Part 34 (1/2)
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 acme, 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 princ.i.p.ally 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 p.r.o.nounced 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 pract.i.tioners 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 pract.i.tioner 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 was.h.i.+ng; it must be, therefore, self-evident, that, under such circ.u.mstances, 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 was.h.i.+ng 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 was.h.i.+ng 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 inst.i.tution, 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 a.s.signed 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 inst.i.tution. On completing the work they afforded us a striking instance of the effects of effluvia on lying-in women; a large quant.i.ty 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 pract.i.tioners respecting its treatment. Where its remote cause has been but imperfectly known, it is not to be wondered that pract.i.tioners, 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 quant.i.ty 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 a.s.sume 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 dyspnoea, 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.
So long as there are symptoms of local inflammation present, leeches and hot poultices, &c., must be applied, as already mentioned; but it must ever be borne in mind, that the local affection is _not_ the disease, but one of its effects. We must, therefore, direct our energies to ridding the system of the cause upon which it depends. In all cases we think it desirable to begin the calomel in doses of five grains, at intervals of two hours; and if properly guarded with Dover's powder, no disposition to purging will be produced: by this means we not only gain time, but, which is also of great importance, we premise a general increase of the excretions, which tends not a little to relieve the system. After two such doses, the calomel may be given at the ordinary rate of two grains every two hours, with half a grain of opium, or, what is still better, a little Dover's powder, until slight marks of salivation begin to appear. The action should now be kept up by an occasional dose, but never allowed to become at all severe, as considerable exhaustion may be the result. The dark and offensive lochia should be constantly removed by the most scrupulous attention to cleanliness, and by frequently was.h.i.+ng out the v.a.g.i.n.a and uterus with warm water.
If diarrhoea has set in to an exhausting degree, the opiates must be increased, and the Hydrarg. c.u.m Creta subst.i.tuted for the calomel. Saline draughts of citrate or acetate of ammonia, rendered alkaline in excess by Sp. Ammon. Arom. may be given from time to time; they appear not only to refresh the patient, but also to allay flatulence and vomiting, if present. For her common drink we recommend a solution of carbonate of soda in water, in the proportion of two drachms to a pint, slightly flavoured with orange peel; and whenever she has taken this freely, we have observed a considerable amelioration in her symptoms.
Although strongly inclined to advocate Dr. Stevens's views respecting the action of salines in diseases of this character, we must confess that we have been in great measure deterred from carrying them out to the full extent that we could have wished, by the repugnance of the patient to taking a draught so intensely salt as his celebrated mixture. On several occasions we have seen the most beneficial effects from the use of salines; and in two cases, during one of the most malignant epidemics, where every thing seemed to be equally fruitless in arresting the progress of the disease, the exhibition of repeated doses of soda, and encouraging the patient to drink largely of the above-mentioned solution, was followed by the happiest effects. We have again recently tried the common salt, disguised as far as possible in the form of an effervescing draught, and in two cases with very decided results.
The acid state of the mouth is a very constant symptom in this disease, and the contents of the stomach after vomiting are frequently intensely sour, so that in most instances the soda drink has been greedily longed for, and by some patients even called lemonade. We have also tried still more recently warm injections into the v.a.g.i.n.a, of a weak solution of salt and water, but at present, can give no opinion from merely a case or two.
Ice has been lately recommended by Professor Michaelis, of Kiel, not only internally but externally, by means of a large bladder. According to his observations it diminished the pain and tympanitis, reduced the quickness of the pulse, and relieved the patient considerably; this was followed by a profuse diarrhoea of light coloured and offensive evacuations, under which the pulse rose in power, followed by general improvement. We tried it on one occasion; it was swallowed with avidity like barley-sugar; it relieved the sense of inward heat and thirst, stopped the hiccough and vomiting which had become very troublesome, and seemed to diminish the tympanitis, but collapse followed as rapidly as in other cases; nor have our subsequent observations been more favourable. It may be given with advantage with other medicines to relieve several distressing symptoms, but does not appear to us to exert any power in arresting the progress of the disease.
The patient's diet should be mild but nutritious, much more so than in the other forms of puerperal fever; and if there be symptoms of sinking, wine and ammonia, &c., must be given with a liberal hand.
In reviewing what we have said upon the treatment of adynamic puerperal fever, we repeat our conviction, that where the state of collapse has precluded all antiphlogistic measures, and given us but little cause to expect much relief from mercury, we know of no treatment which holds out such rational hopes of success as the saline, based as it is upon the same principles on which it has been employed by Dr. Stevens, in the malignant fevers of warm climates, and by British physicians in the epidemic typhus of this country.
CHAPTER XIV.
PHLEGMATIA DOLENS.
_Nature of the disease.--Definition of phlegmatia dolens.--Symptoms.-- Duration of the disease.--Connexion with crural phlebitis.--Causes.-- Connexion between the phlegmatia dolens of lying-in women and puerperal fever.--Anatomical characters.--Treatment.--Phlegmatia dolens in the unimpregnated state._
_Nature of the disease._ Although we shall not be justified in stating that the disease is one of the sequelae of puerperal fever, inasmuch, as it is occasionally met with, entirely independent of labour and the puerperal state, still we must recognise a very close relation between these two diseases, especially between it and the uterine phlebitis, since, in a majority of instances, they both arise from the same cause, viz.
absorption or imbibition of a morbid poison. At the same time, we can by no means agree with Dr. R. Lee, that ”the swelling of the affected limbs in phlegmatia dolens, and all the other local and const.i.tutional symptoms of this affection, invariably depend on inflammation of the iliac and femoral veins;” and, therefore, do not consider his proposition justifiable, ”to subst.i.tute the term crural phlebitis in place of phlegmatia dolens” (_Researches on the Pathology and Treatment of some of the more important Diseases of Women_, p. 116,) for cases occur where the disease has manifested itself to a very considerable extent without any inflammation of the veins whatever. On the other hand, we willingly allow that in many others it has been preceded by crural phlebitis, although we most distinctly deny that it is ever identical with that disease.
_Definition of phlegmatia dolens._ We may define phlegmatia dolens to be tumefaction of a limb from inflammation and obstruction of the main lymphatic trunks leading from it. It is most frequently seen in the puerperal state, attacking one or both extremities, and is then almost always a concomitant or a consequence of puerperal fever. In the unimpregnated state it is usually the result of some organic malignant disease. ”Women of all descriptions are liable to be attacked by it during or soon after childbed; but those whose limbs have been pained and anasarcous during pregnancy, and who do not suckle their offspring, are more especially subject to it. It has rarely occurred oftener than once to the same female. It supervenes on easy and natural as well as on difficult and preternatural births. It sometimes makes its appearance in twenty-four or forty-eight hours after delivery, and at other times not till a month or six weeks after; but in general the attack takes place from the tenth to the sixteenth day of the lying-in.” (_An Essay on Phlegmatia Dolens_, by John Hull, M. D. p. 132.)
_Symptoms._ As the phlegmatia dolens of lying-in women is almost invariably preceded by symptoms of puerperal fever, many of its early symptoms will differ but little from that disease. The patient is usually attacked with rigours, followed by flus.h.i.+ng, headach, and generally more or less abdominal pain, with a quick pulse, or the disease has come on when recovering from a severe attack of puerperal fever.
”The complaint generally takes place on one side at first, and the part where it commences is various: but it most commonly begins in the lumbar hypogastric or inguinal region on one side, or in the hip, or top of the thigh, or corresponding labium pudendi. In this case the patient first perceives a sense of pain, weight, and stiffness, in some of the above-mentioned parts, which are increased, by every attempt to move the pelvis or lower limb. If the part be carefully examined, it generally is found rather fuller or hotter than natural, and tender to the touch, but not discoloured. The pain increases, always becomes very severe, and in some cases is of the most excruciating kind. It extends along the thigh, and when it has subsisted for some time, longer or shorter in different patients, the top of the thigh and labium pudendi become greatly swelled, and the pain is then sometimes alleviated, but accompanied with a greater sense of distention,” (Hull, _op. cit._ p. 184.) The pain next extends down to the knee, and if depending on a state of phlebitis is most severe in the course of the femoral vein, which is felt hard and swollen, and rolling distinctly under the finger when pressed upon: it is precisely in the direction of this vessel that the greatest pain is felt on pressing with the hand: if phlebitis be not present, the pain is diffused more equally over the limb, and is more connected with the state of tension, or otherwise, is confined chiefly to the groin or upper part of the thigh.