine inflammation and phlebitis, which we have described, as resulting from a direct action of putrid matters contained in the uterus, a form which is very liable to pa.s.s into uterine, and afterwards general peritonitis; lastly, there remains that species of nervous abdominable pain, which has received the name of false peritonitis.

_Puerperal Peritonitis._

_Symptoms._ The acute peritonitis, which has been produced by the effects of labour, generally makes its appearance at an early period after. The labour has probably been either tedious or severe, the efforts of the uterus and abdominal muscles have been violent, especially during the last stage; and from the moment of the child's birth, the patient has complained of considerable soreness over the lower part of the abdomen, amounting to much pain and tenderness when touched. At first she is tolerably easy, so long as she lies still, and keeps the abdominal muscles in complete repose; but, by degrees, fits of pain come on, they become more frequent, and the intervals between them shorter and shorter, until the pain is constant; she now complains of much tension and fulness of the abdomen; the tenderness is greatly increased, both in severity and extent, and is often attended with the painful sense of twisting about the umbilicus, which is observed in ordinary forms of peritonitis. The pain and tension are now so severe that she is constrained to lie wholly upon her back, with the knees drawn up, in order to relax the abdominal muscles, and thus, if possible, alleviate her sufferings. The abdomen itself is evidently fuller to the feel, and is beginning to be tympanitic; the breathing is quick and anxious; the tongue has a thin coating of white fur, which is browner and thicker at the back; the pulse is quick and hard, sometimes small and wiry, occasionally full and strong; the lochia and milk have either never appeared, or only in small quant.i.ties, to be quickly suppressed again. As the tympanitis increases, the breathing becomes more anxious and painful; for every effort of the diaphragm in inspiration is followed by severe pain, from the movement which it produces in the abdominal contents. After awhile, the flatulent distention of the intestines, particularly of the stomach, renders the diaphragm irritable, and provokes hiccough, which is excessively painful from the involuntary jerk which it gives to the abdomen; or, what is still worse, retching and efforts to vomit frequently come on, which greatly aggravate her sufferings. She now lies upon her back, perfectly helpless and immoveable, for the slightest attempt to touch her is insupportable; even the jar of a person walking heavily across the room excites pain. The abdomen is now even larger than it was before labour, her anxiety and restlessness increase, and she rapidly becomes exhausted from suffering and want of sleep. The face becomes sallow, the features fallen, the tongue dry and brown, and sordes collect upon the teeth; she falls into an uneasy slumber, during which, the eyelids remain partly open, or she mutters incoherently with low delirium. The abdomen is less painful, but not diminished in size; the pulse is small, hurried, and feeble; subsultus tendinum and picking of the bed-clothes follow, with all the other symptoms of approaching dissolution.

Where the attack has risen from the introduction of putrid matter into the circulating current, it usually appears somewhat later, seldom before the third day after labour: it is almost invariably preceded by a severe rigour, followed by intense headach, and darting pain about the lower part of the abdomen, which gradually becomes constant. There is a nearer approach to the adynamic form, or rather, it is frequently attended, or at least followed, by this disease; hence the inflammatory stage is shorter, the pulse is even more rapid, and loses its strength sooner than in the other form; the milk and lochia have usually not only been established, but continue, we think, longer afterwards than in the other case; the pain is perhaps less in many instances, but in other respects, the first part of the attack does not differ essentially from the form above described; but as the disease advances, it gradually a.s.sumes the adynamic form; the inflammatory symptoms of the early part of the attack are merged in the general collapse which now exists, the same cause which had produced the peritoneal inflammation now acting on the whole system.

Peritonitis occurring by itself, is, as Dr. Ferguson observes, of comparatively rare occurrence in puerperal women, the condition of the system during childbed, disposing it quickly to a.s.sume more or less of the adynamic character.

_Appearances after death._ On examining cases of fatal puerperal peritonitis, we shall find marks of inflammation, or its consequences, over a large extent of the peritoneum; large portions of it are highly congested, and more or less thickened; considerable effusions of serum or sero-purulent fluid, mixed with flakes of coagulable lymph, into the abdominal cavity: the omentum adhering to the intestines, and also the intestines to each other, by means of coagulable lymph, in which they are occasionally completely imbedded; the broad ligaments and ovaries are frequently much inflamed, covered with lymph, and the latter more or less softened; the Fallopian tubes engorged and adhering to the neighbouring parts; the uterus is covered at its fundus with a coating of coagulable lymph, as if it had been smeared with a quant.i.ty of dirty white paint, and this extends more or less in patches over the various reflexions of the peritoneum, in the upper parts of the abdominal cavity.

_Treatment._ We may take it as a rule, that the earlier we see the patient in the disease, the less active will be the treatment required. At first, when the pain has not yet a.s.sumed its full intensity, and only occurs in paroxysms, when little or no traces of abdominal tension and fulness are to be perceived from incipient tympanitis, we may frequently succeed in cutting short the disease by a full dose of calomel and James's powder, with some morphia or Dover's powder, to allay irritation and a.s.sist in producing a general determination to the skin; this must be followed by some castor oil, and if the pain is no longer constant, with the addition of a few drops of Liquor Opii Sedativus. Where the pain has already become severe, a draught of sulphate and carbonate of magnesia in peppermint water, with a little antimonial wine and henbane, will be preferable. We have long since been convinced, that common black draught, or any form of purge which acts violently or gripes, is objectionable, having frequently seen a return of pain brought on by its action. A hot poultice of linseed-meal, large enough to cover the whole abdomen, and as hot as the patient can bear it, must be applied; this, if made properly, will prove a great relief, for it not only allays the pain, but quickly acts as a powerful diaph.o.r.etic: there is a little art in making this, and unless it be done properly, it is apt to produce much discomfort, and do more harm than good. The water should be poured boiling hot on the linseed-meal, and the mixture well beaten with a large spoon, until it forms a nearly gelatinous ma.s.s; it should then be spread upon a large piece of linen, so as to be between a quarter and half an inch in thickness; there is now only one layer of cloth between the poultice and the patient's abdomen, and it can be applied or removed with perfect facility: without these precautions it is apt to form a pudding-like ma.s.s, which greatly annoys the patient from its weight, and from being applied directly to the abdomen, smears about, and is not easily changed. A poultice made in the manner now described, will keep hot for three hours at least, and is by far the most effective form of fomentation which can be employed. Common fomentations of sponges, or flannels wrung out of hot water, are by no means desirable, as from the constant exposure, which is required for their frequent repet.i.tion, the patient has little benefit from the temporary heat, and is very liable to catch cold.

If the symptoms do not yield to this treatment, but a.s.sume a more formidable aspect, or if the attack has not commenced in this gradual manner, but has come on much more suddenly and with greater violence, recourse must be had immediately to the lancet. Leeches are seldom proper as a subst.i.tute for bleeding, although they frequently prove of great value afterwards. A certain effect is required to be produced upon the general circulation, before leeches are capable of affording even a temporary relief; and so far from economizing the patient's powers by using leeches instead of the lancet, we shall find that in order to overcome the inflammation by this means, the patient will require to lose a far greater quant.i.ty of blood than if it had been suddenly removed from the circulation by bleeding. Upon the same principle, therefore, we must take care, that the blood shall be drawn _pleno rivo_ from an ample orifice: we thus spare the patient an unnecessary loss of power, for the required effect upon the circulation is produced in a much shorter time and with less expenditure of blood, than if the blood had been slowly dribbled from a small opening.

”In the treatment of acute inflammation in the vital organs, the customary practice is to consider local bleeding as a milder means of effecting the same object as general bleeding, and to postpone it till the stage for the latter is over. To me it appears that they are calculated to effect two different objects, both of which are necessary at the beginning of the treatment; the one to reduce the violence of the general circulation, the other to empty the distended capillaries of the part. As long as the pulse is quick, full, and hard, it is in vain to take blood from the affected part; if we could completely empty its gorged capillary vessels, they would be instantly gorged again, whilst the heart and large arteries are injecting them with so much violence. On the other hand, after having reduced the force of the general circulation, the capillary vessels of the part often remain preternaturally injected: this, I conclude, from the fact that the patient is often not relieved till local blood-letting has been used, and then is relieved immediately. Hence, as soon as the patient has recovered from the faintness occasioned by bleeding from the arm, leeches ought to be applied without delay.” (Gooch, _on Peritoneal Fevers_, p. 47.)