A System of Midwifery Part 33

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.

Loc.o.c.k has found advantage from the occasional use of very small doses (eight to ten grains) of epsom salts with a few drops of laudanum in some aromatic water. The after treatment, as also, the rules for diet, are the same as in the other form.

_The Contagious, or Adynamic, Puerperal Fever._

Although we have cla.s.sed under the head of "puerperal fevers" a variety of affections connected with, and arising more or less from, the same cause with the dreadful malady which we are now about to describe, and although every form and modification of them is liable to a.s.sume its characters, still we must confess that the term _puerperal fever_ belongs _par excellence_ to this form, the adynamic, malignant, and, as we have upon a former occasion called it, the genuine puerperal fever.

It is in this form of disease that the vitiated state of the blood is shown with most distinctness, not only from the condition of the blood both during life, and after death, but also from the close connexion which exists between it and the plague, African typhus or yellow fever, and the other malignant fevers, both of the temperate as well as the tropical climates.

The interesting and daring researches of M. Bulard upon the pathology of the plague, tend to throw great light upon the nature of this formidable disease, and to confirm the views which we have long entertained of this and other diseases of the same cla.s.s, that the essence of the disease consists in the vitiated condition of the blood.

_Symptoms._ The onset of this disease is almost invariably accompanied with a smart rigour, followed by intense headach, and rapid but generally powerless pulse. It seldom begins before the third day, although in some cases it seems to have commenced from the time of her delivery; whereas, in others the patient has gone on to recover favourably until the tenth or even the fourteenth day before being seized, and had already felt sufficiently well to leave her bed and sit up. The powers of the system seem prostrated at once; the shrunken features and dusky hue of the skin, the leaden colour of the lids, and circ.u.mscribed crimson or almost purple patches upon the cheeks, the short imperfect breathing and occasional deep sighing to relieve it, indicate but too surely the nature of the disease, and its depressing effects upon the whole system.

"The sensorium," says Dr. Douglas in describing this form, "is seldom in any degree disturbed, whereas, in the others, it is so frequently, and even sometimes it is excited to high delirium. The pulse here is usually from the moment of the attack, soft, weak, and yielding, and in quickness often exceeds 150; whereas, in the first species it is full, bounding, and often incompressible; and in the second, small, hard, and contracted, and in both, moderately quick. The eye, instead of being suffused with a reddish or yellow tint, as in the others, is here generally pellucid with a dilated pupil. The countenance, instead of being flushed, as in the others, is here pale and shrunk with an indescribable expression of anxiety; an expression altogether so peculiar, that the disease could on many occasions be p.r.o.nounced or inferred from the countenance alone. The surface of the body instead of being, as in others, dry and of pyrexial high heat, is here usually soft and clammy, and the heat not above the natural temperature; and not only is the skin cool with clammy exudation, but the muscles to the impression of the finger feel soft and flaccid, as if deprived of their vis vitae by the influence of contagion. Indeed, there is such prostration of muscular strength and depression of vital principle from the very outset of the attack, that I must suppose the contagion to act through the medium of the nervous system in a manner a.n.a.logous to that of the contagion of plague." (_Report on Puerperal Fever._ _Dub. Hosp.

Rep._ vol. iii.)

Where the powers of the system are not annihilated from the commencement of the attack by the depressing effects of the poison with which the circulation is impregnated, an effort at reaction is frequently made, and for some hours afterwards the surface of the body is hot and dry; but sooner or later, as the stage of collapse comes on, it then a.s.sumes the same cold death-like feel, as in the worst cases of malignant cholera. The character of the attack will be in great measure modified by the intensity of the poison, and the extent with which the circulation has been infected by it. The same effort to produce such a state of reaction as will raise the temperature of the skin, will probably a.s.sist nature in throwing it off under the form of peritonitic or gastro-enteric species of puerperal fever already described; whereas, where the circulation has been thoroughly impregnated with it in its concentrated form, the vital powers succomb at once, and a state of collapse exists from the very commencement of the disease. The course which the symptoms follow and the duration of the disease, will, therefore, depend not only on the severity of the attack, but also on the power of the particular const.i.tution to resist the deadly effects of the morbid principle upon which the disease depends.

When broken down by previous disease, intemperance, poverty, and depressing pa.s.sions of the mind, the vital powers can make no stand against the powerful enemy by which they are attacked; "the blood is so much vitiated, even early in the disease, that it loses the power of stimulating the heart so as to keep up its healthy action; and, perhaps, also the vascular organs are early affected by the action of the poison, and lose the power of either feeling the stimulus, or reacting with force on the impression, which is communicated to their internal surface by the vitiated blood. In such cases, in place of increased excitement, there is frequently a want of action in the whole system." (Stevens, _op. cit._ p.

188.) The patient sinks without pain or complaint, beyond that of debility, but in such cases with a rapidity which would almost claim for the disease the name of "plague." The tongue becomes dry, red, and brown at the back part, the pulse weaker and more rapid, the debility and exhaustion more overpowering; still, even in this state, her mind usually remains clear, unconscious of the fate which awaits her, and occasionally even cheerful: a peculiar sickly odour exhales from the skin, and in many cases so distinctly, as to warn us the moment we enter the room of the patient's condition. The dusky ashen hue of the skin becomes darker, the fingers are shrivelled, and the nails dark, or of a livid black as in cholera; diarrhoea frequently attends, the faeces are unhealthy, and of the same peculiar odour just noticed; during the first stage the lochia are generally present, although of an unhealthy character; the milk also continues in the milder cases, but as the stage of collapse approaches they both disappear, and the b.r.e.a.s.t.s become quite flaccid. In some cases there is vomiting from an early period, with more or less tympanitic distention; but these symptoms rather depend upon the disease being complicated with one of the other modifications. Livid purpurous blotches sometimes appear upon the legs, &c. and in some epidemics it is accompanied with dark or livid eruptions. The surface has now the cold wet feel in its greatest degree, and in some cases even the tongue feels cold to the finger; a drowsy state of insensibility generally follows and continues until death.

The symptoms here enumerated present the characteristics of fever under its different degrees of intensity. The peritonitic and gastro-enteric forms may be compared with the ordinary fevers of temperate climates, and which are attended with more or less inflammation of some organ. The malignant adynamic form corresponds closely with the malignant typhus of this, and the pestilential fevers of warm countries, more especially the plague and the African typhus or yellow fever. In all of these diseases, the vitiated state of the blood appears to be the essential condition of their existence, quite independent of any inflammatory action; in fact, in this form, so rapid and overpowering are the effects of the poison which pervades the circulation, and so completely does it paralyze the whole system, that there is neither time nor sufficient vis vitae to make any effort at reaction. Hence, as Mr. Moore has correctly observed, "when the patient is rapidly destroyed by the violence of the disease, the morbid changes bear no proportion to the severity of the previous symptoms; a dubious trace of inflammation, a little serum, or a few feeble adhesions, are all that dissection under such circ.u.mstances displays." (_Inquiry into the Pathology, Causes, and Treatment, of Puerperal Fever_, p. 63.) In many of the most rapidly fatal cases which we have witnessed, there have not been even these questionable evidences of inflammation. The tissues have been pale and bloodless, the uterus softened, its internal surface ragged, and with a dark gangrenous appearance, extending to the os uteri, and dark thin claret-like blood in all the larger vessels. The heart is flabby, soft, and filled with dark blood; the lungs, liver, spleen, and kidneys much softened; the spleen dark, sometimes enlarged and almost pulpy. If we compare these appearances with those observed by M. Bulard in cases of plague, we shall find a striking coincidence between the two diseases.

This intrepid pathologist remarks, that "the state of general turgescence and dilatation of the venous system; the presence of inflammable gas in eight cases in the cellular tissue, in the veins of the head, feet, and abdomen; the presence of petechiae, both internally and externally; the general softening of the tissues; the enlargement, softening, and breaking down of the spleen; the petechial state of the mucous membrane of the stomach; the effusions of blood on the inner surface of that organ; the pa.s.sive haemorrhages and boils, are symptoms which result from a change in the condition of the blood. The symptoms connected with the state of the nervous system, viz. the rigours, headach, and confusion of mind, the quick and small pulse, the hurried respiration and vomiting, and also the petechiae, carbuncles, and buboes, are neither those of vascular nor nervous inflammation. The blood has never shown the buffy coat; it was found just as black in the arteries as in the veins, but in the former, in much smaller quant.i.ty; it always had the appearance of being dissolved."

M. Bulard observes, that the decomposition of the blood is quite independent of putrefaction being present before death takes place; and he feels convinced that it is not only the sole cause of death, but must also be looked upon as the origin of the various morbid phenomena during the course of the disease. He considers "these phenomena to result from an actual poisoning of the blood, similar appearances being observed in all cases where putrid matter and morbid secretions have been introduced into the system." With regard to the supposed inflammatory nature of the plague, M. Bulard states, that in many cases not the slightest trace of inflammation could be found. The changes in the spleen are of by far the most invariable occurrence. In one hundred autopsies, this organ was found only five times in a healthy state.

Where, on the other hand, the powers of the const.i.tution, or the diminished virulence of the disease, have enabled the system to withstand the depressing action of its immediate effects, we find it considerably modified, both in the symptoms which it presents during life, and the appearances after death. Instead of being little else than a state of collapse from the very outset of the disease, under which, not a single attempt is made by the powers of the system to set up even the most feeble effort of reaction, a variety of symptoms attend its commencement and progress, indicating that the vis vitae has not altogether succ.u.mbed beneath the deadly effects of the malady. The very rigour itself, when violent, the headach and flus.h.i.+ng of the face, if severe, are rather favourable than otherwise, and show that the system still possesses some power of reaction. It is usually observed, that where the attack commences with these precursory symptoms well marked, it is generally accompanied with peritoneal pain, tympanitis, and other symptoms of inflammatory action; whereas, in the worst cases, we have already stated, that from the very commencement of the disease there is neither a symptom of inflammation during life, nor a trace of it to be found afterwards. Dr.

Armstrong rightly observed, that inflammation is not an essential const.i.tuent of typhus; and the same holds good in the strictest sense of the word, with the typhoid or adynamic puerperal fever.

"Whatever the remote cause of fever may be, it is very evident that this cause must invariably exist, not only at the moment of attack, but even previous to that period. Now in the fevers from poison, the blood is invariably diseased previous to the commencement of the cold stage. During this period there are premonitory symptoms; but these are evidently the effect of the diseased state of the vital fluid: and that these precursors of fever are not the effect of any local inflammatory disease, is evident from the fact, that frequently during this period there is no pain in any of the organs, but a want of action, particularly in the extreme vessels, and consequently a decrease of heat in the whole system.

"If inflammation in any of the organs were, in reality, the cause of fever, then the disease ought to be fatal, exactly in proportion to the violence of the local affection; but the very reverse of this is the truth. Mere excitement can easily be reduced, and the inflammatory form of fever is decidedly the most easily cured, though in it the excitement is often so great that the organs are very liable to be injured; while the malignant form of fever is by far the most fatal, though in this the excitement is less, and the organs are seldom affected. This is particularly the case in the worst form of the African typhus, and probably other varieties of malignant fever, where the blood is under the influence of an active poison, and where its vitality is diminished, and its structure is injured even before the attack.

"Those who have seen most of the malignant diseases know well that excitement in fever is invariably a good symptom; for this is a sure sign that the blood has not yet undergone any fatal change, and independent of this, mere increase of action is always at the mercy of the lancet. But neither the lancet nor leeches, gum water, vitriolic emetics, calomel, antimony, brandy, opium, or acids, can redden the colour of the black blood, which we invariably meet with in pestilential diseases, or remedy the diseased state of the vital current, so as to cure that fatal form of fever where the malignant symptoms are produced, not by excitement, but by the vitiated state of that mysterious fluid, which in health gives life and nourishment to every solid of the system, and which, when diseased to a certain extent, is by far the most frequent cause of death in all those fevers that are produced by some deleterious poison acting, in the first place, on the vital current, and then on the brain and the whole system through the medium of the blood." (Stevens, _on the Blood_, p. 186.)

We have quoted thus largely from the observations of Dr. Stevens and M.

Bulard, to whose admirable researches we are so greatly indebted for our present knowledge, respecting the nature of pestilential diseases both of the East and West, for they tend not only to show the true pathology of malignant puerperal fever, but also the cla.s.s of diseases to which it belongs.

_Appearances after death._ Where more or less inflammatory action has accompanied the first part of the disease, the lesions observed after death differ considerably from those of acute peritonitis: the effusions of cogulable lymph, of serum, and sero-purulent fluid, are seldom met with to such an extent where the case has been one of inflammation uncomplicated with the adynamic form of puerperal fever, even although it may have been exceedingly violent; whereas, in the present case, although there has been scarcely sufficient power in the system to set up even a moderate degree of inflammatory action, the intestines and uterine appendages are found glued together, and thickly imbedded in immense effusions of lymph. The ovaries, Fallopian tubes, and broad ligaments are engorged with purple vascularity, softened, and, especially the ovaries, quite disorganized, with numerous effusions of sero-purulent matter beneath their peritoneal coverings, or into their parenchymatous tissue.

In others, their whole substance has been softened and pulpy, with little cyst-like cavities filled with blood or pus, the remains of the Graafian capsules. During the fatal epidemic which prevailed at the General Lying-in Hospital, in the early part of 1838, we met with several cases where the ovaries had entirely disappeared, their site being only discoverable by an oval thickening of the broad ligament, something like an empty cyst of peritoneum; this contained a small quant.i.ty of livid pulpy debris of the ovary, and (on that side where conception had taken place) a remarkably well marked or rather exaggerated corpus luteum. The uterus is larger and its tissue much softer than under ordinary peritonitis, so that, in many instances, the finger can be easily pushed through its whole substance.

Where the const.i.tution has borne the brunt of the attack without immediate collapse, and the local mischief been controlled by appropriate means, we find that fresh efforts are made to rid the circulation of the morbid matter with which it is infected. The patient is suddenly seized with severe pain, with heat, redness, and swelling of one of the large joints, presenting all the appearances of arthritic or rheumatic inflammation, and also of certain muscles, especially the supinators of the arm, the glutaei, and gastrocnemii. The painful spot soon becomes hard, it is intensely tender, and in two or three days the feeling of fluctuation indicates the formation of an abscess, from which a large quant.i.ty of greenish coloured pus mixed with blood and serum is discharged. The cellular tissue beneath the skin and between the muscles is equally affected, and if examined when the abscess is just beginning to form, will be found of a dirty brown colour, softened, infiltrated, and here and there condensed with lymph or pus, precisely as in cases of gangrenous erysipelas: the muscular tissue has entirely lost its red colour, and closely resembles the appearance of boiled meat, its structure so softened as to tear easily under the fingers, and interspersed with deposites of immature lymph and purulent fluid, the commencement of what would have been an abscess. Like gangrenous erysipelas the extent of the abscess does not seem to be limited by a surrounding wall of healthy lymph, as seen in a common phlegmon, but if deep beneath the surface it continues to spread in all directions until nearly the whole limb appears to be implicated in one immense abscess: hence, in those patients who have recovered under these attacks, the limb has frequently been rendered useless, the muscles being atrophied and coherent.

Inflammation of a similarly arthritic or rheumatic nature occasionally also attacks the eye, and presents all the usual characters of arthritic iritis under ordinary circ.u.mstances: there is the same intolerance of light, pain of the eye, dimness of vision, contracted pupil, and peculiar white ring round the edge of the cornea, which distinguishes this affection; but in the present case, the disease runs a far more rapid course, and defies the remedies which in common cases would be sufficient to check it; the inflammation soon extends to the deeper seated structures of the eye, the pain is excrutiating, and, in two or three days, disorganization takes place, followed by suppuration, staphyloma, and bursting of the cornea. So rapid and destructive is its course, that, although five or six cases have come under our notice, in only one instance, with the greatest difficulty, was the eye saved, and, even then, not before it had been considerably injured.

These attacks are attended by severe pains of a similar nature in different parts of the body, more especially the joints and limbs; and, from the arthritic character which they a.s.sume, tend, in our opinion, still farther to elucidate the real condition of the system. The a.n.a.logy between gout or rheumatism, and those diseases which arise from a vitiated state of the blood, is exceedingly close, nay, even identical, for in both, a princ.i.p.al pervades the circulating fluids which requires to be removed; and if this be not effected by any of the excretory organs, nature endeavours to throw it off by some process of local inflammation.

The connexion between puerperal fever and typhus is very close, for it not only a.s.sumes the characters of the typhus epidemics which may chance to be prevailing at the time, but we have distinct evidence that the contagion of typhus will, in a puerperal woman, manifest itself under the form of puerperal fever. Dr. Collins has recorded a very interesting case of this sort:--"A patient was admitted at a late hour at night into one of the wards, labouring under a bad form of typhus fever, with petechial spots over her body; when observed next morning, she was removed into a separate apartment, where she died shortly after. The two females who occupied the beds adjoining hers, while she remained in the large ward, were attacked with puerperal fever, and died." (Collins, _op. cit._ p. 381.) During a typhus epidemic which prevailed a few years ago in the poor districts of the metropolis, a prominent feature of which were petechiae and a livid rubeoloid eruption, precisely the same appearances were observed among the cases of adynamic puerperal fever at the General Lying-in Hospital.