Part 33 (1/2)

The disease chiefly attacks women of a delicate frame, and irritable habit of body, with small features, fair complexion, and of a nervous hysterical disposition, whose powers have but ill sustained them through the processes of pregnancy and parturition, and are now beginning to fail under that of lactation. Her mind is anxious and depressed, the sleep is restless, the circulation irritable and feeble; she is pale, forebodes all sorts of evils, and is unusually sensitive; complains inordinately of her sufferings in trying to suckle the child, and of the severity of her after-pains; not unfrequently she has severe headach, of that species which affects the top of the head, and which is generally considered to arise from a state of debility and anaemia. In many cases the pain has evidently been produced by the action of a griping purge. The pain is of the most intense character; indeed, in many cases, it is evidently too severe for the ordinary suffering from abdominal inflammation. So irritable are the abdominal muscles, that the slightest motion, even that of respiration, will throw them into cramp-like contractions to the great agony of the patient. The breathing is short and timid, like that of a person under a severe attack of pleurodyne: the slightest touch of the hand, or of a single finger, produces intolerable suffering, not so much from the pain which its pressure produces, but from the sudden and involuntary contraction to which the irritable muscles are thus excited.

The quickened breathing, from a dread of the abdomen being touched, is frequently sufficient to bring on a paroxysm. If by soothing words and promises of cautious proceeding we induce her to let us apply our hand upon the abdomen so gently that it does not even rest with its weight upon it, we shall find that we may now gradually increase the pressure, until by degrees it becomes considerable, not only without her feeling any increase of pain, but with complete relief--the pressure of the hand appearing as it were, to benumb the pain. If we withdraw the hand in the same gradual manner, no pain will be produced; but if we remove it suddenly, a spasm of the muscles, with intense pain, is instantly excited.

The pulse is in an equally irritable state; after a few beats it rises in rapidity as soon as the patient's mind is directed to it; in others it is permanently quick. The tongue is sometimes slightly covered with a thin fur; in others it is pale and flabby; and in others disposed to be glazed, red, and dry.

The disease rarely exists long uncomplicated with any other form of puerperal affection, but soon pa.s.ses either into acute peritonitis, or into the typhoid state of the malignant form, the latter transition being almost certain, if the pract.i.tioner has considered it as an inflammatory affection, and treated it antiphlogistically.

It is to the late Dr. Gooch that we are indebted for having first called the attention of the profession to this disease, and pointed out its true characters by the nature of the remedies which proved successful in relieving it. ”The effects of remedies on a disease, if accurately observed, form the most important part of its history; they are like chemical tests, frequently detecting important differences in objects which were previously exactly similar. How many diseases are there in which the symptoms are inadequate guides?” ”The local pains and const.i.tutional disturbance which occur in feeble and bloodless persons, and which are aggravated by bleeding and other evacuants, strikingly resemble the local pains and const.i.tutional disturbance which occur in vigorous and plethoric persons, and which the lancet and other evacuants relieve and ultimately cure; yet how many years is it before the young pract.i.tioner learns that there are cases apparently so similar, yet really so different, and how to distinguish them; and how many pract.i.tioners are there who never learn it at all? Symptoms and dissections can never do more than suggest probabilities about the nature of the disease, and the effects of a remedy on it. A trial of the remedies themselves is the only conclusive proof.” (_Op. cit._ p. 37.)

In those cases which proved fatal, the post mortem appearances only tended to confirm the nature of the disease. So far from marks of inflammation being found, there was not a single trace to be discovered; in fact, an entirely opposite condition existed; the peritoneum and viscera were pale and bloodless.

_Treatment._ It is of the highest importance to distinguish these affections from a state of inflammation; the treatment of the one will be precisely the reverse of the other. The lancet is as little indicated in this case, as it is in puerperal convulsions from anaemia, and the effects produced will be scarcely less mischievous. The fatal cases which Dr.

Gooch has recorded, show that it was not the disease so much as the treatment which destroyed the patients, and prove, as we have already stated, that the presence of pain and a quick pulse do not surely indicate a state of inflammation, without being confirmed by the general symptoms of the patient's condition. ”These cases taught me a new view of the subject: they taught me that a lying-in woman might have permanent pain and tenderness of the abdomen, with a rapid pulse, independent of acute inflammation of the peritoneum or any other part; that these symptoms may depend on a state which blood-letting does not relieve, and which, if this remedy is carried as far as it requires to be carried in peritonitis, may terminate fatally; and that the most effectual remedies are opiates and fomentations. Most of the patients who were the subjects of these attacks, were women, who, in their ordinary health, were delicate and sensitive; the attack sometimes seems to originate in violent after-pains, gradually pa.s.sing into permanent pain and tenderness, resembling inflammation, or in the painful operation of an active purgative; but it could sometimes be traced to no satisfactory cause--the patient had had a common labour, and had experienced no unusual cause of debility or irritation. The pulse in all these cases, although quick, was soft and feeble: this, together with the previous const.i.tution of the patient, were my chief guides. When I could trace it to any irritating cause, such as a griping purge, and when blood had been already drawn without relief, and without being buffed, I saw my way still clearer. When I doubted, I applied leeches to the abdomen.” (_Op. cit._ p. 72.)

In ordinary cases a dose of Liquor Opii Sedativus, or of Dover's powder, repeated according to circ.u.mstances, will be sufficient to stop the attack, taking care to clear the bowels of any irritating matter with castor oil in some aromatic water, guarded by a few drops of Battley's solution. In many of these cases, where the circulation is below the natural standard in point of power, and the disease is more or less complicated with hysteria, the opiates should be combined with a gentle stimulant, of which camphor is by far the best. Five grains of powdered camphor with half a grain of hydrochlorate of morphia and a sufficient quant.i.ty of extract of henbane, to form two pills, may be repeated at intervals, whenever the pain shows a disposition to return, and constipation prevented by castor oil and Liq. Opii Sedativus as before-mentioned, or a gentle draught of sulphate of pota.s.s, rhubarb, and manna. In most cases, when the stomach and bowels are in a proper condition, mild tonics will prove useful, as equal parts of extract of gentian, henbane, with or without a grain or two of quinine or sulphate of iron, at night; and, if necessary, the infusion of some vegetable tonic during the day. The diet should be simple but nutritious, and a certain quant.i.ty of malt liquor or wine allowed daily, if the condition of the patient permit it. In some instances the low diet which is usually deemed requisite for the first few days after labour, has appeared to have been the cause of this highly irritable condition, especially in those who have habitually accustomed themselves to pamper the appet.i.te, and to use fermented or spirituous liquors in excess: with spirit drinkers, the loss of their daily stimulus is almost sure to be followed by a low, feeble, irritable state of the system, much gastric and nervous derangement, and the paroxysms of pain just described. It is astonis.h.i.+ng how quickly every symptom subsides, and the system returns to a natural condition, by the daily allowance of a small quant.i.ty of their favourite beverage.

_Gastro-bilious Puerperal Fever._

This is the gastro-enteric species of Dr. Ferguson, and corresponds with the ”puerperal intestinal irritation” described by Dr. Loc.o.c.k. In its simple uncomplicated form, this disease cannot be considered as a dangerous affection; it occasionally pa.s.ses into inflammation, but more frequently it a.s.sumes after awhile the typhoid or malignant form, especially where its true characters have not been recognised, and the powers of the system have become much exhausted by its severity and long continuance.

Like the false peritonitis it is frequently met with in cases where, from unwholesome or intemperate living, the digestive organs are greatly deranged, or where the bowels have been much neglected for some weeks before labour. We cannot help thinking that the view which Dr. Ferguson has taken of its cause, viz., a vitiated state of the fluids, as with the case of puerperal peritonitis, is far too exclusive, inasmuch as it is evidently produced in many instances by the direct irritation of matters which are contained in the intestinal ca.n.a.l: in others, we fully agree with him, that it is produced indirectly by the introduction of an animal poison into the circulation, which spends its virulence upon the stomach, liver, or intestines, or which, in other words, nature endeavours to remove from the system by these outlets. In the early stage of uterine irritation, or of phlebitis, from the absorption of putrid fluids, we have shown that the cause at first, in most instances, acts directly, and not through the medium of the circulation, otherwise the symptoms would not be so instantly checked by was.h.i.+ng out the uterus with warm water, and thus removing the source of mischief; so in the gastro-bilious or enteric form, the symptoms _at first_ are produced in most, if not all cases, by the direct irritation of the unhealthy intestinal contents, upon the removal of which they at once disappear; although at the same time, if the source of irritation be not removed, we have no doubt but absorption will take place sooner or later and vitiate the circulation. Thus, Dr. Kirkland considers that retained faeces during a lying-in are capable of bringing on symptoms which ”may, properly enough, be called puerperal fever” (_op.

cit._ p. 87;) and Dr. John Clarke, in enumerating the different causes entertained by ”writers of good reputation,” mentions, where faeces are detained in the intestines, ”the thin putrid parts of which are supposed to be taken up into the blood.” (_Practical Essay on the Management of Pregnancy and Labour_, by J. Clarke, M. D., 1806, p. 53.)

There is, however, no reason to confine the source of the putrilage, which infests the circulating current, in cases of gastro-bilious or intestinal irritation, to unhealthy faecal matter in the intestines; for in the experiment made by Professor Tiedemann, to which we have already alluded, viz. of injecting musk into the femoral vein of an animal, the poison seemed to concentrate itself upon the mucous membrane of the intestinal ca.n.a.l; and from the diarrhoea which had commenced shortly before death, it is probable, if the dose had been smaller, that nature would have succeeded in ridding the system of it by this means; we may, therefore, conclude, in most of the cases of this affection, which are not the result of direct enteric irritation, but an effort of nature to purify the circulation by expelling the morbid matter, with which it had been vitiated, through the medium of the mucous membrane of the bowels, that the uterus had been the source of its origin, introduction, or absorption, into the system.

_Symptoms._ This form of puerperal fever seldom commences so soon after labour as any of the other species, and frequently the symptoms are so trifling, at first, as scarcely to excite attention. There is an indistinct uneasiness about the abdomen; the tongue is never quite natural, being either slightly furred with a few prominent papillae, or pale and flabby; the appet.i.te is irregular, or fails considerably; the patient complains of weariness and la.s.situde; there is, perhaps, slight headach across the eyes and forehead; the face has a sallow tinge, and if her complexion be dark, there is a leaden-coloured ring beneath her eyes; the sleep is unrefres.h.i.+ng; the spirits are unequal and anxious; she is chilly at times, and at others, has considerable flus.h.i.+ngs of heat, with increase of headach. The abdomen becomes full and doughy to the feel; it is somewhat tender to the touch, but not distinctly so, as in peritonitis; the motions are dark, sparing, and excessively offensive; sometimes hard and scybalous; but more usually they a.s.sume the character of an irritable diarrhoea, with much acrid slimy mucus, the evacuation of which, is attended with much flatus, and for a time produces great relief, although, at the moment of pa.s.sing, it is frequently attended with a good deal of forcing. The abdomen becomes more tender, with severe griping flatulent pains at intervals; the diarrhoea a.s.sumes somewhat of the characters of dysentery; the pulse becomes quick and irritable; the tongue red and glossy at the tip and edges, with a patch of thin white fur in the middle, or with a red centre between two parallel streaks of creamy fur--the back part yellow, verging into brown; the breath is of a faint disagreeable odour; the attacks of fever, from time to time, are more distinct; and frequently, during the sweating stage, the skin throws out a strong peculiar odour, which taints the air of the whole room. In some cases there is frequent vomiting, either of watery fluid mixed with ropy mucus, or of a greenish colour; the result probably of subacute inflammation of the stomach. As the irritation of the intestinal ca.n.a.l increases, she becomes more exhausted, and rapidly emaciates. The tongue now becomes preternaturally red, its surface glossy smooth, the centre is parched and brown, and sometimes traversed with fissures; the fever a.s.sumes a low typhoid character, with delirium at night, and gradual sinking. The appearance of the evacuations varies considerably; at times they appear to consist of minute membranous shreds, floating in dark brown water; in others, they are clay-coloured, slimy, adhesive, excessively offensive, and even pungent; whereas, in others, they seem to consist chiefly of dark unhealthy bile, mixed with water and mucus.

This form of disease is frequently met with in patients who have been weakened by haemorrhage, and necessarily tends to aggravate the state of anaemia which is present. She has the intense pain at the summit of the head, which characterizes this condition; she gets but little sleep, and that is disturbed by restless and uneasy dreams; she lies with the eyelids half closed, and the occasional twitchings of the muscles betray the irritable condition of the system; exhaustion quickly supervenes, and is usually attended either with low delirium, or the anaemic form of puerperal mania.

_Appearances after death._ If the dysenteric affection has been very severe, we shall probably find softened or even ulcerated spots in the mucous membrane of the large intestine; but in other cases, there have been no lesions of the kind; the intestines have been found a good deal distended with gas, but pale and bloodless. Where the disease has pa.s.sed into the typhoid species, other appearances belonging to this form will be observed: coagulable lymph will probably be effused, and those changes in the structure of the uterus, which we shall mention when we come to the consideration of this species.

_Treatment._ The treatment will, in great measure, depend upon whether the disease is the result of irritation from loaded bowels, scybalous and unhealthy contents, &c., or from that engorgement of the circulation belonging to the chylopoietic viscera, with more or less fever, which indicates the efforts nature is making to rid the circulation, by this outlet, of any morbid principle with which it may have been infected.

In the first case it is simple enough, and, in most instances, the disease is prevented, or, at any rate, checked in its very outset, by the dose of castor oil which is customarily given on the second or third day after labour. If the pulse be quick, the headach severe, with much fulness and uneasiness of the abdomen, and more especially if the bowels have been constipated, or in an unhealthy state before labour, five grains of calomel and carbonate of soda, made up into two pills, with extract of henbane, and followed in a few hours by a dose of castor oil, guarded with some Liquor Opii Sedativus, as before recommended, will be required. We combine a little soda with the calomel, to prevent it griping and acting violently, which it is liable to do where there is much acidity of stomach, from its being converted into the b.i.+.c.hloride. We also think that there will be less chance of vomiting, when the calomel is combined with the soda, than with an antimonial, as recommended by Dr. Loc.o.c.k; a common domestic enema of gruel and salt will a.s.sist the purgative, and bring away much unhealthy faeculent matter. The medicines will generally require to be repeated in twenty-four hours, to insure the removal of the irritating cause from the bowels; the abdomen becomes softer and more free from uneasiness; the pulse rises in strength and fulness, but diminishes in rapidity, and the patient experiences general relief in her symptoms. She may now take an ammoniated saline, with tincture of hop or henbane during the day; five grains of Hydrarg. c.u.m Creta with carbonate of soda and henbane at night, instead of the calomel, and a draught of rhubarb and magnesia with some aromatic confection the next morning, or of rhubarb and manna with sulphate of potash, rendered warm by a little spirit of nutmeg.

If diarrhoea has come on spontaneously at an early period, the true nature of the case is more liable to be mistaken; still, however, the evidences of gastric and enteric irritation are quite sufficient to guide the cautious and observant pract.i.tioner. The calomel here is not so desirable as where there is constipation; eight or ten grains of Hydrarg. c. Creta will produce less irritation, and act as effectually: it will require to be followed by the same treatment as above-mentioned, and to be repeated according to circ.u.mstances.

The diet should be chiefly farinaceous with milk; rice-milk, when the bowels have been sufficiently cleared, is generally very useful; it is slightly constipating, and soothes the irritable mucous membrane with its bland consistence. Milk and soda-water, as mentioned by Dr. Loc.o.c.k, or with lime-water, is very beneficial, especially where the tongue is disposed to remain red, with a smooth glossy surface; as convalescence proceeds, a tea-spoonful of the concentrated essence or decoction of sarsaparilla may be added with advantage.

This form of puerperal affection is never epidemic; it is mere intestinal irritation after labour from scybalous and other unhealthy contents; but this is not the case with the ”gastro-enteric form,” described by Dr.

Ferguson; in the former, the febrile excitement of the circulation is but trifling, and frequently can scarcely be said to exist; whereas, in the latter, the disease rarely appears sporadically, but in conjunction with numerous cases of the same character, or of the malignant adynamic form; it is also, invariably accompanied with much febrile disturbance, and usually of a low form, unless complicated with abdominal inflammation at an early period.

”This form of puerperal fever,” as Dr. Ferguson observes, ”a.s.sumes the general characters of a mild typhus, accompanied with intestinal irritation.” (_Op. cit._ p. 22.) The object of our treatment here is very different to that of the other form just mentioned; it is to unload the gorged circulation of the stomach, liver, and bowels, of the noxious and excrement.i.tious matters which nature has brought to these emunctories, in order that they may be discharged from the system. It is in these cases where, although little or no food has been taken for some time, and without any evidences of faecal acc.u.mulation, we find the exhibition of certain purgatives, especially calomel, to be followed by such copious faeculent evacuations, which we have every reason to believe have been secreted by the liver and bowels under the action of this powerful remedy.

The treatment recommended by Dr. Ferguson, is so in accordance with our own views, and so concisely expressed, that we may be allowed to quote it.

”The following,” says he, ”I have found the most suitable treatment. Get rid of all local inflammations as soon as possible by leeching or by moderate depletion, so as to reduce the malady into simple fever with gastro-enteric irritation. When the skin is early dusky, and there is nausea or vomiting, begin with an emetic. If there be no nausea nor vomiting, but intestinal flux, with a red tongue smeared with suburra, a large dose of calomel, from ten to fifteen grains should be given. Small doses create purging, pain, and irritation, while the full dose produces one to six large pultaceous stools, after which the tongue is cleaned, rendered less red and more moist, and the pulse usually falls. These stools, when examined, appear to contain the faecal matter suspended in large quant.i.ties of mucus and greenish bile, as if the turgid capillaries of the irritated intestinal ca.n.a.l and liver had been freed from their load. In some instances, a repet.i.tion only of the same dose is required to efface the main features of the malady, and to leave nothing but debility to support. In others, after a short respite, diarrhoea re-commences, and soon is apt to become colliquative.” (_Op. cit._ p. 158, 159.)

We have already shown the effects which calomel possesses in large doses of rousing the different excretory organs into full action, and thus a.s.sisting 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 a.s.suming 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 a.s.sumes the remittent character as described many years ago by Dr. b.u.t.ter, 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. c.u.m Creta 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 r.e.c.t.u.m with a few drops of Battley are also useful. In some cases, where there was continued flatulence, a small quant.i.ty 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.