Part 32 (2/2)

It is impossible to fix what quant.i.ty of blood is to be drawn; nor is it easy, either from the patient's appearance or the feel of her pulse, to foretell how much she will require to lose: a certain effect is to be produced on the circulation in order to bring it under such control as will moderate the state of inflammation. No two patients are alike in this respect; and it frequently happens, that where, from external appearances, we might have expected to find most strength, faintness is quickly produced, and _vice versa_: on the whole, we think that where the patient has a small, quick, and oppressed pulse, we may expect she will require to lose a large quant.i.ty of blood, for in these cases the pulse rises in volume and strength as the bleeding proceeds; hence, as before observed, we must ”carry the bleeding to its proper limits, which is the approach to, or actual state of, syncope.” So far from removing the pillows, and letting her lie with the head low, so as to recover from her faintness as quickly as possible, it will be much better to support her in a sitting posture, and thus prolong the state of faintness for some while; the dilated vessels have now time to contract, the heart returns to a more moderate and healthy action, the effects of the bleeding are much more permanent, and the chances of its repet.i.tion being required considerably diminished. From this state of relaxation and temporary collapse being prolonged, we find that the secretion of the skin, and particularly the intestinal ca.n.a.l, are more easily re-established, the operation of a purgative being now much quicker and more effective.

As soon after the bleeding as possible, a smart dose of calomel and James's powder, followed by an active saline laxative, must be given; and the combination of sulphate and carbonate of magnesia with antimonial wine and Tinct. Hyosc. already recommended, is preferred by us: it is better given in divided doses, as then the effects of the antimonial is prolonged. The action of the bowels may also be a.s.sisted by a domestic enema: and if there are no signs of action in the bowels after two hours, the purgative should be repeated. The results of the leeches, fomentation, and purging, will guide us as to the necessity of repeating the bleeding.

Dr. Gooch's truly practical remarks on these points are well worthy of attention:--”I waited till the purgatives had operated fully, that I might know what impression the combined operation of general and local blood-letting had produced on the disease, before deliberating on the employment of a second blood-letting. The common effect, of these remedies was this, as long as the faintness lasted in the slightest degree, the pulse remained soft and often slower, and the pain was much less, or ceased altogether; but an hour or two after the bleeding, when the circulation had recovered, the pain returned more or less, and the pulse regained much of its hardness or incompressibility. This state continued till the leeches had bled freely, and the purgatives had acted repeatedly and copiously.” (_Op. cit._ p. 48.)

If, however, the pain has experienced but little abatement, or has returned as severely as before; if the pulse has quickly rea.s.sumed its former condition; if the action of the purgatives has not taken place, or has been at most unsatisfactory, even with a repet.i.tion of the saline, we are justified in having recourse to a second bleeding; the faintness this time will probably be more complete; the effect upon the disease more decided; and, in all probability, it will be quickly followed by free evacuations from the bowels, which produce great relief. In some cases the bleeding requires to be repeated again and again before the disease can be subdued: this, however, usually arises not so much from the obstinacy of the attack, as from the first bleedings not having been performed in an effective manner. ”The pulse,” says Dr. Loc.o.c.k, ”is the best guide, for the pain after the first full relief from the bleeding is often of a mixed character, partly inflammatory, partly nervous, to be detected only by watching closely the other symptoms. The tenderness is a less certain guide, for few will bear pressure for a considerable time after the inflammatory symptoms have been entirely relieved. Many patients also from fear shrink from the pressure of the hand, although by drawing off the attention, it will be found that they bear firm and steady pressure very well.” (_Op. cit._ p. 355.)

Throughout the whole process of treatment, the linseed-meal poultices must be continued, and, if not made too heavy, can be borne when there is a considerable degree of abdominal tenderness.

In all cases where the disease has not been completely checked in the very outset, but has shown a disposition to return, the treatment above-mentioned should now be followed by a mild mercurial course. The effects of mercury in allaying inflammation at a certain stage, which does not appear to be fully under the control of mere antiphlogistic remedies, have been amply proved by British pract.i.tioners: this applies particularly to inflammation of serous membranes: mercury not only tends to prevent the effusions of serum and coagulable lymph, but, where they have taken place, it is of great value in promoting their absorption. We agree with Dr.

Loc.o.c.k, that calomel is by far the best form in which it can be used, where we wish to obtain its specific effects. The Hydrargyrum c.u.m Creta, which we have occasionally found useful in the gastro-bilious or enteric form to restore a depraved state of intestinal secretions, has failed us in the other forms where we wished to produce salivation. The purgative dose of calomel, which we have advised to be given after the bleeding, ought not to be less than six to eight grains; but now, as the dose is to be repeated every two or three hours, a smaller quant.i.ty will be sufficient: in order to save time we usually begin with five grains of calomel, and an equal quant.i.ty of Dover's powder, and repeat this in an hour's time, after which, we proceed with doses of two or three grains every second or third hour according to circ.u.mstances. The sooner the system can be brought under the influence of mercury the better, the pulse becomes softer and less frequent, the pain and tension of the abdomen diminish, the tongue becomes moist and natural at the edges, and general improvement follows. Throughout the whole attack the v.a.g.i.n.a should be occasionally washed out with warm water, more especially if we have reason to suspect that the disease has arisen from the imbibition or absorption of putrid matter. The smell of the patient will frequently guide us in this respect, and point out the condition of the pa.s.sages and their contents; even if there be no putrid matter lodging there, the application of warm water will always act as a comfortable fomentation to the patient, and a.s.sists not a little in favouring a return of the lochia.

If the pain and swelling of the abdomen still continue, and the case is evidently becoming more unfavourable, we have occasionally sprinkled the abdomen with spirit of wine or oil of turpentine, and then covered it with a fresh poultice: this has acted as a powerful rubefacient, and has in some cases relieved the patient at a very advanced stage. We have also tried blistering the abdomen, and dressing the vesicated surface with strong mercurial ointment, as recommended by Dr. Loc.o.c.k; but we have not met with the success which he mentions, probably from the disease having already a.s.sumed the malignant characters of the adynamic form, and, in some instances, because the patient could not endure the intense smarting which it produced. We have occasionally covered the abdomen with camphorated mercurial ointment without previous blistering, and with good effect. The internal use of turpentine, circular friction upon the abdomen, and enemata of Mist. a.s.safoetidae, &c., which we have sometimes found useful in removing the tympanites of the adynamic puerperal fever, and which does not depend on an acute form of inflammation, are scarcely applicable in the present case.

When the powers are beginning to fail, as a last hope we must have recourse to stimulants combined with nourishment: the Mist. Spiritus Vini Gallici of the last London pharmacopoeia,--anglice, ”egg and brandy,”--has for many years been used at the Lying-in Hospital to support the system at this last stage, and sometimes even under the most unfavourable circ.u.mstances with marked success; powerful doses of ammonia will be required at frequent intervals, and an occasional opiate, to procure the still farther refreshment of sleep. Even where the face is a.s.suming a Hippocratic appearance, the pulse so feeble and rapid as scarcely to be counted, where the abdomen is immensely distended, with cessation of pain and cold clammy state of the skin, we ought not to despair; no case, however bad, is entirely hopeless; and although the majority of such cases perish in spite of the greatest care and activity, still we are justified in persevering till the last, knowing from experience that we every now and then succeed even at this late hour in rescuing our patient.[145]

_Uterine Phlebitis._

In describing the other species of inflammatory puerperal affection, which we have designated by the t.i.tle of uterine inflammation or phlebitis, and which we conceive arises in most instances, from the presence and absorption of putrid matter in the uterus, we shall merely confine our description to the early part of the disease, because, as it invariably terminates in peritotinis if not stopped at an early period, it will be unnecessary to go over this part of our subject again.

_Symptoms._ This affection generally makes its appearance on the second, third, or fourth day after labour, and varies considerably in its mode of attack. In some cases it will be observed to come on suddenly, with scarcely any premonitory symptoms. The patient is suddenly seized with severe griping pain in the lower part of her abdomen, generally extending more or less to one side, and usually preceded by a smart s.h.i.+vering fit, which is followed by intense headach. On examining the abdomen, the uterus is hard, larger than natural, and excessively painful to the touch; the pulse quick and usually small; the tongue covered with a thin white fur, becoming brown and thicker towards the back part; the countenance anxious.

With all this, the abdomen is neither hard nor painful upon moderate pressure; not even over the uterus itself do we produce pain, until we begin to press so hard, that the organ becomes plainly distinguishable to the hand through the soft integuments. The lochia has either not appeared at all, or has been suddenly suppressed; and in all probability, the secretion of milk has followed a similar course.

Or the disease may commence in a much more gradual manner. The after-pains are observed to increase in severity and duration, producing a considerable degree of pain over the whole abdomen, but especially the uterus, which, during the paroxysms, is harder than in the intervals. The pains are increased by the slightest pressure, if _suddenly_ applied; but, if gradually increased, the patient will bear a considerable degree of pressure, not only without complaining, but will even remark that the pain is, as it were, benumbed by it; if the hand be now suddenly removed, very severe suffering is produced. The pains become more and more constant, until they a.s.sume the uniform character of inflammation of the uterus, as already described, when the disease makes its attack suddenly. If the disease be not checked in its progress, the pain becomes more intense, and gradually extends over the whole surface of the peritoneum; the abdomen swells from tympanitis, and is followed by the other symptoms of acute peritonitis already described. The latter stages of the attack are almost invariably mingled with symptoms of the malignant form of puerperal fever,--a circ.u.mstance which, when we consider the probable source of the disease is not to be wondered at. Indeed, we may say, that by the time the peritonitis is fairly established, the introduction of putrid virus into the circulation has been of sufficient duration and extent to render the production of adynamic symptoms almost unavoidable.

_Appearances after death._ Examination after death shows that the uterus and its appendages have been the chief seat of the inflammation, its whole peritoneal surface thickly covered with exudations of coagulable lymph; the broad ligaments vascular; the Fallopian tubes livid, swollen, and softened; the ovaries greatly altered in appearance and structure, being generally more or less swollen and much softened,--at times the natural tissue of the gland completely broken down into a pulpy semi-purulent ma.s.s, at others the external surface only has been red or gorged with dark-coloured vessels; the whole uterine appendages thickly imbedded in cogulable lymph. The uterus is large and soft, deposites of pus have been found beneath its peritoneal covering, or in the proper muscular tissue of the organ; and in many cases, on cutting into its substance, pus has appeared in numerous little points, oozing from the veins or absorbents which have been divided. In those veins which are large enough to be traced by dissection, their coats have been found vascular, thickened, and in many places lined with lymph, so that the vessel has become completely impervious: in others, they have been filled for a s.p.a.ce with pus, and their ca.n.a.l then obliterated, either by swelling, effusion of lymph, or by plugs of fibrine from coagulated blood. These changes in ordinary cases do not extend beyond the substance of the uterus; but where the disease has been of some duration, as well as severity, they become much more extensive, affecting the neighbouring veins to some distance.

”Inflammation,” says Dr. R. Lee, who has examined this subject with great care, ”having once begun, it is liable, as I have before stated, to spread continuously to the veins of the whole uterine system, to those of the ovaria, of the Fallopian tubes, and broad ligaments. The vena cava itself does not always escape, the inflammation spreading to it from the iliac, or from the spermatic veins.” (_Researches on the Pathology and Treatment of some of the more important Diseases of Women_, p. 54.)

The surrounding structures are generally implicated in the inflammation; the muscular tissue of the uterus becomes soft and of a dark red, or even dirty black colour, and, as before stated, the peritoneum which covers the organ is particularly affected. The appearances after death in this species of puerperal fever are those most commonly observed, for puerperal peritonitis is rarely met with in its uncomplicated form, being usually more or less mixed up with it; on the other hand, the majority of cases which belong to the adynamic form of puerperal fever (except the most malignant) are generally preceded to a certain extent and attended by this disease.

_Treatment._ In the early stage of the disease, before inflammation (especially peritonitis) has been established, we do not consider that the lancet is required, merely because there is pain with a quick pulse. The uterus may be hard, swollen, and painful, and yet there is not actual inflammation present: we will not deny that inflammation will quickly follow, if nothing be done to remove this state of uterine irritation. The pulse is quick, but seldom hard; and even if it be at all sharp, it produces but little resistance to the pressure of the finger. In these cases we may bleed, but we seldom reduce the quickness of the pulse, although it sinks still farther in point of strength. There is seldom much buffy coat upon the blood when drawn at this stage; and if the pain be relieved for a short time, it returns again as soon as the system has recovered from the immediate effects of the syncope. We do not see that striking relief follows a copious venesection in cases of this sort, which is remarkable in inflammation of the abdominal viscera under other circ.u.mstances; and we are more than ever convinced, not only from the fact just mentioned, and from the results of our own experience, but from the unfavourable results of the practice in which bleeding has been uniformly and largely employed, that it is _not_ a remedy which is _always_ to be premised before the employment of other treatment, as in cases of simple inflammation of the viscera or serous membranes. The only circ.u.mstances we apprehend, under which venesection ought to be employed in this affection are, where the pain is constant, without intermission, and where, besides its rapidity, the pulse betrays a degree of wiry resistance to the finger, which can never be mistaken. In this case the blood drawn will show all the usual marks of inflammation, and the relief procured will be proportionally great. On the other hand, where the pain, although severe, is not constant, but the patient experiences every now and then a slight abatement in its severity, or a short intermission altogether; where the pulse, although rapid, is soft, and resists the finger but feebly, we shall seldom produce any permanent relief by bleeding; the pulse becomes weaker, but its rapidity, so far from being diminished, is rather increased. The pain may be relieved for a short time, but it almost always returns as severely as before the venesection.

Under these circ.u.mstances, the pure antiphlogistic treatment seems to have little or no control, either in removing the pain, or diminis.h.i.+ng the pulse, or in preventing the disease from running into that state of tympanitic peritonitis, which is so fatal in its effects; and we are not only losing time by employing an inefficacious mode of treatment, but are exhausting the powers of the system, already more or less depressed.

”Large haemorrhages,” as Dr. Ferguson correctly observes, ”favour absorption,” (_op. cit._ p. 108;) and it would seem that by thus reducing the powers of the system, we diminish its capability of ridding itself by the natural outlets of the virus which has been carried into the circulation; nor do we see how this is to be a.s.sisted by bleeding. If a state of actual haemorrhage has been induced, bleeding, of course, must be used with the greatest promptness; but in employing this remedy in the above-mentioned form of puerperal fever, although we relieve the inflammation for a time, the cause is not removed. It still continues to act, and the symptoms return under much more formidable circ.u.mstances, from the increased debility of the system confining our means of treatment within still narrower limits.

According, therefore, to the views which we have taken of this form of puerperal fever, the indications for treating it will be the following: _first_, to subdue any inflammatory symptoms, if they be present; but it must be remembered, that we have no positive proof of the existence of inflammation, merely from the presence of pain and a rapid pulse, although these two symptoms denote a state of irritation, advancing with rapid strides into actual inflammation. The character of each must be carefully ascertained before we are justified in deciding upon the necessity of bleeding. As this operation is generally performed in the erect posture, to favour a state of syncope, we are following a _second_ indication at the same moment, and perhaps one of the most important, viz. placing the patient in such a posture as will promote the escape of any coagula and discharges which may have been stagnating in the uterus or v.a.g.i.n.a. To effect this still more completely, a stream of warm water should be thrown up briskly into the uterus, to dislodge any offensive irritating matter which may have collected: the relief thus produced is sometimes quite extraordinary, the pain abates, the uterus becomes less hard, the pulse more natural, and the patient expresses herself greatly relieved. The rule which we have made in our treatment of natural labour, viz. that if possible, the patient should sit up to take her food, and suckle her child, and especially that she should always kneel to pa.s.s water, should never be neglected, for in many of these cases it will be found that the patient has not stirred from the horizontal posture, and that the attack had evidently followed the acc.u.mulation of stagnant lochia, &c., which from the warmth of the adjacent parts, and free contact with the external air, has rapidly become offensive; and, moreover, from her position, has been prevented from being discharged. To ensure that the uterus has expelled any coagula which may have lodged in it, is a powerful argument in favour of applying the child to the breast as soon as possible after labour; this refers particularly to those long slender coagula, which were first noticed in the uterine veins by Dr. Burton, in 1751, as one of the chief causes of after-pains; for by thus inducing firm uterine contraction, the greater part of these will be generally expelled, and access of air to the venous orifices prevented. ”These coagula may be distinctly perceived for several weeks after delivery, and both in their form and colour they differ from those produced by inflammation.” (R. Lee, _op. cit._ p. 53.)

Our _third_ indication is to increase the action of all the excretory functions, and thus, as far as possible, remove the virus, which may have already entered the system. There is no remedy with which we are acquainted that has such a power of producing a general erethism throughout the whole excretory system, as calomel in large doses. The secretions of the liver, the mucous membrane of the intestinal ca.n.a.l, of the skin, and kidneys, are all very remarkably increased by the action of a large dose of this medicine, and we cannot help attributing the return of healthy lochia, which so frequently follows such a dose of colomel, to a similar action on the vessels of the uterus and v.a.g.i.n.a. No effort of nature can be so well directed for the removal of any noxious principle from the circulating fluids as a general increased action of the excretory system, and we have seldom or never seen calomel act with such success in this form of puerperal fever, except where it had been given in a sufficient dose to produce this effect. Salivation is by no means a necessary object, nor have we seen it produced even by a scruple dose of calomel. It is, however, seldom necessary to exceed ten grains at a time, although this may occasionally be required to be repeated. It should always be combined with some medicine which will a.s.sist its diaph.o.r.etic action. For this purpose, in cases where the pain is constant, without any remission, showing that a state of inflammation has been already induced, it will be advisable to combine it with a little of James's or antimonial powder. Where, on the other hand, the patient experiences evident abatement or even remissions of pain, ten grains of calomel with an equal quant.i.ty of Dover's powder, made up into pills, will be preferable; the opium acts by relieving the pain, and contributing to induce a copious perspiration. To a.s.sist this, and also to relieve pain still more, a hot linseed-meal poultice, as above described, will be of great service; and in a few hours (or the next morning, if the calomel has been given over night,) a saline of sulphate and carbonate of magnesia should be given.

The v.a.g.i.n.a should be well syringed with warm water, and repeated from time to time as occasion requires; in like manner, the poultice must be continued until the pain has entirely ceased.

The general result of this treatment is, that in twelve or eighteen hours the uterus loses its tenderness and hardness, the pulse becomes fuller and softer, the tongue cleaner and more moist, the kidneys and bowels have acted copiously, and the lochia and milk have returned.

_False Peritonitis._

Under this t.i.tle, which we believe first originated at the General Lying-in Hospital, and which has been adopted by Dr. Loc.o.c.k in his article upon the subject, we propose to describe that peculiar species of abdominable pain, which Dr. Ferguson has called the _transient_ form of peritonitis. Strictly speaking, neither of these terms are exactly appropriate, for the disease appears to depend upon a state of high nervous irritability, perfectly independent of inflammation, or any other affection of the peritoneum; still, however, as it has been most frequently known and described under the former of these appellations, we shall also continue to use it, merely warning our reader, that the appellation of false peritonitis is more conventional than correct.

Properly speaking, it should be called _nervous abdominal pain_; for we have reason to think that its real seat is in the muscular coat of the intestines, and in the abdominal muscles themselves, much more than in any portion of the peritoneum.

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