The history, pathology, and treatment of puerperal fever and crural phlebitis
^/^lS^<^-t4^ i:*iTTSBURGH ACADEI^T 0^ ' 322 North Craig 8t, JPlXTbBURGH, PA. v.»^ ^\»y THE HISTORY, PATHOLOGY, AND TREATMENT OF PUERPERAL FEYER ASH CRURAL PHLEBITIS. I. A TREATISE ON THE EPIDEMIC PUERPERAL FEVER OF ABERDEEN. BY ALEXANDER GORDON, M.D. 11. A TREATISE ON THE PUERPERAL FEVER: ILLUSTRATED BY CASES WHICH OCCURRED IN LEEDS AND ITS VICINITY IN THE YEARS 1809-12. BY WILLIAM HEY, ESQ. III. FACTS AND OBSERVATIONS RELATIVE TO THE FEVER COMMONLY CALLED PUERPERAL. BY JOHN ARMSTRONG, M.D. IV. ON PUERPERAL FEVER AND CRURAL PHLEBITIS. BY ROBERT LEE, M.D., F.R.S. ■WITH AN INTRODUCTORYHSSAY, BY CHARLES D. MEIGS, M.D., Professor of Obstetrics and Diseases of Women and Children in the Jefferson Medical College; ) CO ? I g ED. BARRINGTON & GEO. D. HAS WELL. ^ :^ oi NEW YORK — J. & H. G. LANGLEY : CHARLESTON, S. C.-WM. H. BERRETT: H §} ^_ RICHMOND, VA. — SMITH, DRINKER &. MORRIS: 3 •* ^ LOUISVILLE,KY.— JAMES MAXWELL, JR. ? 1842. 4^ CONTENTS. PA.6E Introductory Essay. By Charles D. Meigs, M.D. ... 9 A Treatise on the Epidemic Puerperal Fever of Aberdeen. By Alexander Gordon, M.D 29 Preface ......... 29 History and Symptoms of the Disease . . . . .31 Cases and Dissections ....... 35 Table of Patients affected with Puerperal Fever, etc. .  A Treatise on the Puerperal Fever : Illustrated by Cases which occurred in Leeds and its Vicinity, in the  the Disease . . . • .80 Cases and Method of Cure ...... 88  Fever commonly called Puerperal. By John Armstrong, M.D. ....•• 166 Preface 166 Description of a Puerperal Fever which appeared at Sunderland in 1813 . 167 Diagnosis of Puerperal Fever . . . . • 172 Prognosis .......•• 175 Prevention ........ 179 Pathological Remarks ....... 183 Treatment ........ 188 Appendix .......•• 199 V'^^\3 8 COXTENTS. PA6B On Puerperal Fever and Crural Phlebitis. By Robert Lee, M.D., F.R.S. 221 Introductory Observations on the Pathology of Puerperal Fever . 221 Of Uterine Inflammation in Puerperal Women .... 231 Inflammation of the Peritoneal Covering of the Uterus, and of the Peri- toneal Sac ....... 233 Inflammation of the Uterine Appendages, viz., the Ovaria, Fallopian Tubes, and Broad Ligaments ...... 235 Inflammation and Softening of the Proper or Muscular Tissue of the Uterus ........ 242 Inflammation and Suppuration of the Absorbent Vessels of the Uterus . 248 Inflammation of the Veins of the Uterus, or Uterine Phlebitis . 249 History of Uterine Phlebitis ...... 254 Causes of Uterine Inflammation in Puerperal Women . . 275 Treatment of Uterine Inflammation in Puerperal Women . .281 Of Crural Phlebitis, or Inflammation of the Iliac and Femoral Veins 290 Of Crural Phlebitis in Puerperal Women .... 291 Cases and Dissections ...... 293 Examples of Crural Phlebitis where Recovery took place . . 306 History of Crural Phlebitis in Puerperal Women . . . 308 Of Crural Phlebitis in Women who are not in the Puerperal State 312 Crural Phlebitis from Malignant Ulceration of the  Cases of Uterine Inflammation in Puerperal Women ....... 329 l^AXiiBURQB. ACADElvIY OF MEDlGii. 322 North Craig St., " WTTSBURGH, pa. INTRODUCTORY ESSAY. BY CHARLES D. MEIGS, M.D, Much has been written of late years on the subject o^ childbed fever, whereby a great hght has been shed upon the pathological features of several disorders heretofore designated under this title. These disorders are — inflammation of the substance of the womb ; inflammation of the veins of the womb; inflammation of the ab- sorbents of the same organ; and lastly, inflammation of the perito- neum : or several of these affections conjoined and grouped in the same subject. One of the most general and comprehensive terms is puerperal fever ; a name said to have been first bestowed upon these affections by Dr. Edward Strother, an English writer, in his Cinticon Febrium, or a Critical Essay on Fevers, with the Dia- gnostics and Methods of Cure, 1 vol. 8vo. Loud. 1716. Strother wrote in the somewhat quaint style of his age ; and, as his name has been often cited by authors upon the subject under consider- ation, I shall here quote the principal part of what he has left us upon the topic. " Puerperal fevers, are shelves poor females are often stav'd upon. They are generally inflammatory from the inflammation of the uterus, which arises from the suppression of the lochia. Custom has prevail'd among the ignorant and obstinate midwives to allow the Inborants ohiokens, and such diet as they pretend cannot prejudice them ; to rise out of bed three days after their labour, and to take some turns across the chamber ; from whence I have seen the lochia stopt or lessen'd, and thence deliria or dangerous fevers ; and yet 'tis easy to prevent these, if the ladies can be aw'd. 'Tis common for hard labours to produce them, as I have often known. If we are called in immediately after the mistake, it may be pre- vented by giving them tincture of castor or spirits of hartshorn in rue water, &c,, and, giving them their diet lean, and so dis- posing them to sweat. But when the fever is begun, if they be plethoric, and the fever of the warm species, bleed in the arm and then in the foot, and after this throw in emollient glysters to dilate (by manner of a lotus) the orifices of the glands of the uterus, whence the lochia v/iU flow afresh. Alexipharmics (with the cautions ■2 10 MEIGS'S INTRODUCTORY ESSAY. above named) must be giYen as a thin diet, cooling and refreshing. If inflammatory symptoms come on, such as pleurisies, anginas, peripneumonies, &c., you will see below how to treat them. If the lochia are over, bleeding and purgatives (if indicated) may safely enough be made use of, as I have often experienced." p. 166. Such is the language of Dr. Strother, who, it will have now been seen, had very faint glimpses of the disorder to which he gave the name of puerperal fever ; but it is clear that he looked upon it as an inflammation, and, as far as he dared to go, he has recommended the proper remedies, in the use of venesection and cooling diet, as well as of purgative medicines. Much has been written since Strother's time ; but it is only very lately that the clearest views have been enjoyed as to the dangerous tendency of the disorder, its varieties, and the modes of treatment. Among numerous individuals who have made public their opi- nions, and the experience on which they were founded, great dis- crepancies are found to exist. One party pushing the use of the most vigorous antiphlogistics to the utmost ; another recommending their very cautious use, while others seem afraid of them, except under the most guarded limitations. So far as I can learn, a discrepancy equally as great as that among foreign writers exists in the profession on this side of the Atlantic. The question as to the nature and treatment of childbed fever behig a most important one, we believe that we confer a benefit upon the public at large, and upon our brethren in particular, by calling their attention anew to the subject. In order to do this in the manner most likely to be useful, we shall lay before them certain works of authors who have acquired a just celebrity, and who are esteemed worthy to be held as authorities on childjjed fever. It is undeniably a great public concern, that we should possess the productions of gentlemen whose theory and practice in these disastrous maladies, not only present doctrines the most consonant with reason and the philosophy of medicine, but claim for them results the most cheering and triumphant. Such are the views that have now led to the reprint of Gordon, Hey, Armstrong, and Robert Lee. Let the reader and practical physician judge, and say whether the information derived from them is not an impayable acquisition. So rapid and fatal in their course have been the epidemic and even the sporadic forms of peurperal fever, and so evident and early have been the signs of great prostration, or exhaustion and down- Avard proclivity of the vital powers, that we have no room for sur- prise at the tendency of mankind to view them as ataxic or typhous in their very nature ; and so requiring, on that account, a careful avoidance of strong antiphlogistic ordebilitating measures. The idea of typhus is inseparably connected, in many minds, with that of great muscular weakness, tremors, dry tongue — with stimulants and cordials, and all the means of rapid reparation. In such persons it is enough to know that to-morrow the patient will be weaker, in PUERPERAL FEVER. XI order to lead them to obviate that fearful debility by opium and brandy, and an alexipharmic course, and beef tea, &c., &:c. Dr. Wm. Hunter, who saved but one case out of thirty-two, persisted to the last, according to Dr. Mackintosh, in beginning the treatment with a generous glass of brandy ; and there are many gentle- men who, having repeatedly seen the belly filled with the fluid deposits of extensive peritoneal inflammations, and the veins gorged with pus, the product solely of inflammation, still con- tend that the employment of venesection is very dangerous, and requires great consideration of the constitution and habits of the patient, and is to be practised only on the most favourable subjects. Not only are there to be found respectable brethren holding these views, but even of those who preach the opposite doctrines, many, though bold in recommending the lancet to others, yet, in their own practice, stop short of the free use of this measure. The mischievous eff"ects of error are continued long after the error itself is overthrown : a man Avho has been trained, by bad teaching, to look upon a grave disorder as of a typhous nature, and therefore to be treated by stimulating means, finds it very difficult to liberate himself from the rules of action imposed by his early prejudices, which continue to bias his practice even long after his judgment has been fully enlightened. At the present day, we know that women in childbed are liable to attacks of chills or rigors, followed by pain in the region of the womb, with a very frequent pulse, rising speedily to 120 or 150 beats per minute; and soon after by distention of the abdomen, pain, and other symptoms, which mark the childbed fever. This fever proves fatal to many of the patients attacked with it ; and the examination of the bodies of those who die reveal either extensive inflammation of the peritoneum alone, or of the womb alone, — or of the womb and peritoneum both. In some of the cases the womb is proved to have become gangrenous or softened by inflammation ; and in others, and many of them, its vehis, and the veins returning its blood, are greatly inflamed and filled with inflammatory deposits of lymph, or gorged full of pus. Deposits of pus are also, in some of the cases, found in the thorax^ or in remote parts of the body ; to such extent, indeed, as to have given rise to the idea of a pyogenic or pus-creating fever. The absorbent vessels are also found to be affected in a manner similar to that of the veins. Diseases of childbed like these have been noticed from time immemorial by writers of great ability. Faint and imperfect views of their nature, and some approaches to good sense in their treatment, as by Strother, had been obtained, but lost sight of again and again, until a great reformer of doctrine, as regards them, appeared in Scotland. I allude here to Dr. Alexander Gor- don of Aberdeen.* This gentleman, who enjoyed an extensive * Author of the History of the Puerperal Fever of Aberdeen. London, 1795. 8vo, 12 MEIGS'S INTRODUCTORY ESSAY. practice there, and in the country round about it, encountered a severe epidemic of puerperal fever, which, from December, 1789, to March, 1792, prevailed epidemically at and near Aberdeen. The first cases he treated without energy and without success. Taught by woful experience the inadequacy of his method, and enlightened by dissections of a few of the early victims, he adopted a more energetic practice, which was founded on the substantial proofs of inflammation revealed in the dissections. It consisted of free bleeding from the arm, aided by the use of purgative medi- cines. The result, to use his own language, was as follows : " When I took away only ten or twelve ounces of blood from my patient, she always died ; but when I had the courage to take away twenty or twenty-four ounces at one bleeding, in the beginning of the disease, the patient never failed to recover, as was the case in No. 23, 28," &c., &c. In another place, he says, after citing the results of practice in other countries — " In my practice, of seventy-seven women who were attacked with puerperal fever, twenty-eight died ; so that very near two-thirds of my patients recovered, which proves that I have been much more successful than any other practitioner. But it will be proper to mention that I was too late in being called to many of the cases, and that I had a fair trial only in fifty of the above number : of these fifty, only five died." Dr. Gordon's volume is small, and is written without arro- gance or great pretensions. It is a plain and, doubtless, a candid detail of his concern with that epidemic ; and has so convincing and truthful an air in every page and line, that I cannot ima- gine anything more fitted to impress the mind of a reader with the warm and irresistible convictions of the author. Fifty years have elapsed since its publication. It is always quoted or referred to in treatises on the same topic, and still retains its good name. Every medical practitioner ought to read it, and I was almost ready to say that its perusal ought to be regarded as indispensably necessary to a right understanding of the history and treatment of puerperal fever. Whatever critics may say as to Dr. Gordon's performance, and however wofully several eminent writers and practitioners may have erred in their theories and practice, Gordon will be regarded as the reformer of the therapia of puerperal fever ; for it can scarcely be denied that, since his publication, there is a more perfect and understood conviction of the inflammatory character of this disorder, and of the little regard to be paid to the state of the pulse in making up one's mind as to the necessity for treating it boldly in the first stage.* The work, * M. Legonais, in his admirable and spirited treatise on tlie subject, pays a just tribute to the merits of this author; and, as he had the most abundant and fortunate opportunities, by a residence of several years in the il/u/c?vn7f' at Paris, to witness the practice and carry out the directions of Chaussier, in the malady, I should conceive that his experience alone, unaided by the fine arguments of his volume, should constitute him a high authority. When 1 read Lcgonais's PUERPERAL FEVER. I3 precious as it is, has long been out of print ; and I cannot conceal the satisfaction I feel at the prospect of its being placed at a cheap rate in the hands of numerous practitioners in our country. Gordon had not the leisure or the privilege requisite to make very numerous and elaborate dissections. This task, however, has been well fulfilled by Robert Lee, in his work which forms part of this volume ; to that degree, indeed, as to leave but little to be desired. All these researches have but added strength and assu- rance to the conviction derivable from Gordon's essay. These new and more minute inquiries, which proceed so much farther than he had gone, ought to be fully known by the medical fraternity. But it will not suffice to know only the later produc- tions of the press. I do not believe that the writings of Hey, of A. Baudelocque, of Armstrong, Mackintosh, and Lee, studied alone, could carry such a weight of argument to the mind as their perusal after Gordon would do. He is the first in the series, and the others wait on him, and honour themselves by illustrating him. Pahnam qui meruit fer at. The four works comprised in this volume constitute, then, a beautiful series — rising from a simple proclamation of a deeply in- teresting and important principle, in the history of the Aberdeen fever, to an illustration and enforcement of it in the Leeds and Sunderland writers ; while a most full, elaborate, and convincing display of the whole subject is found in the London author. The progression is complete. There is no need why I should, in this Introductory Essay, attempt any review of these works. They are here to make their own proper impressions on the reader's mind. It is obvious that the death of a puerperal patient is, in general, more to be deplored than the ordinary fatalities met with in prac- tice. A woman, under these circumstances, appears to have a stronger claim on life ; and the disruption of the ties which bind her to society and to her friends is more painful, from the new relations just established with them. If the child survives, it suf- fers, during the long period of infancy, childhood, and puberty, the bitter fruits of this terrible privation ; while the breaking up of the domestic establishment, which usually follows that event, appeals, with irresistible power, to the public sympathy. Each family is a little patriarchate, state, or kingdom; and the domestic catas- trophe has, within its proper pale, all the importance of a great political overthrow. It is a great misfortune to lose a patjent in childbed. Those diseases, therefore, which, by their attacks, expose wo- men to an imminent danger of death in childbed, ought to be carefully studied by medical men ; and the physician should be excellent work, I am disposed to thank Gordon for it, as I am for every other valuable rule of practice in this most distressing disease. Nothing since Gor- don's work, that I have seen, detracts from his merit by comparison. Few American physicians yet possess it. 14 MEIGS'S INTRODUCTORY ESSAY. deemed inexcusable who undertakes the management of them without a due, nay, an unusually careful preparation for the enter- prise. He ought not to confide alone in his own keen perceptions at the clinic, nor in the results of his own most imperfect ex- perience. He is obliged by his vocation to take up a position which he ought fully to examine and render secure before he enters into the conflict with so dangerous an enemy. I refer to the statements in the volume of Robert Lee for accounts of the mortality produced in some parts of Great Britain, and on the Continent, by puerperal fever. Those gentlemen who, in our own country, have had occasion to observe it either as an epide- mic or sporadic disease, will require no further incitement to a perusal of the volumes now published. They will see Gordon's success, who, by the antiphlogistic treatment, was able to save forty-nine out of seventy-seven cases ; or rather, forty-five out of fifty ; Hey, who met with a most encouraging success by the same method ; and Lee, who lost fifty-nine only out of seventy-two cases ; while Armstrong saved all but five of his patients. In bespeaking so great a share of attention to these writers, I do not mean to disparage the opinions of others who act upon the same practical principles. I would refer, with especial satisfaction, to the opinions and experience of Dr. Legonais, of David D. Davies, of Dr. Mackintosh, and the younger Baudelocque, for confirmation of the views of the gentle- men whose works are now republished. Let us briefly consider the nature of the disorders usually com- prised under the term childbed fever, after taking a view of the organs and tissues known to be afl:ected in its different varieties and complications. In the first place, the gravid womb is a hollow muscle, supplied with a vast profusion of veins, arteries, absorbents, and nerves. It would hardly be deemed the stretch of a prurient imagination, to compare it, on account of its great vascularity, to an enor- mous aneurism by anastomosis, furnished with a suflicient quan- tity of muscular fibres to reduce back and compress within safe and natural limits the luxuriant production of sanguine tissues, of which it is chiefly constituted, and which afibrd a proper nidus for the germ, which derives from so abundant a source the mate- rials of its new development. Its nerves, abundantly distributed through its substance, and having the most intimate and complex connexion with the hypogastric, sacral, and renal plexuses, and indeed, the whole sympathetic system, endow it with a normal and pathological sympathy, coextensive with the body, and a keen sensibility to both intrinsic and extrinsic causes of excitement. Under the circumstances of such a physical constitution we need feel no surprise at observing the extent of disturbing force which it exerts, when diseased, upon the whole economy; nor, indeed, at the rapid destruction it brings upon the living system, whenever it happens to become the scat of disorganizing inflammation. The violent exertions of its contractile power, in labour, are often PUERPERAL FE\'ER. 15 alone sufficient to rupture or lacerate its tissues, and, a fortiori, to injure or disease them. It is also liable to be forcibly and injuri- ously compressed by the tenesmic action of the accessory muscles ; to be subject to contusions by the projecting angles of the foBtus ; or by the bony sides of the pelvis; and to be stimulated by the putrid discharges and absorptions incident to its lochial state. It is con- nected by its vagina in a bond of contiguous sympathies propa- gated along that canal ; which, even more than itself, is subjected to accidents in the parturient act. It is attached to the ovaries, which seem to carry throughout pregnancy, and even for many months after delivery, an invitation to disease in the uncased re- mains of the corj)ora lutea, and in which, it is plausibly sup- posed, the first germs of some of the puerperal intiammations take their rise. It is attached by the broad ligaments to the sides of the pelvis. These ligaments are occupied with an abundant cel- lular tissue, liable to infiltrations and the consequences of pres- sure, contusion, and disruption in labour. It is invested by a peritoneum; a vascular membrane, in which superficial inflam- mation spreads, with the rapidity of erysipelas, over extended sur- faces. This peritoneum is a component part of the womb — it is its investing membrane — its coat ; and it is also common, as a tissue, to the whole alimentary tube, as weU as to the liver, the spleen, the diaphragm, the bladder, and the abdominal muscles. Inflam- mation of the intestinal, gastric, or hepatic peritoneum, is also in- flammation of those several organs ; and, in fine, a peritonitis attacking a childbed patient, which becomes at all extensive, radiating from the surface of the womb, soon involves in its dis- astrous embrace every important abdominal viscus : hence the tympanites ; hence the constipation or the diarrhoea ; and hence, at last, and as closing phenomena, the nausea, the eructations of incipient gastritis, and the last fatal regurgitation of the puer- peral black vomit.* But not only are the reproductive organs liable to be attacked by a simple peritonitis destined to extend far and wide ; they are the not unfrequent seats of phlebitis after labour. The placental superfices of the womb, generally the most vas- cular part of the organ, is frequently left in a state comparable to that of a wounded organ ; portions of the texture are slightly torn, or small shreds of the placental lobules are left adhering, and even the mouths of uterine vessels are, for days in succession, found discharging the lochial fluids. Under such circumstances, the veins inflame as do the veins in an amputated limb — the frequent cause of death from that surgical operation : and when inflamed, their mucous, or common membrane, like the mucous surface of the larynx or trachea, soon begins to be covered with inflammatory or plastic exudation ; it becomes thickened, and is the seat of a pyogenic irritation. Under such circumstances, the future drainage of the blood thrown into the organ by the arteries is impeded or wholly suspended. The blood injected into the womb through the ovarian and uterine arteries can no longer freely pass ofl" by the ute- rine or ovarian veins, whose lining membrane becomes the seat of hasty and plastic inflammation, which either wholly obstructs the tubes, or so far diminishes their calibre as seriously to interfere with the passage through the capillary and even the larger vessels. The observations that I have had opportunities to make, have led me to the conclusion, that the process of inflammation, ob- struction, and destruction of the lining membrane of veins, may be hurried on with a celerity equal to that of the most rapid croup. But these changes of structure in organs indispensably necessary to the constitution of the womb, imply as a consequence its own inevitable destruction with that of the patient. The numerous absorbents of the womb may be viewed under the same light, and as being placed in the same category. Besides the above too abundant sources of danger and evil, there is a great liability to inflammation of the womb alone, and not extending beyond its proper texture. This inflamma- tion, like that in some other tissues, reduces the womb almost to the state of a pulp, in certain cases, so that it may be pierced through with the point of a knife, or torn with the slightest force.* We have seen instances in which considerable portions of the inner extending nearly half way through to the peritoneal surface, have been converted, within seventy or eighty hours, to a soft and gangrenous material, almost fit to be described as a colhivies or liquamen. Such diseases as these are to be cured soon, or not at all. It is like a battle — " Quid est ! Concurritur, et momento horce, aut cita mors venit, aut loeta victoria." If the nurse allow the precious moments of the forming stage to elapse before the alarm is taken ; in ihe uterine veins is squeezed out from their cavities ; and so great is the ap- parent rush, that the sound is extremely disagreeable; on account, I suppose, of the conviction that it is so violent as to compromise, to a certain extent, the safety of the tissues concerned. * Robert Lee gives samples of this ramollissement, or softening, of the uterine texture. PUERPERAL FEVER. 17 or if the physician, through inattention or faihire in making the diagnosis, pursues, in the beginning, a feeble or erroneous prac- tice, no human skill, sagacity, or devotion, can be relied upon to rescue the victim, who has already begun to die before the first- hand is extended for her rescue. We hear and read of numerous cases in which prompt measures have been taken, of the very class we would recommend, but in vain. We admit it has been so, and it must be so often in future ; for, unhappily, the greatest watchfulness is sometimes incapable of detecting the existence of a disease destined to destroy, because the forming stages — the curable ones — are already overpast before the patient herself, much less the nurse or the physician, have perceived the least cause for alarm.* Inflammation of the lining membrane of a vein is not painful in its commencement; nor is inflammation of the bronchus painful in its commencement, to a degree at all commensurate with its dangerous tendency ; so that, it happens, in bad epidemic cases, that the attempt to cure fails, because the aid is presented too late. Unquestionable authority exists to prove, that uterine inflammation, in some cases, has already gone far beyond any curable stage long before the delivery of the child had permitted its existence to be even suspected. Under the above recited circumstances, the question is brought up — What shall we do for the saving of the life committed to our care, humanly speaking ? Can we safely abandon the philosophy of medicine, and, relying upon some vague and ill-defined notion of a constitutional depra- vation, undertake to counteract these vivid and almost electric movements of life, local in their origin and domain, by means of a few drugs applied to the mucous membrane of the stomach or bowels ; by some cataplasms or liniments, or fomentations to the belly ; or, at most, by dozens or hundreds of leeches fixed on the cutis of the abdomen ? What are great inflammations, that they can be overcome by such means; especially inflammations concealed in the very recesses of the body, remote from the surfiices, and deriving their source, their impetus, their proximate cause, their ijisissima causa, from the injecting power of arteries springing directly from the emulgents, the aorta, or the hypogastric tubes '? It would appear to me to be mere dawdling with the malady, in comparison with the vigorons and masterful influences of blood- letting, which is perfectly obedient to the will of the physician, goes directly to its object, and stops short at the desirable point : which reduces the injecting force of the systemic ventricle, and *I am disposed to believe, from opportunities recently enjoyed, that even the constitution of the patient does not take the alarm in some examples of phlebitis, until the disease has already reached a certain stage of development, at which it is incurable. This is undoubtedly the case in certain cases of crural phle- bitis—where our attention is called to a state of the limb, just discovered by the patient, and which must have already existed many hours before she herself detected or even suspected any disorder. 1-8 MEIGS'S INTRODUCTORY ESSAY. brings it to such a state as to leave the necessary equipoise between all the parts of the angiotenic apparatus : a therapeutic agent^ which, wisely and well directed to the exigencies of the case, surpasses all other modes of relief or cure. In the application of this great measure for the cure of these puerperal inflammations, I might feel content to refer to the exhor- tations of Gordon, to be firm and decided ; and I trust that every one of my medical brethren who may read his book, will give due weight to his energetic expressions on that point. But I cannot resist the desire I feel to remark, that a feeble and timid employ- ment of the measure will be likely, not only to fail of success, but even to give additional impetuosity to the disorganising tenden- cies of the malady.* The pulse, under certain circumstances of constitutional irritation, is found to be in the state which Dr. Rush characterised as the oppressed pulse, — a pulse in which the beat is apparently feeble, and rendering it doubtful whether a safe re- course is to be had to the lancet ; but which, after the abstraction of a certain quantity of blood, rises and bounds like a full syno- chusfortis action. To raise the pulse to this condition, and leave it so, is to disengage the heart — the injectingpower — from some- thing that obstructed and embarrassed its action ; and to enable it, by setting it at liberty, as it were, to force new and greater torrents of blood into the inflamed parts, impacting it there, and extending the inflammatory engorgements and obstructions into the collateral capillaries in every direction. Hence it is apparent, that in using venesection as a remedy, it will not suffice to stop as soon as the pulse has risen : it must be carried to the extent of subduing and reducing down within safe limits the power which it is insti- tuted to control. If there be anything true in medicine, it is that all the nervous, muscular, and nutritive functions, have a very close dependence upon the circulation of the blood. An increase of the momentum of the blood tends to augment the development of the nervous force ; every organ is stimulated and brought to a higher degree and expression of vital power by increased rapidity of the blood's motion. On the contrary, diminished intensity of its motion tends to diminish the innervative force, with all the action of all the organs dependent on that force. To bleed in fevers and inflam- mations, is to lessen them. But the question is, not as to bleeding ; it is, as to how much ? by what sign shall we know when to stop ? Is there a safe limit ? What is that safe limit ? The practitioner is the sole judge. It is easy to stop short of its attainment : it is by no means difficult * There is great difliculty, except in the clearest cases of violent reaction, in bringini^ one's mind to the point of courage so anxiouslj' inculcated by Gordon, and which it seems he himself found it hard to attain. Let the reader of his book ponder well his directions ; and if they meet the concurrence of his judg- ment, let him bear them in mind at the clinic — "Jug^/arc/eirtm" should be the motto in such cases. PUERPERAL FEVER. I9 to go beyond it ; and thus render most injurious a means designed only for good. Experience is the only teacher : the physician must have acquired that familiarity with the condition of the pulse, in health and disease, that can alone enable him to say — this is sufficient ; the movement of the circulation is now no longer destructive or dangerous ; the columns of blood driven through the arterial tubes upon the inflamed tissues, reach them with a force sufficiently moderate to permit them to recover. Experience, habit, tact, sagacity, these will govern him, and show him that he can go no further safely. Gordon insists upon twenty-four ounces, as the quantity to be drawn in the early stage — within twenty -four hours of the attack — and looked with confidence to a cure when that quantity could be drawn. I find no objection to his standard, which is concurred in by Hey, with certain excep- tions. It is probably sufficiently large to effect the desirable degree of reduction in most cases, but I should not be willing to adopt it as a universal rule ; since there are m.any constitutions that would bear a greater abstraction than he proposes without injury, while others would not endure to lose near so much without a fall of the rate of circulation below the desirable point: the same point, in a word, being attainable in some by twenty-four ounces, in others by thirty, and in others, again, by twelve or fifteen. Let the pulse de- clare; let the breathing declare; let the cessation of pain declare ; let the general sensations of the patient declare : while her voice, ges- ture, ^ecM6//M5, andphysiognomonic expression, concur in indicat- ing that enough has been done, and not too little, nor too much. There is not, and there cannot be, any safety in practising physic by a rule. The state of the case ought always first to be made out, and understood ; the physiological rate of the parts concerned in disease should be detected, as well as the epiphenomena which the prime disorders have superinduced ; and from this knowledge should be collected the indications of cure, and the precise agents of that process determined. The innervation, the circulation, and the respiration, are the great offices of the constitution : all con- stitutional disorders must implicate one or more of them. Let the physician take care that these sufter no material detriment in the case ; and the remaining functions that are of greater or less vital importance will be all the safer for the wise precau- tions he may take as to these principal ones. Death must, in every instance, depend upon the cessation of vital action, either in the brain, or heart, or lungs, according to the beautiful exposition of Bichat. Let the medical attendant, then, in his plan for the treat- ment of such grave disorders as those under consideration, adapt his measures to the conservation or rectification of these functions. I say again, then, let the pulse declare ; let the breathing declare ; let the pain, the decubitus, the expression, &c., all concur in declaring what he ought to do, and teach him that he is about to do, or has done, right ; neither too little, nor too much. 20 MEIGS'S INTRODUCTORY ESSAY. There is a valuable work by Dr. Legonais, published in 4to., Paris, 1820. It is entitled, " Reflections and Observations on the Employment of Bleeding, and of Purgatives in the Treatment of Puerperal Fever^ This gentleman appears to have had a very- enlarged field for observation on the subject in question, and claims, with apparent justice, to be heard on the topic. He sets forth (p. 12) the evidences which go to prove that the disease is an inflammation. He says : — To acknowledge that the disorder most common to lying-in women is an inflammatory one, is to admit that san- guine evacuations must constitute an essential part of its treat- ment. We cannot avoid the adoption of such a proposition : its truth is demonstrated to us; and we have on this point the highest degree of conviction that can be attained in medicine. But we are far from admitting this without qualification ; and, however great may be the acknowledged utility of venesection in puerperal peri- tonitis, as a general proposition, it appears to us equally important that its employment should be subjected to certain rules in order to insure its success: without such rules even venesection, instead of proving useful, becomes injurious to the disease, (p. 17.) Dr. L. thinks, that venesection is applicable to the first stage, or stage of irritation ; and that, when the inflammatory move- ment has gone so far as clearly to indicate to what termination it tends, the use of bloodletting serves only to derange the action or hasten that result, whatever it may be. He admits that the duration of this stage may be very different in diflerent subjects : the medical attendant is to judge of the duration, (p. 17-18.) He contends that this stage does not extend beyond twenty-four hours, and that he has never seen any good result from it at a later day, except in a very small number of cases ; and even in these the abstractions have been so small in quantity as to leave room to doubt of their influence, if any. (p. 19.) The paragraph commencing at p. 21 is devoted to the question, as to the quantity of blood to be taken ; which, Dr. L. insists, should be large enough, Jugularefehrim, as Galen says, to destroy it at a blow, and not merely to weaken the force of the disease for a short period, in order that it might rise with greater power in a system weakened and not saved by the first operation. He finds the fault, generally found with Leake, who, understanding the nature of the case well, and urging early and free bloodletting, yet did not himself go beyond eight or ten ounces. Again: — "We believe, then, that in treating puerperal fever by bloodletting, the object sliould be to abolish the disease entirely by the powerful and energetic use of the remedy. It is the fabu- lous hydra, which can only be destroyed by cutting oft' at a blow all the heads. If a single one be spared it is sufficient to keep alive a vital principle, which soon reproduces the monster- more terrible than before." (p. 23.) TUERPERAL FEVER. 21 In a paragraph, at p. 24, he regards the quantity needful as eighteen, twenty, or twenty-four ounces at the first operation ; less than this rarely produces an advantageous and sure result. The student of the history of childbed fever will not have failed to observe, that many individuals of the profession v/ho have been called upon to encounter the disease in question, when it pre- vailed as an epidemic, have trusted to the use of remedies, which, although not successful in curing the disorder, or saving the pa- tient from death, yet could not be accused of mischievous or per- nicious action in the case. This arises from tlie less obvious or less evident nature of the operation of drugs than of venesection, which produces effects so sudden and palpable upon the great vital functions, as to render them intelligible to the ordinary by- standers and friends. A patient taking large doses of calomel or James's powder, or ipecacuanha, or purgatives, if she grows worse and worse in childbed fever, will be readily supposed to do so, notwithstanding the salubrious tendencies of their operations : Post hoc,sed non propter hoc. Whereas, should she decline as rapidly under the use of the lancet, that decline is apt to be charged directly to the loss of blood. Dr. Robert Collins of Dublin, in his Practical Treatise on Midwifery ^"^ says, that of the eighty-eight cases which he had under his care while Master of the Dublin Lying- in Hospital, thirty-two recovered and fifty-six died. (p. 190.) Dr. Collins, in this important work, discourages the use of vene- section in the epidemic forms of the disorder. Let it be observed, however, that he had eighty-eight cases, of which fifty-six died, and thirty-two recovered. He says, " In fifteen only of the eighty- eight, did we deem it advisable to bleed generally ; seven of the fif- teen recovered." Notwithstanding this, the doctor gives the follow- ing summary : — "The result of my observations upon the treatment of puerperal fever is, that general bleeding, except when there is a strong, full pulse, and the symptoms are of a highly inflammatory character, is injurious. On the contrary, local depletion, by the application of three or four dozen leeches, followed by the warm- bath and stuping, all of which should be repeated according to circumstances, and as often as the strength will permit, seemed most beneficial. These means, together with the active employ- ment of calomel, conjoined with hippo or opium, ofier the best prospect of relief. this opinion he has many supporters. But, accustomed to look for causes sufficient, and not more than sufficient, for the production of certain effects, I find myself still unable to believe that he and those who think with him are right. Phlebitis of the recently dis- charged womb is alone sufficient to produce all the frigVitful rapidity of which Dr. Collins speaks — so is gangrenous inflam- mation of the inner paries of the organ ; and equally capable of causing a rapid, a most sudden overthrow of all the functions, is an inflammation of the whole peritoneum ; by which is implied, as I have before explained, a disease of every organ which receives an investment of the peritoneal membrane as part and parcel of its own nature and texture. 