Chapter XIII: Puerperal Fevers (2)

As soon after the bleeding as possible, a smart dose of calomel and James's powder, followed by an active saline laxative, must be given; and the combination of sulphate and carbonate of magnesia with antimonial wine and Tinct. Hyosc. already recommended, is preferred by us: it is better given in divided doses, as then the effects of the antimonial is prolonged. The action of the bowels may also be assisted by a domestic enema: and if there are no signs of action in the bowels after two hours, the purgative should be repeated. The results of the leeches, fomentation, and purging, will guide us as to the necessity of repeating the bleeding. Dr. Gooch's truly practical remarks on these points are well worthy of attention:--"I waited till the purgatives had operated fully, that I might know what impression the combined operation of general and local blood-letting had produced on the disease, before deliberating on the employment of a second blood-letting. The common effect, of these remedies was this, as long as the faintness lasted in the slightest degree, the pulse remained soft and often slower, and the pain was much less, or ceased altogether; but an hour or two after the bleeding, when the circulation had recovered, the pain returned more or less, and the pulse regained much of its hardness or incompressibility. This state continued till the leeches had bled freely, and the purgatives had acted repeatedly and copiously." (_Op. cit._ p. 48.)

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

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

In all cases where the disease has not been completely checked in the very outset, but has shown a disposition to return, the treatment above-mentioned should now be followed by a mild mercurial course. The effects of mercury in allaying inflammation at a certain stage, which does not appear to be fully under the control of mere antiphlogistic remedies, have been amply proved by British practitioners: this applies particularly to inflammation of serous membranes: mercury not only tends to prevent the effusions of serum and coagulable lymph, but, where they have taken place, it is of great value in promoting their absorption. We agree with Dr. Locock, that calomel is by far the best form in which it can be used, where we wish to obtain its specific effects. The Hydrargyrum cum Cretâ, which we have occasionally found useful in the gastro-bilious or enteric form to restore a depraved state of intestinal secretions, has failed us in the other forms where we wished to produce salivation. The purgative dose of calomel, which we have advised to be given after the bleeding, ought not to be less than six to eight grains; but now, as the dose is to be repeated every two or three hours, a smaller quantity will be sufficient: in order to save time we usually begin with five grains of calomel, and an equal quantity of Dover's powder, and repeat this in an hour's time, after which, we proceed with doses of two or three grains every second or third hour according to circumstances. The sooner the system can be brought under the influence of mercury the better, the pulse becomes softer and less frequent, the pain and tension of the abdomen diminish, the tongue becomes moist and natural at the edges, and general improvement follows. Throughout the whole attack the vagina should be occasionally washed out with warm water, more especially if we have reason to suspect that the disease has arisen from the imbibition or absorption of putrid matter. The smell of the patient will frequently guide us in this respect, and point out the condition of the passages and their contents; even if there be no putrid matter lodging there, the application of warm water will always act as a comfortable fomentation to the patient, and assists not a little in favouring a return of the lochia.

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

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

_Uterine Phlebitis._

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

_Symptoms._ This affection generally makes its appearance on the second, third, or fourth day after labour, and varies considerably in its mode of attack. In some cases it will be observed to come on suddenly, with scarcely any premonitory symptoms. The patient is suddenly seized with severe griping pain in the lower part of her abdomen, generally extending more or less to one side, and usually preceded by a smart shivering fit, which is followed by intense headach. On examining the abdomen, the uterus is hard, larger than natural, and excessively painful to the touch; the pulse quick and usually small; the tongue covered with a thin white fur, becoming brown and thicker towards the back part; the countenance anxious. With all this, the abdomen is neither hard nor painful upon moderate pressure; not even over the uterus itself do we produce pain, until we begin to press so hard, that the organ becomes plainly distinguishable to the hand through the soft integuments. The lochia has either not appeared at all, or has been suddenly suppressed; and in all probability, the secretion of milk has followed a similar course.

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

_Appearances after death._ Examination after death shows that the uterus and its appendages have been the chief seat of the inflammation, its whole peritoneal surface thickly covered with exudations of coagulable lymph; the broad ligaments vascular; the Fallopian tubes livid, swollen, and softened; the ovaries greatly altered in appearance and structure, being generally more or less swollen and much softened,--at times the natural tissue of the gland completely broken down into a pulpy semi-purulent mass, at others the external surface only has been red or gorged with dark-coloured vessels; the whole uterine appendages thickly imbedded in cogulable lymph. The uterus is large and soft, deposites of pus have been found beneath its peritoneal covering, or in the proper muscular tissue of the organ; and in many cases, on cutting into its substance, pus has appeared in numerous little points, oozing from the veins or absorbents which have been divided. In those veins which are large enough to be traced by dissection, their coats have been found vascular, thickened, and in many places lined with lymph, so that the vessel has become completely impervious: in others, they have been filled for a space with pus, and their canal then obliterated, either by swelling, effusion of lymph, or by plugs of fibrine from coagulated blood. These changes in ordinary cases do not extend beyond the substance of the uterus; but where the disease has been of some duration, as well as severity, they become much more extensive, affecting the neighbouring veins to some distance. "Inflammation," says Dr. R. Lee, who has examined this subject with great care, "having once begun, it is liable, as I have before stated, to spread continuously to the veins of the whole uterine system, to those of the ovaria, of the Fallopian tubes, and broad ligaments. The vena cava itself does not always escape, the inflammation spreading to it from the iliac, or from the spermatic veins." (_Researches on the Pathology and Treatment of some of the more important Diseases of Women_, p. 54.)

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

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

Under these circumstances, the pure antiphlogistic treatment seems to have little or no control, either in removing the pain, or diminishing the pulse, or in preventing the disease from running into that state of tympanitic peritonitis, which is so fatal in its effects; and we are not only losing time by employing an inefficacious mode of treatment, but are exhausting the powers of the system, already more or less depressed. "Large hæmorrhages," as Dr. Ferguson correctly observes, "favour absorption," (_op. cit._ p. 108;) and it would seem that by thus reducing the powers of the system, we diminish its capability of ridding itself by the natural outlets of the virus which has been carried into the circulation; nor do we see how this is to be assisted by bleeding. If a state of actual hæmorrhage has been induced, bleeding, of course, must be used with the greatest promptness; but in employing this remedy in the above-mentioned form of puerperal fever, although we relieve the inflammation for a time, the cause is not removed. It still continues to act, and the symptoms return under much more formidable circumstances, from the increased debility of the system confining our means of treatment within still narrower limits.

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

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

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

_False Peritonitis._

Under this title, which we believe first originated at the General Lying-in Hospital, and which has been adopted by Dr. Locock in his article upon the subject, we propose to describe that peculiar species of abdominable pain, which Dr. Ferguson has called the _transient_ form of peritonitis. Strictly speaking, neither of these terms are exactly appropriate, for the disease appears to depend upon a state of high nervous irritability, perfectly independent of inflammation, or any other affection of the peritoneum; still, however, as it has been most frequently known and described under the former of these appellations, we shall also continue to use it, merely warning our reader, that the appellation of false peritonitis is more conventional than correct. Properly speaking, it should be called _nervous abdominal pain_; for we have reason to think that its real seat is in the muscular coat of the intestines, and in the abdominal muscles themselves, much more than in any portion of the peritoneum.

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 anæmia. 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 passes either into acute peritonitis, or into the typhoid state of the malignant form, the latter transition being almost certain, if the practitioner 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 constitutional disturbance which occur in feeble and bloodless persons, and which are aggravated by bleeding and other evacuants, strikingly resemble the local pains and constitutional 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 practitioner learns that there are cases apparently so similar, yet really so different, and how to distinguish them; and how many practitioners 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 anæmia, 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 passing 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 constitution 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 circumstances, 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 quantity 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 potass, 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 quantity 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 appetite, 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 astonishing how quickly every symptom subsides, and the system returns to a natural condition, by the daily allowance of a small quantity 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. Locock. In its simple uncomplicated form, this disease cannot be considered as a dangerous affection; it occasionally passes into inflammation, but more frequently it assumes 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 canal: 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 washing 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 fæces 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 fæces 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 fæcal 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 canal; 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 papillæ, or pale and flabby; the appetite is irregular, or fails considerably; the patient complains of weariness and lassitude; 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 unrefreshing; the spirits are unequal and anxious; she is chilly at times, and at others, has considerable flushings 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 assume 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 passing, it is frequently attended with a good deal of forcing. The abdomen becomes more tender, with severe griping flatulent pains at intervals; the diarrhoea assumes 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 canal 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 assumes 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 hæmorrhage, and necessarily tends to aggravate the state of anæmia 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 anæmic 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 passed 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 bichloride. 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. Locock; a common domestic enema of gruel and salt will assist the purgative, and bring away much unhealthy fæculent 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. cum Cretâ 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 practitioner. The calomel here is not so desirable as where there is constipation; eight or ten grains of Hydrarg. c. Cretâ 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 circumstances.

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. Locock, 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, "assumes 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 excrementitious 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 fæcal accumulation, we find the exhibition of certain purgatives, especially calomel, to be followed by such copious fæculent 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 fæcal matter suspended in large quantities of mucus and greenish bile, as if the turgid capillaries of the irritated intestinal canal and liver had been freed from their load. In some instances, a repetition 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 assisting 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 assuming 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 assumes the remittent character as described many years ago by Dr. Butter, 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. cum Cretâ 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 rectum with a few drops of Battley are also useful. In some cases, where there was continued flatulence, a small quantity 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. Locock 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 classed 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 assume 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 class, 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 circumscribed 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 pronounced 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 vitæ 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 analogous to that of the contagion of plague." (_Report on Puerperal Fever._ _Dub. Hosp. Rep._ vol. iii.)