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PUERPERAL STATE. 
Being Part the Fifth 
FROM 
A TREATISE ON THE SCIENCE AND PRACTICE OF MIDWIFERY. 
By W. S. PLAYFAIR, M.D., F.R.C.P., 
PHYSICIAN ACCOUCHEUR TO H. I. AND R. H. THE DUCHESS OF EDINBURGH; PROFESSOR OF OBSTETRIC 
MEDICINE IN KING’S COLLEGE, LONDON, ETC. 
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By ROBERT P. HARRIS, M.D. 
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HENRY C. LEA’S SON & CO. 
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[all rights reserved.] CONTEXTS. 
CHAPTER. PAGE. 
I. The Puerperal State and its Management, .... 3 
II. Management of the Infant, Lactation, etc., . . . .10 
III. Puerperal Eclampsia, 20 
IV. Puerperal Insanity, 26 
V. Puerperal Septicaemia, 33 
VI. Puerperal Venous Thrombosis and Embolism, . . .48 
VII. Puerperal Arterial Thrombosis and Embolism, . . .55 
VIII. Other Causes of Sudden Death during Labor and the 
Puerperal State, 56 
IX. Peripheral Venous Thrombosis (Syn. : Crural Phlebitis— 
Phlegmasia Dolens—Anasarca Serosa—(Edema Lac- 
teum—White Leg, etc.), 58 
X. Pelvic Cellulitis and Pelvic Peritonitis, . . . .62 THE PUERPERAL STATE. 
CHAPTER I. 
THE PUERPERAL STATE AND ITS MANAGEMENT. 
Importance of Studying the Puerperal State.—The key to the management of women 
after labor, and to the proper understanding of the many important diseases which may 
then occur, is to be found in a study of the phenomena following delivery, and of the 
changes going on in the mother’s system during the puerperal period. No doubt nat- 
ural labor is a physiological and healthy function, and during recovery from its effects 
disease should not occur. It must not be forgotten, however, that none of our patients 
are under physiologically healthy conditions. The surroundings of the lying-in woman, 
the effects of civilization, of errors of diet, of defective cleanliness, of exposure to con- 
tagion, and of a hundred other conditions, which it is impossible to appreciate, have 
most important influences on the results of childbirth. Hence it follows that labor, 
even under the most favorab'e conditions, is attended with considerable risk. 
The Mortality of Childbirth.—It is not easy to say with accuracy what is the precise 
mortality accompanying childbirth in ordinary domestic practice, since the returns de- 
rived from the reports of the Registrar-General, or from private sources, are manifestly 
open to serious error. The nearest approach to a reliable estimate is that made by Dr. 
Matthews Duncan,1 who calculates from figures derived from various sources, that not 
fewer than 1 out of every 120 women, delivered at or near the full time, dies within 
four weeks of childbirth. This indicates a mortality far above that which has been 
generally believed to accompany child-bearing under favorab'e circumstances. It, how- 
ever, closely approximates to a similar estimate made by McClintock,2 who calculates 
the mortality in England and Wales as 1 in 126; and in the upper and middle classes 
alone, where the conditions may naturally be supposed to be more favorab'e, at 1 in 
146; more recently he has come to the conclusion, from his own increased experience, 
and the published results of the practice of others, that 1 in 100 would more correctly 
represent the rate of puerperal mortality.3 In these calculations there are some obvious 
sources of error, s’nce they include deaths from all causes within four weeks of delivery, 
some of which must have been independent of the puerperal state. 
But it is not the deaths a’one which should be considered. All practitioners know 
how large a number of their patients suffer from morbid states which may be directly 
traced to the effects of child-bearing. It is impossible to arrive at any statistical con- 
clusion on this point, but, it must have a very sensible and important influence on the 
health of child-bearing women. 
Alterations in the Blood after Delivery.—The state of the blood during pregnancy, 
already referred to, has an important bearing on the puerperal state. There is hyperi- 
nosis, which is largely increased by the changes going on immediately after the birth of 
the child: for then the large supply of blood, which has been going to the uterus, is 
suddenly stopped, and the system must also get rid of a quantity of effete matter 
thrown into the circulation, in consequence of the degenerative changes occurring in 
the muscular fibres of the uterus. Hence all the depurative channels, by which this 
can be eliminated, are called on to act with great activity. If, in addition, the peculiar 
condition of the generative tract be borne in mind—viz., the large open vessels on its 
inner surface—the partially bared inner surface of the uterus, and the channels for ab- 
sorption existing in consequence of slight lacerations in the cervix or vagina—it is not 
a matter of surprise that septic diseases should be so common. 
Condition after Delivery.—It will be well to consider successively the various changes 
1 The “Mortality of Childbed/’ Edin. Med. Journ., Nov., 1869. 
2 Dublin Quarterly Journ., Aug., 1869. 8 Brit. Med. Journ., Aug. 10, 1878. Til E PUERPERAL STATE AND ITS MANAGEMENT. 
going on after delivery, and then we shall be in a better position for studying the 
rational management of the puerperal state. 
Nervous Shock.—Some degree of nervous shock or exhaustion is observable after 
most labors. In many cases it is entirely absent; in others it is well marked. Its 
amount is in proportion to the severity of the labor, and the susceptibility of the patient ; 
and it is, therefore, most likely to be excessive in women who have suffered greatly from 
pa n, who have undergone much muscular exertion, or who have been weakened from 
undue lo s of b’ood. It is evidenced by a feeling of exhaustion and fatigue, and not 
uncommonly there is some shivering, which soon passes off, and is generally followed 
by refreshing sleep. The extreme nervous susceptibility continues for a considerable 
time after delivery, and indicates the necessity of keeping the lying-in patient as free 
from all sources of excitement as possible. 
Fall of the Pulse.—Immediately after delivery the pulse falls, and the importance of 
this, as indicating a favorable state of the patient, has already been alluded to. The 
condition of the pulse has been carefully studied by Blot,1 who has shown that this 
diminution, which he believes to be connected with an increased tension in the arteries, 
due to the sudden arrest of the uterine circu’ation, continues, in a large proportion of 
cases, for a considerable number of days after delivery; and, as a matter of clinical 
import, as long as it does, the patient may be considered to be in a favo able state. In 
many instances the slowness of the pulse is remarkable, often sinking to 50 or even 40 
beats per minute. Any increase above the normal rate, especial'y if at all continuous, 
should always be carefully noted, and looked on with suspicion. In connection with 
this subject, however, it must be remembered that in pue peral women the most trivial 
circumstances may cause a sudden rise of the pu’se. This must be fam liar to every 
practical obstetric an, who has constant opportunity of observing this effect after any 
transient excitement or fatigue. In lying-in hospitals it has gene: ally been observed 
that the occurrence of any particularly bad case will send up the pulse of all the other 
patients who may have heard of it. 
Temperature in, the Puerperal State.—The temperature in the lying-in state affords 
much valuable information. During, and for a short time after labor, there is a s ight 
e’evation. It soon falls to, or even somewhat below, the normal level. Squire found 
that the fall occurred within twenty-four hours, sometimes within twelve hours, after 
the termination of labor.2 For a few days there is often a slight increase of tempera- 
ture, which is probab’y caused by the rapid oxidation of tissue in connection with the 
invo'ution of the uterus. In about forty-eight hours there is a rise connected with the 
establishment of lactation, amounting to one or two degrees over the normal level; but 
this again subsides as soon as the milk is fteely secreted. Crede has a’so shown3 that 
rapid, but transient, rises of temperature may occur at any period, connected with 
trivial causes, such as constipation, errors of diet, or mental disturbances. But, if there 
be any rise of temperature which is at all continuous, especially to over 100° Fahr., and 
associated with rapidity of the pulse, there is reason to fear the existence of some com- 
plication. 
The Secretions and Excretions.—The various secretions and excretions are carried on 
with increased activity after labor. The skin especially acts freely, the patient often 
sweat ing profuse'y. The'e is a’so an abundant secretion of urine, but not uncommon’y 
a difficulty of voiding it, either on account of temporary paralysis of the neck of the 
bladder, resulting from the pressure to which it has been subjected, or ft om swelling 
and occlus'on of the u-ethra. For the same reason the rectum is s’uggish for a tune, 
and constipation is not infrequent. The appetite is generally indifferent, and the patient 
is often thirsty. 
Secretion of Milk.—Generally in about forty-eight hours the secretion of milk be- 
comes established, and th s is occasionally accompanied by a certain amount of consti- 
tutional irritation. The breasts often become turgid, hot, and painful. There may, or 
may not, be some general d’sturbance, quickening of pulse, elevation of temperature, 
possibly shght shiveiing, and a general sense of oppress or), wh'ch are qu'ck’y r elieved 
as the milk is formed, and the breasts erupted by suckling. Squire says that the most 
constant phenomenon connected with the temperature is a s’ight elevat on as the m'lk 
is secreted, rapidly fading when lactation is established. Barker noted elevation, eh her 
of tempo-ature or pu’se, in only 4 out of 52 cases which we>e careful’y watched. There 
can be little doubt that the importance of the so-called “milk fever” has been im- 
mensely exaggerated, and its existence, as a normal accompaniment of the puerperal 
state, is more than doubtful. It is certain, however, that, in a small minority of cases, 
1 Arch. Gen. de Med., 1864. * “ Puerperal Temperatures,” Obstetrical Transactions, vol. ix. 
3Monat. f. Geburt, Dec., 1868. FATTY TRANSFORMATION OF THE MUSCULAR FIBRES. 
5 
there is an appreciable amount of disturbance about the time that the milk is formed. 
Out of 423 cases Maean1 found that in 114, or about 27 per cent., there was no rise of 
temperature; in 226 the temperature did rise to 100° and over, and of these in 32, or 
a.Ltt:e over 7 per cent., the only ascertainable cause was a painful or distended condi- 
tion of the breast. Many modern writers, such as Winckel, Griinewaldt, and d'E-p.ne, 
entirely deny the connection of this disturbance with lactation, and refer it to a slight 
and transient septicaemia. Graily Hewitt remarks that it is most commonly met with 
when the patient is kept low and on deficient diet after delivery, especial y when the 
system is beiow par from haemorihage, or any other cause. This observation wi 1, no 
doubt, account for the comparative rarity of febrile disturbance in connection with lac- 
tation in these days, in which the starving of puerperal patients is not considered neces- 
sary. It is certain that anything deserving the name of mi k fever is now a together 
exceptional, and such feverishness as exists is generally quite transient. It is also a 
fact, that it is most apt to occur in delicate and weakly women, especially in those who 
do not, or are unable to, nurse. There does not, however, seem to be any sufficient 
reason for referring it, even when tolerab’y well marked, to sep.icaenf a. The rel'ef 
which attends the emptying of the breasts seems sufficient to prove its connection with 
lactation, and the discomfort which is necessarily associated with the swollen and turgid 
mammae, is, of itself, quite sufficient to explain it. 
In the urine of women during lactation an appreciable amount of sugar may readily 
be detected. The amount varies according to the condition of the breasts. It increases 
when they are turgid and congested, and is, therefore, most abundant in women in 
whom the breasts are not emptied, as when the child is dead, or when lactation is not 
attempted. 
Contraction of the Uterus after Delivery.—Immediately after delivery the uterus 
contracts firmly, and can be felt at the lower part of the abdomen as a hard, firm mass, 
about the size of a cricket ball. After a time it again relaxes somewhat, and alternate 
relaxations and contractions go on, at intervals, for a considerable time after the expul- 
sion of the p’acenta. The more complete and permanent the contraction, the greater 
the safety and comfort of the patient; for when the organ remains in a state of partial 
relaxation, coagula are apt to be retained in its cavity, while, for the same reason, a:r 
enters more readily into it. Hence decomposition is favored, and the chances of septic 
absorption are much increased; while, even when this does not occur, the muscular 
fibres are excited to contract, and severe after-pains are produced. 
Subsequent Diminution in the Size of the Uterus.—After the first few days the dimi- 
nution in the size of the uterus progresses with great rapidity. By about tlm sixth day 
it is so much lessened as to project not more than.l \ or 2 inches above the pelvic brim, 
while by the eleventh day it is no longer to be made out by abdom’nal palpation. Its 
increased size is, however, still apparent per vaginam, and/shou’d occasion arise for 
making an internal examination, the mass of the lower segment of the uterus, with its 
flabby and patulous cervix, can be felt for some weeks after delivery. This may some- 
times be of practical value in c-a< es in which it is necessary to ascertain the fact of re- 
cent delivery, and, under these circumstances, as pointed out by Simpson, the uter’ne 
sound would also enable us to prove that the cavity of the uterus is considerab-y elon- 
gated. Indeed the normal condition of the uterus and cervix is not regamed untd six 
weeks or two months after labor. These observations are corroborated bv investiga- 
tions on the weight of the organ at different periods after labor. Thus Heschl2 has 
shown that the uterus, immediately after delivery, weighs about 22 to 24 oz. ; within a 
week, it weighs 19 to 21 oz. ; and at the end of the second week, 10 to 11 oz. onljr. At 
the end of the th'rd week, it weighs 5 to 7 oz. ; but it is not until the end of the second 
month that it reaches its normal weight. Hence it appears that the most rapid dimi- 
nution occurs during the second week after delivery. 
Fatty Transformation of the Muscular Fibres.—The mode in which this diminution 
in size is effected is by the transformation of the muscu’ar fibres into molecular fat, 
which is absorbed into the maternal vascular system, which, therefore, becomes loaded 
with a hrge amount of effete material. Heschl has shown that the entire mass of the 
enlarged uterine muse’es are removed, and replaced by newly-formed fibres, which com- 
mence to be developed about the fourth week after delivery, the change being complete 
about the end of the second month. Generally speaking, involution goes on without 
interruption. It is, however, apt to be interfered with by a variety of causes, such as 
premature exertion, intercurrent disease, and, very probably, bv neg’ect of lactation, 
lienee the uterus often remains large and bulky, and the foundation lor many subse- 
quent uterine ailments is laid. 
1 Dublin Journ. of Med. Science, May, 1878. 
2 Researches on the Conduct of the Human Uterus after Delivery. 6 
THE PUERPERAL STATE AND ITS MANAGEMENT. 
Changes in the Uterine Vessels.—Williams has drawn attention to changes occurring 
in the vessels of the uterus, some of which seem to be permanent, and may, should 
further observations corroborate his investigations, prove of value in enabling us to 
ascertain whether a uterus is nulliparous or the reverse ; a question which may be of 
medico-legal importance. After pregnancy he found all the vessels enlarged in calibre. 
Fig. 1. 
Section of a Uterine Sinus from the Placental Site, nine weeks after Delivery. 
(After Williams.) 
The coats of the arteries are thickened and hypertrophied, and this he has observed 
even in the uteri of aged women who have not borne children for many years. The 
venous sinuses, especially at the placental site, have their walls greatly thickened and 
convoluted, and contain in their centre a small clot of blood (Fig. 1). This thickening 
attains its greatest dimensions in the third month after gestation, but traces of it may 
be detected as late as ten or twelve weeks after labor. 
Changes in the Uterine Mucous Membrane.—The changes going on in the lining 
membrane of the uterus immediately after delivery are of great importance in leading 
to a knowledge of the puerperal state. Its cavity is covered with a reddish-gray film, 
formed of blood and fibrine. The open mouths of the uterine sinuses are still visible, 
more especially over the site of the placenta, and thrombi maybe seen projecting from 
them. The placental site can be distinctly made out, in the form of an irregularly oval 
patch, where the lining membrane is thicker than elsewhere. 
Contraction of the Vagina, etc.—The vagina soon contracts, and, by the time the 
puerperal month is over, it has returned to its normal dimensions, but after child- 
bearing it always remains more lax, and less rugose than in nulliparae. The vulva, at 
first very lax and much distended, soon regains its former state. The abdominal 
parietes remain loose and flabby for a considerable time, and the white streaks, p:o- 
duced by the distension of the cutis, very generally become permanent. In some 
women, especially when proper support by bandaging has not been given, the abdomen 
remains permanently loose and pendu’ous. 
The Loclvial Discharge.—From the time of delivery, up to about three weeks 
afterwards, a discharge escapes from the interior of the uterus, known as the lochia. 
At first this consists almost entirely of pure blood, mixed with a variable amount of 
coagula. If efficient uterine contraction have not been secured after the expulsion of 
the placenta, coagula of considerable size are frequently expelled with the lochia for 
one or two days after delivery. In three or four days the distinctly bloody character 
of the lochia is altered. They have a reddish watery appearance, and are known as ADMINISTRATION OF OPIATES GENERALLY UNAD VIS ABLE. 
7 
the lochia rubra or cruenta. According to the researches of Wertheimer,1 they are at 
this time composed chiefly of blood corpuscles, mixed with epithelium scales, mucous 
corpuscles, and the debris of the decidua. The change in the appearance of the dis- 
charge progresses gradually, and about the seventh or eighth day it has no longer a 
red color, but is a pale greenish fluid, with a peculiar sickening and disagreeable odor, 
and is familiarly described as the “ green waters.” It now contains a smaller quantity 
of blood corpuscles, which lessen in amount from day to day, but a considerable num- 
ber of pus corpuscles, which remain the principal constituent of the discharge until it 
ceases. Besides these, epithelial scales, fatty granules, and crystals of cholesterine, are 
observed. Occasionally a small infusorium, which has been named the “ trichomena 
vaginalis,” has been detected ; but it is not of constant occurrence. 
Variation in its Amount and Duration.—The amount of the lochia varies much, 
and in some women it is habitually more abundant than in others. Under ordinary 
circumstances it is very scanty after the first fortnight, but occasionally it continues 
somewhat abundant for a month or more, without any bad results. It is apt again to 
become of a red color, and to increase in quantity, in consequence of any slight excite- 
ment or disturbance. If this red discharge continue for any undue length of time, 
there is reason to suspect some abnormality, and it may not unfrequently be traced to 
slight lacerations about the cervix, which have not healed properly. This result may 
also follow premature exertion, interfering with the proper involution of the uterus; 
and the patient should certainly not be allowed to move about as long as much colored 
discharge is going on. 
Occasional Fetor of the Discharge.—Occasionally the lochia have an intensely fetid 
odor. This must always give rise to some anxiety, since it often indicates the reten- 
tion and putrefaction of coagula, and involves the risk of septic absorption. It is not 
very rare, however, to observe a most disagreeable odor persist in the lochia without 
any bad results. The fetor always deserves careful attention, and an endeavor should 
be made to obviate it by directing the nurse to syringe out the vagina freely night and 
morning with Condy’s fluid and water; while, if it be associated with quickened pulse 
and elevated temperature, other measures, to be subsequently described, will be 
necessary. 
The after-pains, which many child-bearing women dread even more than the labor- 
pains, are irregular contractions, occurring for a varying time after delivery, and result- 
ing from the efforts of the uterus to expel coagula which have formed in its interior. 
If, therefore, special care be taken to secure complete and permanent contraction after 
labor, they rarely occur, or to a very slight extent. Their dependence on uterine 
inertia is evidenced by the common observation that they are seldom met with in 
primiparae, in whom uterine contraction may be supposed to be more efficient, and are 
most frequent in women who have borne many children. They are a preventible com- 
plication, and one which need not give rise to any anxiety; they are, indeed, rather 
salutary than the reverse, for if coagula be retained in utero, the sooner they are 
expelled the better. The after-pains generally begin a few hours after delivery, and 
continue, in bad cases, for three or four days, but seldom longer. They are generally 
increased when the mammae are irritated by suction. When at their height they are 
often relieved by the expulsion of the coagula. In some severe cases they are appar- 
ently neuralgic in character, and do not seem to depend on the retention of coagula. 
They may be readily distinguished from pains due to more serious causes, by feeling 
the enlarged uterus harden under their influence, by the uterus not being tender on 
pressure, and by the absence of any constitutional symptoms. 
Management of Women after Delivery.—The management of women after child- 
birth has varied much at different times, according to fashion or theory. The dread 
of inflammation long influenced the professional mind, and caused the adoption of a 
strictly antiphlogistic diet, which led to a tardy convalescence. The recognition of the 
essentially physiological character of labor has resulted in more sound views, with 
manifest advantage to our patients. The main facts to bear in mind with regard to the 
puerperal woman are, her nervous susceptibility, which necessitates quiet and absence 
of all excitement; the importance of favoring involution by prolonged rest; and the 
risk of septicaemia, which calls for perfect cleanliness and attention to hygienic pre- 
cautions. 
The Administration of Opiates is generally Unadvisable.■—As soon as we are satisfied 
that the uterus is perfectly contracted, and that all risk of. haemorrhage is over, the 
patient should be left to sleep. Many practitioners administer an opiate; but, as a 
matter of routine, this is certainly not good practice, since it checks the contractions of 
1 Virchow’s Arch., 1861. 8 
THE PUERPERAL STATE AND ITS MANAGEMENT, 
the uterus, and often produces unpleasant effects. Still, if the labor have been long 
and tedious, and the patient be much exhausted, 15 or 20 drops of Battley’s solution 
may be administered with advantage. 
Attention to the State of the Puke, Bladder, and Uterus.—Within a few hours the 
patient should be seen, and at the first visit particular attention should be paid to the 
state of the pulse, the uterus, and the bladder. The pulse during the whole period of 
convalescence should be carefully watched, and, if it be at all elevated, the temperature 
should at once be taken. If the pulse and temperature remain normal, we may be 
satisfied that things are going on wed; but if the one be quickened and the other ele- 
vated, some disturbance or comp’ication may be apprehended. The abdomen should 
be felt to see that the uterus is not unduly distended, and that there is no tenderness. 
After the first day or two this is no longer necessary. 
Treatment of Retention of Urine.—Sometimes the patient cannot at first void the 
urine, and the application of a hot sponge over the pubis may enable her to do so. 
If the retention of urine be due to temporary paralysis of the bladder, three or four 
20-minim doses of the liquid extract of er ;ot, at intervals of half an hour, may prove 
succe sfxd. Many horn s should not be allowed to elapse without relieving the patient 
by the catheter, since prolonged retention is on’y likely to make matters worse. Sub- 
sequently, it may be necessary to empty the bladder night and morning, until the 
patient regain her power over it, or until the swelling of the urethra subsides, and this 
will generally be the case in a few days. Occasionally the bladder becomes largely dis- 
tended, and is relieved to some degree by dribbling of urine from the urethra, Such 
a state of things may deceive the patient and nurse, and may produce serious conse- 
quences by caus’ng cystitis. Attention to the condition of the abdomen will prevent 
the practitioner from being deceived, for in addition to some constitutional disturbance, 
a large, tender, and fluctuating swelling will be found in the hypogastric region, dis- 
tinct from the uterus, which it disp’aces to one or other side. The catheter will at 
once prove that this is produced by distension of the bladder. 
Treatment of Severe After-paiis.—If the after-pains be very severe, an opiate may 
be administered, or, if the lochia be not over-abundant, a linseed-meal poultice, 
sprinkled with laudanum, or with the chloroform and belladonna lirfment, may be 
applied. If proper care have been taken to induce uterine contraction, they will seldom 
be sufficiently severe to lequire treatment. In America, quinine in doses of 10 grains 
twice daily, has been strongly recommended, especiady when opiates fail, and when the 
pa’ns are neuralgic in character, and I have found this remedy answer extremely well. 
The quin'ne is best given in solution with 10 or 15 minims of hydrobromic acid, which 
materially lessens the unpleasant head symptoms often accompanying the administra- 
tion of such large doses. 
Diet and Regimen.—The diet of the puerperal patient claims careful attention, the 
more so as old prejudices in this respect are as yet far from exploded, and as it is by no 
means rare to find mothers and nurses who still cling tenaciously to the idea that it is 
essential to prescribe a low regimen for many days after labor. The erroneousness of 
this plan is now so thoroughly recognized, that it is hardly necessary to argue the point, 
There is, however, a tendency in some to err in the opposite direction, which leads 
them to ins:st. on the patient’s consnm ng solid food too soon after delivery, before she 
has regained her appetite, tiie.eby producing nausea and intestinal derangement. Our 
best guide in th:s matter is the feelings of the patient herself. If, as is often the case, 
she be disincl'ned to eat, there is no reason why she should be urged to do so. A good 
cup of beef-tea, some b"ead and milk, or an egg beat up with milk, may generally be 
given with advantage shortly after delivery, and many patients are not inclined to take 
more for the first day or so. If the patient be hungry there is no reason why she 
should not have some more solid, but easily digested food, such as white fish, chicken, 
or sweet-b ead; and, after a day or two, she may resume her ordinary diet, bearing in 
mind that, being confined to bed, she cannot with advantage consume the same amount 
of solid food as when she is up and about. Dr. Oldham, in his presidential address to 
the Obstetrical Society,1 has some apposite remarks on this point, which are worthy of 
quotation. “A puerperal month under the guidance of a monthly nurse is easily drawn 
out, and it is well if a love of the comforts of illness and the persuasion of be'ng deli- 
cate, which are the infirmities of many women, do not induce a feeb’e life, which long 
survives af,er the occasion of it is forgotten. I know no reason why, if a woman is 
confined early in the monfing, she should not have her breakfast of tea and toast at 
nine, her luncheon of some digestible meat at one, her cup of tea at five, her dinner 
with chicken at seven, and her tea again at nine, or the equivalent, according to the 
1 Obstet. Trans., vol. vi. SUBSEQUENT TREATMENT. 
9 
variation of her habits of living. ’ ’ [The practice in general in the United States has 
been to avoid the use of stimulating food for two or three days after delivery, on the 
same principle that low diet is used in the different forms of abdominal surgery. FulF 
diet and animal food might poss.bly answer in many of our cases without risk; and beef 
essence, we know, is of much value after haemorrhage, but in healthy, vigorous subjects 
I see no occasion to ignore the teaching of the past, when based upon sound reasoning. 
I believe in dieting the robust, and feeding up the delicate. By “dieting” I do not 
mean the o d starvation system; but plain, simple, nutritious food.—Ed. J “ Of course, 
there is the common-sense selection of articles of food, guarding against excess, and 
avoiding stimu'ants. But gruel and slops, and all intermediate feeding are to be 
avoided.” No one who has seen both methods adopted can fail to have been struck 
with the more rapid and satisfactory convalescence which takes place when the patient’s 
strength is not weakened by an unnecessarily low diet. Stimu ants, as a rule, are not 
required; but, if the patient be weakly and exhausted, or if she be accustomed to their 
use, there can be no reasonable objection to their judicious administration. 
Attention to Cleanliness, etc.—Immediately after delivery a warm napkin is applied 
to the vulva, and, after the patient has rested a little, the nuise removes the so led 
linen from the bed, and washes the external genitals. It is impossible to pay too much 
attention during the subsequent progress of the case to the maintenance of perfect 
cleanliness. Perfectly antiseptic midwifery is no doubt an impossibility; but a near 
approach to it may be made, and the greater the care taken, the more certainly will the 
safety of the patient be insured. It will be a wise precaution to advise the nurse never 
to touch the genitals for the first few days, unless her hands have been moistened in a 
I in 20 solution of carbolic acid, or lubricated with carbolized oil. The linen should be 
frequently changed, and all d'rty linen and discharges immediately removed from the 
apartment. The vulva should be washed dally with Condy’s fluid and water, and the 
patient wi.l derive great comfort from having the vagina syringed gently out once a day 
with the same solution. The remarkable diminution of mortality which has followed 
such antiseptic precautions in certain Lying-in Hospitals in Germany, well shows the 
importance of these measures. The room should be kept tolerably cool, and fresh air 
freely adm'tted. 
Action of the Bowels. —It is customary on the morning of the second or third day, 
to secure an action of the bowels; and there is no better way of doing this than by a 
large enema of soap and water. If the patient object to this, and the bowels have not 
acted, some mild aperient may be administered, such as a small dose of castor oil, a few 
frains of colocynth and henbane pill, or the popular French aperient, the “Tamar 
ndien. ” 
Lactation.—The management of the suckling and of the breasts forms an important 
part of the duties of the monthly nurse, which the practitioner should himself super- 
intend. This will be more conveniently discussed under the head of lactation. 
Importance of Prolonged Rest.—The most import ant part of the management of the 
puerperal state is the securing to the patient prolonged rest in the horizontal position, 
m order to favor proper involution of the uterus. For the first few days she should be 
kept as quiet and still as poss’ble, not receiving the visits of any but her nearest rela- 
tives, thus avoiding all chance of undue excitement. It is customary among the better 
classes for the patient to rema’n in bed for eight or ten days; but, provided she be 
doing well, there can be no objection to her lying on the outside of the bed, or slipping 
on to a sofa, somewhat sooner. After ten days or a fortnight she may be permitted to 
sit on a cha'r for a little; but I am convinced that the longer she can be persuaded to 
retain the recumbent position, the more complete and satisfactory will be the progress 
of involution, and she should not be allowed to walk about until the third week, about 
which time she may also be permitted to take a drive. If it be borne in mind that it 
takes from six weeks to two months for the uterus to regain its natural size, the reason 
for prolonged rest will be obvious. The judicious practitioner, however, while insisting 
on this point, will take measures at the same time, not to allow the patient to lapse into 
the habit of an invalid, or to give the necessary rest the semblance of disease. 
Subsequent Treatment. —Towards the termination of the puerperal months some slight 
tonic, such as small doses of quinine with phosphoric acid, may be often given with 
advantage, especially if convalescence be tardy. Nothing is so beneficial in restoring 
the patient to her usual health as change of air, and in the upper classes a short visit 
to the seaside may generally be recommended, with the certainty of much benefit. 10 
MANAGEMENT OF THE INFANT, LACTATION, ETC. 
CHAPTER II. 
MANAGEMENT OE THE INFANT, LACTATION, ETC. 
Commencement of Respiration.—Almost immediately after its expulsion, a healthy 
child cries aloud, thereby showing that respiration is established, and this may be taken 
as a signal of its safety. The first respiratory movements are excited, partially by reflex 
action resulting from the contact of the cold external air on the cutaneous nerves, and 
partly by the direct irritation of the medulla oblongata, in consequence of the circula- 
tion through it of blood no longer oxygenerated in the placenta, 
Apparent Death of the New-born Child.—Not infrequently the child is born in an 
apparently lifeless state. This is especially likely to be the case when the second stage 
of labor has been unduly prolonged, so that the head has been subjected to long-con- 
tinued pressure. The utero-placental circulation is also apt to be injuriously interfered 
with before the birth of the child when a tardy labor has produced tonic contraction of 
the uterus, and consequent closure of the uterine sinuses ; or, more rarely, from such 
causes as the injudicious administration of ergot, premature separation of the placenta, 
or compression of the umbilical cord. In any of these cases it is probable that the 
arrest of the utero-placental circulation induces attempts at inspiration, which are 
necessarily fruitless, since air cannot reach the lungs, and the foetus may die asphyxi- 
ated ; the existence of the respiratory movement being proved on post-mortem exami- 
nation by the presence in the lungs of liquor amnii, mucus, and meconium, and by the 
extravasation of blood from the rupture of their engorged vessels. 
Appearance of the Child in such Cases.—In most cases, when the child is born in a 
state of apparent asphyxia, its face is swollen and of a dark livid color. It not infre- 
quently makes one or two feeble and gasping efforts at respiration, without any definite 
cry; on auscultation the heart may be heard to beat weakly and slowly. Under such 
circumstances there is a fair hope of its recovery. In other cases the child, instead of 
being turgid and livid in the face, is pale, with flaccid limbs, and no appreciable cardiac 
action, then the prognosis is much more unfavorable. 
Treatment of Apparent Death.—No time should be lost in endeavoring to excite res- 
piration, and, at first, this must be done by applying suitable stimulants to the cutane- 
ous nerves, in the hope of exciting reflex action. 'The cord should be at once tied, and 
the child removed from the mother; for the final uterine contractions have so com- 
pletely arrested the utero-placental circulation, as to render it no longer of any value. 
If the face be very livid, a few drops of blood may with advantage be allowed to flow 
from the cord before it is tied, with the view of relieving the embarrassed circulation. 
Very often some slight stimulus, such as one or two sharp slaps on the thorax, or 
rapidly rubbing the body with brandy poured into the palms of the hands, will suffice 
to induce respiration. Failing this, nothing acts so well as the sudden and instantane- 
ous application of heat and cold. For this purpose extremely hot water is placed in 
one basin, and quite cold water in another. Taking the child by the shoulders and legs, 
it should be dipped for a single moment into the hot water, and then into the cold; and 
these alternate applications may be repeated once or twice, as occasion requires. The 
effect of this measure is often very marked, and I have frequently seen it succeed when 
prolonged efforts at artificial respiration had been made in vain. 
Artificial Respiration.—If these means fail, an endeavor must be at once made to 
carry on respiration artificially. The Sylvester method is, on the whole, that which is 
most easily applied, and, on account of the compressibility of the thorax, it is peculiarly 
suitable for infants. The child being laid on its back, with the shoulders slightly ele- 
vated, the elbows are grasped by the operator, and alternately raised above the head, 
and slowly depressed against the sides of the thorax, so as to produce the effect of in- 
spiration and expiration. If this do not succeed, the Marshall Hall method may be 
substituted ; and one or more of the plans of exciting reflex action through the cutane- 
ous nerves may be alternated with it. 
Insufflation of the Lungs.—Other means of exciting respiration have been recom- 
mended. One of them, much used abroad, is the artificial insufflation of the lungs by 
means of a flexible catheter guided into the glottis. It is not difficult to pass the end 
of a catheter into the glottis, using the little finger as a guide ; and once in position, it 
may be used to blow air gently into the lungs, which is expelled by compression on the APPLICATION OF TIIE CHILD TO THE BREAST. 
11 
thorax, the insufflation being repeated at short, intervals of about ten seconds. One 
advantage of this plan is, that it allows the liquor amnii and other fluids, which may 
have been drawn into the lungs in the premature efforts at respiration before birth, to 
be sucked up into the catheter, and so removed from the lungs. The same effect may 
be produced, but less perfectly, by placing the hand over the nostrils of the child, 
blowing into its mouth, and immediately afterwards compressing the thorax.1 One of 
these methods should certainly be tried, if all other means have failed. Faradization 
along the course of the phrenic nerves is a promising means of inducing respiration, 
which should be used if the proper apparatus can be procured. Encouragement to 
persevere in our endeavors to resuscitate the child may be derived from the numerous 
authenticated instances of success after the lapse of a considerable time, even of an 
hour or more. As long as the cardiac pulsations continue, however feebly, there is no 
reason to despair. 
Washing and Dressing of the Child.—When the child cries lustily from the first, 
it is customary for the nurse to wash and dress it as soon as her immediate attendance 
on the mother is no longer required. For this purpose it is placed in a bath of warm 
water, and carefully soaped and sponged from head to foot. With the view of facili- 
tating the removal of the unctuous material with which it is covered, it is usual to 
anoint it with cold cream or olive oil, which is washed off in the bath. Nurses are 
apt to use undue roughness in endeavoring to remove every particle of the vernix 
caseosa, small portions of which are often firmly adherent. This mistake should be 
avoided, as these particles will soon dry up and become spontaneously detached. The 
cord is generally wrapped in a small piece of charred linen, which is supposed to have 
some slight antiseptic property, and this is renewed from day to day until the cord has 
withered and separated. This generally occurs within a week; and a small pad of 
soft linen is then placed over the umbilicus, and supported by a flannel belly-band, 
placed round the abdomen, which should not be too tight, for fear of embarrassing 
the respiration. By this means the tendency to umbilical hernia is prevented. [As 
the vernix caseosa is readily miscible with pure lard, and can be easily removed by its 
means, it has become the practice with many obstetricians in the United States to 
order the infant to be well anointed and then wiped from head to foot with soft rags, 
until all the vernix disappears and the skin retains a slight oily trace, not enough to 
soil the clothing. By this means water is avoided, and with it much of the risk of 
taking cold; and the skin is left less sensitive after the sudden change which it is 
made to endure at birth than when subjected to hot water and soap. In the hot 
months water is preferable at the first dressing.—Ed.] 
Clothing, etc.—The clothing of the infant varies according to fashion and the cir- 
cumstances of the parents. The important points to bear in mind are that it should 
be warm (since newly-born children are extremely susceptible to cold), and at the same 
time light and sufficiently loose to allow free play to the limbs and thorax. All tight 
bandaging and swaddling, such as is so common in some parts of the Continent, should 
be avoided, and the clothes should be fastened by strings or by sewing, and no pins 
used. At the jiresent day it is customary not to use caps, so that the head may be 
kept cool. The utmost possible attention should be paid to cleanliness, and the child 
should be regularly bathed in tepid water, at first once daily, and after the first few 
weeks both night and morning. After drying, the flexures of the thighs and arms, 
and the nates, should be dusted with violet powder or Fuller’s earth, to prevent chaf- 
ing of the skin. The excrements should be received in napkins wrapped round the 
hips, and great care is required to change the napkins as often as they are wet or 
soiled, otherwise troublesome irritation will arise. A neglect of this precaution, and 
the washing of the napkins with coarse soap or soda, are among the pr’ncipal causes 
of the eruptions and excoriations so common in badly cared for children. When 
washed and dressed the ch’ld may be placed in its cradle, and covered with soft 
blankets or an eider-down quilt. 
Application of the Child to the Breast.—As soon as the mother has rested a little, 
it is advisable to place the child to the breast. This is useful to the mother by favoring 
uterine contraction. Even now there is in the breasts a variable quantity of the peculiar 
fluid known as colostrum. This is a viscid yellowish secretion, different in appear- 
ance from the thin bluish milk which is subsequently formed. Examined under the 
microscope it is found to contain some milk globules, a number of large granular and 
small fat corpuscles. It has a purgative property, and soon produces with less irritation 
than any of the laxatives so generally used, a discharge of the meconium with which 
[l When this is done the oesophagus must be closed by placing the thumb and fingers on opposite 
sides of the larynx, and pressing it backward, just before blowing in the mouth. When this is ac- 
complished so as to fill the lungs, the thorax should be pressed, and the inflation repeated.—Ed.] 12 
MANAGEMENT OF THE INFANT, LACTATION, ETC. 
the bowels are loaded. Hence the accoucheur should prohibit the common practice of 
administering castor oil, or other aperient, within the first few days after birth, 
although there can be no objection to it, in special cases, if the bowels appear to act 
inefficiently and with difficulty. 
Ocer-frequent Suckling should he Avoided.—For the first few days, and until the 
secretion of milk is thoroughly established, the child should be put to the breast at 
long intervals only. Constant attempts at suckling an empty breast lead to noth'ng 
but disappointment, both to the mother and child, and by unduly irritating the 
mammae, sometimes to positive harm. Therefore, for the first day or two, it is suffi- 
cient if the child be appl'ed to the breast twice, or at most three times, in the twenty- 
four hours. Nor is it necessary to be apprehensive, as many mothers naturally are, 
that the child will suffer from want of food. A few spoonfuls of milk and water being 
given from time to time, the child may generally wait without injury until the milk is 
secreted. This is generally about the third day, when the secretion is found to be a 
whitish fluid, more watery in appearance than cow’s milk, and showing under the 
microscope an abundance of minute spherical globules, refracting light strongly, which 
are abundant in proportion to the quality of the milk. A certa'n number of granular 
corpuscles may also be observed shortly after the birth of the child, but after the first 
month, these should have almost altogether disappeared. The reaction of human 
milk is decidedly alkaline, and the taste much sweeter than that of cow s milk. 
Importance of Nursing when Practicable.—The importance to the mother of nurs- 
ing her own child, whenever her health permits, on account of the favorable influence 
of lactation in promoting a proper involution of the uterus, has already been insisted 
on. Unless there be some positive contra-indication, such as a marked strumous 
cachexia, an hereditary phthisical tendency, or great general debility, it is the duty of 
the accoucheur to urge the mother to attempt lactation, even if it be not carried on 
more than a month or two. It is, however, the fact that in the upper classes of 
society a large number of patients are unable to nurse, even though willing and 
anxious to do so. In some there is hardly any lacteal secretion at all, in others there 
is at first an over-abundance of watery and innutritious milk, which floods the breasts, 
and soon dies away altogether. 
When the Mother cannot Nurse a Wet Nurse should he Procured..—Whenever the 
mother cannot or will not nurse, the question will arise as to the method of bringing 
up the child. From many causes there is an increasing tendency to resort to bottle- 
feeding, instead of procuring the services of a wet nurse, even when the question of 
expense does not come into cons’deration. No long experience is required to prove 
that hand-feeding is a bad and imperfect substitute for nature’s mode, and one which 
the practitioner should discourage whenever it lies in his power to do so. It is true 
that, in many cases, bott’e-fed children do well; but there is good reason to believe 
that, even when apparently most successful, the children are not so strong in after-life 
as they would have been had they been brought up at the breast. When, in addition, 
it is borne in mind how much of the success of hand-feeding depends on intelligent 
care on the part of the nurse, what evils arc apt to accrue from injurious selection of 
food, and from ignorance of the commonest laws of dietetics, there is abundant reason 
for urging the substitution of a wet nurse, whenever the mother is unable to undertake 
the sucki ng of her child. It must be admitted that good hand-feeding is better than 
bad wet-nursing, and the success of the latter hinges on the proper selection of a wet 
nurse. As this falls witlun the dut:es of the practitioner, it will be we 1 to po'nt out 
the qualities which should be sought for in a wet nurse, before proceeding to discuss 
the mode of rearing the child at the breast. 
Selection of a, Wet Nurse.—In selecting a wet nurse, we should endeavor to choose a 
strong, healthy woman, who should not be over 30, or 35 years of age at the outside, since 
the quality of the milk deteriorates in women who are more advanced in life. For a 
simi'ar reason a very young woman of 16 or 17 should be rejected. It is needless to 
say that care must be taken to ascertain the absence of all traces of constitutional dis- 
ease, especially marks of scrofula, or enlarged cervical or inguinal g’ands, which may 
poss'bly be due to antecedent syphilitic taint. If the nurse be of good muscular devel- 
opment, healthy-looking, with a clear complexion, and sound teeth (indicating a 
generally good state of health), the color of the hair and eyes is of secondary impor- 
tance. It is commonly stated that brunettes make better nurses than blondes, but this 
is by no means necessarily the case; and, provided all the other points be favorable, 
fairness of skin and hair need be no bar to the selection of a nurse. The breasts 
should be pear-shaped, rather firm, as indicating an abundance of gland-tissue, and 
with the superficial veins well marked. Large, flabby breasts owe much of their size 
to an undue deposit of fat, and are generally unfavorable. The nipple should be prom- PERIOD OF WEANING. 
13 
inent, not too large, and free from cracks and erosions, which, if existing, might lead 
to subsequent difficulties in nursing. On pressing the breast the milk should flow from 
it easily in a number of small jets, and some of it should be preserved for examinafon. 
It should be of a bluish-white color, and when placed under the microscope, the field 
should covered with an abundance of milk corpuscles, and the large granular cor- 
puscles of the colostrum should have entirely disappeared. If the latter be observed 
in any quantity in a woman who has been confined five or six weeks, the inference is 
that the milk is inferior in quality. It is not often that the practitioner has an oppor- 
tunity of inquiring into the moral qualities of the nurse, although much valuable infor- 
mation might be derived from a knowledge of her previous character. An iraseib’e, 
excitable, or highly nervous woman will certainly make a bad nurse, and the most 
trivial causes might afterwards interfere with the quality of her milk. Particular 
attention should be paid to the nmse's own child, since its condition affords the best 
criterion of the quality of her miffi. It should be plump, well nourished, and free 
from all blemishes. If it be at all thin and wizened, especially if there be any snuffling 
at the nose, or should any eruption exist affording the slightest suspicion of a syphilitic 
taint, the nurse should be unhesitatingly rejected. 
Management of Suckling.—The management of suckling is much the same whether 
the child is nursed by the mother or by a wet nurse. As soon as the supply of milk is 
sufficiently established, the child must be put to the breast at short intervals, at first of 
about two hours, and, in about a month or six weeks, of three hours. Prom the first 
few days it is a matter of the greatest importance, both to the mother and child, to 
acquire regular habits in this respect. If the mother get into the way of allowing the 
infant to take the breast whenever it cries, as a means of keeping it quiet, her own 
health must soon suffer, to say nothing of the discomfort of being incessantly tied to 
the ch'ld's side: while the child itself has not sufficient rest to digest its food, and, 
very shortly, diarrhoea, or other .symptoms of dyspepsia, are pretty sure to follow. 
After a month or two the infant should be trained to require the breast less often at 
night, so as to enable the mother to have an undisturbed sleep of six or seven hours. 
Por this purpose she should arrange the times of nursing so as to give the breast just 
before she goes to bed, and not again until the early morning. If the child should 
require food in the interval, a little milk and water, from the bottle, may be advan- 
tageously given. 
Diet of Nursing Women.—The diet of the nursing woman should be arranged on 
ordinary principles of hygiene. It should be abundant, simple, and nutritious, and all 
rich and stimulating articles of food should be avoided. A common error in the diet 
of wet nurses is over-feeding, which constantly leads to deterioration of the milk. 
Many of these women, before entering on their functions, have been living on the sim- 
p'est and even sparest diet, and not uncommonly, in the better class of houses, they 
are suddenly given heavy meat mea's three and even four times a day, and often three 
or four glasses of stout. It is hardly a matter of astomshment that, under such cir- 
cumstances, their milk should be found to disagree. For a nursing woman in good 
health, two good meat mea’s a day, with two glasses of beer or po.ter, and as much 
milk and bread and butter as she likes to take in the interval, should be amply suffi- 
cient. Plenty of moderate exercise should be taken, and the more nurse and child are 
out in the open air, p ovided the weather be reasonably fine, the better it is for both. 
[As it is not the custom of American wet nurses to drink beer or stout, this part of 
their d’et is undesirable. A healthy woman should have milk enough from her ordinary 
diet, which should be largely farinaceous. If milk agrees with her, it is far better than 
malt drinks in the production of a lacteal supply.—Ed.] 
Signs of Successful Lactation.—Carried on methodically in this manner, wet nursing 
should give but little trouble. In the intervals between its meals the child sleeps most 
of its time, and wakes with regularity to feed; but if the chid be wakeful and restless, 
cry after feeding, have d’sordered bowels, and, above all, if it do not gain, week by 
week, in weight (a point which should be, from time to time, ascertained by the scales), 
we may '■•onclude that the e is either some grave defect in the management of sucld'ng, 
or mat the mi k is not agreeing. Should this unsatisfactory progress continue, in sp'ie 
of our endeavors to remedy it, the e is no resource left but the alteration of the diet, 
either by changing the nu se, or by bringing up the child by hand. The fo mer should 
be preferred whenever it is practicable, and, in the upper ranks of life, it is by no means 
rare to have to change the wet n u’se two or three times, before one is met with whose 
milk agrees perfectly. If the child have reached six or seven months of age, it may 
be preferable to wean it altogether, especially if the mother have nursed it, as hand-feed- 
ing is much less objectionable if the infant have had the breast for even a few months. 
Feriod of Weaning.—As a rule, weaning should not be attempted until dentition is 14 
MANAGEMENT OF THE INFANT, LACTATION, ETC. 
fairly established, that being the sign that nature has prepared the child for an altera- 
tion of food; and it is better that the main portion of the diet should be breast milk 
until at least six or seven teeth have appeared. This is a safer guide than any arbitrary 
rule taken from the age of the child, since the commencement of dentition varies much 
in different cases. About the sixth or seventh month it is a good plan to commence the 
use of some suitable artificial food once a day, so as to relieve the strain on the mother 
or nurse, and prepare the child for weaning, which should always be a very gradual 
process. In this way a meal of rusks, of the entire wheat flour, or of beef- or chicken- 
tea, with bread crumb in it, may be given with advantage; and, as the period for 
weaning arrives, a second meal may be added, and so eventually the child may be 
weaned without distress to itself, or trouble to the nurse. 
The Disorders of Lactation.—The disorders of lactation are numerous, and, as they 
.frequently come under the notice of the practitioner, it is necessary to allude to some 
of the most common and important. 
Means of Arresting the Secretion of Milk.—The advice of the accoucheur is often 
required in cases in which it has been determined that the patient is not to nurse, when 
we desire to get rid of the milk as soon as possible, or when, at the time of weaning, 
the same object is sought. The extreme heat and distention of the breasts, in the 
former class of cases, often give rise to much distress. A smart saline aperient will aid 
in removing the milk, and for this purpose a double Seidlitz powder, or frequent small 
doses of sulphate of magnesia, act well; while, at the same time, the patient,should 
be advised to take as small a quantity of fluid as possible. Iodide of potassium in large 
doses, of 20 or 25 grains, repeated twice or thrice, has a remarkable effect in arresting 
the secretion of milk. This observation was first empirically made by observing that 
the secretion of milk was arrested wdien this drug wTas administered for some other 
cause, and I have frequently found it answer remarkably well. The distention of the 
breasts is best relieved by covering them with a layer of lint or cotton wool, soaked in 
a spirit lotion, or eau de cologne and water, over which oiled silk is placed, and by 
directing the nurse to rub them gently with warm oil. whenever they get hard and 
lumpy. Breast-pumps and similar contrivances only irritate the breasts, and do more 
harm than good. The local application of belladonna has been strongly recommended 
as a means for preventing lacteal secretion. As usually applied, in the form of bella- 
donna plaster, it is likely to prove hurtful, since the breast often enlarges after the 
plasters are applied, and the pressure of the unyielding leather on which they are spread 
produces intense suffering. A better way of using it is by rubbing down a drachm of 
the extract of belladonna with an ounce of glycerin, and applying this on lint. In 
some cases it answers extremely well; but it is very uncertain in its action, and fre- 
quently is quite useless. 
Defective Secretion of Milk.—A deficiency of milk in nursing mothers is a very com- 
mon source of difficulty. In a wet nurse this drawback is, of course, an indication for 
changing the nurse; but to the mother the importance of nursing is so great, that an 
endeavor must be made either to increase the flow of milk, or to supplement it by other 
food. Unfortunat ely, little reliance can be placed on any of the so-called galactagogues. 
The only one which in recent times has attracted attention is the leaves of the castor-oil 
plant, which, made into pultices and applied to the breast, are said to have a beneficial 
effect in increasing the flow of milk. More reliance must be placed in a sufficiency of 
nutritious food, especially such as contains phosphatic elements; stewed eels, oysters, 
And other kinds of shellfish, and the Revalenta Arabica, a- e recommended by Dr. Routh, 
who has paid some attention to this point,,1 as peculiarly appropriate. If the amount 
of m'lk be decidedly deficient, the child should be less often applied to the breast, so as 
to a low milk to collect, and properly prepared cow's milk from a bottle should be given 
alternately with the b east. This mixed diet generally answers well, and is far prefer- 
able to pure hand-feeding. 
I In the year 1870,2 1 prepared an article showing by three typical cases the value of 
milk as a diet for certain delicate mothers, who, under the’r ordinary food, invariably 
fail to be able to nurse longer than a few weeks or months after parturition. This 
paper was published by var ous periodicals during two years, and the plan has been 
brought largely into use, as the diet is capable of making a good nurse out of a mother, 
who but for it would make a complete failure, and of fattening her up during the time 
that she is secreting milk in abundance. When a delicate mother of 86 pounds weight, 
after failing in a month with each of three infants, is enabled by it to nurse a child 18 
months, and gain at the same time 19 pounds, the diet must be an effective one.—Ed.] 
1 Routh on Infant-feeding. 
[2 Am. Journ. Obstet., Feb., 1870, p. 675.] MAMMARY ABSCESS. 
15 
Depressed Nipples.—A not uncommon source of difficulty is a depressed condition of 
the nipples, which is generally produced by the constant pressure of the stays. The 
result is, that the child, unable to grasp the nipple, and wearied with ineffectual efforts, 
may at last refuse the breast altogether. An endeavor should be made to elongate the 
nipple before putting it into the child's mouth, either by the lingers, or by sdme form 
of breast-pump, which here finds a useful indication. In the worst class of cases, when 
the nipple is permanently depressed, it may be necessary to let the child suck through 
a glass nipple shield, to which is attached an India-rubber tube, similar to that of a 
sucking-bottle ; that it is generally well able to do. 
[In some instances this anatomical defect appears to be beyond remedy, unless a 
recently proposed surgical operation can be made effective. I have tried to prepare 
primiparae for several months before labor, and then failed as soon as the breasts filled 
with milk. In some cases there is absolutely no nipple, and as a shield is of no value 
in protection, the escaping milk produces an eczema over the waist and upper part of 
the abdomen. This condition I have seen associated with a most obstinate galactor- 
rhoea lasting several months.—Ed.] 
Fissures and excoriations of the nipples are common causes of suffering, in some cases 
leading to mammary abscess. Whenever the practitioner has the opportunity, he 
should advise his patient to prepare the nipple for nursing in the latter months of preg- 
nancy ; and this may best be done by daily bathing it with a spirituous or astringent 
lotion, such as eau de cologne and water, or a weak solution of tannin. After nursing 
has begun, great care should be taken to wash and dry the nipple after the child has 
been applied to it, and, as long as the mother is in the recumbent position, she may, 
if the nipples be at all tender, use zinc nipple-shields with advantage, when she is not 
nursing. In this way these troublesome complications may generally be prevented. 
The most common forms are either an abrasion on the surface of the nipple, which, 
if neglected, may form a small ulcer, or a crack at some part of the nipple, most gen- 
erally at its base. In either case, the suffering when the child is put to the breast is 
intense, sometimes indeed amounting to intolerab'e anguish, causing the mother to 
look forward with dread to the application of the child. Whenever such pain is com- 
plained of, the nipple should be carefully examined, since the fissure or sore is often 
so minute as to escape superficial examination. The remedies recommended are very 
numerous, and not always successful. Amongst those most commonly used are astrin- 
gent applications, such as tannin, or weak solutions of nitrate of silver, or cauterizing 
the edges of the fissure with the solid nitrate of silver, or applying the flexible collo- 
dion of the Pharmacopoeia. Dr. Wilson, of Glasgow, speaks highly of a lotion com- 
posed of ten grains of nitrate of lead in an ounce of glycerin, which is to be applied 
after suckling, the nipple-being carefully washed before the child is again put to the 
breast. I have myself found nothing answer so well as a lotion composed of half an 
ounce of sulphurous acid, half an ounce of the glycerin of tannin, and an ounce of 
water, the beneficial effects of which are sometimes quite remarkable. Relief may 
be obtained by inducing the child to suck through a nipple-shield, espe- 
cially when there is only an excoriation; but this will not always answer, on account 
of the extreme pain which it produces. 
Excessice Flow of Milk.—An excessive flow of milk, known as galactorrhoea, often 
interferes with successful lactation. It is by no means rare in the first weeks after de- 
livery for women of delicate constitution, who are really unfit to nurse, to be flooded 
with a superabundance of watery and innutritious milk, which soon produces disor- 
dered digestion in the child. Under such circumstances, the only thing to be done is 
to give up an attempt which is injurious both to the mother and child. At a later stage 
the milk, secreted in large quantities, is sufficiently nourishing to the child, but the 
drain on the mother’s constitution soon begins to tell on her. Palpitation, giddiness, 
emaciation, headache, loss of sleep, spots before the eyes, and even amaurosis, indicate 
the serious effects which are being produced, and the absolute necessity of at once stop- 
ping lactation. Whenever, therefore, a nursing woman suffers from such symptoms, 
it is far better at once to remove the cause, otherwise a very serious and permanent 
dete -iorat'on of health m'ght result. 
Mammon/ Abscess.—There is no more troublesome complication of lactation than 
the formation of abscess in the breast; an occurrence by no means rare, and which, 
if improper1 v treated, may, by long-continued suppuration and the formation of numer- 
ous sinuses in and about the breast, produce very serious effects on the general health. 
The causes of breast abscesses are numerous, and very trivial circumstances may occa- 
sionally pet up inflammation, ending in suppuration. Thus it may follow exposure to 
cold ; a blow, or other injury to the breast; some temporary engorgement of the lac- 
teal tubes; or even sudden or depressing mental emotions. The most frequent cause 16 
MANAGEMENT OF THE INFANT, LACTATION, ETC. 
is irritation from fissures or erosions of the nipples, which must, therefore, always be 
regarded with suspicion, and cured as soon as possible. 
Signs and Symptoms.—The absce.-s may iorm in any part of the breast, or in the 
areolar tissue below it; in the latter case, the inflammation very genera ly extends to 
the gland structure. Abscess is usually ushered in by constitutional symptoms, vary- 
ing in severity with the amount of the inflammation. Pyrexia is always present; e.e- 
vated temperature, rapid pulse, and much mala se and sense of feverishness, fo lowed, 
in many cases, by distinct rigor, when deep-seated suppuration is taking p’ace. On 
examining the breast it will be found to be generally enlarged and very tender, while, 
at the site of the abscess, an indurated and painful swelling may be felt. If the in- 
flammation be chiefly limited to the subglandular areolar tissue, there may be no local- 
ized swelling felt, but the whole breast will be acutely sensitive, and the slightest move- 
ment will cause much pain. As the case progresses, the abscess becomes more and 
more superficial, the skin covering it is red and glazed, and if left to itself, it bursts. 
In the more serious cases, it is by no means rare for multiple abscesses to iorm. These 
opening, one after the other, lead to the formation of numerous fistulous tracts, by 
which the breast may become completely riddled. Sloughing of portions of the gland- 
tissue may take place, and even considerable haemorrhage, from the destruction of 
blood-vessels. The general health soon suffers to a marked degree, and, as the s’nuses 
continue to suppurate for many successive months, it is by no means uncommon for the 
patient to be reduced to a state of profound and even dangerous debility. 
Treatment.—Much may be done by proper care to prevent the formation of abscess, 
especially by removing engorgement of the lacteal ducts, when threatened, by gentle 
hand friction in the manner already indicated. When the general symptoms, and the 
local tenderness, indicate that inflammation has commenced, we should at once endeavor 
to moderate it, in the hope that resolution may occur without the formation of pus. 
Here general principles must be attended to, especially giving the affected part as much 
rest as possible. Feverishness may be combated by gentle saline, minute doses of 
aconite, and large doses of quinine; while pain should be relieved by opiates. The 
patient should be strictly confined in bed, and the affected breast supported by a sus- 
pensory bandage. Warmth and moisture are the best means of relieving the local 
pain, either in the form of hot fomentations, or of light poultices of linseed-meal or 
bread and milk, and the breast may be smeared with extract of belladonna rubbed down 
with glycerin, or the belladonna liniment sprinkled over the surface of the poultices. 
Generally the pain and irritation produced by putting the child to the breast are so 
great as to contra-indicate nursing from the affected side altogether, and we must trust 
to relieving the tension by poultices; suckling being, in the. meantime, carried on by 
the other breast alone. In favorable cases this is quite possible for a time, and it may 
be that, if the inflammation do not end in suppuration, or if the abscess be small 
and localized, the affected breast is again able to resume its functions. Often this is 
not possible, and it may be advisable, in severe cases, to give up nursing altogether. 
Pus should he. Removed as soon as Possible.—The subsequent management of the 
case consists in the opening of the abscess as soon as the existence of pus is ascertained, 
either by fluctuation, or, if the site of the abscess be deep-seated, by the exploring 
needle. It may be laid down as a principle, that the sooner the pus is evacuated the 
better, and nothing is to be gained by waiting until it is superficial. On the contrary, 
such delay only leads to more extensive disorganization of tissue and the further spread 
of inflammation. 
Antiseotic Treatment.—The method of opening the abscess is of primary importance. 
It has always been customary simply to open the abscess at its most depending part, 
without using any precaution against the admission of air, and afterwards to treat sec- 
ondary abscesses in the same way. The results are well known to all practical accouch- 
eurs, and the records of surgery fully show how many weeks or months generally elapse 
in bad cases before recovery is complete. The antiseptic treatment of mammary ab- 
scess, in the way first pointed out by Lister, afford results which are of the most re- 
markable and satisfactory kind. Instead of being weeks and months in healing, I 
believe that the practitioner who fairly and minutely carries out Mr. Lister's directions 
may confidently look for complete closure of the abscess in a few days; and I know 
nothing, in the whole range of my professional experience, that has given me more 
satisfaction than the application of this method to abscesses of the breast. The plan I 
first used is that recommended by Lister in the Lancet for 1867, but which is now 
superseded by his improved methods, which, of course, will be used in preference by all 
who have made them elves familiar with the details of antiseptic surgery. The former, 
however, is easily within the reach of every one, and is so simple that no special skill 
or practice is required in its application; whereas the more perfected antiseptic appli- CAUSES OF MORTALITY IN HAND-FED CHILDREN. 
17 
ances will probably not be so readily obtained, and are much more difficult to use. I, 
therefore, insert Mr. Lister's original directions, which he assures me are perfectly 
aseptic, for the guidance of those who may not be able to obtain the more elaborate 
dressings: “A solution of one part of crystallized carbolic acid in four parts of boiled 
linseed oil having been prepared, a piece of rag from four to six inches square is dipped 
into the oily mixture, and laid upon the skin where the incision is to be made. The 
lower edge of the rag being then raised, while the upper edge is kept from slipping by 
an assistant, a common scalpel or bistoury dipped in the oil is plunged into the cavity 
of the abscess, and an opening about three-quarters of an inch in length is made, and 
the instant the knife is withdrawn the rag is dropped upon the skin as an antiseptic 
curtain, beneath which the pus flows out into a vessel placed to receive it. The cavity 
of the abscess is firmly pressed, so as to force out all existing pus as nearly as may be 
(the old fear of doing mischief by rough treatment of the pyogenic membrane being 
quite ill-founded); and if there be much oozing of blood, or if there be considerable 
tnickness of parts between the abscess and the surface, a piece of lint dipped in the 
antiseptic oil is introduced into the incision to check bleeding and prevent primary ad- 
hesion, which is otherwise very apt to occur. The introduction of the lint is effected 
as rapidly as may be, and under the protection of the antiseptic rag. Thus the evac- 
uation of the original contents is accomplished with perfect security against the intro- 
duction of living germs. This, however, would be of no avail unless an antiseptic 
dressing could be applied that would effectually prevent the decomposition of the stream 
of pus constantly flowing out beneath it. After numerous disappointments, I have 
succeeded with the following, which may be relied upon as absolutely trustworthy: 
About six teaspoonfuls of the above-mentioned solution of carbolic acid in linseed oil 
are mixed up with common whiting (carbonate of lime) to the consistence of a firm 
paste,—which is, in fact, glazier’s putty with the addition of a little carbolic acid. 
This is spread upon a piece of common tin-foil about six inches square, so as to form a 
layer about a quarter of an inch thick. The tin-foil, thus spread with putty, is placed 
upon the skin, so that the middle of it corresponds to the position of the incision, the 
antiseptic rag used in opening the abscess being removed the instant before. The tin 
is then fixed securely by adhesive plaster, the lowest edge being left free for the escape 
of the discharge into a folded towel placed over it and secured by a bandage. The 
dressing is changed, as a general rule, once in 24 hours, but if the abscess be a very 
large one, it is prudent to see the patient 12 hours after it has been opened, when, if 
the towel should be much stained with discharge the dressing should be changed, to 
avoid subjecting its antiseptic virtues to too severe a test. But after the first 24 hours 
a single daily dressing is sufficient. The changing of the dressing must be methodically 
done as follows: A second similar piece of tin-foil having been spread with the putty, 
a piece of rag is dipped in the o’ly solution and placed on the incision the moment the 
first tin is removed. This guards against the possibility of mischief occurring during 
the cleansing of the skin with a dry cloth, and pressing out any discharge which may 
exist in the cavity. If a plug of lint was introduced when the abscess was opened, it 
is removed under cover ot the antiseptic rag, which is taken off at the moment when 
the new tin is to be applied. The same process is continued daily until the sinus 
closes. ’ ’ 
Treatment of Long-continued Suppuration and Fever.—If the case come under our 
care when the abscess has been long discharging, or when sinuses have formed, the 
treatment is directed mainly to procuring a cessation of suppuration and closure of the 
sinuses. For this purpose, methodical strapping of the breast with adhesive p'aster, 
so as to afford steady support and compress the opposing pyogenic surfaces, will give 
the best results. It may be necessary to Jay open some of the sinuses, or to inject 
tinct. iodi or other stimulating lotions, so as to moderate the discharge, the subsequent 
surgical treatment varying according to the requirements of each case. As the drain 
on the system is great, and the constitutional debility generally pronounced, much 
attention must be paid to general treatment; and abundance of nourishing food, 
appropriate stimulants, and such medicines as iron and quinine, will be indicated. 
Hand-feeding.—In a considerable number of cases, the inability of the mother to 
nurse the child, her invincible repugnance to a wet nurse, or inability to bear the ex- 
pense, renders hand-feeding essential. It is, therefore, of importance that the accouch- 
eur should be thoroughly familiar with the best method of bringing up the child by 
hand, so as to be able to direct the process in the way that is most likely to be suc- 
cessful. 
Causes of Mortality in Hand-fed Children.—Much of the mortality following hand- 
feeding may be traced to unsuitable food. Among the poorer classes especially there 
is a prevalent notion that milk alone is insufficient; and hence the almost universal 18 
MANAGEMENT OF THE INFANT, LACTATION, ETC. 
custom of administering various farinaceous foods, such as corn-flour or arrow-root, 
even from the earliest period. Many of these consist of starch alone, and are there- 
fore absolutely unsuited for forming the staple of diet, on account of the total absence 
of nitrogenous elements. Independently of this, it has been shown that the saliva of 
infants has not the same digestive property on starch that it subsequently acquires, and 
this affords a further explanation of its so constantly producing intestinal derangement. 
Reason, as well as experience, abundantly prove that the object to be aimed at in hand- 
feeding is to imitate as nearly as possible the food which nature supplies lor the new- 
born child, and therefore the obvious course is to use milk from some animal, so treated 
as to make it resemble human milk as nearly as may be. 
Ass’s Milk.—Of the various milks used, that of the ass, on the who’e, most closely 
resembles human milk, containing less case'n and butter and more saline ingredients. 
It is not always easy to obtain, and in towns is excessively expensive. Moreover, it 
does not always agree with the child, being apt to produce diarrhoea. We can, how- 
ever, be more certain of its being unadulterated, which, in large cities, is in itself no 
small advantage, and it may be given without the addition of water or sugar. 
Goat's milk in this country is st'll more difficult to obtain, but it often succeeds 
admirably. In many places the infant sucks the teat directly, and certainly thrives 
well on the plan. 
[We reverse the order in this country, where the ass is seldom seen, and the goat 
quite common, particularly in the suburbs of our large cities, where its milk is most 
required. I have seen marvellous results from feeding sick infants with its milk 
freshly drawn, and diluted with hot water. I do not believe its milk is as suitable as 
that of the cow, but it has the advantage that it can be obtained freshly drawn in a 
city, by keeping the animal in the yard or on a vacant lot. The goat should be fed 
upon grass and other suitable diet, and not permitted to run at large, as it eats with 
impunity stramonium and other noxious weeds.—Ed.] 
Coro's Milk and its Preparation.—In a large majority of cases we have to rely on 
cow’s milk alone. It differs from human milk in containing less water, a larger amount 
of casein and solid matters, and less sugar. Therefore, before being given, it requires 
to be diluted and sweetened. A common nrstake is over-dilution, and it is far from rare 
for nurses to administer one-third cow’s milk to two-thirds water. The result of this 
excessive dilution is, that the child becomes pale and puny, and has none of the firm 
and p’ump appearance of a well-fed infant. The practitioner should, therefore, ascer- 
tain that this mistake is not being made; and the necessary dilution will be best 
obtained by adding to pure fresh cow’s milk, one-third hot water, so as to warm the 
mixture to about 96°, the whole being slightly sweetened with sugar of milk, or ordi- 
nary crystallized sugar. After the first two or three months the amount of water may 
be lessened, and pure milk, warmed and sweetened, given instead.1 Whenever it is 
possible, the milk should be obtained from the same cow, and in towns some care is 
requisite to see that the animal is properly fed and stabled. Of late years it has been 
customary to obviate the difficulties of obtaining good fresh milk by using some of the 
tinned milks now so easily to be had. These are a’ready sweetened, and sometimes 
answer well, if not given in too weak a dilution. One great drawback in bottle-feed- 
ing is the tendency of the milk to become acid, and hence to produce diai-rhoea. This 
may be obviated to a great extent by adding a tablespoonful of lime-water to each 
bottfo, instead of an equal quantity of water. 
Artificial Human Milk.—An admirable plan of treating cow’s milk, so as to reduce 
it to almost absolute chemical identity with human milk has been devised by Professor 
Frankland, to whom I am indebted for permission to insert the receipt. I have fol- 
lowed this method in many cases, and find it far superior to the usual one, as it pro- 
duces an exact and uniform compound. With a little practice nurses can employ it 
with no more trouble than the ordinary mixing of cow's milk with water and sugar. 
The following extracts from Dr. Frankland’s work2 will explain the principles on which 
the preparation of the artificial human milk is founded: “ The rearing of infants who 
cannot be supplied with their natural food is notoriously difficult and uncertain, owing 
chiefly to the great difference in the chemical composition of human milk and cow s 
milk. The latter is much richer in casein and poorer in milk-sugar than the former, 
pi have been obliged with quite young infants, in some instances, to change from Alderney to 
common cow’s milk, as the larger proportion of butter in the former makes it too unlike that of the 
woman to agree with the child. It is well to recommend the milk of one cow, but many who 
claim to bring it fill the little can out of the big one on their round in the city. A very young cow 
and an old one are not suitable. In country practice, the selected cow system is often quite effec- 
tive.—Ed.] 
'2 Frankland’s Experimental Researches in Chemistry, p. 843. OTHER KINDS OF FOOD. 
19 
whilst asses’ milk, which is sometimes used for feeding infants, is too poor in casein 
and butter, although the proportion of sugar is nearly the same as in human milk. 
The relations of the three kinds of milk to each other are clearly seen from the fol- 
lowing analytical numbers, which express the percentage amounts of the different 
constituents: 
Woman. Ass. Cow. 
Casein 2.7 1.7 4.2 
Butter 3.5 1.3 3.8 
M ilk-sugar 5.0 4.5 3.8 
Salts 2 .5 .7 
These numbers show that by the removal of one-third of the casein from cow’s milk 
and the addition of about one-third more milk-sugar a liquid is obtained which 
closely approaches human milk in composition, the percentage amounts of the four 
chief constituents being as follows: 
Casein 2.8 
Butter 3.8 
Milk-sugar 5.0 
Salts .7 
The following is the mode of preparing the milk: Allow one-third of a pint of new 
milk to stand for about twelve hours, remove the cream and add to it two-thirds of a 
pint of new milk, as fresh from the cow as possible. Into the one-third of a pint of 
blue milk left after the abstraction of the cream, put a piece of rennet about one inch 
square. Set the vessel in warm water until the milk is fully curdled, an operation 
requiring from five to fifteen minutes, according to the activity of the rennet, which 
should be removed as soon as the curdling commences, and put into an egg-cup for ose 
on subsequent occasions, as it may be employed daily for a month or two. Break up 
the curd repeatedly, and carefully separate the whole of the whey, which should then 
be rapidly heated to boiling in a small tin pan placed over a spirit or gas lamp. 
During the heating a further quantity of casein, technically ea led ‘fieetings, ’ sepa- 
rates, and must be removed by straining through muslin. JN ow dissolve 110 grains of 
powdered sugar of milk in the hot whey, and mix it with the two-thirds of a p nt of 
new milk to which the cream from the other third of a pint was added as already 
described. The artificial milk should be used within twelve hours of its preparation, 
and it is almost needless to add that all the vessels employed in its manufacture and 
adm n'stration should be kept scrupulously clean. ” 
Method of Hand feeding.—Much of the success of bottle-feeding must depend on 
minute care and scrupulous cleanliness, points which cannot be too strongly insisted on. 
Particular attention should be paid to preparing the food fresh for every meal, and to 
keeping the feeding-bottle and tubes constantly in water when not in use, so that 
nrnute particles of milk may not remain about them and become sour. A neglect of 
this is one of the most fertile sources of the thrush from which bottle-fed infants 
often suffer. The particular form of bottle used is not of much consequence. Those 
now commonly employed, with a long India-rubber tube attached, are preferable to 
the older forms of flat bottle, as they necessitate strong suction on the part of the 
infant, thus forcing it to swallow the food more slowly. Care must be taken to give 
the meals at stated periods, as in breast-feed.ng, and these should be at first about 
two hours apart, the intervals being gradually extended. The nurse should be 
strictly cautioned against the common practice of placing the bottle beside the infant 
in its cradle, and allowing it to suck to repletion, a p actice which leads to over-dis- 
tension of the stccnach, and consequent dyspepsia. The child should be raised in the 
arms at the proper time, have its food administered, and then be replaced in the 
cradle to sleep. In the first few weeks of bottle-feed ng constipation is very common, 
and may be effectually remedied by placing as much phosphate of soda as will lie on a 
threepenny p:ece in the bottle, two or three times in the twenty-four hours. 
Other kinds of Food.—If this system succeed, no other food should be given until 
the child is six or seven months old, and then some of the various infant’s food may be 
cautiously commenced. Of these there are an immense number in common use; some 
of which are good articles of diet, others are unfitted for infants. In selecting them 
we have to see that they contain the essential elements of nutrition in proper combina- 
tion. All those, therefore, that are purely sta chy in character, such as arrow-root, 
corn-flour, and the like, should be avoided; while those that contain nitrogenous as well 
as starch elements, may be safely given. Of the latter the entire wheat flour, which 20 
PUERPERAL ECLAMPSIA. 
contains the husks ground down with the wheat, generally answers admirably; and of 
the same character are rusks, tops and bottoms, Nestle’s or Liebig’s infant’s food, and 
many others. If the child be pale and flabby, some more purely animal food may often 
be given twice a day, and great benefit may be derived from a single meal of beef, 
chicken, or veal tea, with a little bread crumb in it, especially after the sixth or seventh 
month. Milk, however, should still form the main article of diet, and should continue 
to do so for many months. 
Management when Milk disagrees.—If the child be pale, flabby, and do not gain 
flesh, more especially if diarrhoea or other intestinal disturbance be present, we may be 
certain that hand-feeding is not answering satisfactorily, and that some change is re- 
quired. If the child be not too old, and will still take the breast, that is certainly the 
best remedy, but if that be not possible, it is necessary to alter the diet. When milk 
disagrees, cream, in the proportion of one tab'espoonfnl to three of water, sometimes 
answers as well. Occasionally also Liebig’s infant’s food, when carefully prepared, 
renders good service. Too often, however, when once diarrhoea or other intestinal 
disturbance has set in, all our efforts may prove unavailing, and the health, if not the 
life, of the infant, becomes seriously imperilled. It is not, however, within the scope 
of this work to treat of the disorders of infants at the breast, the proper consideration 
of which requires a large amount of space, and I, therefore, refrain from making any 
further remarks on the subject. 
[As a general rule, children in this country are better kept exclusively on a milk diet 
for at least ten months, especially if it is in the summer season. The best addition 
then, is exsiccated wheat flour prepared by the process of Hards, and known as Hards’s 
farinaceous food, prepared wheat, imperial granum, etc. Ohio groats made of the oat 
kernel, and prepared barley flour, are sometimes useful where the habit of the child is 
constipated. —Ed. J 
CHAPTER III. 
PUERPERAL ECLAMPSIA. 
By the term 'puerperal eclampsia is meant a peculiar kind of epileptiform convulsions, 
which may occur in the latter months of pregnancy, or during, or after parturition, and 
it constitutes one of the most formidable diseases with which the obstetrician has to 
cope. The attack is often so sudden and unexpected, so terrible in its nature, and 
attended with such serious danger both to the mother and child, that the disease has 
attracted much attention. 
Its Doubtful Etiology.—The researches of Lever, Braun, Frerichs, and many other 
winters who have shown the frequent association of eclampsia with albuminuria, have, 
of late years, been supposed to clear up to a great extent the etiology of the disease, 
and to prove its dependence on the retention of urinary elements in the blood. While 
the urinary origin of eclampsia has been pretty generally accepted, more recent obser- 
vations have tended to throw doubt on its essential dependence on this cause; so that 
it can hardly be said that we are yet in a position to explain its true pathology with 
certainty. These points will require separate discussion, but it is first necessary to 
describe the character and history of the attack. 
Considerable confusion exists in the description of puerperal convulsions from the 
confounding of several essentially distinct diseases under the same name. Thus, in 
most obstetric works, it lias been customary to describe three distinct classes of con- 
vulsion; the epileptic, the hysterical, and the apoplectic. The two latter, however, 
come under a totally, different category. A pregnant woman may suffer from hysterical 
paroxysms, or she may be attacked with apoplexy, accompanied with coma, and fol- 
lowed by paralysis. But these conditions in the pregnant or parturient woman are 
identical with the same diseases in the non-pregnant, and are in no way special in their 
nature. True eclampsia, however, is different in its clinical history from epilepsy; al- 
though the paroxysms, while they last, are essentially the same as those of an ordinary 
epileptic fit. 
Premonitory Symptoms.—An attack of eclampsia seldom occurs without having been 
preceded by certain more or less well-marked precursory symptoms. It is true that in CONDITION BETWEEN THE ATTACKS. 
21 
a considerable number of cases these are so slight as not to attract attention, and 
suspicion is not aroused until the patient is seized with convulsions. Still, subsequent 
investigations will very generally show that some symptoms did exist, which, if observed 
and properly interpreted, might have put the practitioner on his guard, and possibly 
enable him to ward off the attack. Hence a knowledge of them is of real practical 
value. The most common are associated with the cerebrum, such as severe headache, 
which is the one most generally observed, and is sometimes limited to one side of the 
head. Transient attacks of dizziness, spots before the eyes, loss of sight, or impairment 
of the intellectual faculties, are also not uncommon. These signs in a pregnant woman 
are of the gravest import, and should at once call for investigation into the nature of 
the case. Less marked indications sometimes exist in the form of irritability, slight 
headache, or stupor, and a general feeling of indisposition. Another important pre- 
monitory sign is oedema of the subcutaneous cellular tissue, especially of the face or 
upper extremities, which should at once lead to an examination of the urine. 
Symptoms of the Attack.—Whether such indications have preceded an attack or 
not, as soon as the convulsion comes on there can no longer be any doubt as to the 
nature of the case. The attack is generally sudden in its onset, and in its character i3 
precisely that of a severe epileptic fit, or of the convulsions in children. Close obser- 
vation shows that there is at first a short period of tonic spasm, affecting the entire 
muscular system. This is almost immediately succeeded by violent clonic contractions, 
generally commencing in the muscles of the face, which twitch violently; the expres- 
sion is horribly altered; the globes of the eyes are turned up under the eyelids, so as 
to leave only the white sclerotics visible, and the angles of the mouth are retracted 
and fixed in a convulsive grin. The tongue is at the same time protruded forcibly, 
and, if care be not taken, is apt to b« lacerated by the violent grinding of the teeth. 
The face, at first pale, soon becomes livid and cyanosed, while the veins of the neck 
are distended, and the carotids beat vigorously. Frothy saliva collects about the mouth, 
and the whole appearance is so changed as to render the patient quite unrecognizable. 
The convulsive movements soon attack the muscles of the body. The hands and arms, 
at first rigidly fixed, with the thumbs clinched into the palms, begin to jerk, and the 
whole muscular system is thrown into rapidly-recurring convulsive spasms. It is evi- 
dent that the involuntary muscles are implicated in the convulsive action, as well as 
the voluntary. This is shown by a temporary arrest of respiration at the commence- 
ment of the attack, followed by irregular and hurried respiratory movements, producing 
a peculiar hissing sound. The occasional involuntary expulsion of urine and faeces 
indicates the same fact. During the attack the patient is absolutely unconscious, 
sensibility is totally suspended, and she has afterwards no’ recollection of what has 
taken place. Fortunately the convulsion is not of long duration, and, at the outside, 
does not last more than three or four minutes, generally not so long. In most cases, 
after an interval, there is a recurrence of the convulsion, characterized by the same 
phenomena, and the paroxysms are repeated with more or less force and frequency 
according to the severity of the attack. Sometimes several hours may elapse before 
a second convulsion comes on ; at others the attacks may recur very often, with only a 
few minutes between them. In the slighter forms of eclampsia there may not be more 
than 2 or 3 paroxysms in all; in the more serious as many as 50 or 60 have been 
recorded. 
Condition between the Attacks.—After the first attack the patient generally soon 
recovers her consciousness, being somewhat dazed and somnolent, with no clear per- 
ception of what has occurred. If the paroxysms be frequently repeated, more or less 
profound coma continues in the intervals between them, which, no doubt,_ depends 
upon intense cerebral congestion, resulting' from the interference with the circulation 
in the great veins of the neck, produced by spasmodic contraction of the muscles. 
The coma is rarely complete, the patient showing signs of sensibility when irritated, 
and groaning during the uterine contractions. In the worst class of cases, the torpor 
may become intense and continuous, and in this state the patient may die. When the 
convulsions have entirely stopped, and the patient has completely regained her conscious- 
ness, and is apparently convalescent, recollection of what has taken place during, and 
sometime before, the attack, may be entirely lost, and this condition may last for a 
considerable time. A curious instance of th:s once came under my notice in a lady who 
had lost a brother to whom she was greatly attached, in the week immediately pre- 
ceding her confinement, and in whom the mental distress seemed to have had a good 
deal to do in determining the attack. It was many weeks before she recovered her 
memory, and during that time she recollected nothing about the circumstances con- 
nected with her brother’s death, the whole of that week being, as it were, blotted out 
of her recollection. 22 
PUERPERAL ECLAMPSIA. 
Relation of the Attacks to Labor.—If the convulsions come on during pregnancy, 
we may look upon the advent of labor as almost a certainty; and if we consider the 
severe nervous shock and general disturbance, this is the result we might reasonably 
anticipate. If they occur, as is not uncommon, for the first time during labor, the 
pains generally continue with increased force and frequency, since the uterus partakes 
of the convulsive action. It has not rarely happened that the pains have gone on 
with such intensity that the child has been born quite unexpectedly, the attention of 
the practitioner being taken up with the patient. In many cases the advent of fresh 
paroxysms is associated with the commencement of a pain, the irritation of which 
seems sufficient to bring on the convulsion. 
Results to the Mother and Child.—The results of eclampsia vary according to the 
severity of the paroxysms. It is generally said that about 1 in 3 or 4 cases dies. The 
mortality has certainly lessened of late years, probably in consequence of improved 
knowledge of the nature of the disease, and more rational modes of treatment. This 
is well shown by Barker,1 who found in 1855 a mortality of 32 per cent, in cases occur- 
ring before and during labor, and 22 per cent, in those after labor; while since that 
date the mortality has fallen to 14 per cent. The same conclusion is arrived at by 
Dr. Phillips,2 who has shown that the mortality has greatly lessened since the practice 
of repeated and indiscriminate bleeding, long considered the sheet anchor in the 
disease, has been discontinued, and the administration of chloroform substituted. 
Cause of Death.—Death may occur during the paroxysm, and then it may be due 
to the long continuance of the tonic spasm producing asphyxia. It is certain that, as 
long as the tonic spasm lasts, the respiration is suspended, just as in the convulsive dis- 
ease of children known as laryngismus stridulus ; and it is possible also that the heart 
may share in the convulsive contraction which is known to affect other involuntary mus- 
cles. More frequently, death happens at a later period, from the combined effects of 
exhaustion and asphyxia. The records of post-mortem examinations are not numer- 
ous ; in those we possess the principal changes have been an anaemic condition of the 
brain, with some cedematous infiltration. In a few rare cases the convulsions have re- 
sulted in effusion of blood into the ventricles, or at the base of the brain. The prog- 
nosis as regards the child is also serious. Out of 36 children, Hall Davis found 26 bora 
alive, 10 being still-born. There is good reason to believe that the convulsion may 
attack the child in utero; of this several examples are mentioned byCazeaux; or it 
may be subsequently attacked with convulsions, even when apparently healthy at biith. 
Pathology of the Disease.—The precise pathology of eclampsia cannot be considered 
by any means satisfactorily settled. When, in the year 1843, Lever first showed that 
the urine in patients suffering from puerperal convulsions was generally highly charged 
with albumen—a fact which subsequent experience has amply confirmed—it was thought 
that a key to the etiology of the disease had been found. It was known that chronic 
forms of Bright’s disease were frequently associated with retention of urinary elements 
in the blood, and not rarely accompanied by convulsions. The natural inference was 
drawn, that the convulsions of eclampsia were also due to toxaemia resulting from the 
retention of urea in the blood, just as in the uraemia of chronic Bright's disease ; and 
this view was adopted and supported by the authority of Braun, Frerichs, and many 
other writers of em'nence, and was pretty generally received as a satisfactory explana- 
tion of the facts. Frerichs modified it so far, that he held that the true toxic element 
was not urea as such, but carbonate of ammonia, resulting from its decomposition ; and 
experiments wrere made to prove that the injection of this substance into the veins of 
the lower animals produced convulsions of precisely the same character as eclamps'a. 
Dr. Hammond,3 of Maryland, subsequently made a series of counter experiments, 
which were held as proving that there was no reason to believe that urea ever did be- 
come decomposed in the blood in the way that Frerichs supposed, or that the symp- 
toms of uraemia were ever produced in this way. Spiegelberg4 has, more recently, 
again examined the question both clinically, in a patient suffering from convulsions, in 
whose blood an excess of ammonia and urea was found, and by experiments on dogs, 
and maintains the accuracy of Frerich’s views. Others have believed that the poison- 
ous retained in the blood are not urea or the products of its decomposition, 
but other extractive matters which have escaped detection. As time elapsed, evidence 
accumulated to show that the relation between albuminuria and eclampsia was not so 
universal as was supposed, or at least that some other factors were necessary to expla:n 
many of the cases. Numerous cases were observed in which albumen was detected in 
large quantities, without any convulsion following, and that, not only in women who 
1 The Puerperal Disease, p. 125. 
3 Amer. Journ., 1861. 
2 Guy’s Hosp. Reps., 1870. 
4 Arch. f. Gyn., 1870. EXCITING CAUSES. 
23 
had been the subject of Bright’s disease before conception, but also when the albu- 
minuria was known to have developed during pregnancy. Thus Imbert Goubeyre found 
that out of 164 cases of the latter kind, 95 had no eclampsia; and Blot, out of 41 
cases, found that 34 were delivered without untoward symptoms. It may be taken as 
proved, therefore, that albuminuria is by no means necessarily accompanied by eclamp- 
sia. Cases were also observed in which the albumen only appeared after the convul- 
sion ; and in these it was evident that the retention of urinary elements could not have 
been the cause of the attack ; and it is highly probable that in them the albuminuria 
was produced by the same cause which induced the convulsion. Special attention has 
been called to this c'ass of cases by Braxton Hicks,1 who has recorded a considerable 
number of them. He says that the nearly simultaneous appearance of albuminuria 
and convulsion—and it is admitted that the two are almost invrlriably combined—must 
then be explained in one of three ways. 
1. That the convulsions are the cause of the nephritis. 
2. That the convulsions and the nephritis are produced by the same cause, e. g., 
some detrimental ingredient circulating in the blood, irritating both the cerebro-spinal 
system and other organs at the same time. 
3. That the highly congested state of the venous system, induced by the spasm of 
the glottis in eclampsia, is able to produce the kidney complication. 
Theory of Traube and Rosenstein.—More recently Traube and Rosenstein have ad- 
vanced a theory of eclampsia, purporting to explain these anomalies. They refer the 
occurrence of eclampsia to acute cerebral anaemia, resulting from changes in the blood 
incident to pregnancy. The primary factor is the hydraemic condition of the blood, 
which is an ordinary concomitant of the pregnant state, and, of course, when there is 
also albuminuria, the watery condition of the blood is greatly intensified; hence the 
frequent association of the two states. Accompanying this condition of the blood, 
theie is increased tension of the arterial system, which is favored by the hypertrophy 
of the heart, which is known to be a normal occurrence in pregnancy. The result of 
these combined states is a temporary hyperaemia of the brain, which is rapidly suc- 
ceeded by serous effusion into the cerebral tissues, resulting in pressure on its minute 
vessels, and consequent anaemia. Thei e is much in this theory that accords with the 
most recent views as to the etiology of convulsive disease; as, for example, the re- 
searches of Kussmaul and Tenner, who had experimentally proved the dependence of 
convulsion on cerebral anaemia, and of Brown-Sequard, who showed that an anaemic 
condition of the nerve-centres preceded an epileptic attack. It explains also very sat- 
isfactorily how the occurrence of labor should intensify the convulsions, since, during 
the acme of the pains, the tension of the cerebral aiterial system is necessarily greatly 
increased. There are, however, obvious difficulties against its general acceptance. For 
examp’e, it does not satisfactorily account for those cases which are preceded by well- 
mar-ked precursory symptoms, and in which an abundance of albumen is present in the 
urine. Here the premonitory s’gns are precisely those which precede the development 
of uraemia in chronic Blight’s disease, the dependence of which on the retention in the 
blood of urina'-y elements can hardly be doubted. 
Views of MacDonald.—MacDonald2 has published an interesting paper on this sub- 
ject, in which he describes two very careful post-mortem examinations. In these he 
found extreme anaemia of the cerebro-spinal centres, with congestion of the meninges, 
but no evidence of cedema. He inclines to the belief that eclampsia is caused by irri- 
tation of the vaso-motor centre in consequence of an anaemic condition of the blood, 
produced by the retention in it of excrementitious matters which the kidneys ought to 
nave removed, this over-stimulation resulting in anaemia of the deeper seated nerve- 
centres and consequent convulsion. 
Excitability of Nervous System.—The key to the liability of the puerperal woman to 
convulsive attacks is, no doubt, to be found in the peculiar excitable condition of the 
nervous system in pregnancy—a fact which was clearly pointed out by the late Dr. 
Tyler Smith, and by many other writers. Her nervous system is, in this respect, not 
unlike that of children, in wdiom the predominant influence and great excitability of 
the nervous system are well-established facts, and in whom precisely similar convulsive 
seizures are of common occurrence on the application of a sufficiently exciting cause. 
Exciting Causes.—Admitting this, we require some cause to set the predisposed ner- 
vous system into morbid action; and this we may have either in a toxsemic, or in an 
extremely watery, condition of the blood, associated with albuminuria; or along with 
these, or sometimes independently of them, in some excitement, such as strong emo- 
1 Obstet. Trans., vol. viii. 
2 See his vol. of Collected Essays, entitled Heart Disease During Pregnancy, London, 1878. 24 
PUERPERAL ECLAMPSIA. 
tional disturbance. It is highly probable, however, that extreme anfemia is one of the 
actual conditions of the nerve-centres—a fact of much practical importance in reference 
to treatment. 
Treatment.—The management of cases in which the occurrence of suspicious symp- 
toms has led to the detection of albuminuria, has already been fully discussed. We 
shall, therefore, here only consider the treatment of cases in which convulsions have 
actually occurred. 
Venesection.—Until quite recently venesection was regarded as the sheet anchor in 
the treatment, and blood was always removed cop;ously, and, there is sufficient reason 
to believe, with occasional remarkable benefit. Many cases are recorded in which a 
patient, in apparently profound coma, rapidly regained her consciousness when blood 
was extracted in sufficient quantity. The improvement, however, was often transient, 
the convulsions subsequently recurring with increased vigor. There are good (heoretical 
grounds for believing that blood-letting can only be of merely temporary use, and may 
even increase the tendency to convulsion. These are so well put by Schroeder, that I 
cannot do better than quote his observations on this point. ‘‘ If, ’ ’ he says, ‘‘ the theory 
of Traube and Rosenstein be correct, a sudden depletion of the vascular system, by 
which the pressure is diminished, must stop the attacks. From experience it is known 
that after venesection the quantity of blood soon becomes the same through the serum 
taken from all the tissues, while the quality is greatly deteriorated by the abstraction of 
blood. A short time after venesection we shall expect to find the former blood-pressure 
in the arterial system, but the blood far more watery than previously. From this theo- 
retical consideration, it follows that abstraction of blood, if the above-mentioned con- 
ditions really cause convulsions, must be attended by an immediate favorable result, 
and, under certain, circumstances, the whole disease may surely be cut short by it. But, 
if all other conditions remain the same, the blood-pressure will, after some time, again 
reach its former height. The quantity of blood has, in the meantime, been greatly 
deteriorated, and consequently the danger of the disease will be increased.” 
In Properly-selected Cases Venesection is a Valuable Remedy.—These views suffi- 
ciently well explain the varying opinions held with regard to this remedy, and enable 
us to understand why, while the effects of venesection have been so lauded by certain 
authors, the mortality has admittedly been much lessened since its indiscriminate use 
has been abandoned. It does not follow because a remedy, when carried to excess, is 
apt to be hurtful, that it should be discarded altogether; and I have no doubt that, in 
properly-selected cases, and judiciously employed, venesection is a valuable aid in the 
treatment of eclampsia, and that it is specially likety to be useful in mitigating the first 
violence of the attack, and in giving time for other remedies to come into action. Care 
should, however, be taken to select the cases properly, and it will be specially indicated 
when there is marked evidence of great cerebral congestion and vascular tension, such 
as a livid face, a full bounding pulse, and strong pulsation in the carotids. The general 
constitution of the patient may also serve as a guide in determining its use, and we 
shall be the more disposed to resort to it if the patient be a strong and healthy woman; 
while, on the other hand, if she be feeble and weak, we may wisely discard it, and trust 
entirely to other means. In any case, it must be looked upon as a temporary expedient 
only ; useful in warding off immediate danger to the cerebral tissues, but never as the 
main agent in treatment. Nor can it be permissible to bleed in the heroic manner fre- 
quently recommended. A single bleeding, the amount regulated by the effect produced, 
is all that is ever likely to be of service. 
[After the discovery of the uraemic origin of eclampsia in pregnant women, the 
treatment by bleeding was very generally abandoned in the United States: but the 
more recent investigations of the causes of death have produced a reconsideration of 
this plan of treatment, and the tendency of the profession during the last ten years has 
been towards venesection, as a preventive of cerebral complications. In primipara? 
with a full pulse and flushed face, the rule with many of our obstetrical practitioners is 
to bleed the patient as early as practicable, and do this at least once effectually, so as to 
produce, if poss'ble, a noticeable impression. Where there are positive evidences of 
the existence of Bright's disease, of course this is inadmissible.—Ed.] 
Compression of the Carotids.—As a temporary expedient, having the same object in 
view, compression of the carotids during the paroxysms is worthy of trial. Th:s was 
proposed by Trousseau in the eclampsia of infants, and in the single case of eclampsia 
in which I have tried it, it seemed to be decidedly beneficial. It is a simple measure, 
and it offers the advantage of not leading to any permanent deterioration of the blood, 
as in venesection. 
Administration of Purgatives.—As a subsidiary means of diminishing vascular ten- 
sion, the administration of a strong purgative is desirable, and has the further effect of OBSTETRIC MANAGEMENT. 
25 
removing any irritant matter that may be lodged in the intestinal tract. If the patient 
be conscious, a full dose of the compound jalap powder may be given, or a few grains 
of calomel combined with jalap ; and if she be comatose, and unable to swallow, a drop 
of croton oil, or a quarter of a grain of elaterium, may be placed on the back of the 
tongue. 
Administration of Sedatives and Narcotics.—The great indication in the management 
of eclampsia is the controlling of convulsive action by means of sedatives. Foremost 
amongst them must be placed the inhalation of chloroform, a remedy which is fre- 
quently remarkably useful, and which has the advantage of being applicable at all 
stages of the disease, and whether the patient be comatose or not. Theoretical objec- 
tions have been raised against its employment, as being likely to increase cerebral con- 
gestion ; of this there is no satisfactory proof; on the contrary, there is reason to think 
that chloroform inhalation has rather the effect of lessening arterial tension, while it 
certainly controls the violent muscular action by which the hypenemia is so much in- 
creased. Practically no one who has used it can doubt its great value in diminishing 
the force and frequency of the convulsive paroxysms. Statistically its usefulness is 
shown by Charpentier, in his thesis on the effects of various methods of treatment in 
eclampsia, since out of G3 cases in which it was used, in 48 it had the effect of dimin- 
ishing or arresting the attacks. 1 only proving fatal. The mode of administration has 
varied. Some have given it almost continuously, keeping the patient in a more or less 
profound state of anaesthesia. Others have contented themselves with carefully watch- 
ing the patient, and exhibiting the chloroform as soon as there were any indications of 
a recurring paroxysm, with the view of controlling its intensity. The latter is the plan 
I have myself adopted, and of the value of which, in most, cases, I have no doubt. 
Every now and again, cases will occur in which chloroform inhalation is sufficient to 
control the paroxysm, or in which, from the very cyanosed state of the patient, its ad- 
ministration seems contra-indicated. Moreover, it is advisable to have, if possible, 
some remedy more continuous in its action, and requiring less constant personal super- 
vision. Latterly the internal administration of chloral has been recommended for this 
purpose. My own experience is decidedly in its favor, and I have used, as I believe, 
with marked advantage a combination of chloral with bromide of potassium, in the 
proportion of twenty grains of the former to half a drachm of the latter, repeated at 
intervals of from four to six hours. If the patient be unable to swallow, the chloral 
may be given in an enema, or hypodermically, six grains being diluted in 3j of water, 
and injected under the skin. The remarkable influence of bromide of potassium in 
controlling the eclampsia of infants would seem to be an indication for its use in puer- 
peral cases. Fordyce Barker is opposed to the use of chloral, which he thinks excites 
instead of lessening reflex irritability.1 Another remedy, not entirely free from theo- 
retical objections, but strongly recommended, is the subcutaneous injection of morphia, 
which has the advantage of being applicable when the patient is quite unable to swal- 
low. It may be given in doses of one-third of a grain, repeated in a few hours, so as 
to keep the patient well under its influence. It is to be remembered that the object is 
to control muscular action, so as to prevent, as much as possible, the violent convulsive 
paroxysm, and, therefore, it is necessary that the narcosis, however produced, should 
be continuous. It is rational, therefore, to combine the intermittent action of chloro- 
form with the more continuous action of other remedies, so that the former should sup- 
plement the latter when insufficient. Pilocarpin has recently been tried in the hope 
that the diaphoresis and salivation it produces might diminish arterial tension and free 
the blood of toxic matters. Braun2 administered three centigrammes of the muriate 
of pilocarpin hypodermically, and reports favorably of the result; Fordyce Barker,3 
however, is of opinion that it produces so much depression as to be dangerous. 
Other remedies, supposed to act in the way of antidotes to uraemic poisoning, have 
been advised, such as acetic or benzoic acid, but they are far too uncertain to have any 
reliance placed on them, and they distract attention from more useful measures. 
Precautions during the Paroxysm.—Precautions are necessary during the fits to pre- 
vent the patient injuring herself, especially to obviate laceration of the tongue; the 
latter can be best done by placing something between the teeth as the paroxysm comes 
on, such as the handle of a teaspoon enveloped in several folds of flannel. 
Obstetric Management.—The obstetric management of eclampsia will naturally give 
rise to much anxiety, and on this point there has been considerable difference of opinion. 
On the one hand, we have practitioners who advise the immediate emptying of the 
uterus, even when labor has commenced; on the other, those who would leave the 
1 The Puerperal Diseases, p. 120. 2 Berlin Klin. Woch., June 16, 1879. 
3 New York Med. Rec., March 1, 1879. 26 
PUERPERAL INSANITY. 
labor entirely alone. Thus Gooch said, “ attend to the convulsions, and leave the labor 
to take care of itselfand Schroeder says, “especially no kind of obstetric man pula- 
tion is required for the safety of the mother, ’ ’ but he admits, however, that it is some- 
times advisable to hasten the labor to insure the safety of the child. 
In cases in which the convulsions come on during labor, the pains are often strong 
and regular, the labor progresses satisfactorily, and no interference is needful. In 
others we cannot but feel that emptying the uterus would be decidedly beneficial. 
We have to reflect, however, that any active interference might, of itself, prove very 
irritating, and excite fresh attacks. The influence of uterine irritation is apparent, by 
the frequency with which the paroxysms recur with the pains. If, therefore, the os 
be undilated, and labor have not begun, no active means to induce it should be 
adopted, although the membranes may be ruptured with advantage, since that pro- 
cedure tends to no irritation. Forcible dilatation of the os, and especially turning, are 
strongly contra-indicated. 
The rule laid down by Tyler Smith seems that which is most advisable to follow— 
that we should adopt the course which seems least likely to prove a source of irritation 
to the mother. Thus if the fits seem evidently induced and kept up by the p essure 
of the foetus, and the head be within reach, the forceps or even craniotomy may be 
resorted to. But if, on the other hand, there be reason to think that the operation 
necessary to complete delivery is likely per se to prove a greater source of irritation 
than leaving the case to nature then we should not interfere. 
CHAPTER IY. 
PUERPERAL INSANITY. 
Classification.—Under the head of “ Puerperal Mania ” writers on obstetrics have 
indiscriminately classed all cases of mental disease connected with pregnancy and par- 
turition. The result has been unfortunate, for the distinction between the var ous 
types of mental disorder has, in consequence, been very generally lost sight of. But 
little study of the subject suffices to show that the term Puerperal Mania is wrong in 
more ways than one, for we find that a large number of cases are not cases of “mania ” 
at all, but of melancholia; while a considerable number are not, strictly speaking, 
“puerperal,” as they either come on during pregnancy, or long after the immediate 
risks of the puerperal period are over, being in the latter case associated with a rise mi a 
produced by over-lactation. For the sake of brevity, the generic term “ Puerperal 
Insanity" may be emp'oyed to cover all cases of mental disorders connected with ges- 
tation, which may be further conveniently subdivided into three classes, each having 
its special characteristics, viz.: 
I. The Insanity of Pregnancy. 
II. Puerperal Insanity, properly so called, that is, insanity coming on within a 
limited period after delivery. 
III. The Insanity of Lactation. 
This division is a strictly natural one, and includes aT the cases likely to come under 
observation. The relative proportion these classes bear to each other can only be 
determined by accurate statistical observations on a large scale, but these maerials we 
do not possess. The returns from large asylums are obvious’y open to objection, for 
only the worst and most confirmed cases find their way into these institutions, while by 
far the greater proportion, both before and after labor, are treated in their own homes. 
Taking such returns as only approximate, we find from Dr. Batty Tuke1 that in 
the Edinburgh Asylum out of 105 cases of puerperal insanity, 28 occurred before 
delivery, 13 during the puerperal period, and 54 during lactation. The relative pro- 
portions of each per hundred are as follows: 
Insanity of Pregnancy, 18.06 per cent. 
Puerperal Insanity, 47.09 “ 
Insanity of Lactation, 34.08 “ 
Marce2 collects together several series of cases from various authorities, amounting to 
1 Edin. Med. Journ., vol. x. 
* Traite de la Folie des Femmes enceintes. TRANSIENT MANIA DURING DELIVERY. 
27 
310 in all, and the results are not very different from those of the Edinburgh Asylum, 
except in the relatively smaller number of cases occurring before delivery. The per- 
centage is calculated from his figures: 
Insanity of Pregnancy, 8.06 per cent. 
Puerperal Insanity, 58.06 “ 
Insanity of Lactation, 30.30 “ 
As each of these classes differs in various important respects from the others, it will 
be better to consider each separately. 
Insanity of Preynancy.—The insanity of pregnancy is, without doubt, the least 
common of the three forms. The intense mental depression which in many women 
accompanies pregnancy, and causes the patient to take a despond.ng view of her con- 
dition, and to look forward to the result of her labor with the most gloomy apprehen- 
sion, seems to be often only a lesser degree of the actual mental derangement which is 
occasionally met with. The relation between the two states is further borne out by 
the fact that a large majority of cases of insanity during pregnancy are well-marked 
types of melancholia; out of 28 cases reported by Tuke, 15 were examples of pure 
melancholia, 5 of dementia with melancholia. In many of these the attack could be 
traced as developing itself out of the ordinary hypochondriasis of pregnancy. In 
others the symptoms came on at a later period of pregnancy, the earlier months of 
which had not been marked by any unusual lowness of spirits. The age of the patient 
seems to have some influence, the proportion of cases between 30 and 40 years of age 
being much larger than in younger women. A large proportion of cases occur in 
pvimiparas than in multipart, a fact that no doubt, depends on the greater dread and 
apprehension experienced by women who are pregnant for the first time, especially if 
not very young. Hereditary indisposition plays an important part, as in all forms of 
puerperal insanity. It is not always easy to ascertain the fact of an hereditary taint, 
since it is often studiously concea’ed by the friends. Tuke, however, found distinct 
evidence of it in no less than 12 out of 28 cases. Fiirstner1 believes that other neu- 
roses have an important influence in the causation of the disease. Out of 32 cases he 
found direct hereditary taint in 9, but in 11 more there was a family history of epilepsy, 
drunkenness, or hysteria. 
Period of Pregnancy at which it Occurs.—The period of pregnancy at which mental 
derangement most commonly shows itself, varies. Most generally, perhaps, it is at the 
end of the third, or the beginning of the fourth month. It may, however, begin with 
conception, and even return with every impregnation. Montgomery relates an instance 
in which it recurred in three successive pregnancies. Maree distinguishes between 
true insanity coming on during pregnancy and aggravated hypochondriasis, by the fact 
that the latter usually lessens after the third month, wh le the former most commonly 
only begins after that date. It is unquestionable that in many cases no such distinc- 
tion can be made, and that the two are often very intimately associated. 
Form of Insanity.—The form of insanity does not differ from ordinary melancholia. 
The suicidal tendency is generally very strongly developed. Should the mental dis- 
order continue after delivery, the patient may very probably experience a strong 
impulse to kill her child. Moral perversions have been not uncommonly observed. 
Tuke especially mentions a tendency to dipsomania in the early months, even in 
women who have not shown any d'spos'tion to excess at other times. He suggests 
that this may be an exaggeration of the depraved appetite, or morbid craving, so com- 
monly observed in pregnant women, just as melancholia may be a further development 
of lowness of spirits. Laycock mentions a disposition to “k’eptomania” as very 
characteristic of the disease. Casper2 relates a curious case where this occurred in a 
pregnant lady of rank, and the influence of pregnancy, in developing an irresistible 
tendency, was pleaded in a criminal trial in which one of her petty thefts had in- 
volved her. 
Prognosis.—The prognosis may be said to be, on the whole, favorable. Out of Dr. 
Take’s 28 cases, 19 recovered within six months. There is little hope of a cure until 
after the termination of the pregnancy, as out of 19 cases recorded by Maree only in 2 
did the insanity disappear before delivery. 
Transient Mania during Delivery.—There is a peculiar form of mental derangement 
sometimes observed during labor, which is by some talked of as a temporary insanity. 
It may, perhaps, be more accurately described as a kind of acute delirium, produced, 
in the latter stage of labor, by the intensity of the suffering caused by the pains. 
1 Archiv. fiir Psychiatrie, Band v. Heft 2. 
2 Casper’s Forensic Medicine, vol. iv. 28 
PUERPERAL INSANITY. 
According to Montgomery, it is most apt to occur as the head is passing through 
the os uteri, or, at a later period, during the expulsion of the child. It may consist 
of merely a loss of control over the mind, during which the patient, unless carefully 
watched, might, in her agony, seriously injure herself or her child. Sometimes it 
produces actual hallucination, as in the case described by Tarnier, in which the patient 
fancied she saw a spectre standing at the foot of her bed, which she made violent 
efforts to drive away. This kind of mania, if it may be so called, is merely transitory 
in its character, and disappears as soon as the labor is over. From a medico-legal 
point of view it may be of importance, as it has been held by some that in certain 
cases of infanticide the mother has destroyed the child when in this state of transient 
frenzy, and when she was irresponsible for her acts. In the treatment of this variety 
of delirium we must, of course, try to lessen the intensity of the suffering, and it is in 
such cases that chloroform wdl find one of its most valuable applications. 
Puerperal Insanity [proper).—True puerperal insanity has always attracted much 
attention from obstetricians, often to the exclusion of other forms of mental disturb- 
ance connected with the puerperal state. We may define it to be, that form of insanity 
which comes on within a limited period after delivery, and which is probably inti- 
mately connected with that process. Out of 73 examples of the disease tabulated by 
Dr. Tuke, only 2 came on later than a month after delivery, and in these there were 
other causes present, which might possibly remove them from this class. 
Although a large number of these cases assume the character of acute mania, that 
is by no means the only kind of insanity which is observed, a not inconsiderable num- 
ber being well-marked examples of melancholia. The distinction between them was 
long ago pointed out by Gooch, whose admirable monograph on the disease contains one 
of the most graphic and accurate accounts of puerperal insanity that has yet been written. 
There are also some peculiarities as to the period at which these varieties of insanity 
show themselves, which taken in connection with certain facts in their etiology, may 
eventually justify us in drawing a stronger line of demarcation between them than has 
been usual. It appears that cases of acute mania are apt to come on at a period much 
nearer delivery than melancholia. Thus Tuke found that all the cases of mania came 
on within sixteen days after delivery, and that all cases of melancholia developed them- 
selves after that period. We shall presently see that one of the most recent theories 
as to the causation of the disease attributes it to some morbid condition of the blood. 
Should further investigation confirm this supposition, inasmuch as septic conditions of 
the blood are most likely to occur a short time after labor, it would not be an im- 
probable hypothesis that cases of acute mania, occurring within a short time after 
labor, may depend on such septic causes, while melancholia is more likely to arise from 
general conditions favoring the development of mental disease. This must, however, 
be regarded as a mere speculation requiring further investigation. 
Causes.—Hereditary predisposition is very frequently met with, and a careful inquiry 
into the patient’s history will generally show that other members of the family have 
suffered from mental derangement. Reid found that out of 111 cases in Bethlehem 
Hospital there was clear evidence of hereditary taint in 45. Tuke made the same 
observation in 22 out of his 73 cases; and, indeed, it is pretty generally admitted by 
all alienist physicians that hereditary tendencies form one of the strongest predisposing 
causes of mental disturbance in the puerperal state. In a large proportion of cases 
circumstances producing debility and exhaustion, or mental depression, have preceded 
the attack. Thus it is often found that patients attacked with it have had post-partum 
haemorrhage, or have suffered from some other conditions producing exhaustion, such 
as severe and complicated labor; or they may have been weakened by over-frequent 
pregnancies, or by lactation during the early months of pregnancy. Indeed, anaemia 
is always well marked in this disease. Mental conditions also are frequently traceable 
in connection with its production. Morbid dread during pregnancy, insufficient to pro- 
duce insanity before delivery, may develop into mental derangement after it. Shame 
and fear of exposure in unmarried women not unlfequently lead to it, as is evidenced 
by the fact that out of 2281 cases, gathered from the reports of various asylums, above 
64 per cent, were unmarried.1 Sudden moral shocks or vivid mental impressions may 
be the determining cause in predisposed persons. Gooch narrates an example of this 
in a lady who was attacked immediately after a fright produced by a fire close to her 
house, the hallucinations in this case being all connected with light; and Tyler Smith 
that of another whose illness dated from the sudden death of a relative. The age of 
the patient has some influence, and there seems to be a decidedly greater liability at 
advanced ages, especially when such women are pregnant for the first time. 
1 Journ. of Mental Science, 1870-71, p. 159. PROGNOSIS. 
29 
Theory of its Dependence on Morbid State of the Blood.—The possibility of the acute 
form of puerperal insanity, coming on shortly after delivery, being dependent on some 
form of septicaemia is one which deserves careful consideration. The idea originated 
with Sir James Simpson, who found albumen in the urine of 4 patients. He suggested 
that this might probably indicate the presence in the blood of certain urinary con- 
stituents, which might have determined the attack, much in the same way as in 
eclampsia. Dr. Donkin subsequently wrote an important paper,1 in which he warmly 
supported this theory, and arrived at the conclusion, “that the acute dangerous class 
of cases are examples of uraemic blood-poisoning, of which the mania, rapid pulse, and 
other constitutional symptons are merely the phenomena; and that the affection, 
therefore, ought to be termed uraemic or renal puerperal mania, in contradistinction to 
the other form of the disease. ’ ’ He also suggests that the immediate poison may be 
carbonate of ammonia, resulting from the decomposition of urea retained in the blood. 
It will be observed, therefore, that the pathological condition producing puerperal 
mania would, supposing this theory to be correct, be precisely the same as that which, 
at other times, is supposed to give rise to puerperal eclampsia. There can be no doubt 
that the patient, immediately after delivery, is in a condition rendering her peculiarly 
liable to various forms of septic disease; and it must be admitted that there is no in- 
herent improbability in the supposition that some morbid material circulating in the blood 
may be the effective cause of the attack, in a person otherwise predisposed to it. It is 
also certain, as I have already pointed out, that there are two distinct classes of cases, 
differing according to the period after delivery at which the attack comes on. Whether 
this difference depends on the presence in the blood of some septic matter—especially 
urinary excreta—is a question which our knowledge by no means justifies us in answer- 
ing ; it is, however, one which well merits further careful study. 
Objections to this Theory.—It is only fair to point out some difficulties which appear 
to militate against the view which Dr. Donkin maintains. In the first place, the albu- 
minuria is merely transient, while its supposed effects last for weeks or months. Sir 
James Simpson says, with regard to his cases: “I have seen all traces of albuminuria 
in puerperal insanity disappear from the urine within fifty hours of the access of the 
malady. The general rapidity of its disappearance is, perhaps, the principal, or, indeed, 
the only reason why this complication has escaped the notice of those physicians among 
us who devote themselves with such ardor and zeal to the treatment of insanity in our 
public asylums. ’ ’ This apparent anomaly Simpson attempts to explain by the hypothe- 
sis that, when once the uraemic poisoning has done its work, and set the disease in 
progress, the mania progresses of itself. This, however2 is pure speculation; and, in 
the supposed analogous case of eclampsia, the albuminuria certainly lasts as long as its 
effects. It is not' easy to understand, also, why uraemic poisoning should in one case 
give rise to insanity, and in another to convulsions. For all we know to the contrary, 
transient albuminuria may be much more common after delivery than has been gener- 
ally supposed, and further investigation on this point is required. Albumen is by no 
means unfrequently observed in the urine, for a short time, in various conditions of the 
body, without any serious consequences, as, for example, after bathing; and we inay 
too readily draw an unjustifiable conclusion from its detection in a few cases of mania. 
There are, however, many other kinds of blood-poisoning, besides uraemia, which may 
have an influence in the production of the disease, and it is to be hoped that future 
observations may enable us to speak with more certainty on this point. 
Prognosis.—The prognosis.of puerperal insanity is a point which will always deeply 
interest those who nave to deal with so distressing a malady. It may resolve itself 
into a consideration of the immediate risk to life, and of the chances of ultimate res- 
toration of the mental faculties. It is an old aphorism of Gooch’s, and one the cor- 
rectness of which is justified by modern experience, that “mania is more dangerous to 
life, malancholia to reason. ’ ’ It has very generally been supposed that the immediate 
risk to life in puerperal mania is not great, and, on the whole, this may be taken as 
correct. Tuke found that death took place, from all causes, in 10.9 of the cases under 
observation; these, however, were all women who had. been admitted into asylums, 
and in whom the attack may be assumed to have been exceptionally severe. Great 
stress was laid by Hunter and Gooch on extreme rapidity of the pulse, as indicating a 
fatal tendency. There can be no doubt that it is a symptom of great gravity, but by no 
means one which need lead us to despair of our patient’s recovery. The most danger- 
ous class of cases are those attended with some inflammatory complication; and if 
there be marked elevation of temperature, indicating the presence of some such con- 
comitant state, our prognosis must be more grave than when there is mere excitement 
of the circulation. 
1 Edin. Med. Journ., vol. vii. 30 
PUERPERAL INSANITY. 
Post-mortem Signs.—There are no marked post-mortem signs found in fatal cases to 
guide us in form.ng an opinion as to the nature of the disease. “ No constant morbid 
changes,” says Tyler Smith, “are found within the head, and most frequently the only 
condition found in the brain is that of unusual paleness and exsanguinity. Many 
pathologists have also remarked upon the extremely empty condition of the blood-ves- 
sels, particularly the veins.” 
Duration of the Disease.—The duration of the disease varies considerably. Gener- 
al’y speaking, cases of mania do not last so long as melancholia, and recovery takes 
place wi.hin a per.od of three months, often earlier. Very few of the cases admitted 
into the Edinburgh Asylum remained the’e more than six months, and after that time 
the chances of ultimate recovery greatly lessened. When the patient gets well, it often 
happens that her recollection of the events occurring during her illness is lost; at other 
times, the delusions from which she suffered remain, as, for example, in a case which 
was under my care, in which the personal antipathies which the patient formed when 
insane became permanently establ ished. 
Insanity of Lactation.—Fifty-four out of the 155 cases collected by Dr. Tuke were 
examples of the insanity of lactation, which would appear, therefore, to be nearly 
twice as common as that of pregnancy, but considerably less so than the true puerperal 
form. Its dependence on causes producing anaemia and exhaustion is obvious and well 
marked. In the large majority of cases, it occurs in multiparae who have been debili- 
tated by frequent pregnancies, and by length of nursing. When occurring in primi- 
parae, it is generally in women who have suffered from post-partum haemorrhage, or 
other causes of exhaustion, or whose constitution was such as should have contra-indi- 
cated any attempt at lactation. The bruit-de-diable is almost invariably present in the 
veins of the neck, indicating the impoverished condition of the blood. 
The type is far more frequently melancholic than maniacal, and when the latter form 
occurs, the attack is much more transient than in true puerperal insanity. The danger 
to life is not great, especially if the cause producing debility be recognized and at once 
removed. 
There seems, however, to be more r:sk of the insanity becoming permanent than in 
the other forms. In 12 out of Dr. Tuke’s cases the melancholia degenerated into 
dementia, and the patients became hopelessly insane. 
Symptoms.—The symptoms of these various forms of insanity are practically the 
same as in the non-pregnant state. 
Generally in cases of mania there is more or less premonitory indication of mental 
disturbance, which may pass unperceived. The attack is often preceded by restlessness 
and loss of sleep, the latter being a very common and well-marked symptom ; or, if the 
patient do sleep, her rest is broken and disturbed by dreams. Causeless d'slikes to 
those around her are often observed ; the nurse, the husband, the doctor, or the child, 
becomes the object of suspicion, and, unless proper care be taken, the child may be 
seriously injured. As the disease advances, the patient becomes incoherent and ram- 
bling in her talk, and, in a fully-developed case, she is incessantly pouring forth an un- 
connected jumble of sentences, out of which no meaning can b»* made. Often some 
Erevalent idea which is dwelling in the patient's mind can be traced running through 
er ravings, and it has been noticed that this is frequently of a sexual character, caus- 
ing women of unblemished reputation to use obscene and disgusting language, which it 
is difficult to understand their even having heard. The tendency of such pat ents to 
make accusations impugning their own chastity was specially insisted on by many emi- 
nent authorities in a recent celebrated trial, when Sir James Simpson stated that in his 
experience “the organ diseased gave a type to the insanity, so that with women suffer- 
ing from affections of the genital organs the delusions would be more likely to be con- 
nected with sexual matters.” Religious delusions, as a fear of eternal damnation, or 
of having committed some unpardonable sin, are of f equent occurrence, but perhaps 
more often in cases which are tending to the melancholic type. There is generally in- 
tolerable restlessness, and the patient's who'e manner and appearance are those of ex- 
cessive excitement. She may refuse to remain in bed, may tear off her clothes, or 
attempt to injure herself. The suicidal tendency is often very marked. In one case 
under mv care, the patient made incessant efforts to destroy herself, which were only 
frustrated by the most careful watching; she endeavored to strangle herself with the 
bedclothes, to swa'low any article she could lay ho'd of, and even to gouge out her own 
eyes. Food is generally persistently refused, and the utmost coaxing may fail in induc- 
ing the patient to take nourishment. The puke is rapid and small, and the more vio- 
lent the excitement and furious the delirium, the more excited is the circulation. The 
tongue is coated and furred, the bowels constipated and disordered, and the feces, as 
well as the urine, are frequently passed involuntarily. The urine is scanty and high- STIMULANTS. 
31 
colored, and, after the disease has lasted for some time, it becomes loaded with phos- 
phates. The lochia, and the secretion of milk, generally become arrested at the com- 
mencement of the disease. The waste of tissue, from the incessant restlessness and 
movement of the patient, is very great; and, if the disease continue for some time, she 
falls into a condition of marasmus, which may be so excessive that she becomes wasted 
to a shadow of her former size. 
Symptoms of Melancholia.—When the insanity assumes the form of melancholia, its 
advent is more gradual. It may commence with depression of spirits, without any 
adequate cause, associated with insomnia, disturbed digestion, headache, and other in- 
dications of bodily derangement. Such symptoms, showing themselves in women who 
have been nursing for a length of time, or in whom any other evident cause of exhaus- 
tion exists, should never pass unnoticed. Soon the signs of mental depression increase, 
and positive delusions show themselves. These may vary much in their amount, but 
they are all more or less of the same type, and very often of a religious character. The 
amount of constitutional disturbance varies much. In some cases which approach in 
character those of mania, there is considerable excitement, rapid pulse, furred tongue, 
and restlessness. Probably cases of acute melancholia, coming on during the puerperal 
state, most often assume this form. In others again there is less of these general 
symptoms, the patients are profoundly dejected, sit for hours without speaking or 
moving; but there is not much excitement, and this is the form most generally char- 
acterizing the insanity of lactation. In all cases there is a marked disinclination to food. 
There is also, almost invariably, a disposition to suicide; and it should never be for- 
gotten, in melancholic cases, that this may develop itself in an instant, and that a 
moment’s carelessness on the part of the attendants may lead to disastrous results. 
Treatment.—Bearing in mind what has been said of the essential character of puer- 
peral insanity, it is obvious that the course of treatment must be mainly directed to 
maintain the strength of the patient, so as to enable her to pass through the disease 
without fatal exhaustion of the vital powers, while we endeavor, at the same time, to 
calm the excitement and give rest to the disturbed brain. Any over-active measures— 
for example, bleeding, blistering the shaven scalp, and the like—are distinctly contra- 
indicated. 
There is a general agreement on the part of the alienist physicians that in cases of 
acute mania the two things most needful are a sufficient quantity of suitable food and 
sleep. 
Importance of Administering Nourishment.—Every endeavor should be made to 
induce the patient to take abundance of nourishment, to remedy the effects of the ex- 
cessive waste of tissue, and support her strength until the disease abates. Dr. Bland- 
ford, who has especially insisted on the importance of this, says,1 “Now, with regard 
to the food, skilful attendants will coax a patient into taking a large quantity, and we 
can hardly give too much. Messes of minced meat with potato and greens, diluted 
with beef-tea, bread and milk, rum and miik, arrow-root, and so on, may be got down. 
Never give mere liquids so long as you can get down solids. As the malady progresses, 
the tongue and mouth may become so dry and foul that nothing but liquids can be 
swallowed; but, reserving our beef-tea and brandy, let us give plenty of solid food while 
we can. ’ ’ 
Forcible Administration of Food.—The patient may, in mania as well as in melan- 
cholia, perhaps even more in the latter, obstinately refuse to take nourishment at all, 
and we may be compelled to use force. Various contrivances have been employed for 
this purpose. One of the simplest is introducing a dessert-spoon forcibly between the 
teeth, the patient being controlled by an adequate number of attendants,. and slowly 
injecting into the mouth suitable nourishment, by an India-rubber bottle with an ivory 
nozzle, such as is sold by all chemists. Care must be taken not to inject more than an 
ounce at a time, and to allow the patient to breathe between each deglutition. So ex- 
treme a measure will seldom be required, if the patient have experienced attendants, 
who can overcome her resistance to food by gentler means; but it may be essential, and 
it is far better to employ it than to allow the patient to become exhausted from want of 
nourishment. In one case I had to feed a patient in this way three times a day for 
several weeks, and used for the punrose a contrivance known in asylums as Paley’s 
feeding-bottle, which reduced the difficulty of the process to a minimum. Beef-tea, or 
strong soup, mixed with some farinaceous material, such as Bevalenta Arabica, or 
wheaten flour, or milk, forms the best mess for this purpose. 
Stimulants.—In the early stages the patient is probably better without stimulants, 
which seem only to increase the excitement. As the disease progresses, and exhaustion 
1Blandford, Insanity and its Treatment. 32 
PUERPERAL INSANITY. 
becomes marked, it may be necessary to have recourse to them. In melancholia they 
seem to be more useful, and may be administered with greater freedom. 
State of the Bowels.—The state of the bowels requires especial attention. They are 
almost always disordered, the evacuations being dark and offensive in odor. In the 
ear'v stages of the disease, the prompt clearing of the bowels by a suitable purgative 
sometimes has the effect of cutting short an impending attack. A curious example of 
this is recorded by Gooch, in which the patient’s recovery seemed to date from the free 
evacuation of the bowels. A few grains of calomel, or a dose of compound jalap powder, 
or of castor oil, may generally be readily given. During the continuance of the illness 
the state of the prima) viac should be attended to, and occasional aperients will be useful, 
but strong and repeated purgation is hurtful from the debility it produces. 
The procuring sleep will necessarily form one of the most important points of treat- 
ment. For this purpose there is no drug so valuable as the hydrate of chloral, either 
alone, or in combination with bromide of potassium, which has a distinct effect in in- 
creasing its hypnotic action. Given in a full dose at bedtime, say 15 grs. to oss, it 
rarely fails in procuring at least some sleep, and, in an early stage of acute mania, this 
may be followed by the best effects. It may be necessary to repeat this draught night 
after night, during the acute stage of the malady. If we cannot induce the patient to 
swallow the medicine, it may be given in the form of enema. 
Question of Administering Opiates.—It is generally admitted that in mania prepara- 
tions of opium, formerly much relied on in the treatment of the disease, are apt to do 
more harm than good. I)r. Blandford gives a strong opinion on this point, lie says: 
“In prolonged delirious mania I believe opium never does good, and may do great 
harm. We shall see the effects of narcotic poisoning if it be pushed, but none that are 
beneficial. This applies equally to opium given by the mouth, and by subcutaneous 
injection. The latter, as it is more certain and effectual in producing good results, is 
also more deadly when it acts as a narcotic poison. After the administration of a dose 
of morphia by the subcutaneous method, the patient will probably at once fall asleep, 
and we congratulate ourselves that our long-wished-for object is attained. But after 
half an hour or so the sleep suddenly terminates, and the mania and excitement are 
worse than before. Here you may possibly think that had the dose been larger, instead 
of half an hour's sleep you would have obtained one of longer duration, and you may 
administer more, but with a like result. Large doses of morphia not merely fail to 
produce refreshing sleep; they poison the patient, and produce, if not the symptoms 
of actual narcotic poisoning, at any rate that typhoid condition which indicates prostra- 
tion and approaching collapse. I believe there is no drug, the use of which more often 
becomes abused, than that of opium.” It is otherwise in cases of melancholia, espe- 
cially in the more chronic forms. In these opiates, in moderate doses, not pushed to 
excess, may be given with great advantage. The subcutaneous injection of morphia is 
by far the best means of exhibiting the drug, from its rapidity of action, and facility 
of administration. 
Other Calmatives.—There are other methods of calming the excitement of the pat ient 
besides the use of medicines. The prolonged use of the warm bath, the patient being 
immersed in water at a temperature of 90° or 92° for at least half an hour, is highly 
recommended by some as a sedative. The wet pack serves the same purpose, and is 
more readily applied in refractory subjects. 
Importance of Judicious Nursing.—Judicious nursing is of primary importance. The 
patient should be kept in a cool, well-ventilated, and somewhat darkened room. If 
possible she should remain in bed, or, at least, endeavors should be made to restrain 
the excessive restless motion, which has so much effect in promoting exhaustion. The 
presence of relatives and friends, especially the husband, has generally a prejudicial 
and exciting effect; and it is advisable to place the patient under the care of nurses 
experienced in the management of the insane, who, as strangers, are likely to have 
more control over her. It is not too much to say that much of the success in treatment 
must depend on the manner in which this indication is met. Rough, unskilled nurses 
who do not know how to use gentleness combined with firmness, will certainly aggravate 
and prolong the disorder. Inasmuch as no patient should be left unwatched by day or 
night, more than one nurse is essential. 
Question of Removal to an Asylum.—The question of the removal of the patient to 
an asylum is one which will give rise to anxious consideration. As the fact of having 
been under such restraint of necessity fixes a certain lasting stigma upon a patient, this 
is a step which every one would wish to avoid if possible. In cases of acute mania, 
which will probably last a comparatively short time, home treatment can generally be 
efficiently carried out. Much must depend on the circumstances of the patient. If 
these be of a nature which preclude the possibility of her obtaining thoroughly efficient HISTORY OF THE DISEASE. 
33 
nursing and treatment in her own home, it is advisable to remove her to a place where 
these essentials can be obtained, even at the cost of some subsequent annoyance. In 
cases of chronic melancholia, the management of which is on the whole more difficult, 
the necessity for such a measure is more likely to arise, and should not be postponed too 
late. Many examples of incurable dementia, arising out of puerperal melancholia, can 
be traced to unnecessary delay in placing the patients under the most favorable condi- 
tions for recovery. 
Treatment during Convalescence.—When convalescence is commencing, change of air 
and scene will often be found of great value. Removal to some quiet country place, 
where the patient can enjoy abundance of air and exercise, in the company of her 
nurses, without the excitement of seeing many people, is especially to be recommended. 
Great caution must be used in admitting the visits of relatives and friends. In two 
cases under my own care the patients relapsed, when apparently progressing favorably, 
because the husbands insisted, contrary to advice, on seeing them. On the other hand, 
Gooch has pointed out that, when the patient is not recovering, when month after 
month has been passed in seclusion without any improvement, the visit of a friend or 
relative may produce a favorable moral impression, and inaugurate a change for the 
better. It is probably in cases of melancholia, rather than in mania, that this is likely 
to happen. The experiment may, under such circumstances, be worth trying; but ic 
is one the result of which we must contemplate with some anxiety. 
CHAPTER V. 
PUERPERAL SEPTICAEMIA. 
There is no subject in the whole range of obstetrics which has caused so much 
discussion and difference of opinion as that to which this chapter is devoted. Under 
the name of “Puerperal Fever” the disease we have to consider has given rise to 
endless controversy. One writer after another has stated his view of the nature of the 
affection with dogmatic precision, often on no other grounds than his own preconceived 
notions, and an erroneous interpretation of some of the post-mortem appearances. 
Thus, one states that puerperal fever is only a local inflammation, such as peritonitis ; 
others declare it to be phlebitis, metritis, metro-peritonitis, or an essential zymotic 
disease sui generis, which affects lying-in women only. The result has been a hopeless 
confusion ; and the student rises from the study of the subject with little more useful 
knowledge than when he began. Fortunately, modern research is beginning to throw 
a little light upon this chaos. 
Modern View of the Disease.—The whole tendency of recent investigation is daily 
rendering it more and more certain that obstetricians have been led into error by the 
special virulence and intensity of the disease, and that they have erroneously consid- 
ered it to be something special to the puerperal state, instead of recognizing in it a 
form of septic disease practically identical with that which is familiar to surgeons 
under the name of pyaemia or septicaemia. 
Objection to the Name.—If this view be correct, the term “ puerperal fever,” con- 
veying the idea of a fever such as typhus or typhoid, must be acknowledged to be 
misleading, and one that should be discarded as only tending to confusion. Before 
discussing at length the reasons which render it probable that the disease is in no way 
specific or peculiar to the puerperal state, it will be well to relate briefly some of the 
leading facts connected with it. 
History of the Disease.—More or less distinct references to the existence of the 
so-called puerperal fever are met with in the class:eal authors, proving, beyond doubt, 
that the disease was well known to them ; and Hippocrates, besides relating several 
cases, the nature of which is unquestionable, clearly recognizes the possibility of its 
originating in the retention and decomposition of portions of the placenta. Although 
Harvey and other writers showed that they were more or less familiar with it, and 
even made most creditable observations on its etiology, it was not until the latter half 
of the last century that it came prominently into notice. At that time the frightful 
mortality occurring in some of the principal lying-in hospitals, especially in the Hotel PUERPERAL SEPTICAEMIA. 
Dieu at Paris attracted attention; and ever since the disease has been familiar to 
obstetricians. 
Mortality resulting from it in Lying-in Hospitals. —Its prevalence in hospitals in 
which lying-in women are congregated has been constantly observed both in th's 
country and abroad, occas:onally producing an appalling death-rate; the disease, when 
once it has appeared, frequently spreading from one patient to another, in spite of all 
that could he done to arrest it. It would be easy to give many startling instances of 
this. Thus it prevailed in London in the years 1760, 1768, and 1770, to such an ex- 
tent that in some lying-in institutions nearly all the patients died. Of the Edinburgh 
Infirmary in 1773, it is stated that “almost every woman, as soon as she was delivered, 
or perhaps about twenty-four horn s after, was seized with it, and all of them died, though 
every method was used to cure the disorder.” On the Continent, where the lying-'n 
institutions are on a much larger scale, the mortality was equally great. Thus in the 
Maison d’ Accouchements of Paris, in a number of different years, sometimes as many 
as 1 in 3 of the women delivered died ; on one occasion 10 women dying out of 15 de- 
livered. Similar results were observed in other great Continental hospitals, as in 
Vienna, where, in 1823, 19 per cent, of the cases died, and, in 1842, 16 per cent. ; 
and in Berlin, in 1862, hardly a single patient escaped, the hospital being eventually closed. 
Such facts, the correctness of which is beyond any question, prove to demonstration 
the great risk which may accompany the aggregation of lying-in women. Whether 
they justify the conclusion that all lying-in hospitals should be abolished, is another 
and a very wide question, which can scarcely be satisfactorily discussed in a practical 
work. It is to be observed, however, that most of the cases in which the disease 
produced such disastrous results, occurred before our more recent knowledge of its 
mode of propagation was acquired, when no sufficient hygienic precautions were 
adopted, when ventilation was little thought of, and when, in a word, every condition 
prevailed that would tend to favor the spread of a contagious disease from one patient 
to another. More recent experience proves that when the contrary is the case (as for 
example in such an institution as the Rotunda Hospital in Dublin), the occurrence of 
epidemics of this kind may be entirely prevented, and the mortality approximated to 
that of home practice. 
The Assumption of a Puerperal Miasm is Unnecessary.—The more closely the history 
of these outbreaks in hospitals are studied, the more apparent does it become that 
they are not dependent on any miasm necessarily produced by the aggregation of 
pue:peral patients, but on the direct conveyance of septic matter from one patient to 
another. 
In numerous instances the disease has been said to be generally epidemic in domi- 
ciliary practice, much in the same way as scarlet fever, or any other zymotic complaint 
might be. Such epidemics are described as having occurred in London in 1827-28, 
in Leeds in 1809-12, in Edinburgh in 1825, and many others might be cited. There 
is, however, no sufficient ground for believing that the disease has ever been epidemic 
in the strict sense of the word. That numerous cases have often occurred in the same 
place, and at the same time, is beyond question; but this can easily be explained with- 
out admitting an epidemic influence, knowing, as we do, how readily septic matter may 
be conveyed from one patient to another. In many of the so-called epidemics the dis- 
ease has been limited to the patients of certain midwives or practitioners, while those 
of others have entirely escaped; a fact easily understood on the assumption of the 
disease being produced by septic matter conveyed to the patient, but irreconcilable with 
the view of general epidemic influence. We are not in possess'on of any reliable 
statistics of the mortality arising from puerperal septicaemia in ordinary general prac- 
tice. It has, however, been well pointed out in the Report on Puerperal Fever, pre- 
sented by the Obstetrical Society of Berlin to the Prussian Minister of Health,1 that 
not only do the published returns of death from metria afford no reliable estimate of 
the actual mortality from this source, but that they are very far more numerous than 
deaths from any other cause in connection with pregnancy and childbirth. 
Numerous Theories advanced regarding its Nature.—It would be a useless task to 
detail at length the theories that have been advanced to explain the disease. Indeed 
it may safely be held that the supposed necessity of providing a theory which would 
explain all the facts of the disease, has done more to surround it with obscurity than 
even the difficulties of the subject itself. If any real advance is to be made, it can 
only be by adopting an humble attitude, by admitting that we are orfy on the threshold 
of the inquiry, and by a careful observation of clinical facts, without drawing from them 
too positive deductions. 
JSee Edinburgh Med. Journ., Nov., 1878. ABSORPTION OF SEPTIC MATTER. 
35 
Theory of its Local Origin.—Many have taught that the disease is essentially a local 
inflammation, producing secondary constitutional effects. This view doubtless origi- 
nated from too exclusive attention to the morbid changes found on post-mortem exami- 
nation. Extensive peritonitis, phlebitis, inflammation of the lymphatics, or of the 
tissues of the uterus, are very commonly found after death; and each of these has, in 
its turn, been believed to be the real source of the disease. This view finds but little 
favor with modern pathologists, and is in so many ways inconsistent with clinical facts, 
that it may be cons:dered to be obsolete. No one of the conditions above mentioned is 
universally found, and in the worst cases, definite signs of local inflammation may be 
entirely absent. Nor will this theory explain the conveyance of the disease from one 
pat ent to another, or the peculiar seventy of the constitutional symptoms. 
Theory of an Essential Zymotic Fever.—A more admissible theory, and one which 
has been extensively entertained, is, that there is an essential zymotic fever peculiar to, 
and only attacking, puerperal women, which is as specific in its nature as typhus or 
typhoid, and to which the local phenomena observed after death bear the same relation 
that the pustules on the skin do to small-pox, or the ulcers in the intestinal glands'to 
typhoid. This fever is supposed to spread by contagion and infection, and to prevail 
epidemically, both in private and in hospital practice. The most recent exponent of 
this view is Fordyce Barker, who, in his excellent work on the Puerperal Diseases, 
has entered at length into all the theories of the disease. He, like others who hold his 
opinions, has, I cannot but think, entirely failed to bring forward any conclusive evi- 
dence of the existence of such a specific fever. It is no doubt true that in typhus and 
typhoid, and other undoubted examples of this class of disease, there are well-marked 
local secondary phenomena ; but then they are distinct and constant. lie makes no 
attempt to prove that anything of the kind occurs in puerperal fever. On the contrary, 
probably there are no two cases in which similar local phenomena occur; nor is there 
any case in which the most practised obstetrician could foretell, either the course and 
duration of the illness, or the local phenomena. Again, this theory altogether fails to 
explain the very important class of cases which can be distinctly traced to sources origi- 
nating in the patient herself, viz., the absorption of septic matter from decomposing 
coagula, and the like. Barker meets this difficulty by placing such cases of auto-infec- 
tion under a separate category, admitting that they are examples of septicaemia. • But 
he fails to show that there is any difference in symptomatology or post-mortem signs 
between them and the cases he be’ieves to depend on an essential fever; nor would it 
be possible to distinguish the one from the other by either their clinical or pathological 
history. 
Theory of Identity with Surgical Septicaemia.—The modern view which holds that 
the disease is, in fact, identical with the condition known as pyaemia or septicaemia, is 
by no means free from objections, and much patient clinical investigation is required to 
give a satisfactory explanation of cer.arn peculiarities which the disease presents; but, 
in spite of these difficulties, which time may serve to remove, it offers a far better ex- 
planation of the phenomena observed than any other that has yet been advanced. 
Nature of this View.—According to this theory, the so-called puerperal fever is pro- 
duced by the absorption of septic matter into the system, through solutions of continuity 
in the generative tract, such as always exist after labor. It is not essential that the 
po;son should be peculiar or specific j for, just as in surgical pyaemia, any decomposing 
organic matter, either originating within the generative organs of the patient herself, 
or coming from without, may set up the morbid action. 
In describing the disease under discussion, I shall assume that, so far as our present 
knowledge goes, this view is the one most consonant with facts; but, bearing in mind 
that very little is yet known of surgical septicaemia, it must not be expected that ob- 
stetricians can satisfactorily explain all the phenomena they observe. 
Basis of Description.—The best basis of description I know of, is that given by 
Burdon Sanderson, when he says, “ in every pyaemia process you may trace a focus, a 
centre of origin, 1 nes of diffusion or distribution, and secondary results from the dis- 
tribution. In every case an initial process from which infection commences, from which 
the infection spreads, and secondary processes which come out of this primary one.” 1 
Adopting th:s division, I shall first treat of the mode in which the. infection may com- 
mence in obstetric cases, and point out the special difficulties which this part of the 
subject presents. 
Channels through which Septic Matter may he Absorbed.— The fact that all recently 
delivered women present lesions of continuity in the generative tract, through which 
septic matter, brought into contact with them, may be readily absorbed, has long been 
1 Clinical Transactions, vol. viii. p. cviii. PUERPERAL SEPTICAEMIA. 
recognized. The analogy between the interior of the uterus after delivery and the 
surface of a stump after operation, was particularly insisted on by Cruveilhier, Simp- 
son, and others ; an analogy which was, to a great extent, based on erroneous concep- 
tions of what took place, since they conceived that the whole interior of the uterus 
was bared. It is now well known that that is not the case; but the fact remains that 
at the p’acental site, at any rate, there are open vessels through which absorption may 
readily take place. That absorption of septic material occurs through this channel is 
probable in certain cases in which decomposing materials exist in the interior of the 
uterus, especially when, from defective uterine contraction, the venous sinuses are 
abnormally patulous, and are not occluded by thrombi. It is difficult to understand 
how septic matter, introduced from without, can reach the placental site. Other sites 
of absorption are, however, always available. These exist in every case in the form of 
slight abrasions or lacerations about the cervix, or in the vagina, or especially in primi- 
parae, about the fourchette and perinaeum. There is even some reason to think that 
absorption of septic matter may take place through the mucous membrane of the 
vagina or cervix without any breach of surface. This might serve to account for the 
occasional, although rare cases, in which symptoms of the disease develop themselves 
before delivery, or so soon after it as to show that the infection must have preceded 
labor; nor is there any inherent improbability in the supposition that septic material 
may be occasionally absorbed through the unbroken mucous membrane, as is certainly 
the case with some poisons ; for example, that of syphilis. Hence, there is no difficulty 
in recognizing the similarity of a lying-in woman to a patient suffering from a recent 
surgical lesion, or in understanding how septic matter conveyed to her, during or 
shortly after labor, may be absorbed. It is necessary, however, to suppose, that 
absorption takes p’ace immediately or very shortly after these lesions of continuity 
are formed, for it is well known that the power of absorption is arrested after they 
have commenced to heal. This fact may explain the case in which sloughing about 
the perinaeum or vagina exists without any septicaemia resulting, or the far from un- 
common cases, in which an intensely fetid lochial discharge may be present a few days 
after delivery, without any infection taking place. 
The character andlsources of the septic matter constitute one of the most obscure 
questions in connection, with septicaemia, and that which is most open to discussion. 
The most practical division of the subject is into cases in which the septic matter 
originates within the patient, so that she infects herself, the disease then being properly 
autogenetic; and into those in which the septic matter is conveyed from without, and 
brought into contact with absorptive surfaces in the generative tract, the disease then 
being heterogen etic. 
Sources of Self-infection.—The sources of auto-infection may be various, but they 
are not difficult to understand. Any condition giving rise to decomposition, either of 
the tissues of the mother herself, of matters retained in the uterus or vagina that 
ought to have been expelled, or decomposing matter derived from a putrid foetus, may 
start the septicaemic process. Thus it may happen that from continuous pressure on 
the maternal soft parts during labor, sloughing has set in; or there may be already 
decomposing material present from some previous morbid state of the genital tracts, as 
in carcinoma. A.moie common origin is the retention of coagula, or of small portions 
of membrane, or of placenta, in the interior of the uterus, which have putrefied from 
access of air; or in the decomposition of the lochia. That the retention of portions 
of the placental tissue has at all times been the cause of septicaemia may be illustrated 
by the case of the Duchesse d'Orleans, in the time of Louis XIII., who had an easy 
labor, but died of child-bed fever. An examination was made by the leading physi- 
cians of Paris, in their report of which it was stated, “ On the right side of the womb 
was found a small portion of after-birth, so firmly adherent that it could hardly be torn 
off by the finger nails.” 1 The reason why self-intection does not more often occur from 
such sources, s nee more or less decomposition is of necessity so often present, has al- 
ready been referred to in the fact that absorption of such matters is not apt to occur 
when the lesions of continuity, always existing after parturition, have commenced to 
heal. This observation may also serve to explain how previous bad states of health, 
by interfering with the healthy reparative process occurring after delivery, may pre- 
dispose to self-infection. It is interesting to note that puerperal septicaemia, arising 
from such sources, is not limited to the human race. In the debate on pyaemia at the 
Clinical Society Mr. Hutchinson recorded several well-marked examples occurring in 
ewes, in whose uteri portions of retained placenta were found. 
Source of Jfeterogenetic Infection.—The sources of septic matter conveyed from 
1 Louise Bourgeois, by Goodell. INFECTION FROM ERYSIPELAS. 
37 
without are much more difficult to trace, and there are many facts connected with 
helerogenetic infection which are very difficult to reconcile with theory, and of which, 
it must be admitted, we are not yet able to give a satisfactory explanation. 
It is probable that any decomposing organic matter may infect, but that some forms 
operate with more certainty and greater virulence than others. 
Influence of Cadaveric Poisoning.—One of these, which has attracted special atten- 
tion, is what may be termed cadaveric poison, derived from dissection of the dead sub- 
ject in the anatomical and post-mortem theatre, and conveyed to the genital tract by 
the hands of the accoucheur. Attention was particularly directed to this source of in- 
fection by the observations of Semmclweiss, who showed that in the division of the 
Vienna Lying-in Hospital attended by medical men and students who frequented the 
dissecting-rooms, the mortality was seldom less than 1 in 10, while in the division solely 
attended by women the mortality never exceeded 1 in 34 ; the number of deaths in the 
former division at once falling to that of the latter as soon as proper precautions and 
means of disinfection were used. Many other facts of a like nature have since been re- 
corded, which render this origin of puerperal septicaemia a matter of certainty. An inter- 
esting example is related by Simpson with characteristic candor: “In 1836 or 1837, 
Mr. Sidey, of this city, had a rapid succession of five or six cases of puerperal fever in 
his practice, at a time when the disease was not known to exist in the practice of any 
other practitioners in the locality. Dr. Simpson, who had then no firm or proper 
belief m the contagious propagation of puerperal fever, attended the dissection of Mr. 
Sidey’s patients, and freely handled the diseased parts. The next four cases of mid- 
wifery which Dr. Simpson attended were all affected with puerperal fever, and it was 
the first time he had seen it in practice. Dr. Patterson, of Leith, examined the ova- 
ries, etc. The three next cases which Dr. Patterson attended in that town were attacked 
with the disease.” 1 Negative examples are, of course, brought forward, of those who 
have attended post-mortem examinations without injury to their obstetric patients, 
which merely prove that the cadaveric poison does not, of necessity, attach itself to the 
hands of the dissector; and no amount of such testimony can invalidate such positive 
evidence as that just narrated. Barnes believes that there is not so much danger 
attending the dissection of patients who have died of any ordinary disease, but that 
the risk attending the dissection of those who have died of infectious or contagious 
complaints is very great indeed.2 I presume there is no doubt that the risk is greater 
when the subject has died from zymotic disease; but the distinction is too delicate to 
rely on, and the attendant on midwifery will certainly err on the safe side by avoiding, 
as much as possible, having anything to do with the conduct of dissections or post- 
mortem examinations. 
Infection from Erysipelas.-—Another possible source of infection is erysipelatous dis- 
ease in all its forms. The intimate connection between erysipelas and surgical pyaemia 
has long been recognized by surgeons, and the influence of erysipelas in producing 
puerperal septicaemia has been especially observed in surgical hospitals in which lying- 
in patients were also admitted. Trousseau relates instances of this kind occurring m 
Pa is. The only instance that I know of in London was in the lying-in ward of King’s 
College Hospital, where, in spite of every hygienic precaution, the mortality was so 
great as to necessitate the closure of the ward. Here the association of erysipelas with 
puerperal septicaemia was again and again observed ; the latter proving fatal in direct 
proportion to the prevalence of the former in the surgical wards. The dependence of 
the two on the same poison was in one instance curiously shown by the fact of the child 
of a patient who died of puerperal septicaemia, dying from erysipelas which started 
from a sight abrasion produced by the forceps. A more recent and very remarkable ex- 
ample is re’ated by Dr. Lombe Atthill.3 A patient suffering from erysipelas was 
admitted into the Botunda Hospital on February 15, 1877. The sanitary condition of 
the hospital was at the time excellent. The patient was removed next day; but of the 
next 10 patients confined in adjoining wards, 9 were attacked with puerperal peritonitis, 
the only one who escaped being a case of abortion. But the connection between ery- 
sipelas and puerperal septicaemia is not limited to hospitals, having been often observed 
in dom ciliary practice. Some interesting facts have been collected by Dr. Minor,4 who 
has shown that the two diseases have frequently prevailed together in various parts of 
the Tin ted States, and that during a recent outbreak of puerperal fever in Cincinnati, 
it occurred chiefly in the practice of those physicians who attended cases of erysipelas. 
Many children also died from erysipelas, whose mothers had died from puerperal fever. 
1 Selected Obst. Works, p. 508. 
2 “Lectures on Puerperal Fever,” Lancet, vol. ii., 1865. 
3 Medical Press and Circular, April, 1877. 
4 Erysipelas and Childbed Fever. Cincinnati, 1874. 38 
PUERPERAL SEPTICAEMIA. 
Infection from other Zymotic Diseases.—There is good reason to believe that the con- 
tagium of other zymotic diseases may produce a form of disease indistinguishable Pom 
ordinary puerperal septicaemia, and presenting none of the characteristic features of the 
specific complaint from which the contagium was derived. This is admitted to be a fact 
by the majority of our most eminent British obstetricians, although it does not seem to 
be allowed by Continental authorities, and it is strongly controverted by some writers 
in this country. It is certainly difficult to reconcile this w th the theory of septicaemia, 
and we are not in a position to give a satisfactory explanation of it. 1 believe, how- 
ever, that the evidence in favor of the possibility of pue;peral septicaemia originating 
in this way is too strong to be assailable. 
The scarlatinal poison is that regarding which the greatest number of observations 
have been made. Numerous cases of this kind are to be found scattered th ough our 
obstetric literature, but the largest number are to be met with in a paper by Dr. Brax- 
ton Hicks in the 12th volume of the Obstetrical Transactions, and they are espe- 
cially valuable from that gentleman's well-known accuracy as a clinical observer. Out 
of 68 cases of puerperal disease seen in consultation, no less than 37 were distinctly 
traced to the scarlat inal poison. Of these 20 had the characteristic rash of the disease; 
but the remaining 17, although the history deary proved exposure to the contagium of 
Scarlet lever, showed none of its usual symptoms, and were not to be distingu’shed from 
ordinary typical cases of the so-called puerperal fever. On the theory that it is impossi- 
ble for the specific contagious diseases to be modified by the puerperal state, we have 
to admit that one physician met with 17 cases of puerperal septicaenria in which, by 
a mere coincidence, the contagion of scarlet fever had been traced, and that the dis- 
ease nevertheless originated from some other source; an hypothesis so improbable, 
that its mere mention carries its own refutation. 
With regard to the other zymotic diseases the evidence is not so strong ; probably 
from the comparative rarity of the d’seases. Hicks mentions one case in which the 
diphtheritic poison was traced, although none of the usual phenomena of the d:sease 
were present. I lately saw a case in which a lady, a few days after delivery, had a 
very serious attack of septicaemia, without any diphtheritic symptoms, her husband 
beffig at the same time attacked with diphtheria of a most marked type. Here it 
would be difficult not to admit the dependence of the two diseases on the same poison. 
It is, however, certain that all the zymotic diseases may attack a newly-delivered 
woman, and run their characteristic course without any peculiar intensity. Probably 
most practitioners have seen cases of this kind; and this is precisely one of the points 
of difficulty which we cannot at present explain, but on which future research may be 
expected to throw some light. It seems to me not improbable that the explanation of 
the fact that zymotic poison may in one puerperal patient run its ordinary course, and 
jn another produce, symptoms of intense septicrenria, may be found in the channel 
of absorption. It is at any rate comprehensible that if the contagium be absorbed 
through the skin or the ordinary channels, it may produce its characteristic symptoms, 
and run its. usual course; while if brought into contact with lesions of continuity in 
the generative tract, it may act more in the way of septic poison, or with such in- 
tensity that its specific symptoms a.e not developed. 
It may reasonably be objected that if puerperal and surgical septicaemia be iden- 
tical, the zymotic poisons ought to be s'milady modified when they infect patients 
after surgical operations. Tbe subject of specific contagium as a cause of surgical 
pyaemia has been so little studied, that I do not th'nk any one would be justified in 
asserting that such an occurrence is not possible. Fritsch, of Halle, and other German 
physicians have recently shown how elaborate antiseptic precautions in lying-in hos- 
Eita's may prevent the origin of the disease from such sources. Sir James Paget, in 
is Clinical Lectures, seems to believe in the possibility of such modification. He 
says, “I think it not improbable that, in some cases, results occurring wi ll obscure 
symptoms, within two or three days after operations, have been due to the scarlet-fever 
poison, hindered in some way from its usual progress.” Mr. Spencer Wells informs 
me that he has seen cases of surgical pyaemia, which he had reason to believe origi- 
nated in the scarlatinal poison ; and his well-known success as an ovariotomist is, no 
doubt, in a great measure to be attributed to his extreme care in seeing that no one, 
likely to come in contact with his patients, has been exposed to any such source of 
infection. 
Septiccemia from Contagion conveyed from other Puerperal Patients.—The last 
source from which septic matter may be conveyed is from a patient suffering from 
puerperal septicaemia, a mode of origin which has, of late, attracted special attention. 
That this is the explanation of the occasional endemic prevalence of the disease in 
lying-in hospitals can scarcely be doubted. The theory of a special puerperal miasm CONVEYING OF THE POISON TO THE PATIENT. 
39 
pervading the hospital is not required to account for the facts, for there are a hundred 
ways impossible to detect or avoid—on the hands of nurses or attendants, in sponges, 
bed-pans, sheets, or even suspended in the atmosphere—in which septic material, 
deiived from one patient, may be carried to another. 
The poison may be conveyed, in the same manner, from one private patient to 
another. Of this there are many lamentable instances recorded. Thus it was men- 
tioned by a gentleman at the recent discussion at the Obstetrical Society, that 5 out of 
14 women he attended died, no other practitioner in the neighborhood having a case. 
Til's origin of the disease was clearly pointed out by Gordon 1 towards the end of last 
century, who stated that he himself “was the means of carrying the infection to a 
great number of women,” and he also traced the spread of the disease in the same way 
in the practice of certain midwives. In some remarkable instances the unhappy property 
of carrying contagion has clung to individuals in a way which is most mysterious, and 
which has led to the supposition that the whole system becomes saturated with the poison. 
One of the strangest cases of this kind was that of Dr. Rutter, of Philadelphia, 
which caused much discussion. lie had 45 cases of puerperal septicaemia in his own 
practice in one year, while none of his neighbors’ patients were attacked. Of him it is 
related, “Dr. Rutter, to rid himself of the mysterious influence which seemed to attend 
upon Ifs practice, left the city for ten days, and before waiting on the next parturient 
case had his hair shaved off, put on a wig, took a hot bath, and changed every article 
of his apparel, taking nothing with him that he had worn or carried, to his knowledge, 
on any former occasion: and mark the result. The lady, notwithstanding that she 
had an easy parturition, was seized the next day with child-bed fever, and died on the 
eleven!h day after the birth of the child. Two years later he made another attempt 
at self-purification, and the next case attended fell a victim to the same disease.” 
No wonder that Meigs, in commenting on such a history, refused to believe that the 
doctor carried the poison, and rat her thought that he was “ merely unhappy in meeting 
with such accidents through God’s providence.” It appears, however, that Dr. 
Rutter was the subject of a form of ozoena, and it is quite obvious that, under such 
circumstances, his hands never could have been free from septic matter.2 [The Author 
quotes from the Editor. Dr. Rutter had an ozoena which in time much disfigured 
him from its effects upon the contour of his nose. He was unfortunately inoculated 
in his index finger from a patient, and neglected the pustule. He had 95 cases of 
puerperal septicaemia in 4 years and 9 months, with 18 deaths. The question of Dr. 
Meigs, who was a non-contagionist in regard to puerperal peritonitis, was remarkably 
apposite, “did he distil a subtle essence which he carried with him?”—Ed.] This 
observation is of peculiar interest as showing that the sources of infection may exist 
in conditions difficult to suspect and impossib'e to obviate, and it affords a satisfactory 
explanation of a case which was for years considered puzzling in the extreme. It is 
quite possible that other similar cases, of which many are on record, although none so 
remarkable, may possibly have depended on some similar cause personal to the 
medical attendant. 
The sources of septic poison being thus multifarous, a few words may be said as to 
the mode in which it may be conveyed to the patient. 
Mode in which the Poison may he Conveyed to the Patient.—As on the view of puer- 
peral septicaemia which seems most to agree with recorded facts, the poison, from 
whatever source it may be derived, must come into actual contact with lesions of con- 
tinuity in the generative tract, it is obvious that one method of conveyance may be on 
the hands of the accoucheur. That this is a possibility, and that the disease has often 
been unhappily conveyed in this way, no one can doubt. Still it would be unfair in the 
ext;erne to conclude that this is the only way in wh:ch infection may arise. In town 
practice, especially, there are many other ways in which septic matter may reach the 
patient. The nurse may be the means of communication, and, if she have been in 
contact with septic matter, she is even more likely than the medical attendant to convey 
it when washing the genitals during the first few days after delivery, the time that 
absorption is most apt to occur. Barnes re’ates a whole series of cases occurr’ng in a 
suburb of London, in the practice of different practh'oners, every one of which was 
attended by the same nurse. Again sept’c matter maybe carried in sponges, linen, and 
other articles. What is more likely, for example, than that a careless irr.se might use 
an imperfectly washed sponge, on which discharge has been a'lowed to remain and 
decompose? Nor do I see any leason to question the possibility of infection from septic 
matter suspended in the atmosphere; and in lying-in hospitals, where many women are 
1 Seo Lectures on Puerperal Fever. Bv Robert J. Lee, M D. 
2 This is stated on the authority of an obstetrical contemporary of Dr. Rutter. See Amer. Journ. 
of Med. Sciences, April, 1875, p. 471. 40 
PUERPERAL SEPTICAEMIA. 
congregated together, there can be little doubt that this is a common origin of the dis- 
ease. It is certain, whatever view we may take of the character of the septic material, 
that it must be in a state of very minute subdivision, and there is no theoretical difficulty 
in the assumption of its being conveyed by the atmosphere. 
Conduct of the Practitioner in relation to the Disease.—This question naturally in- 
volves a reference to the duty of those who are unfortunately brought into contact with 
septic matter in any form, either in a patient suffering from puerperal septicaemia, 
zymotic disease, or offensive discharges. The practitioner cannot always avoid such 
contact, and it is practically impossible, as Dr. Duncan has insisted, to relinquish ob- 
stetric work every time that he is in attendance on a case from which contagion may be 
f carried. Nor do I believe, especially in these days when the use of antiseptics is so well 
understood, that it is essential. It was otherwise when antiseptics were not employed; 
but I can scarcely conceive any case in which the risk of infection cannot be prevented 
by proper care. The danger I believe to be chiefly in not recognizing the possible risk, 
and in neglecting the use of proper precautions. It is impossible, therefore, to urge 
too strongly the necessity of extreme and even exaggerated care in this dir ection. The 
practitioner should accustom himself, as much as possible, to use the left hand only in 
touching patients suffering from infectious diseases, as that which is not used, under 
ordinary circumstances, in obstetric manipulations. lie should be most careful in the 
frequent employment of antiseptics in washing his hands, such as Condy’s fluid, carbolic 
acid, or tincture of iodine. Clothing should be changed on leaving the infectious case. 
Much more care than is usually practised should be taken by nurses, especially in 
securing perfect cleanliness in everything brought into contact with the patient. When, 
however, a practitioner is in actual and constant attendance on a case of puerperal 
septicaemia, when he is visiting his patient many times a day, especially if he be him- 
self washing out the uterus with antiseptic lotions, it is certain that he cannot deliver 
other patients with safety, and he should secure the assistance of a brother practitioner, 
although there seems no reason why he should not visit women already confined, in 
whom he has not to make vaginal examinations. 
Prophylaxis of Septiccemia.—If the views here inculcated as to the nature of, and 
mode of infection in, puerperal septicaemia be correct, it is obvious that much may be 
done in the way of prophylaxis. A perfectly aseptic management of puerperal women 
is practically impossible. In many lying-in institutions on the Continent, and in some 
in this country, very rigid ru’es have been laid down to prevent the possibility of in- 
fective matter being conveyed to the patient either on the hands of the attendants or 
on instruments, napkins, and the like, and, it is said, with very satisfactory resu.ts. As 
the risk is much greater when lying-in women are collected together, such precautions, 
which this is not the p’ace to discuss, are absolutely indicated. _ They are not, however, 
applicable in ordina’-y private practice; but there are certain simple precautions which 
every one might adopt without tioub’e, which will materially lessen the risk of septic 
po'soning. Amongst these may be indicated the use of a lotion of 1 in 20 carbolic acid, 
with which the practitioner and nurse shou’d always wash their hands before attending 
any case, or touching the genital organs; the use of carbolized oil. 1 in 8, for lubricating 
the fingers, catheter, forceps, etc. ; syringing out the vagina night and morning with 
diluted Condy's fluid; rigid attention to cleanliness in bedding, napkins, etc. Precau- 
tions such as these, although they may appear to some frivolous and useless, indicate a 
recognition of danger and an endeavor to remove it, and if they were generally inculcated 
on nurses and others, might go far to p event the occurrence of septic mischief. 
Nature of the Septic Poison.—As to the precise character of the septic poison—- 
although of late much has been said about it. and there is good reason to believe that 
further research may throw light on this ob cure subject—too little is known to jus. fy 
any positive statement. With regard to the influence of the minute organisms known 
as bacteria, and their supposed connection w th the production of the disease, th s is 
espec ally the case. He.berg has proved that they may be traced, in most eases of 
puerperal septicaemia, pass ng through the veins and lymphatics, and that they are 
foun 1 in var ous organs and pa ho ogical products. But what their relation is to the 
disea e, whether they themselves fo m the septic matter, or carry it, or whether they 
are mere accidental con-onrtants of the pyacmic processes, it is impossible, in the 
present state of our knowledge, to state; and I, therefore, prefer to dwell on that part 
of the subject wh eh is of clinical importance, rather flian enter into speculative theo- 
ries. which may to-morrow p ove to be valueless. 
Channels of Diffusion.—Basing on to the channels of diffusion through which the 
septic matter may act, we have to consider its effects on the structures with which it is 
brought into contact, and the mode in which it may infect the system at large; and this 
will include a consideration of the pathological phenomena. LOCAL CHANGES CONSEQUENT ON ABSORPTION OF POISON. 
41 
Local changes consequent on the absorption of the poison are pretty constant, and of 
these we may form an intelligible idea by thinking of them as similar in character and 
causation to those which we have the opportunity of studying when septic matter is 
applied to a wound open to observation, as, for example; in cases of blood-poisoning 
fo flowing a dissection wound. Distinct traces of local action are not of invariable oc- 
currence, and in some of the worst class of cases, when the amount of septic matter is 
great, and its absorption rapid, death may occur after an illness of short duration, but 
great intensity, and before appreciable local changes, either at the site of absorption or 
in the system at large, have had time to develop themselves. The fact that puerperal 
fever may prove fatal, without leaving any tangible post-mortem signs, has often been 
pointed out. such cases most frequently occurring during the endemic prevalence of the 
disease in lying-in hospitals. There can be little doubt, however, that in such cases of 
intense septicaemia marked pathological changes exist, in the form of alterations of the 
blood and degenerations of tissue, but not of a character which can be detected by an 
ordinary post-mortem examination. In the great majority of cases, indications of the 
disease exist at the site of absorption. These are described by pathologists as identical 
in their character with the inflammatory oedema which occurs in connection with phleg- 
monous erysipelas. If lacerations exist in the cervix or vagina they take on unhealthy 
action, the:r edges swell, and their surfaces become covered with a yellowish coat, simi- 
lar in appearance to diphtheritic membrane. The mucous membrane of the uterus is 
also generally found to be atfected, and in a degree varying with the intensity of the 
local septic process. There is evidence of severe endometritis; and, very frequently, 
the whole lining of the uterus is profoundly altered, softened, covered with patches of 
diphtheritic deposit, and it may be in a state of general necrosis. In the severer cases 
these, changes affect the muscular tissue of the uterus, which is found to be swollen, 
soft, imperfectly contracted, and even partially necrosed, a condition which is likened 
by TIeiberg to hospital gangrene. The connective tissue surrounding the generative 
tract is also swollen and oedematous, and the inflammation may in this way reach the 
peritonaeum, although peritonitis, so often observed in puerperal septicaemia, does not 
necessarily depend on the direct transmission of inflammation from the pelvic connec- 
tive tissue, but is more often a secondary phenomenon. 
The channels through which general systemic infection may supervene are the lymph- 
atics and the venous sinuses, the former being by far the most important. Decent re- 
searches have shown the great number and complexity of the lymphatics in connection 
with the pelvic viscera, and marked traces of the absorption of septic matter are 
almost always to be found, except in those very intense cases already alluded to, in 
which no appreciable post-mortem signs are discoverable. The septic matter is prob- 
ably absorbed from the lymph spaces abounding in (he connective tissue, and carried 
along the lymphatic canals to the nearest glands. The result is inflammation of their 
coats, and thrombosis of their contents, which may be seen on section as a creamy, 
Eundent substance. The absorption of septic material may, as Virchow has shown, 
e delayed by the local changes produced in the lymphatics and in the glands with 
which they communicate, which are, therefore, conservative in their action ; and the 
further progress of the case may in this way be stopped, and local inflammation alone 
result, such cases being believed by Heiberg to be examples of abortive pyaemia. On 
the other hand, the free septic material may be too abundant and intense to be so 
arrested, it may pass on through the lymph canals and glands, until it reaches the blood 
current through the thoracic duct, and so produces a general blood-infection. This 
mode of absorption of septic matter, and the tendency of the glands to arrest its further 
progress, serve to explain the progressive character of many cases in which fresh ex- 
acerbations seem to occur from time to time ; since fresh quantities of poison, gener- 
ated at its source of origin, may be absorbed as the case progresses. The uterine ve'ns 
are supposed by D'Espinne to be the channel of absorption in the intense form of dis- 
ease which proves fatal very shortly after delivery, too soon for the more gradual proc- 
ess of lymphatic absorption to have become established. It is evident that the veins 
are not likely to act in this way, since they must, under ordinary circumstances, be 
completely occluded by thrombi, otherwise haemorrhage wrould occur. If, however, 
uterine contraction be incomplete, the occlusion of the venous sinuses may be impel feet, 
and absorption of septic material through them may then take place. Some writers 
have laid great stress on imperfect uterine contraction in predisposing to septicaemia, 
and its influence may thus be well explained. The veins may bear an important part 
in the production of septicaemia, independent of the direct absorption of septic matter 
through them, by means of the detachment of minute portions of their occluding 
thrombi, in the form of emboli. If phlegmonous inflammation occur in the imme- 
diate vicinity of the veins, the thrombi they contain may become infected. When 42 
PUERPERAL SEPTICAEMIA. 
once blood infection has occurred, by any of these channels, general septicaemia, the 
so-called puerpe: al fever, is developed. 
Pathological Phenomena observed after general Blood-infection.—The variety of path- 
ological phenomena found on post-mortem examination has had much to do with the 
prevalent confusion as to the nature of the disease. This has resulted in the description 
of many distinct forms of puerperal fever; the most marked pathological alteration 
having been taken to be the essential e'ement of the disease. As a matter of fact there 
is no doubt that various types of pathological change are met with. Heiberg describes 
four chief classes which are by no means distinct y separated from one another, ate 
often found s'multaneously in the same subject, and are certainly not to be distinguished 
by the symptoms during 1 fe. 
Intense Cases without marked Post-mortem Signs.—Of these, the first is the class of 
cases in which no appieciable morbid phenomena are found after death. This formid- 
able and fatal fo.m of the disease has long been well known, and is that described by 
some of our autho: s as adynamic, or malignant puerperal fever. It is the variety which 
was so prevalent in our lying-in hospital, and which Ramsbotliam talks of as being 
second only to cho’era in the severity and suddenness of its onset, and in the rapidity 
with which it carried off its victims. It is quite erroneous to suppose that the existence 
of patho'ogical changes in this form of disease has never been lecognized. Even with 
the coarse methods of examination formerly used, the occurrence of a fluid and a’teied 
state of the blood, and ecchymoses in connection with various organs—especially the 
lungs, spleen, and kidneys—were noticed and specially described by Copland in his 
dict.onary of medicine. More recently it has been c'early proved by the microscope 
that there exist, in addition, the commencement of inflammation in most of the tissues, 
shown by cloudy swellings, and granular infiltration and disintegration of the cell e’e- 
ments; p oving that the blood, heavily charged with septic matter, had set up morbid 
action whenever it circulated, the patient succumbing before this had time to develop. 
Cases Characterized by Inflammation of the Serous Membranes.—In the second type, 
and that perhaps most commonly met with, the morb d changes are more frequently 
found in the serous membranes, in the pleura, the pericardium, but, above all, in the 
peritonaeum, the alterations in which have long attracted notice, and have been taken 
by many write: s as proving peritonitis to be the main e'ement of the disease. Evi- 
dences of more or less peritonitis ate very general. In the more severe cases the:e is 
little or no exudation of plastic lymph, such as is found in peritonitis unassociated with 
septicaemia. There is a greater or less quantity of brown:sh serum only, the colls of 
intestine, distended with flatus, and highly congested, being surrounded by it. More 
often there are patchy deposits of fibrinous exudation over many of the viscera, the 
fundus uteri, the under surface of the liver, and the distended intestine. There is then 
also a considerable quantity of sero-purulent fluid in the abdominal cavity. 'The pleural 
cavities may also exhibit similar traces of inflammatory action, containing imperfectly 
organized lymph, and sero-purulent thud. Schroeder states that pleurisy is moi e often 
the diiect result of transmission of inflammation through the substance of the dia- 
phragm or lung, than a secondary consequence of the septicaemia. In like manner 
evidences of pericarditis may exist, the surface of the pericardium being highly injected, 
and its cavity containing serous fluid. Inflammation of the synovial membranes of the 
larger joints, occasionally ending in suppuration, is not uncommon, and may probably 
be best included under this c’ass of cases. 
Cases Characterized by Changes in the Mucous Membrane. —In the third type the 
mucous membranes appear to bear the brunt of the d'sease. The pathological changes 
are most marked in the mucous membrane lining the intestines, which is highly con- 
gested and even rdeerated in patches, with numerous small spots of blood extravasated 
in the sub-mucous tissue. Similar small apoplectic effusions have been observed in the 
substance of the kidneys and under the mucous membrane of the bladder. Pneu- 
monia is of common occurrence. In most cases it is probably secondary to the im- 
paction of minute emboli in the smaller branches of the pu monary artery; but it may 
doubtless arse from independent inflammation of the lung tissue, and wi:l then be 
included in the c’ass of cases now under consideration. 
Cases Characterized by the Impaction of Infected Emboli and Secondary/ Inflamma- 
tion and. Abscess.—The iouith class of pathological pdienomona are those which are 
produced chiefly by the impaction of minute infected emboli in small vessels in various 
Earis of the body. These are the cases which most closely resemble surgical pyaemia, 
oth in their symptoms and post-mortem signs, and which by many writers are de- 
scribed under the name of puerperal pyaemia. The dependence of puerperal fever on 
phlebitis of the uterine veins was a favorite theory, and in a large proportion of cases 
the coats of the veins show signs of inflammation, their canals being occupied with DURATION OF THE DISEASE. 
43 
thrombi in a more or less advanced state of disintegration. The mode in which these 
thrombi may become infected has been shown by Babnoff, who has proved that leuco- 
cytes may penetrate the coats of the vein, and entering its contained coagulum, may 
set up disintegration and suppuration. This observation brings these pyaemic forms 
of d'sease into close relation with septicaemia, such as we have been studying, and 
justifies the conclusion of Verneuil that purulent infection if not a distinct disease, 
but on’y a termination of septicaemia, with which it ought to be studied. We have, 
moreover, to differentiate these results of embolism from those considered in a sub- 
sequent chapter; the cha: acteristic of these cases being the infected nature of the 
minute emboli. Localized inflammations and abscesses, from the impaction of minute 
capillary emboli are found in many parts of the body; most frequently in the lungs, 
then in the kidneys, spleen, and liver, and also in the muscles and connective tissues. 
Pathologists are by no means agreed as to the invariable dependence of these on 
embolsm, nor is it possible to prove their origin from this source by post-mortem ex- 
amination. Some attribute al! such cases to embolism, othei s think that (hey may be the 
results of primary septicaemie inflammation. It has been proved by Weber that minute 
infested emboli may pass through the lung capillaries; and this disposes of one argu- 
ment against the embo.ic theory, based on the supposed impossibility of their passage. 
It is probable that both causes may operate, and that localized inflammations occurring 
a short time after delivery are directly produced by the infected blood, while those 
occurring after the lapse of some time, as in the second or third week, depend upon 
embolism. 
Description of the Disease.—From what has been said as to the mode of infection in 
puerperal septicaemia, and as to the very various pathological changes which accom- 
pany it, it will not be a matter of surprise to find that the symptoms are also very 
various in different cases. This can readily be explained by the amount and viru'ence 
of the po’son absorbed, the channe’s of infection, and the organs which are chiefly 
implicated ; but it renders it very difficult to describe the disease satisfactorily. 
The symptoms generally show themselves within two or three days after delivery. 
As infection most often occurs during labor, or, in cases which are autogenetic, 
within a short time afterwards, and before the lesions of continuity in the generative 
tract have commenced to cicatr'ze, it can be understood why septicaemia rarely com- 
mences later than the fourth or fifth day. 
In the great majority of cases the disease begins insiduously. There are, generally, 
some chilliness and rigor, but by no means always, and even when present they fre- 
quently escape observation, or are refer, ed to some trans'ent cause. The first symp- 
tom which excites attention is a rise in the pulse, which may vary from 100 to 140 or 
more, according to the severity of the attack; and the thermometer will also show 
that the temperature is raised to 102°, or, in bad cases, even to 104° or 106°. Still, it 
must be borne in mind that both the pu’se and temperature may be increased in the 
puerperal state from transient causes, and do not, of themselves, justify the diagnosis of 
septicaemia. " 
Symptoms of Intense Septiccemia.—In the more intense class of cases, in which 
the who'e system seems overwhelmed wi.h the severity of the attack, the d’sease pro- 
gresses with great rapidity, and often without any appreciable indication of local com- 
plication. The pulse is very rapid, small, and feeble, varying from 120 to 140, and 
there is generally a temperature of 103° or 104°. There may be little or no pain, or 
there may be slight tenderness on p essure over the abdomen or uterus; and, as the 
disease progresses, the intestines get largely distended with flatus, so that intense 
tympanites often form a most distressing symptom. The coun enance is sa low, 
sunken, and has a very anxious expression. As a rule, intelligence is unimpaired, and 
this may be the case even in the worst forms of the disease, and up to the period of 
death. At other times, there is a good deal of low muttering delirium, which often 
occurs at night alone, and alternates with intervals of complete consciousness, but is 
occasionally intensified, for a short time, into a more acute form. D’arrhoca and vomit- 
ing are of very frequent occurrence ; by the latter dark, grumous, coffee-ground sub- 
stances are ejected. The diarrhoea is occasionally very profuse and unc-ontrol able; in 
mild cases it seems to relieve the severity of the symptoms. The. tongue is moist 
and loaded with sordes; but sometimes it gets dark and dry, especially towards (he 
termination of the disease. The lochia are generally suppressed, or altered in charac- 
ter, and sometimes they have a highly offensive odor, especial’y when (he disease is 
autogenetic. The breathing is hurried and panting, and the breath itself has a very 
characteristic, heavy, sweetish odor. The secretion of milk is often, but not always, 
arrested. 
Duration of the Disease.—With more or less of these symptoms the case goes on; 44 
PUERPERAL SEPTICAEMIA. 
and when it ends fatally it generally does so within a week, the fatal termination being 
indicated by more weakness, rapid, threadlike, or intermittent pulse, marked delirimn, 
great tympanites, and sometimes a sudden fall of temperature, until at last the patient 
sinks with all the symptoms of profound exhaustion. 
Variety of Symptoms in Different Cases.—In milder cases similar symptoms, 
variously modified and combined are present. It is seldom that two precisely similar 
cases are met with; in some the rapid, weak pulse is most marked; in others, ab- 
dominal distention, vomiting, diarrhoea, or delirium. 
Symptoms of Peritonitis.—Local complications variously modify the symptoms and 
course of the disease. The most common is peritonitis, so much so that with some 
authors puerperal fever and puerperal peritonitis are synonymous terms. Here the 
first symptom is severe abdominal pain, commencing at the lower part of the abdomen, 
where the uterus is felt enlarged and tender. As the abdominal pain and tenderness 
spread, the sufferings of the patient greatly increase, the intestines become enormously 
distended with flatus, and the breathing is entirely thoracic, in consequence of the 
upward displacement of the diaphragm and the fact that the abdominal muscles are 
instinctively kept as much in repose as possible. The patient lies on her back, with 
her knees drawn up, and sometimes cannot bear the slightest pressure of the bed- 
clothes. There is generally much vomiting, and often severe diarrhoea. The tem- 
perature generally ranges from 102° to 104°, or even 106°, and is subject to occasional 
exacerbations and remissions, possibly depending on fresh absorption of septic matter. 
The case generally lasts for a week or more, the symptoms going on from bad to worse, 
and the patient dying exhausted. D’Espinne points out that rigors, with exacerba- 
tions of the general symptoms, not unfrequently occur about the sixth or seventh day, 
which he attributes to fresh systemic infection, from fetid pus in the peritoneal cavity. 
It must not be supposed that all these symptoms are necessarily present, when the 
peritonic complication exists. Pain especially is often entirely absent, and I have seen 
cases in which post-mortem examination proved the existence of peritonitis in a very 
marked degree, in which pain was entirely absent. Sometimes the pain is only slight, 
and amounts to little more than tenderness over the uterus. 
Other local complications are characterized by their own special symptoms; thus, 
pneumonia by dyspnoea, cough, dulness, etc.; pericarditis by the characteristic rub; 
pleurisy by dulness on percussion ; kidney affection by albuminuria and the presence of 
casts ; liver complication by jaundice ; and so on. 
Pycemic Forms of the Disease.—The course of the disease is not always so intense and 
rapid, being, in some cases, of a more chronic character, and lasting many weeks. The 
symptoms in the early stage are often indistinguishable from those already described; 
and it is generally only after the second week that indications of purulent infection 
develop themselves. Then we often have recurrent and very severe rigors, with 
marked elevations and remissions of temperature. At the same time there is generafy 
an exacerbation of the general symptoms, a peculiar yellowish discoloration of the skin, 
and occasionally well-developed jaundice. Transient patches of erythema are not un- 
commonly observed on various parts of the skin, and such eruptions have often been 
mistaken for those of scarlet fever or other zymotic disease. Localized inflammations 
and suppuration may rapidly follow. Amongst the most common are inflammation or 
even suppuration of the joints—the knees, or Ifips—which is pieceded by 
difficulty of movement, swelling, and very acute pain. Large collections of pus in 
various parts of the muscles and connective tissues are not rare. Suppurative inflam- 
mation may also be found in connection with many organs, as in the eye, in the pleura, 
pericardium, or lungs: each of which will, of course, give r’se to characteristic symp- 
toms, more or less modified by the type of the disease and the intensity of the inflam- 
mation. 
Treatment.—In considering the all-important subject of treatment, the views of the 
practitioner are naturally biased by the theory he has adopted of the nature of the dis- 
ease. If that here inculcated be coirect, the indications we have to bear in mind are: 
1st, to discover, if possible, the source of the poison, in the hope of arresting further 
septic absorption ; 2d, to keep the patient alive until the effects of the poison are worn 
oft'; and ;id, to treat any local complications that may arise. 
The Use of Antiseptic Injections.—The first is likely to be of great importance in 
cases of self-infection, as fresh quantities of septic matter may be, from time to time, 
absorbed. We, fortunately, are in possession of a powerful means of preventing fur- 
ther absorption, by the application of antiseptics to the interior of the uterus and to the 
canal of the vagina. This is especially valuable when the existence of decompos'ng 
coagula, or other sources of septic matter, is suspected in the uterine cavity, or when 
offensive discharges are present. Disinfection is readily accomplished by washing out the ADMINISTRATION OF FOOD AND STIMULANTS. 
45 
uterine cavity, at least twice daily, by means of a Higginson’s syringe with a long vaginal 
pipe attached.1 The results are sometimes very remarkable, the threatening symptoms 
rapidly disappearing, and the temperature and pulse falling so soon after the use of the 
antiseptic injections as to leave no doubt of the 
beneficial effects of the treatment. I cannot better 
illustrate the advantages of this treatment than by 
the accompanying temperature chart, which is 
from a case which came under my observation in 
the out-door practice of King’s College Hospital. 
It was that of a healthy woman, thirty-six years 
of age, who had an easy and natural labor. N othing 
remarkable was observed until the 3d day after de- 
livery, when the temperature was found to be 
slightly increased. On the morning of the 8th 
day the temperature had risen to 105.4°. She was 
delirius, with a rapid, thready pulse, clammy per- 
spiration, tympanitic abdomen, and her general 
condition indicated the most urgent danger. On 
vaginal examination, a piece of compressed and 
putrid placenta was found in the os. This was removed by my colleague, Dr. Hayes, 
and the uterus thoroughly washed out with Condy’s fluid and water. The same evening 
the temperature had sunk to 99°, and the general symptoms were much improved. 
The next day there was a slight return of offensive discharge, and an aggravation of 
the symptoms. After again washing out the uterus the temperature fell, and from 
that date the patient convalesced without a single bad symptom. 
This is a very well-marked example of the value of local antiseptic treatment, and I 
have seen many cases of the same kind. It should, therefore, never be omitted in 
all cases in which self-infection is possible ; and, indeed, even when there is no reason 
to suspect the presence of a local focus of infection, the use of antiseptic lotions is 
advisable, as a matter of precaution, since it can do no harm, and is generally comfort- 
ing to the patient. Any antiseptic may be used, such as a weak solution of carbolic 
acid, 1 in 50, or of tincture of iodine, or Condy’s fluid largely diluted. I generally use 
the two latter alternately, the one in the morning, the other in the evening. The nozzle 
of the syringe should be guided well through the cervix, and the cavity of the uterus 
thoroughly washed out, until the fluid that issues from the vagina is no longer discol- 
ored. As the os is always patulous, there is no risk of producing the troublesome 
symptoms of uterine colic which occasionally follow the use of intra-uterine injections 
in the unimpregnated state. It is quite useless to entrust the injection to the nurse, 
and it should be performed at least twice daily by the practitioner himself, in all cases 
in which the discharges are offensive. 
Administration of Food and Stimulants.—In a disease characterized by so marked 
a tendency to prostration, the importance of sustaining the vital powers by an abun- 
dance of easily assimilated nourishment cannot be overrated. Strong beef-tea, or other 
forms of animal soup, milk, alone or mixed either with lime or soda water, and the 
yelk of eggs, beat up with milk and brandy, should be given at short intervals, and in 
as large quantities as the patient can be induced to take; and the value of thoroughly 
efficient nursing will be specially apparent in the management of this important part 
of the treatment. As there is frequently a tendency to nausea, the patient may resist 
the administration of food, and the resources of the practitioner will be taxed in ad- 
ministering it in such form and variety as will prove least distasteful. Generally speak- 
1 My colleague, Dr. Hayes, has invented a silver tube for the purpose of administering such 
intra-uterine injections (Fig. 2), which answers its purpose admirably. The numerous apertures 
at its extremity allow of a number of minute streams of fluid being thrown out in the form of a 
Fig. 2. 
spray over the interior of the uterus, the complete bathing of its surface and washing out of its 
cavity being thus insured. It is, moreover, introduced more easily than the ordinary vaginal pipe, 
and can be attached to a Higginson syringe. 46 
PUERPERAL SEPTICEMIA. 
ing, not more than one or two hours should he allowed to elapse without some nutri- 
ment be ng given. The amount of stimulant required will vary with the intensity of 
the symptoms and the indications of debility. Generally, stimulants are well borne, 
prove decided y beneficial, and require to be given pretty freely. In cases of moderate 
severity a tablespoonful of good old brandy or whiskey every four hours may suffice; 
but when the pulse is very rapid and thready, when the;e is much low delirium, tym- 
panites, or sweating (indicating profound exhaustion), it may be advisable to give them 
in much larger quantities and at shorter intervals. The caieful practitioner will closely 
watch the el ects produced, and regulate the amount by the state of the patient, rather 
than by any fixed ru’e ; but in severe cases, eight or twelve ounces of brandy, or even 
more, in the twenty-four hours, may be given with decided benefit. 
Venesection not Admissible.1—Venesection, both general and local, was long consid- 
ered a sheet-anchor in this disease. Modern views are, however, entirely opposed to 
its use ; and in a disease characterized by so profound an alteration of the blood, and 
so much prostration, it is too dangerous a remedy to employ, although it is possible 
that it might alleviate temporarily the severity of some of the symptoms, especially 
in cases in which peritonitis is weii marked, and much local pain and tenderness are 
present. 
Medicinal Treatment.—The rational indications in medicinal treatment are to lessen 
the force of the circulation as much as is possible without favoring exhaustion, and to 
dim’nish the temperature. 
Use of Arterial Sedatives.—For the former purpose, Barker strongly advocates the 
use of veratrum viride, in doses of five drops of the tincture every hour, until the pulse 
falls to be ow 100, when its effects are subsequently kept up by two or three drops every 
second hour. Of this drug I have no personal experience; but I have extensively used 
minute doses of tincture of aconite for the same purpose, and, when carefully given, I 
believe it to be a most valuable remedy. The way I have adnfnistered it is to give a 
sing'e drop of the tincture, at first every half hour, increasing the interval of adminis- 
tration according to the effect produced. Generally, after giving four or five doses at 
interva's of ha f an hour, the pulse begins to fall, and afterwards a few doses, at inter- 
vals of one or two hours, will suffice to prevent the heart’s action rising to its former 
rapidity. The advantage of thus modifying cardiac action, with the view of prevent- 
ing excessive waste of tissue, cannot be questioned. It is evident that so powerful a 
remedy must not be used without the most caieful supervision, for, if continued too 
long or given at too frequent intervals, it may unduly depress the circulat on, and do 
more harm than good. It is necessary, therefore, that the practitioner should con- 
stantly watch the effect of the drug, and stop it if the pulse become very weak, or if 
it interm t. It is most likely to be useful at an early stage of the disease before much 
exhaustion is present, and then on’y when the pulse is of a certain force and volume. 
Barker says of the veratrum viride, what is also true of aconite, that “it should not 
be given in those cases in which rapid prostration is manifested by a feeble, threadlike, 
irregular pulse, profuse sweats, and coll extremities.” 
Reduction of Temperature.—The reduction of temperature must form an important 
pa t of our treatment, and for this purpose many agents are at our disposal. 
Quinine in large doses, of from 10 to 20 grains, has been much used for this purpose, 
especiady in Ge many. After its exhibition the temperature frequently falls one or 
two degrees. It may be given morning and evening. Unpleasant head-symptoms, 
deafness, and ringing in the ears often render its continuance for a length of time im- 
poss ble; these may, however, be much lessened by the addition of 10 to 15 minims of 
nydrobromic acid to each dose. 
Salicf/lic acid, in doses of from 10 to 20 grains, or the salicylate of soda in the same 
doses, is a valuab’e antipyretic, which I have found on the whole more manageable 
than quinine. Under its use the temperature often falls considerably in a short 
space of time. It is, however, apt to depress the circulation, and thus requires to be 
f1 I believe that the entire abandonment of venesection has been a grave error, and that where 
there is early in the attack a high pulse, with great abdominal distention and tenderness, and a 
decided elevation of temperature, we ought to bleed the patient sitting, at once, and to such a de- 
greo as to produce a decided impression. One of the worst cases I ever saw, was cured in this way. 
The woman was delivered at 3$ p.m. of one day, and the disease manifested itself in twenty hours. 
At 9 the next morning she wns apparent'v doing well; at 1 she was in great suffering, and could 
not bear her abdomen to be touched; vs. f§ xvj ; at 9 p.m., symptoms more grave; vs. in a sit- 
ting posture until she felt sick. At 10 p.m., pulse 150 ; in twenty-four hours from this, no fever and 
very little pain; in three days, regarded as out of danger. Saw her in robust health, with her 
child living, a year later.—Ed.] EVACUANT REMEDIES. 
47 
carefully watched while it is being administered, and, should the pulse become very 
small and feeble, it should be discontinued. 
Warburg's Tincture.—In some cases, especially when the fever has assumed a remit- 
tent type, I have administered, with marked benefit, a drug which is of high repute in 
India in the worst class of malarious remittent fevers, and the almost marvellous effects 
of which, in such cases, I had myself witnessed in India many years ago. This is the 
so-called Warburg’s tincture, the value of which has been testified to by many high 
authorities, among whom I may mention Dr. Maclean, of Net’ey, Dr. Broadbent, and 
Sir Alexander Armstrong, the Director-General of the Medical Department of the 
Navy, who informs me that it is now supplied to all Her Majesty’s ships in the tropics, 
because it is found to be of the utmost value in cases in which quinine has little or no 
effect. 
Recently its composition has been made public by Dr. Maclean. The basis is quinine, 
in combination with various aromatics and bitters, some of which probably intensity its 
action. Be this as it may, the testimony in favor of the antipyretic action of the rem- 
edy is very strong. I have found its exhibition followed by a profuse diaphoresis (this 
being its almost invariable effect), and sometimes a rapid amelioration of the symptoms. 
In other cases in which I have tried it, like everything else, it lias proved of no avail. 
Application of Cold.—Cold may be advantageously tried in suitable cases. The sim- 
plest mode of using it is by Thornton's ice-cap, by which a current of cold water is kept 
continuously running round the head. This has been found of great value in pyrexia 
after ovariotomy, and I have a1 so found it useful as a means of reducing temperature 
in puerperal cases. It is a comforting application, and gives great relief to the throb- 
bing headache, which often causes much suffering. Under its use the temperature 
often falls two or more degrees, and it is easily continued day or night. 
In very serious cases, when the temperature reaches 105° and upwards, the external 
application of cold to the rest of the body may be tried. I have elsewhere related a 
case of puerperal septicaemia with hyperpyrexia, the temperature continuously ranging 
over 105°, in which I kept the patient for eleven days1 nearly continuously coveted with 
cloths soaked in iced water, by which means only was the temperature kept within 
moderate bounds, and life preserved. But this method of treatment is excessively 
troublesome, and is in no way curative. It is only of use in moderating the temperature 
when it has reached a point at which it could not continue long without destroying the 
patient. I should, therefore, never think of employing it unless the temperature w7as 
over 105°, and then only as a temporary expedient, requiring incessant watching, to be 
desisted from as soon as the temperature had reached a more moderate height. It is 
clearly impossible to place a puerperal patient in a bath, as is practised in hyperpyrexia 
associated with acute rheumatism. The same effect may, however, be obtained by 
placing her on Mackintosh sheeting, and covering the body with towels soaked in iced 
water, which are frequently renewed by the attendant nurses. During the application 
the temperature should be constantly taken, and as soon as it has fallen to 101° the cold 
applications should be discontinued. 
Administration of Turpentine.—Amongst other remedies which have been used is 
turpentine, which was highly thought of by the Dublin school. In cases with much tym- 
panitic distention and a small, weak pulse it is sometimes of unquestionable value, and 
it probably acts as a strong nervine stimulant. Given in doses of 15 to 20 minims, 
rubbed up with mucilage, it can generally be taken in spite of its nauseous taste. 
Evacuant Remedies.—Purgatives, diaphoretics, or even emetics, have often been 
employed as eliminants of the poison. The former are strongly recommended by 
Schroeder and other German authorities, and in this country they were formerly 
amongst the most favorite remedies, and there is a general concurrence of opinion 
amongst our oldest writers as to their value. In the first volume of the Obstetrical 
Journal, there is a paper by Mr. Morton, in which this practice is strongly advocated, 
and some interesting cases are recorded in which it apparently acted well. He admin- 
isters calomel in doses of 3 or 4 grains with compound extract of colocynth, so as to 
keep up a free action of the bowels. It seems quite reasonable, when there is consti- 
pation, to promote a gentle action of the bowels by some mild aperient; but, bearing 
m mind that severe and exhausting diarrhoea is a common accompaniment of the dis- 
ease, I should myself hesitate to run the risk of indue ng it artificially, especially as 
there is no proof whatever that septic matter can really be eliminated in this way. At 
the commencement of the disease, however, I have often given one or two aperient 
doses of calomel with decided beneft. 
*A Lecture on a case of Puerperal Septicaemia, with Hyperpyrexia, treated by the continuous 
application of Cold.—Brit. Med. Journ., Nor. 17, 1877. 48 
PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 
Internal Antiseptic Remedies.—It is possible that further research will give us some 
means of counteracting the septic state of the blood, and the sulphites and carbolates 
have been given for this purpose, but as yet with no reliable results. 
Tincture of Per chloride of Iron.—The tincture of the perchloride of iron naturally 
suggests itself, from its well-known effects in surgical pyaemia. In the less intense 
forms of the disease, especially when local suppurations exist, it is certainly useful, and 
may be given in doses of 10 to 20 minims every 3 or 4 hours. In very acute cases 
other remedies are more reliable, and the iron has the disadvantage of not unfrequently 
causing nausea or vomiting. 
Opiates.—When restlessness, irritation, and want of sleep are prominent symptoms, 
sedatives may be requiied. Under such circumstances opiates may be given at night, 
and Battley’s solution, nepenthe, or the hypodermic injection of morphia, are the forms 
which answer best. 
Treatment of Local Complications.—Pain and tenderness, and local complications, 
must be treated on general principles. The distress from them is most experienced 
when peritonitis is well marked. Then warm and moist applications, in the form of 
poultices or fomentations, are very useful. Relief is also sometimes obtained from 
turpentine stupes, and, when the tympanites is distressing, turpentine enemata are very 
serviceable. 1 have found the free application over the abdomen of the flexible collo- 
dium of the pharmacopoeia decidedly useful in alleviating the suffering from peritonitis. 
Such are the remedies most used in the treatment of this disease. It is needless to 
say that it is quite impossible to lay down fixed rules for the management of any in- 
dividual case ; and it is obvious that, if puerperal septicaemia be not a special and dis- 
tinct disease, its judicious management must depend on the general knowledge of the 
attendant, and on a careful study of the symptoms each separate case presents. 
CHAPTER VI. 
PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 
Under the head of thrombosis we may class several important diseases connected 
with the puerperal state, wdiich have received far less attention than they deserve. It 
is only of late years that some, we may probably safely say the majority, of those ter- 
ribly sudden deaths which from time to time occur after delivery, have been traced to 
their true cause, viz., obstruction of the right side of the heart and pulmonary arteries 
from a blood-clot, either carried from a distance, or, as I shall hope to show, formed 
in situ. Although the result, and, to a great extent, the symptoms, are identical in 
both, still a careful consideration of the history of these two classes of cases tends to 
show that in their causation they are distinct, and that they ought not to be confounded. 
In the former, we have primarily a dotting of blood in some part of the peripheral 
venous system, and the separation of a portion of such a thrombus due to changes 
undergone during retrograde metamorphosis tending to its eventual absorption. In the 
latter we have a local deposition of fibrine, the result of blood changes consequent on 
pregnancy and the puerperal state. The formation of such a coagulum in vessels, the 
complete obstruction of which is incompatible with life, explains the fatal results. 
When, however, a coagulum chances to be formed in more distant parts of the circula- 
tion, the vital functions are not immediately interfered with, and we have other phe- 
nomena occurring, due to the obstruction. The disease known as phlegmasia dolens, I 
shall presently attempt to show, is one result of blood-clot forming in peripheral ves- 
sels. But from the evident and tangible symptoms it produces it has long been con- 
sidered an essential and special disease, and the general blood dyscrasia which produces 
it, as well as other allied states, has not been studied separately. I shall hope to show 
that all these various conditions, dissimilar as they at first sight appear, are very c’osely 
connected, and that they are in fact due to a common cause; and thus, I think, we 
shall arrive at a clearer and more correct idea of their true nature, than if we looked 
upon them as distinct and separate affections, as has been commonly done. I am 
aware that in phlegmasia dolens, the pathology of which has received perhaps more 
study than that of almost any other puerperal affection, something beyond simple ob- 
struction of the venous system of the affected limb is probably required to account for COAGULATION IN THE PUERPERAL STATE. 
49 
the peculiar tense and shining swelling which is so characteristic. Whether this he an 
obstruction of the lymphatics, as l)r. Tilbury Fox and others have maintained with 
much show of reason, or whether it is some as yet undiscovered state, further invests 
gation is required to show. But. it is beyond any doubt that the important and essential 
part of the disease is the presence of a thrombus in the vessels; and I think it will not 
be difficult to prove that in its causation and history it is precisely similar to the more 
serious cases in which the pulmonary arteries are involved. 
It will be well to commence the study of the subject by a consideration of the condi- 
tions which, in the puerperal state, render the blood so peculiarly liable to coagulation, 
and we may then proceed to discuss the symptoms and results of the formation of 
coagula in various parts of the circulatory system. 
Conditions which favor Thrombosis.—The researches of Virchow, Benjamin Ball, 
Humphrey, Richardson, and others, have rendered us tolerably familiar with the con- 
ditions which favor the coagulation of the blood in the vessels. These are chiefly: 1. 
A stagnant or arrested circulation ; as, for example, when the blood coagulates in the 
veins which draw blood from the gluteal region in old and bed-ridden people, or as in 
some forms of pulmonary thrombosis, in which the clots in the arteries are probably 
the result of obstruction in the circulation through the lung-capillaries, as in certain 
cases of emphysema, pneumonia, or pulmonary apoplexy. 2. A mechanical obstruc- 
tion around which coagula form, as in certain morbid states of the vessels, or, a better 
example still, secondary coagula which form around a travelled embolus impacted in the 
pulmonary arteries. 3. And most important of all, in which the coagulation is the 
result of some morbid state of the blood itself. Examples of this last condition are 
frequently met with in the course of various diseases, such as rheumatism or fever, in 
which the quantity of fibrine is increased, and the blood itself is loaded with morbid 
material. Thrombosis from this cause is of by no means infrequent occurrence after 
severe surgical operations, especially such as have been attended with much hemorrhage, 
or when the patient is in a weak and anemic condition. This has been specially dwelt 
upon as a not infrequent source of death after operation by Fayrer and other surgeons.1 
Conditions which favor Coar/vlation in the Puerperal Sta te.—But little consideration 
is required to show why thrombosis plays so important a part in the puerperal state, 
for there most of the causes favoring its occurrence are present. Probably there is no 
other condition in which they exist in so marked a degree, or are so frequently com- 
bined. The blood contains an excess of fibrine, which largely increases in the latter 
months of utero-gestation, until, as has been pointed out by Andral and Gavarret, it 
not unfrequently contains a third more than the average amount present in the non- 
pregnant state. As soon as delivery is completed, other causes of blood dyserasia come 
into operation. Involution of the largely hypertrophied uterus commences, and the 
blood is charged with a quantity of effete material, which must be present, in greater 
or less amount, until that process is completed. It is an old observation that phlegmasia 
dolens is of very common occurrence in patients who have lost much blood during labor; 
thus Dr. Le'shman says: '‘In no class of cases has it been so frequently observed as 
in women whose strength has been reduced to a low ebb by haemorrhage either during 
or after labor; and this, no doubt, accounts for the observation made by Merrimanj 
that it is relatively a common occurrence after placenta praevia. ’ ’2 An examination of 
the cases in which death results from pulmonary thrombosis shows the same facts, as 
in a large proportion of them severe post-partum haemorrhage has occurred. The 
exhaustion following the excessive losses so common after labor must of itself strongly 
predispose to thrombosis, and, indeed, loss of blood has been distinctly pointed out 
by Richardson to be one of its most common antecedents. “There is,” he observes, “a 
condition which has been long known to favor coagulation and fibrinous deposition: I 
mean loss of blood, and syncope or exhaustion during impoverished states of the body.” 
Since, then, so many of the predisposing causes of thrombosis arc present in the'puer- 
peral state, it is hardly a matter of astonishment that it should be of frequent occur- 
rence, or that it should lead to conditions of serious gravity. And yet the attention: of 
the profession has been for the most part limited to a study of one only of the results 
of this tendency to blood-clotting after delivery, no doubt because of its comparative 
frequency and evident symptoms. True, the balance of professional opinion has lately 
held that phlegmasia dolens is chiefly the result of some morbid condition of the bl'ood 
producing plugging of the veins; but the wider view which I am attempting to main- 
tain, which would bring this disease into close relation with the more rarely observed, 
but infinitely important, obstructions of the pulmonary arteries, has scarcely, if at all, 
1 Edin. Med. Journ., March, 1861; Indian Annals of Med., July, 1867. 
a Leishman, System of Obstetrics, p. 710. 50 
PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 
been insisted on. Doubtless further investigation will show that it is not in these parts 
of the venous system alone that puerperal thrombosis occurs; but the symptoms and 
effects of venous obstruction elsewhere, important though they may be, are unknown. 
I propose, then, to describe the symptoms and pathology of blood-clot in the right 
side of the heart and pulmonary artery. It may be useful here to repeat that this is 
essentially distinct from embolism of the same parts. The latter is obstruction due to 
the impaction of a separated portion of a thrombus formed elsewhere, and for its pro- 
duction it is essential that thrombosis should have preceded it. Embolism is in fact an 
accident of thrombosis, not a primary affection. The condition we aie now discussing 
I hold to be primary, precisely similar in its causation to the venous obstruction which, 
in other situations, gives rise to phlegmasia do’ens. 
At the threshold of this inquiry we have to meet the objection, started by several 
who have written on this subject,1 that spontaneous coagulation of the blood, in the 
right side of the heart and pulmonary arteries, is a mechanical and physiological im- 
possibility. This was the view of Virchow, who, wiih his followers, maintained that 
whenever death from pulmonary obstruction occurred, an embolus was of necessity the 
starting-point of the ma'ady, and the nucleus round which secondary deposition of 
fibr'ne took place. Virchow holds that the primary factor in thrombosis is a stagnant 
state of the blood, and that the impulse imparted to the blood by the right ventricle is 
of itself sufficient to prevent coagulation. It is to be observed that these objections 
are purely theoretical. Without denying that there is considerable force in the argu- 
ments adduced, I think that the clinical h’story of these cases strongly favors the view 
of spontaneous coagulation; and I would apply to the theoretical objections advanced 
the argument used by one of their strongest upholders, with regard to another disputed 
point, “ Je prefere laisser la parole aux fails, car devant eux la theorie s’incline. ”2 
The anatomical arrangement of the pulmonary arteries shows how spontaneous co- 
agulation may be favored in them; for, as Dr. Humphrey has pointed out,3 “the 
artery breaks up at once into a number of branches, which radiate from it, at different 
angles, to the several parts of the lungs. Consequently, a large extent of surface is 
Eresented to the blood, and there are numerous angular projections into the currents; 
oth of which conditions are calculated to induce the spontaneous coagulation of the 
fibrine. ” We know also, that thrombosis generally occurs in patients of feeble con- 
stitution, often debilitated by haemorrhage, in whom the action of the heart is much 
weakened. These facts, of themselves, go far to meet the objections of those who 
deny the possibility of spontaneous coagulation at the roots of the pulmonary arteries. 
Results of Post-mortem Examinations.—The records of post-mortem examinations 
show also, that in many of the cases the right side of the heart, as well as the larger 
branches of the pulmonary arteries, contained firm, leathery, decolorized, and lamin- 
ated coagula, which could not have been recently formed. The advocates of the purely 
embolic theory maintain that these are secondary coagula, formed around an embolus. 
But surely the mechanical causes which are sufficient to prevent spontaneous deposition 
of fibrine, would also suffice to prevent its gathering round an embolus; unless, indeed, 
the obstruction was sufficient to arrest the circulation altogether, when death would 
occur before there was any time for secondary deposit. Before we can admit the pos- 
sibility of embolism, we must have at least one factor, that is, thrombosis in a periph- 
eral vessel, from which an embolus can come. In many of the recorded cases noth.ng 
of the kind wras found, and although, as is argued, this may have been overlooked, 
yet such an oversight can hardly always have been made. 
The strongest argument, however, in favor of the spontaneous origin of pulmonary 
thrombosis, is one which I originally pointed out in a series of papers “On thrombosis 
and embolism of the pulmonary artery as a cause of death in the puerperal state.”4 
I there showed, from a caieful analysis of 25 cases of sudden death, after delivery, in 
which accurate post-mortem examination had been made, that cases of spontaneous 
thrombosis and embolism may be divided from each other by a clear line of demarca- 
tion, depending on the period after delivery at which the fatal result occurs. In 7 out 
of these cases there was distinct evidence of embol sm, and in them death occurred at 
a remote period after delivery; in none before the nineteenth day. This contrasts re- 
markably with the cases in which the post-mortem examination afforded no evidence 
of embolism. These amounted to 15 out of the 25, and in all of them, with one ex- 
ception, death occurred before the fourteenth day, often on the second or third. The 
reason of this seems to be that in the former, time is required to admit of degenera- 
tive changes taking place in the deposited fibrine leading to separation of an embolus; 
1 See especially Bertin, Des Einbolies, p. 46 et seq. 1 Bertin, Des Embolies, p. 149. 
* Humphrey, On the Coagulation of the Blood in the Venous System during Life. 4 Lancet, 1867. SYMPTOMS OF PULMONARY OBSTRUCTION. 
51 
while in the latter, the thrombosis corresponds in time, and to a great extent, no doubt, 
also, in cause, to the original peripheral thrombosis from which, in the former, the em- 
bolus was derived. Many cases 1 have since collected illustrate the same rule in a very 
curious and instructive way. 
Another clinical fact I have observed, points to the same conclusion. In one or two 
cases, distinct s'gns of pulmonary obstruction have shown themselves, without proving 
immediately fatal, ana shortly afterwards, peripheral thrombosis, as evidenced by 
phlegmasia dolens of one extremity, has commenced. Here the peripheral thrombosis 
obvious y followed the central, both being produced by identical causes, and the order 
of events, necessary to uphold the purely embolic theory, was reversed. 
I hold, then, that those who deny the possibility of spontaneous coagulation in the 
heart and pulmonary arteries, do so on insufficient ground, and that we may consider 
it to be an occurrence, rare no doubt, but still sufficiently often met with, and certainly 
of sufficient importance, to merit very careful study. 
History.—Dr. Charles I). Meigs, of Philadelphia, was one of the first to direct at- 
tention to spontaneous coagulation of the blood in the right side of the heart and pul- 
monary arteries, as a cause of sudden death in the puerperal state. The occurrence 
itself, however, has been carefully studied by Paget, whose paper was published in 
1855, four years before Meigs wrote on the subject.1 It is true that none of Paget’s 
cases happened after delivery, but he none the less clearly apprehended the nature of 
the obstruction. In 1855, Hecker2 attributed the majority of these cases to embolism 
proper; and since that date most authors have taken the same view, believing that 
spontaneous coagulation only occurs in exceptional cases, such as those in which, on 
account of some obstruction in the lung or in the debility of the last few hours before 
death, coagula form in the smaller ramifications of the pulmonary arteries, and grad- 
ually creep backwards towards the heart. 
Symptoms of Pulmonary Obstruction.—The symptoms can hardly be mistaken, and 
there seems to be no essential difference between the symptomatology of spontaneous 
and embolic obstructions, so that the same description will suffice for both. In a large 
proportion of cases the attack comes on with an appalling suddenness, which forms one 
of its most striking characteristics. Nothing in the condition of the patient need have 
given rise to the least suspicion of impending mischief, when, all at once, an intense 
and horrible dyspnoea comes on ; she gasps and struggles for breath ; tears off the cov- 
erings from her chest in a vain endeavor to get more air; and, often, dies in a few 
minutes, long before medical aid can be had, with all the symptoms of asphyxia. The 
muscles of the face and thorax are violently agitated in the attempt to oxygenate the 
blood, and an appearance closely resembling an epileptic convulsion may be presented. 
The face may be either pale or deeply cyanosed. Thus in one case I have elsewhere 
recorded, which was an undoubted example of true embolism, Mr. Pedler, the resident 
accoucheur at King’s College Hospital, who was present during the attack, writes of 
the patient,3 “She was suffering from extreme dyspnoea, the countenance was exces 
sively pale, her lips white, the face generally expressing deep anxiety.” In another, 
which was probably an examp1 e of spontaneous thrombosis/ occurring on the twelfth 
day after delivery, it is stated “the face had assumed a livid, purple hue, which was 
so rema- kable as to attract the attention both of the nurse and of her mother, who 
was with her. ’ ’ The extreme embarrassment of the circulation is shown by the tumul- 
tuous and irregular action of the heart, in its endeavor to send the venous blood through 
the obstructed arteries. Soon it gets exhausted, as shown by its feeble and fluttering, 
beat. The pulse is thread-Ike, and nearly imperceptible, the respirations short and 
hurried, but air may be heard entering the lungs freely. The intelligence during the 
strugg’e is un’mpaiied ; and the dreadful consciousness of impending death adds not 
a little to the patient’s sufferings, and to the terror of the scene. Such is an imperfect 
account of the symptoms, gathered from a record of what has been observed in fatal 
cases. It wiil be readily understood why, in the presence of so sudden and awful an 
attack, symptoms have not been recorded with the accuracy of ordinary clinical 
observation. 
A question of great practical interest, which has been entirely overlooked by writers 
on the sub’ect is—Have we any ground for supposing that there is a possibility of 
recovery after symptoms of pulmonary obstruction have developed themselves ? That 
such a result must be of extreme rarity is beyond question; hut I ha.ve little doubt 
that in some few eases, entirely inexplicable on any other hypothesis, life is prolonged 
1 Medieo-Chir. Trans., vol. xxvii., p. 162 and vol. xxviii., p. 352; Philadelphia Medical Exam- 
iner, 1849. 2 Deutsche Khnicko, 1855. 
3 Brit. Med. Journ., March 27, 1869. * Obst. Trans., vol. xii., p. 194. 52 
PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 
until the coagulum is absorbed, and the pulmonary circulation restored. In order to 
admit of this it is, of course, essential that the obstruction be not sufficient to prevent 
the passage of a certain quantity of blood to the lungs, to carry on the vital functions. 
The history of many cases tends to show that the obstructing clot was present for a 
considerable time before death, and that it was only when some sudden exertion was 
made, such as ris'ng fi om bed or the like, calling for an increased supply of blood which 
could not pass through the occluded arteries, that fatal symptoms manifested them- 
selves. This was long ago pointed out by Paget,1 who says, ‘' The case proves that, in 
certain circumstances, a great part of the pulmonary circulation may be arrested in 
the course of a week (or a few days more or less), without immediate danger to 
life, or any indication of what had happened.” And, after referring to some illustra- 
tive cases, “Yet in all these cases the characters of the clots by which the pulmonary 
arteries were obstructed, showed plainly that they had been a week or more in the proc- 
ess of formation.” If we admit the possibility of the continuance of life for a certain 
time, we must, I think, also admit the possibility, in a few rare cases, of eventual 
complete recovery. What is required is time for the absorption of the clot. In the 
peripheral venous system coagula are constantly removed by absorption. So strong, 
indeed, is the tendency to this, that Humphrey observes with regard to it, “It appears 
that the blood is sure to revert to its natural channel in process of time.? ’2 If, 
then, the obstruction be only partial, if sufficient blood pass to keep the patient alive, 
and a sudden supply of oxygenated blood is not demanded by any exertion which the 
embarrassed circulation is unable to meet, it is not inconceivable that the patient may 
live until the obstruction is removed. 
Illustrative Cases.—Such, I believe, to be the only explanation of certain cases, 
some of which, on any other hypothesis, it is impossible to understand. The symp- 
toms are precisely those of pulmonary obstruction, and the description I have given 
above may be applied to them in every particular; and after repeated paroxysms, 
each of which seems to threaten immediate dissolution, an eventual recovery takes 
place. What, then, I am entitled to ask, can the condition be, if not that which I 
suggest? As the question I am considering has never, so far as I am aware, been 
treated of by any other writer, I may be permitted to state, very briefly, the facts of 
one or two of the cases on which I found my argument, some of which I have already 
published in detail elsewhere. 
K. H., delicate young lady. Labor easy. First child. Profuse post-partum hsemmorhage. 
Did well until the 7th day, during the whole of which she felt weak. Same day an alarming 
attack of dyspnoea came on. For several days she remained in a very critical condition, the 
slightest exertion bringing on the attacks, A slight blowing murmur heard for a few days at the 
base of the heart, and then disappeared. For two months patient remained in the same state. 
As long as she was in the recumbent position she felt pretty comfortable, but any attempt at 
sitting up in bed, or any unusual exertion immediately brought on the embarrassed respiration. 
During all this time it was found necessary to administer stimulants profusely to ward off the 
attacks. Eventually the patient recovered completely. 
Q. F., set. 44. Mother of twelve children. Confined on July 6. On the 11th day she went to 
bed feeling well. There was no swelling or discomfort of any kind about the lower extremities at 
this time. About half-past 3 a.m. she was sitting up in bed, when she was suddenly attacked 
with an indescribable sense of oppression in the chest, and fell back in a semi-unconscious state, 
gasping for breath. She remained in a very critical condition, with the same symptoms of em- 
barrassed respiration, for three days, when they gradually passed away. Two days after the 
attack, phlegmasia dolens came on, the leg swelled, and remained so for several months. 
Tbis case is an example of the fact I have already referred to, of phlegmasia dolens 
coming on after the symptoms of pulmonary obstruction had manifested themselves ; 
the inference > being that both depended on similar causes operating on two distinct 
parts of the circulatory system. 
C. H., eet. 24. Confined of her first child on August 20, 1867. Thirty hours after delivery she 
complained of great weakness and dyspnoea. This was alleviated by the treatment employed, 
but on the ninth day, after making a sudden exertion, the dyspnoea returned with increased 
violence, and continued unabated until I saw the patient on September 4, fourteen days after her 
confinement. The following are the notes of her condition made at the time of the visit: “I 
found her sitting on the sofa, propped up with pillows, as she said she could not breathe in the 
recumbent position. The least excitement or talking brought on the most aggravated dyspnoea, 
which was so bad as to threaten almost instant death. Her sufferings during these paroxysms 
were terrible to witness. She panted and struggled for breath, and her chc« t heaved with short 
gasping respirations. She could not even bear any one to stand in front of her, waving them 
away with her hand, and calling for more air. These attacks were very frequent and were 
brought on by the most trivial causes. She talked in a low, suppressed voice, as if she could not 
1 Op. cit., p. 358. 
2 Med. Chir. Trans., vol. xxrii., p. 14. CARDIAC MURMURS IN PULMONARY OBSTRUCTION. 
53 
spare breath for articulation. On auscultation air was found to enter the lungs freely in every 
direction, both in front and behind. Immediately over the site of the pulmonary arteries there 
was a distinct harsh, rasping murmur, confined to a very limited space, and not propagated either 
upwards or downwards. The heart-sounds were feeble and tumultuous.” These symptoms led 
me to diagnose pulmonary obstruction, and I, of course, gave a most unfavorable prognosis, but 
to my great surprise the patient slowly recovered. I saw her again six weeks later, when her 
heart-sounds were regular and distinct, and the murmur had completely disappeared. 
E. E., set. 42, was confined for the first time on November 5, 1873, in the sixth month of utero- 
gestation. She had severe post-partum haemorrhage, depending on partially adherent placenta, 
which was removed artificially. She did perfectly well until the 14th day after delivery, when 
she was suddenly attacked with intense dyspnoea, aggravated in paroxysms. Pulse pretty full, 
130, but distinctly intermittent. Air entered lungs freely. The heart’s action was fluttering and 
irregular, and, at the juncture of the fourth and fifth ribs with the sternum there was a loud blow- 
ing systolic murmur. This was certainly non-existent before, as the heart had been carefully 
auscultated before administering chloroform during labor. For two days the patient remained in 
the same state, her death being almost momentarily expected. On the 21st, that is two days after 
the appearance of the chest symptoms, phlegmasia dolens of a severe kind developed itself in the 
right thigh and leg. She continued in the same state for many .days, lying more or less, tranquilly, 
but having paroxysms of the most intense apnoea, varying from two to six or eight in the twenty- 
four hours. No one who saw her in one of these could have expected her to live through it. 
Shortly after the first appearance of the paroxysms it was observed that the cellular tissue of the 
neck and part of the face became swollen and oedematous, giving an appearance not unlike that 
of phlegmasia dolens. The attacks were always relieved by stimulants. These she incessantly 
called for, declaring that she felt they kept her alive. During all this time the mind was clear 
and collected. The pulse varied from 110 to 130. Respirations about 60, temperature, 101° to 
102.5°. By slow degrees the patient seemed to be rallying. The paroxysms diminished in num- 
ber, and after December 1, she never had another, and the breathing became free and easy. The 
pulse fell to 80, and the cardiac murmur entirely disappeared. The patient remained, however, 
very weak and feeble, and the debility seemed to increase. Towards the second week in Decem- 
ber she became delirious and died, apparently exhausted, without any fresh chest symptoms, on 
the 19th of that month. No post-mortem examination was allowed. 
I have narrated this case, although it terminated fatally, because I hold it to be one 
of the class I am considering. The death was certainly not due to the obstruction, all 
symptoms of which had disappeared, but apparently to exhaustion from the severity 
of the former illness. It illustrates, too, the simultaneous appearance of symptoms of 
pulmonary obstruction and peripheral thrombosis. The swelling of the neck was a 
curious symptom, which has not been recorded in any other cases, and may possibly be 
a further proof of the analogy between this condition and phlegmasia dolens. 
Now, it may, of course, be argued that these cases do not prove my thesis, inasmuch 
as I only assume the presence of a coagulum. But I may fairly ask in return what 
other condition could possibly explain the symptoms? The}'’ are precisely those which 
are noticed in death from undoubted pulmonary obstruction. No one seeing one of 
them, or even reading an account of the symptoms, while ignorant of the result, could 
hesitate a single instant in the diagnosis. Surely, then, the inference is fair that they 
depended on the same cause ? In the very nature of things my hypothesis cannot be 
verified by post-mortem examination; but there is at least one case on record in which, 
after similar symptoms, a clot was actually found. The case is related by Dr. Ilichard- 
son.1 It was that of a man who for weeks had symptoms precisely similar to those 
observed in the cases I have narrated. In one of his agonizing struggles for breath he 
died, and after death it was found “that a fibrinous band, having its hold in the ven- 
tricle, extended into the pulmonary artery.’’ This observation proves to a certainty 
that life may continue lor weeks after the deposition of a coagulum; and, more- 
over, this condition was precisely what we should anticipate, since, of course, the 
obstructing coagulum must necessarily be small, otherwise the vital functions would be 
immediately arrested. 
Cardiac Murmurs in Pulmonary Obstruction.—There is a symptom noted in two of 
the above cases, and to less extent in a third, which has not been mentioned in any 
account of fatal cases occurring after delivery, viz., a murmur over the site of the 
pulmonary arteries. It is a sign we should naturally expect, and very possibly it would 
be met with in fatal cases if attention were particularly directed to the point. In both 
these instances it was exceedingly well marked, and in both it entirely disappeared' 
when the symptoms abated. The probability of such a murmur being audible in cases 
of thrombos’s of the pulmonary artery, has been recognized by one of our highest 
authorities in cardiac disease, who actua'ly observed it in a non-puerperal case. In the 
last edition of his work on diseases of the heart, Dr. Walshe2 says: “The only phys- 
ical condition connected with the vessel itself would probably be systolic basic murmur 
1 Clinical Essays, p. 224 et seq. 2 Walshe, On Diseases of the Heart, 4th ed., 1873. PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 
following the course of the pulmonaiy main trunk and of its immediate divisions to the 
left and right of the sternum. This sign I most certainly heard in an old gentleman 
whose life was brought to a sudden close, in the course of an acute affection, by coagu- 
lation in the pulmonary artery, and to a moderate extent in the right ventricle.” 
Similar cases have, probably, been overlooked or misinterpreted. Many seem to 
have been attributed to shock, in the absence of a better explanation, a condition to 
which they bear no kind of resemblance. 
Cannes of Death.—The precise mode of death in pulmonary obstruction, whether 
dependent on thrombosis or embolism, has given rise to considerable difference of 
opinion. Virchow attributes it to syncope,1 depending on stoppage of the cardiac con- 
traction. Panum,2 on the other hand, contests this view, maintaining that the heart 
continues to beat even after all signs of life have ceased. Certainly tumultuous and 
irregular pulsations of the heart are prominent symptoms in most of the recorded 
cases, and are not reconcilable with the idea of syncope. Panum’s own theory is, that 
death is the result of cerebral anaemia. Paget seems to think that the mode of death 
is altogether peculiar, in some respects resembling syncope, in others anaemia. Berlin, 
who has d'scussed the subject at great length, attributes the fatal result purely to as- 
phyxia. The condition, indeed, is in all respects similar to that state ; the oxygenation 
of the blood being prevented, not because air cannot get to the blood, but because blood 
Cannot get to the air. The symptoms also seem best explained by this theory; the 
intense dyspnoea, the terrible struggle for air, the preservation of intelligence, the 
tumultuous action of the heart, are certainly not characteristic either of syncope or 
anaemia. 
Post-mortem, Appearances of Clots.—The anatomical character of the clots seems to 
vary considerably. Ball, by whom they have been most carefully described, believes 
that they generally commence in the smaller ramifications of the arteries, extending 
backwards towards the heart, and filling the vessels more or less completely. Towards 
its cardiac extremity the coagulum terminates in a rounded head, in which respect it 
resembles those spontaneously formed in the peripheral veins. It is non-adherent to 
the coats of the vessels, and the blood circulates, when it can do so at all, between it 
and the vascular walls. Such clots are white, dense, and of a homogeneous structure, 
consisting of layers of decolorized fibrine, firm at the periphery, where the fibrine has 
been most recently deposited, and softened in the centre, where amylaceous or fatty 
degeneration has commenced. Ball maintains that if the coagulum have commenced 
iti the larger branches of the arteries, it must have first begun in the ventricle, and 
extended into them. According to Humphrey, the same changes take place in pulmo- 
rtary as in peripheral thrombi, and they may become adherent to the walls of the 
vessels, or converted into threads or bands. When the obstruction is due to embolism, 
provided the case is a well-marked one, and the embolus of some size, the appearances 
presented are different. We have no longer a laminated and decolorized coagulum, 
with a rounded head, similar to a peripheral thrombus. The obstruction in this case 
generally takes place at the point of bifurcation of the artery, and we there meet with 
a grayish-white mass, contrasting remarkably with the more recently deposited fibrine 
before and behind it. It may be that the form of the embolus shows that it has re- 
cently been separated from a clot elsewhere ; and in many cases it has been possible to 
fit the travelled portion to the extremity of the clot from which it has been broken. 
We may also, perhaps, find that the embolus has undergone an amount of retrograde 
tnetamorphosis corresponding with that of the peripheral thrombus from which we 
suppose it to have come, but differing from that of the more recently deposited fibrine 
around it. It must be admitted, however, that the anatomical peculiarities of the 
Coagula will by no means always enable us to trace them to their true origin. In many 
Cases emboli may escape detection from their smallness, or from the quantity of fibrine 
surrounding them. 
Treatment.—But few words need be said as to the treatment of pulmonary obstruc- 
tion. In a large majority of cases the fatal result so rapidly follows the appearance of the 
Symptoms, that no time is given us even to make an attempt to alleviate the patient’s 
bufferings. Should we meet with a case not immediately fatal, it seems that there are 
but two indications of treatment affording the slightest rational ground of hope. 
1. To keep the patient alive by the administration of stimulants—brandy, ether, 
ammonia, and the like—to be repeated at intervals corresponding to the intensity of 
the paroxysms, and the results produced. In the cases I have above narrated, in which 
recovery ensued, this took the place of all other medication. Possibly leeches, or dry 
cupping to the chest, might prove of some service in relieving the circulation. 
1 Gesamm. Abhandl., 1862, p. 316. 
3 Virchow’s Archiv, 1863. SYMPTOMS. 
55 
2. To enjoin the most absolute and complete repose. The object of this is evident. 
The only chance for the patient seems to be, that the vital functions should be carried 
on until the coagulum has been absorbed, or, at least, until it has been so much lessened 
in size as to admit of blood passing it to the lungs. The slightest movements may give 
rise to a fatal paroxysm of dyspnoea, from the increased supply of oxygenated blood 
required. It must not be forgotten that in a large proportion of cases death immedi- 
ately followed some exertion in itself trivial, such as rising out of bed. Too much 
attention, then, cannot be given to this point. The patient should be absolutely still; 
she should be fed with abundance of fluid food, such as milk, strong soups, and the 
like; and should on no account be permitted to raise herself in bed, or attempt the 
slightest muscular exertion. If we are fortunate enough to meet with a case appar- 
ently tending to recovery, these precautions must be carried on long after the severity 
of the symptoms has lessened, for a moment’s imprudence may suffice to bring them 
back in all their original intensity. 
Bertin,1 indeed, recommends a system of treatment very different from this. In the 
vain hope that the violent effort induced may cause the displacement of the impacted 
embolus (to which alone he attributes pulmonary obstruction), he recommends the 
administration of emetics. Few, I fancy, will be found bold enough to attempt so 
hazardous a plan of treatment. 
Various drugs have been suggested in these cases. Richardson recommended am- 
monia, a deficiency of which he at that time believed to be the chief cause of coagula- 
tion. He has since advised that liquor ammoniae should be given in large doses, 20 
minims every hour, in the hope of causing solution of the deposited fibrine; and he 
has stated that he has seen good results from the practice. Others advise the adminis- 
tration of alkalies, in the hope that they may favor absorption. The best that can be 
said for them is, that they are not likely to do much harm. 
CHAPTER VII. 
PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. 
The same condition of the blood which so strongly predisposes to coagulation in the 
vessels through which venous blood circulates, tends to similar results in the arterial 
system. These, however, are by no means so common, and do not, as a ride, lead 
to such important consequences. The subject has been but little studied, and almost 
all our knowledge of it is derived from a very interesting essay by Sir James Simpson.2 
As I have devoted so much space to the consideration of venous thrombosis and embol- 
ism, I shall but briefly consider the effects of arterial obstruction. 
Causes.—In a considerable number of recorded cases the obstruction has resulted 
from the detachment of vegetations deposited on the cardiac valves, the result of endo- 
carditis, either produced by antecedent rheumatism or as a complication of the puer- 
peral state. Sometimes the obstruction seems to depend on some general blood dys- 
ciasia, s’mdar to that producing venous thrombosis, or on some local change in the 
artery itself. Thus, Simpson records a case apparently produced by local arteritis, 
which caused acute gangrene of both lower extremities, ending fatally in the third week 
after delivery. In other cases it has been attributed to coagulation following sponta- 
neous laceration and corrugation of the internal coat of the artery. 
Symptoms.—The symptoms of puerperal arterial obstruction must, of course, vary 
with the particular arteries affected. Those with the obstruction of which we are most 
familiar are the cerebral, the humeral, and the femoral. The effects produced must 
a1 so be modified by the size of the embolus, and the more or less complete obstruction 
it produces. Thus, for example, if the middle cerebral artery be blocked up entirely, 
the functions of those portions of the brain suppl ed by it w 11 be more or less com- 
pletely arrested, and hemiphlegia of the opposite side of the body, fol'owed by soften- 
ing of the brain-texture, will probably result. If the nervous symptoms be deve!oped 
gradually, or increase in intensity after their first appearance, it may be that an obstruc- 
1 Op. cit., p. 393. 
2 Selected Obst. Works, vol. i., p. 523. 56 
CAUSES OF SUDDEN DEATH DURING LABOR. 
tion, at first incomplete, has increased by the deposition of fibrine around it. So the 
occasional sudden supervention of blindness, with destruction of the eyeball—cases of 
which are recorded by Simpson—not improbably depend on occlusion of the ophthalmic 
artery, the function of the organ depending on its supply through the single artery. 
The effects of obstruction of the visceral arteries in the puerperal state are entirely 
unknown; but it is far from unlikely that further investigation may prove them to be 
of great importance. In the extremities arterial obstruction produces effects which are 
well marked. They are elass'fied by Simpson under the fo’lowing heads: 1. Arrest of 
pulse below the site of obstruction.—This has been observed to come on either suddenly 
or gradually, and if the occlusion be in one of the large arterial trunks, it is a symptom 
which a careful examination will readily enable us to detect. 2. Increased force ofpid- 
sation in the arteries above the seat of obstruction. 3. Fall in the temperature of the limb. 
—This is a symptom which is easily appreciable by the thermometer, and, when the 
main artery of the limb is occluded, the coldness of the extiemity is well marked. 4. 
Lesions of motor and sensory functions, paralysis, neuralgia, etc., etc.—Loss of power 
in the affected limb is often a prominent symptom, and when it comes on and 
is complete, the main artery will probab'y be occluded. It may be diagnosed from 
paralysis depending on cerebral or spinal causes by the absence of head symptoms, by 
the history of the attack, and by the presence of other indications of arterial obstruc- 
tion, such as loss of pulsation in the artery, fall of temperature, etc. The sensory 
functions in these cases are generally also seriously disturbed, not so much by loss of 
sensation as by severe pain and neuralgia. Sometimes the pain has been excessive, and 
occasionally it has been the first symptom which directed attention to the state of the 
limb. 5. Gangrene below or beyond the seat of arterial obstruction.—Several interesting 
cases are recorded, in which gangrene has fo'lowed arterial obstruction. Generally 
speaking, gangrene will not follow occlusion of the ma:n arterial trunk of an extremity, 
as the collateral circulation becomes soon sufficiently developed to maintain its vitality. 
In many of the cases, either thrombi have obstructed the channels of collateral circu- 
lation as well, or the veins of the limb have also been blocked up. When such exten- 
sive obstructions occur they obviously cannot be embolic, but must depend on a local 
thrombosis, traceable to some general blood dyscrasia depending on the puerperal state. 
Treatment.—Little can be said as to the treatment of such cases, which must vary 
with the gravity and nature of the symptoms in each. Beyond absolute rest (in the 
hope of eventual absorption of the thrombus or embolus), generous diet, attention to 
the general health of the patient, and sedative applications to relieve the local pain, 
there is little in our power. Should gangrene of an extremity supervene in a puerperal 
patient, the case must necessarily be wellnigh hopeless. Simpson, however, records 
one instance in which amputation was performed above the line of demarcation, the 
patient eventually recovering. 
CHAPTER VIII. 
OTHER CAUSES OF SUDDEN DEATH DURING LABOR AND 
THE PUERPERAL STATE. 
A LARGE number of the cases in which sudden death occurs during or after delivery 
find their exp’anation, as I have already pointed out, in thrombosis or embolism of the 
heart and pulmonary ai teries. Probably many cases of the so-called idiopathic asphyxia 
we:e, in fact, examp’es of this accident, the true nature of which had been misunder- 
stood. Besides these, there are, no doubt, many other conditions which may lead to a 
fatal result in connection with parturition. 
Some of these are of an organic, otheis of a functional nature. 
Organic Causes.—Among ihe former may be mentioned cases in which the straining 
efforts of the second stage of labor have produced death in patients suffering from some 
pre-existent disease of the heart. Rupture of that organ has probably occurred from 
fatty degeneration of its walls. Behous1 narrates an instance in which the efforts of 
labor caused the rupture of an aneurism. Another case, from interference with the 
1 Dehous, Sur les Morts subites. AIR IN THE VEINS—CAUSE OF DEATH IN SUCH CASES. 
57 
action of the heart in a patient who had pericardial effusion, is narrated by Ramsbotham. 
Dr. Devilliers relates an instance occurring in a young woman during the second stage 
of labor. The heart was found to be healthy, but the lungs were intensely congested, 
and blood was extensively extravasated all through their texture. This was probably 
caused by pulmonary congestion and apop'exy, produced by the severe straining efforts. 
Many cases from effusion of blood into the brain-substance, or on its surface, are on 
record, no doubt in patients who, from arterial degeneration or other causes, were 
predisposed to apoplectic effusions. The so-called apoplectic convulsions, formerly de- 
scribed in most works on obstetrics as a variety of puerperal convulsions, are evidently 
nothing more than apoplexy coming on during or after labor. As regards their pathology 
they do not seem to diff er from ordinary cases of apoplexy in the non-pregnant condition.. 
One example is recorded of death which was attributed to rupture of the diaphragm 
from excessive action in the second stage. 
Functional Causes.—Among the causes of death which cannot be traced to some 
distinct organic les'on, may be classed cases of syncope, shock, and exhaustion. Many 
instances of this kind are recorded. Thus in some women of susceptible nervous or- 
ganization, the severity of the suffering appears to bring on a condition similar to that 
produced by excessive shock or exhaustion, which has not unfrequently proved fatal. 
Several examples of this kind have been'cited by McClintock.1 It is also not unlikely 
that sadden syncope sometimes produces a fatal result, during or after labor. Most 
cases of death, otherwise inexplicable, used to be referred to this cause; but accurate 
autopsies were seldom made, and even when they were—the important effects of pul- 
monary coagula being unknown—it is more than probable that the true cause of death 
was overlooked. It has been supposed that the sudden removal of pressure from the 
veins of the abdomen, by the emptying of the gravid uterus after delivery, may favor 
an increased afflux of blood into the lower parts of the body, and thus tend to an 
anaemic condition of the brain, and the production of syncope. However this maybe, 
the possibility of its occurrence, and its manifest danger in a recently delivered woman, 
are sufficient reasons for enforcing the recumbent position after labor is over. In 
some of the cases the syncope was evidently produced by the patient’s suddenly sitting 
upright. 
Death from Air in the Veins.—Some cases of sudden death immediately after labor 
seem to be due to the entrance of air into the veins. Six examples are cited by 
McClintock which were probably due to this cause. La Chapelle relates two. An 
interesting case is related by M. Lionet.2 In this the patient died five and a half hours 
after an easy and natural labor, the chief symptoms being extreme pallor, efforts at 
vomiting, and dyspnoea. Air was found in the heart and in the arachnoid veins. There 
can be no question that the uterine sinuses after delivery are nearly as well adapted as 
the veins of the neck for allowing the entrance of air. They are firmly attached to the 
muscidar walls of the uterus, so that they gape open when that organ is relaxed, and 
it is easy to understand how air might enter. Indeed, in the post-mortem examination 
in one of the cases occurring in the practice of Mme. La Chapelle, it is stated that 
“the uterine sinuses opened in the interior of the uterus by large orifices (one line and 
a half in diameter), through which air could readily be blown as far as the iliac veins, 
and vice versa. ’ ’ The condition of the uterus after delivery also enables the air to have 
ready access to the mouths of the sinuses, for the alternate relaxation and contraction 
of the uterus, occurring after the p’acenta is expelled, would tend to draw in the air as 
by a suction pump. Hence, an additional reason for insisting on firm contraction of 
the uterus, as this will lessen the risk of this accident. 
Cause of Death in such Cases.—The precise mechanism of death from air in the 
veins, has been a subject of dispute among pathologists. By Bichat,3 it was referred 
to anaemia and syncope from want of blood in the vessels of the brain, which are 
occupied by air; Nysten4 attributed it to distention of the cavities of the heart by 
rarefied air, producing paralysis of its wall; Leroy to a stoppage of the pulmonary 
circulation, and consequent want of proper blood-supply to the left heart; while Leroy 
d’Etoilles thought it might depend on any of these causes, or a combination of a’l of 
them. These, and many other hypotheses on the subject, have been advanced, to all 
of which serious objection could be raised. The most recent theory is one maintained 
by V irchow and Oppo'zer,5 and more recently by Feltz, which attributes the fatal results 
to impaction of the air-globules in the lesser divisions of the pulmonary arteries, where 
1 Union Medic., 1853. 2 Dehous, op. cit. p. 58. 
8 Recherches sur la Vie et la Mort, 1853. 
4 Nysten, Recherches de Phys. et Chem. Path., 1811. 
6 Casuistics des Embolie; Wiener Med. Woch., 1863. Des Embolies Capillaires, 1868. Op. cit. 
p. 115. 58 
PERIPHERAL VENOUS THROMBOSIS, ETC. 
they form gaseous emboli, and cause death exactly in the same way as when the ob- 
struction depends on a fibrinous embolus. The symptoms observed in fatal cases close'y 
correspond to those of pu’monaiy obstruction, and it is not unlike’y that some cases, 
attributed to other causes, may really depend on the entrance of air through the uterine 
sinuses. Such, for example, was most probab’y the explanation of a refer; ed to 
by Dr. Graily Hewitt in a discussion at the Obstetrical Society.1 Death occurred shortly 
after the removal of an adherent placenta, during w7hich, no doubt, air could readily 
enter the uterine cavity. The symptoms, viz., “severe pain in the cardiac region, 
d’sti ess as regards respii ation, and pulselessness, ’ ’ are identical with those of pulmonary 
obsttuction. Dr. Hewitt refers the death to shock, which certainly does not generally 
produce such phenomena. 
CHAPTER IX. 
PERIPHERAL VENOUS THROMBOSIS —(SYN.: CRURAL PHLE- 
BITIS-PHLEGMASIA DOLENS —ANASARCA SEROSA —(EDE- 
MA LACTEUM-WHITE LEG, ETC.). 
We now come to discuss the symptoms and pathology of the conditions associated 
with the formation of thrombi in the peripheral venous system, or rather in the veins 
of the lower extremities, since too little is known of their occurrence in other parts to 
enable us to say anything on the subject. 
The most important of these is the well-known disease which, under the name of 
phlegmasia dolens, has attracted much attention, and given lise to numerous theories 
as to its nature and pathology. In describing it as a local manifestation of a general 
blood-dyscrasia, and not as an essential local disease, I am making an assumption as to 
its pathology that many eminent authorities would not consider justifiable. I have, 
however, already stated some of the reasons for so doing, and I shall shortly hope to 
show that this view is not incompatible with the most probable explanation of the pecu- 
liar state of the affected limb. 
Symptoms. —The first symptom which usual’y attracts attention is severe pain in 
some part of the limb that is about to be affected. The character of the pain varies 
in different cases. In some it is extreme’y acute, and is most felt in the neighborhood 
of and along the course of the chief venous trunks. It may begin in the groin or hip 
and extend downwards, or it may commence in the calf and proceed rpwaids towaids 
the pelvis. The pain abates somewhat after swell'ng of the limb (which generally 
begins within twenty-four hours), but it is always a distressing symptom, and continues 
as long as ihe acute stage of the disease lasts. The restlessness, want of sleep, and 
suffering whi h it produces are sometimes excessive. Coincident with the pain, and 
sometimes preceding it, more or less malaise is experienced. The patient may for a day 
or two be jestless, irritable, and out of sorts, without any very definite cause; or the 
disease may be ushered in by a distinct rigor. Generally there is constitutional dis- 
turbance, varying with the intensity of the case. Ihe pu’se is lapid and weak, 120 or 
thereabouts; the temperature elevated from 101° to 102°, wTith an evening exace: bation. 
The patient is thirsty; the tongue glazed, or white and loaded ; the bowels constipated. 
In some few cases, when the local affection is slight, none of these constitutional symp- 
toms are observed. 
Condition of the Affected Limb.—The characteristic swelling rapidly fo’lows the com- 
mencement of the symptoms. It generally begins in the gro'n, from whence it extends 
downwards. It may be l'mited to the thigh, cr the whole 1 mb, even to the feet, may 
be implicated. More rarely it commences in the calf of the leg, extending upwards to 
the thigh and downwards to the feet. The affected parts have a peculiar appearance, 
which is pathognomon’c of the disease. They are hard, tense, and brawny, of a shiny, 
white co or, and not yielding on pressure, except towards the beginning and end of the 
illness. The appearances presented aie quite different from those of ordinary oedema. 
When the whole thigh is affected, the limb is enormously increased in size. Frequently 
the venous trunks, especially the femoral and popliteal veins, are felt obstructed with 
coagula, and rolling under the finger. They are painful when handled, and in their 
1 Obstet. Trans., yol. x., p. 28. PHLEBITIC THEORY. 
59 
course more or less redness is occasionally observed. Either leg may be attacked, but 
the left more frequently than the right. There is a marked tendency for the disease 
to spread, and we often find, in a case which is progre sing apparently well, a rise of 
temperature and an accession of febrile symptoms, followed by the swelling of the 
other limb. 
Programs of the Disease.—After the acute stage has lasted from a week to a fortnight, 
the constitutional disturbance becomes less ma ked, the pulse and temperature fall, the 
pain abates, and the sleeplessness and resile, sness are less. The swelling and tension 
of the limb now begin to diminish, and absorption commences. This is invariably a 
slow process. It is always many weeks before the effusion has disappeared, and it may 
be many months. The limb retains for a length of time the peculiar wooden feeling, 
as Dr. Churchill terms it. Any imprudence, such as a too early attempt at walking, 
may bring on a relapse and fresh swelling of the limb. Ths gradual recovery is by tar 
the most common termination of the disease. In some rare cases, suppuration may 
take place either in the subcutaneous cellular tissue, the lymphatic glands, or even in 
the joints, and death may result from exhaustion. The possibility of pulmonary 
obstruction and sudden death from separation of an embolus have al eady been pointed 
out, and the fact that this lamentable occurrence has generally followed some undue ex- 
ertion shou'd be borne in mind, as a guide in the management of our patient. 
Period of Commencement.—The disease usua’ly begins within a short time after 
delivery, rarely after the second week. In 22 cases tabulated by Dr. Robert Lee, 7 were 
attacked between the fourth and twelfth days, and 14 after the second week. Some 
cases have been described as commencing even months after delivery. It is question- 
able if these can be classed as puerperal, for it must not be forgotten that phlegmasia 
dolens is by no means necessarily a puerperal disease. There are many other conditions 
which may give rise to it, all of them, however, such as produce a septic and hyper- 
inosed state of the blood, such as malignant disease, dysentery, phthisis, and the like. 
My own experience would lead me to think that cases of this kind are much more 
common than is generally believed. 
History and Pathology.—The d:sease has long attracted the attention of the profes- 
sion. Passing over more or less obscure notices by Hippocrates, De Castro, and others, 
we find the first c'ear account in the writings of Mauriceau, who not only gave a very 
accurate description of its symptoms, but made a guess at its pathology, which was 
certainly more happy than the speculations of his successors; it is, he says, caused 
“by a reflux on the part3 of certain humors which ought to have been evacuated by 
the lochia.’’ Puzos ascribed it to the arrest of the secretion of m’lk, and its extrava- 
sation in the affected limb. This theory, adopted by Levret and many subsequent 
writers, took a strong hold on both professional and pub ic op'nion, and to it we owe 
many of the names by which the disease is known to this day, such as oedema, lacteum, 
milk leg, etc. In 1784, Mr. White, of Manchester, attributed it to some morbid con- 
dition of the lymphatic glands and vessels of the affected pa’ ts; and this, or some 
ana’ogous theory, such as that of rupture of the lymphatics crossing the pelvic brim, 
as maintained by Tyre, of Gloucester, or general inflammation of the absorbents, as 
held by Dr. Ferriar, was geneially adopted. 
Phlebitic Theory.—It was not until the year 1823 that attention was drawn to the 
condition of the veins. To Bouillaud belongs the undoubted merit of first po’nting 
out that the veins of the affected limb were blocked up by coagula, although the fact 
had been previously observed by Dr. Davis, of University College. Dr. Davis made 
dissection of the veins in a fatal case, and found, as Bouillaud had done, that they 
were filled with coagula, which he assumed to be the results of inflammation of their 
coats; hence the name of “crural phlebitis,” which has been extensively adopted 
instead of phlegmasia do’ens. Dr. Robert Lee did much to favor this view, and find- 
ing that thrombi were present in the iliac and uterine, as well as in the femoral, veins, 
he concluded that the ph’ebitis commenced in the ute-ine branches of the hypogastric 
veins, and extended downwards to the femorals. He pointed out that phlegmasia 
dolens was not limited to the puerperal state ; but that when it did occur independ- 
ently of it, other causes of uterine phlebitis were present, such as cancer of the os 
and cervix uteri. The inflammatory theory was pretty generally received, and even 
now is considered by many to be a sufficient explanation of the disease. Indeed, ihe 
fact that more or less thrombus wa3 always present could not be denied, and on the 
supposition that thrombus could only be caused by phlebitis, as was long supposed 
to be the case, the inflammatory theory was the natural one. Before long, however, 
pathologists pointed out that thrombosis was by no means necessarily, or even gener- 
ally, the result of inflammation of the vessels in which the clot was contained, but 
that the inflammation was more generally the result of the coagulum. 60 
PERIPHERAL VENOUS THROMBOSIS, ETC. 
Theory of its Dependence on Septic Cannes.—The late Dr. Mackenzie took a promi- 
nent part in opposing the phlebitic theory. lie proved by numerous experiments in 
the lower animals, that inflammation is not sufficient of itself to produce the extensive 
thrombi which are found to exist, and that inflammation originating in one part of a 
vein is not apt to spread along its canal, as the phlebitic theory assumes. His conclu- 
sion is, that the origin of the disease is rather to be sought in some septic or altered 
condition of the blood, producing coagulation in the veins. Dr. Tyler Smith1 pointed 
out an occasional analogy between the causes of phlegmasia dolens and puerperal 
fever, evidently recognizing the dependence of the former on blood dyscrasia. ‘ ‘ I 
believe,” he says, “that contagion and infection play a very important part in the 
Ereduction of the disease. I look on a woman attacked with phlegmasia dolens as 
aving made a fortunate escape from the greater dangers of diffuse phlebitis or 
puerperal fever. ” In illustration of this he narrates the following instructive history: 
“A short time ago a friend of mine had been in close attendance on a patient dying 
of erisypelatous sore-throat with sloughing, and was himself affected with sore-throat. 
Under these circumstances, he attended, within the space of twenty-four hours, three 
ladies in their confinements, all of whom were attacked with phlegmasia dolens. ’ ’ 
View of Tilbury Fox.—The latest important contribution to the pathology of the 
disease is contained in two papers by Dr. Tilbury Fox, published in the second volume 
of the Obstetrical Transactions. He maintains that something beyond the mere 
presence of coagula in the veins is required to produce the phenomena of the disease, 
although he admits that to be an important, and even an essential, part of pathological 
changes present. The thrombi he believes to be produced either by extrinsic or 
intrinsic causes: the former comprising all cases of pressure by tumor or the like; the 
latter, and the most important, being divisible into the heads of— 
1. True inflammatory changes in the vessels, as seen in the epidemic form of the 
disease. 
2. Simple thrombus, produced by rapid absorption of morbid fluid. 
3. Virus action and thrombus conjoined, the phlegmasia dolens itself being the 
result of simple thrombus, and not produced by diseased (inflamed) coats of vessels; 
the general symptoms the result of the general blood state ; the virus present. 
He further points out that the peculiar swelling of the limbs cannot be explained by 
the mere presence of oedema, from which it is essentially different. The white appear- 
ance of the skin, the severe neuralgic pain, and the persistent numbness indicating 
that the whole of the cutaneous textures, the cutis vera and even the epithelial layer, 
are infiltrated with fibrinous deposit. He concludes, therefore, that the swelling is 
the result of oedema plus something else; that something being obstruction of the 
lymphatics, by which the absorption of effused serum is prevented. The efficient 
cause which produces these changes he believes to be, in the majority of cases, a 
septic action originating in the uterus, producing a condition similar to that in which 
phlegmasia dolens'iarises in the non-puerperal state. 
There is no doubt much force in Dr. Fox’s arguments, and it may, I think, be con- 
ceded that obstruction of the veins per se is not sufficient to produce the peculiar 
appearance of the limb. It is, moreover, certain that phlebitis alone is also an insuf- 
ficient explanation, not only of the symptoms, but even of the presence of thrombi so 
extensive as those that are found. The view which traces the disease solely to inflam- 
mation or obstruction of lymphatics, is purely theoretical, has no basis of facts to sup- 
port it, and finds, nowadays, no supporters. The experiments of Mackenzie and Lee, 
as well as the vastly increased knowledge of the causes of thrombosis, which the re- 
searches of modern pathologists have given us, seem to point strongly to the view 
already stated, that the disease can only be explained by a general b’ood dyscrasia, de- 
pending on the puerperal state. It by no means fo’lows that we are to consider Dr. 
Fox's speculations as incorrect. It is far from improbable that the lymphatic vessels 
are implicated in the production of the peculiar swelling, only we are not, as yet, in a 
position to prove it. There is no inherent improbability in the supposition that the 
same morbid state of the blood which produces thrombosis in the veins, may also give 
rise to su- h an amount of irritation in the lymphatics as may interfere with their func- 
tions, and even obstruct them altogether. The essential and all-important point in the 
pathology of the disease, however, seems undoubtedly to be thrombosis in the veins; 
and the probability of there being some as yet undetermined pathological changes in 
addition to this, by no means militates against the view I have taken of the intimate 
connection of the disease with other results of thrombosis in different vessels. 
Changes Occurring in the Thrombi.—The changes which take place in the thrombi 
1 Tyler Smith, Manual of Obstetrics, p. 538. SUBSEQUENT LOCAL TREATMENT. 
61 
all tend to their ultimate absorption. These have been described by various authors 
as leading to organization or suppuration. It is probable, however, that the appear- 
ances which have led to such a supposition are fallacious, and that they are really due 
to retrograde metamorphosis of the fibrine, generally of an amylaceous or fatty char- 
acter. 
Detachment of Emboli.—The peculiarities of a clot that most favor detachment of 
an embolus are such a shape as admits of a portion floating freely in the blood-current, 
by the force of which it is detached and carried to its ultimate destination. When the 
accident has occurred, it is often possib’e to recognize the peripheral thrombus from 
which the embolus has separated, by the fact of its terminal extremity presenting a 
freshly fractured end, instead of the rounded head natural to it. Such detachment is 
unlikely to occur, even when favored by the shape of the clot, unless sufficient time 
have elapsed after its formation to admit of its softening and becoming brittle. The 
curious fact I have before mentioned, of true puerperal embolism occurring, in the 
large majority of cases, only after the nineteenth day from delivery, finds a ready ex- 
planation in this theory, which it remarkably corroborates. 
Treatment.—On the supposition that phlegmasia dolens was the result of inflamma- 
tion of the veins of the affected limb, an antiphlogistic course of treatment was nat- 
urally adopted. Accordingly, most writers on the subject recommended depletion, 
generally by the application of leeches, along the course of the affected vessels. We 
are told that if the pain continue the leeches should be applied a second, or even a 
third time. If we admit the septic origin of the disease, we must, I think, see the 
impropriety of such a practice. The fact that it occurs, in a large majority of cases, 
in patients of a weakly and debilitated constitution, often in women who have already 
suffered from haemorrhage, is a further reason for not adopting this routine custom. 
If local loss of blood be used at a’l, it should be strictly limited to cases in which there 
is much tenderness and redness along the course of the veins, and then only in patients 
of plethoric habit and strong constitution; cases of this kind will form a very small 
minority of those coming under our observation. 
Over-active Treatment Unadvisable.—What has been said of the pathology of the 
affection tends to the conclusion that active treatment of any kind, in the hope of curing 
the disease, is likely to be useless. Our chief reliance must be on time and perfect 
rest, in order to admit of the thrombi and the secondary effusion being absorbed; while 
we relieve the pain and other prominent symptoms, and support the strength and im- 
prove the constitution of the patient. 
Relief of Pain, etc.—The constant application of heat and moisture to the affected 
limb, will do much to lessen the tension and pain. Wrapping the entire limb in lin- 
seed-meal poultices, frequently changed, is one of the best means of meeting this indi- 
cation. If, as is sometimes the case, the weight of the poultices be too great to be 
readily borne, we may substitute warm flannel stupes, covered with oi’ed silk. Local 
anodyne applications afford much relief, and may be advantageously used along with 
the poultices and stupes, either by sprinkling their surface freely with laudanum, or 
chloroform and belladonna liniment, or by soaking the flannels in poppy-head fomen- 
tation. It is needless to say that the most absolute rest in bed should be enjoined, 
even in slight cases, and that the limb should be effectually guarded from undue press- 
ure by a cradle or some similar contrivance. Local counter-irritation has been strongly 
recommended, and frequent blisters have been considered by some to be almost specific. 
I should myself hesitate to use blisters, as they would certainly not be soothing appli- 
cations, and one hardly sees how they can be of much service in hastening the absorp- 
tion of the effusion. 
Constitutional Treatment.—During the acute stage of the disease the constitutional 
treatment must be regulated by the condition of the patient. Light, but nutritious 
diet, must be administered in abundance, such as milk, beef-tea, and soups. Should 
there be much debility, stimulants, in moderation, may prove of service. With regard 
to medicines, we shall probably find benefit from such as are calculated to improve the 
condition of the blood and the general health of the patient. Chlorate of potash, with 
diluted hydrochloric acid, quinine, either alone or in combination with sesquicarbonate 
of ammonia, the tincture of the perchloride of iron, are the drugs that are most likely 
to prove of service. Alkalies and other medicines, which have been recommended in 
the hone of hastening the absorption of coagula, must be considered as altogether use- 
less. Pain must be relieved and sleep produced by the judicious use of anodynes, such 
as Dover’s powder, the subcutaneous injection of morphia, or chloral. Generally no 
form answers so well as the hypodermic injection of morphia, 
Subsequent Local Treatment.—When the acute symptoms have abated, and the 
temperature has fallen, the poultices and stupes may be discontinued, and the limb 62 
PELVIC CELLULITIS AND PELVIC PERITONITIS. 
swathed in a flannel roller from the toes upwards. The equable pressure and support 
thus afforded materially a:d the absorption of the effus:on, and tend to diminish the 
size of the l’mb. At a still later stage very gentle inunctions of weak iodine ointment 
may be used with advantage once a day before the roller is app’ied. Shampooing and 
frict:on of the limb, gene ally recommended for the purpose of hastening absolution, 
should be carefully avoided, on account of the possible risk of detaching a portion of 
the coagulum, and producing embol sm. This is no merely imag'nary danger, as the 
following fact narrated by Trousseau proves. ‘ ‘ A phlegmasia alba dolens had appeared 
on the left side in a young woman suffering from peri-uterine phlegmon. The pain 
hav'ng ceased, a thickened venous trunk was fe t on the upper and internal part of the 
thigh. Rather strong pressure was being made, when M. Demarquay felt something 
yield under h’s fingers. A few m'nutes afterwards the patient was attacked with 
dreadful palpitation, tumultuous card ac action, and extreme pallor, and death was 
believed to be eminent. After some hours, however, the oppression ceased, and the 
patient eventua’ly recovered. A s ightly attached coagulum must have become sepa- 
rated, and conveyed to the heart or pulmonaiy artery.”1 Wairn douches of water, of 
salt water if it can be obtained, may be advantageously used in the later stages of the 
disease, and they may be applied night and morning, the limb being bandaged in the 
interval. The occasional use of the electric current is said to promote absorption, and 
would seem likely to be a servicable remedy. 
Change of Air, etc.—When the patient is well enough to be moved, a change of air 
to the seaside will be of value. Cheat caution, however, should be recommended in 
using the limb, and it is far better not to run the r’sk of a relapse by any undue haste 
in this respect. It is well to warn the patient and her friends, mat a considerable time 
must of necessity elapse, before the local signs of the disease have completely dis- 
appeared. 
CHAPTER X. 
PELVIC CELLULITIS AND PELVIC PERITONITIS. 
From the earliest time the occurrence after parturition of severe forms of inflam- 
matory disease in and about the pelvis, frequently ending in suppuration, has been well 
known. It is only of late years, however, that these diseases have been made the 
subject of accurate clinical and pathological investigation, and that their true nature 
has begun to be understood. Nor is our knowledge of them as yet by any means 
complete. They merit careful study on the part of the accoucheur, for they give rise 
to some of the most severe and protracted illnesses from which puerperal patients 
suffer. They are often obscuie in their origin and apt to be overlooked, and they not 
rarely leave behind them lasting mischief. 
These diseases are not limited to the puerperal state. On the contrary, many of the 
seve est cases arse A om causes altogether unconnected with child-bearing. These will 
not be now cons:dered, and this chapter deals solely with such forms as may be directly 
traced to child-birth. 
Two Distinct Forms.—Recent researches have demonstrated that there are two 
distinct varieties of inflammatory disease met with, after labor, which differ materially 
from each other in many respects. In one of these, the inflammation affects chiefly 
the connective tissue surrounding the generative organs contained within the pelvis, or 
extends up from beneath the peritonaeum, and into the iliac fossae. In the other, it 
attacks that portion of the peritonaeum which covers the pelvic viscera, and is limited 
to it. 
f o much is admitted by all wr'ters, but great obscurity in description, and consequent 
difficulty in understanding satisfactorily the nature of these affections, have resulted 
from the variety of nomenc’ature which different authors have adopted. 
Thus the former d'sease has been variously described as pelvic ce lulitis, peri-uterine 
phlegmon, para-metritis, or pelvic abscess, while the latter is not unfrequently called 
peri-metritis, as contradistinguished from para-metritis. The use of the prefix para or 
1 Trousseau, Clinique de l’Hotel-Dieu in Gas. des Hop., 1860, p. 577. SEAT OF THE INFLAMMATION IN PELVIC CELLULITIS. 
63 
peri, to distinguish the cellular or peritoneal variety of inflammation, originally sug- 
gested by Virchow, has been pretty generally adopted in Germany, and has been 
strongly advocated in this country by Matthews Duncan. It has never, however, found 
much favor with English writers, and the similarity of the two names is so great as to 
lead to confusion. I have, therefore, selected the terms “pelvic peritonitis,'' and 
‘‘pelvic cellulitis," as conveying in themselves a fairly accurate notion of the tissues 
mainly involved. 
Importance of Distinguishing the Two Classes of Cases.—The important fact to re- 
member is that there exist two distinct varieties of inflammatory disease, presenting 
many similarities in their course, symptoms, and results, ofien occuirng simultaneously, 
but in the main distinct in their pathology, and capab'e of being differentiated. 
Thomas compares them—and, as serving to fix the facts on the memory, the illustration 
is a good one—to pleurisy and pneumonia. “ Like them,1’ he says, “they are separate 
and distinct, like them affect different kinds of structure, and like them they generally 
complicate each other.” It might, therefore, be advisable, as most writers on the dis- 
ease occurring in the non-puerperal state have done, to treat of them in two separate 
chapters. There is, however, more difficulty in distinguishing them as puerperal than 
as non-puerperal affections, for which reason, as we.l as for the sake of brevity, I think 
it better to consider them together, pointing out, as I proceed, the distinctive peculiari- 
ties of each. 
Seat, of Disease.—When attention was first directed to this class of diseases, the 
pelvic cellular tissue was believed to be the only structure affected. This was the view 
maintained by Nonat, Simpson, and many modern write;s. Attention was first promi- 
nently directed to the importance of localized inflammation of the peritonseum, and to 
the fact that many of the supposed cases of cellulitis were real y peritonitic, by Ber- 
nutz. There can be no doubt that he here made an enormous step in advance. Like 
many authors, however, he rode his hobby a little too hard, and he erred in denying 
the occurrence of cellulitis in many cases in which it undoubtedly exists. 
Etiology.—The great influence of child-biith in producing these diseases has long 
been ful.y recognized. Com ty estimates that about two-thirds of all the cases met with 
occur in connection with delivery or abortion, and Duncan found that out of 40 care- 
fully observed cases, 25 were associated with the puerperal state. 
Hie Inflammation is Secondary and never Idiopathic.—It is pretty generally ad- 
mitted by most modern writers that both varieties of the disease are produced by the 
extension of inflammation from either the uterus, the Fallopian tubes, or the ovaries. 
This point has been especially insisted on by Duncan, who maintains that the disease is 
never idiopathic, and is “ invariably secondary either to mechanical injury, or to the 
extension of inflammation of some of the pelvic viscera, or to the irritation of the 
noxious discharges through or from the tubes or ovaries. ’ ’ 
Often intimately connected with Septiccemia.—Their intimate connection with puer- 
peral septicaemia is also a prominent fact in the natural history of the diseases. Barker 
mentions a curious observation illustrative of this, that when puerperal fever is endemic 
in the Bellevue Hospital in New York, cases of pelvic peritonitis and cellulitis are also 
invariable met with. Olshausen has also remarked that in the Lying-in Hospital at 
Halle, during the autumn vacation, when the patients are not attended by practitioners, 
and when, therefore, the chance of septic infection being conveyed to them is less, 
these inflammations are almost always absent. As inflammation of the lining mem- 
brane of the uteius, of the vaginal mucous membrane, and of the pelvic connective 
tissue, are of very constant occuirence as local phenomena of septic absorption, the 
connection between the two classes of cases is read ly susceptible of explanation. 
Schroeder, indeed, goes further, and includes his description of these diseases under 
the head of puerperal fever. I hey do not, however, necessarily depend upon it; for, 
although it must be admitted that cases of this kind form a large proportion of those 
met with, others unquestionably occur which cannot be traced to such sources, but are 
the direct result of causes altogether unconnected with the inflammation attending on 
septic absorption, such as undue exertion shortly after delivery, or premature coition. 
Mechanical causes may beyond doubt excite the disease in a woman predisposed by the 
puerperal process, but they cannot fairly be included under the head of puerperal fever. 
Seat of the Inflammation in Pelvic Cellulitis.—Abundance of areolar tissue exists in 
connection with the pelvic viscera, which may be the seat of cellulitis. It forms a 
loose padding between the organs contained in the pelvis proper, surrounds the vagina, 
the rectum, and the bladder, and is found in considerable quantity between the folds of 
the broad ligaments. From these parts it extends upwards to the iliac fossae, and the 
inner surface of the abdominal panetes. In any of these positions it may be the seat 
of the kind of inflammation we are discussing. The essential character of the inflam- 64 
PELVIC CELLULITIS AND PELVIC PERITONITIS. 
mation is similar to that which accompanies areolar inflammation in other parts of the 
body. There is first an acute inflammatory oedema, followed by the infiltration of the 
areolae of the connective tissue with exudation, and the consequent iormation of ap- 
preciable swelinps. These may foim in any part of the pelvis. Thus we may meet 
with them, and this is a very common situation, between the io’ds of the broad liga- 
ments, forming distinct hard tumors, connected with the uterus, and extending to the 
pelvic walls, their rounded outlines being readily. made out by bi-manual examination* 
if the cellulitis be limited in extent, such a swelling may exist on one side of the uterus 
only, forming a rounded mass of varying size, and apparently attached to it. At other 
times the exudation is more extensive, and may completely or partially surround the 
uterus, extending to the cellular tissue between the vagina and rectum, or between the 
uterus and the bladder. In such cases the uteius is imbedded and firmly fixed in dense 
hard At other times, the inflammation chiefly affects the cellular tissue 
covering the muscles lining the iliac fossae. There it forms a mass, easily made out by 
palpation, but on vaginal examination little or no trace of the exudation can be felt, or 
only a sense of thickness at the roof of the vagina on the same side as the swelling. 
Seat of the Inflammation in Pelvic Peritonitis.—In pelvic peritonitis the inflamma- 
tion is limited to that portion of the peritonaeum which invests the pelvic viscera. Its 
extent necessarily varies with the intensity and duration of the attack. In some cases 
there may be little more than irritation, while more often it runs on to exudation of 
plastic material. The result is generally com {let e fixation of the uterus and hardening 
and swelling in the root of the vagina, and the lymph poured out may mat together the 
surrounding viscera so as to form swellings, difficult, in some cases, to differentiate from 
those resulting from ce lulitis. On post-mortem examination, the pelvic viscera are 
found extensively adherent, and the agglutination may involve the coils of the intestine 
in the vicinity, so as sometimes to form tumors of considerab’e size. 
Relative Frequency of the Two Forms of Disease.—The lelative frequency of these 
two forms of inflammation as puerperal affections is not easy to ascertain. In the non- 
puerperal state the pevitonitic variety is much the more common, but in the puerperal 
state they very generally complicate each other, and it is rare for cellulitis to exist to 
any great extent without more or less peritonitis. 
Symptomatology.—The earliest symptom is pain in the lower part of the abdomen, 
which is generally preceded by rigor or chilliness. The amount of pain varies much. 
Somet’mes it is comparatively slight, and it is by no means rare to meet with patients 
who are the subjects of very considerable exudations, who suffer little more than a cer- 
tain sense of weight and discomfort at the lower part of the abdomen. On the other 
hand, the suffering maybe excessive, and is characterized by paroxysmal exacerbations, 
the patient being comparatively fiee from pain for several successive hours, and then 
having attacks of the most acute agony. Sehroeder says that pain is always a symptom 
of peritonitis, and that it does not exist in uncomplicated cellulitis. The swe lings of 
cellulitis are certainly sometimes remarkably free from tenderness, and I have often 
seen masses of exudation in the iliac fossae which could bear even rough handling. On 
the other hand, although th s is certainly more often met with in non-puerperal cases, 
the tenderness over the abdomen is sometimes excessive, the patient shrinking from the 
slightest touch. The pulse is raised, generally from 100 to 120, and the thermometer 
shows the presence of pyrexia. During the entire course of the d’sease both these 
symptoms continue. The temperature is often very high, but more frequently it varies 
from 100° to 104°, and it generally shows moie or less marked remissions. In some 
cases the temperature is said not to be elevated at all, or even to be subnormal, but this 
is certainly quite exceptional. Other signs of local and general irritation often exist. 
Among them, and most distinctly in cases of peritonitis, are nausea and vomiting, and 
an anxious, pinched express on of the countenance, while the local mischief o'ten 
causes distressing dysuria and tenesmus. The latter is especially apt to occur when 
there is exudation between the rectum and vagina, which presses on the bowel. The 
passage of faeces, unless in a very liquid form, may then cause intolerable suffering. 
Such symptoms may show themselves within a few days after delivery, and then they 
can barely fail to attract attention. On the other hand, they may not commence for 
some weeks after labor, and then they are often insidious in their onset, and apt to be 
overlooked. It is far from rare to meet with cases s’x weeks or more after confinement 
in which the patient complains of little beyond a feeling of malaise and discomfort, and 
in which, on investigation, a considerable amount of exudation is detected, which had 
previously entirely escaped observation. 
Results of Physical Examination.—On introducing the finger into the vagina, it will 
be found to be hot and swollen, in some cases distinctly oedematous, and on reaching 
the vaginal cul-de-sac the existence of exudation may generally be made out. The CHANNELS THROUGH WHICH PUS MAY ESCAPE. 
65 
amount of this varies much. Sometimes, especially in the early stage of the disease, 
there is little more than a diffuse sense of thickness and induration at either side of or 
behind the uterus. More generally careful bi-manual examination enables us to detect 
a distinct hardening and swelling, possibly a tumor of considerable size, which may 
apparently be attached to the sides of the uterus, and rise above the pelvic brim, 
or may extend quite to the pelvic walls. The examination should be very carefully and 
systematically conducted with both hands, so as to explore the whole contour of the 
uterus before, behind, and on either side, as well as the iliac fossae; otherwise a con- 
siderable exudation might readily escape detection. When the exudation is at all 
great, more or less fixity of the uterus is sure to exist, and is a very characteristic 
symptom. The womb, instead of being freely movable by the examining finger, is 
firmly fixed by the surrounding exudation, and in severe forms of the disease is quite 
encased in it. More or less displacement of the organ is also of common occurrence. 
If the swelling be limited to one side of the pelvis or to Douglas’s space, the uterus is 
displaced in the opposite direction, so that it is no longer in its usual central position. 
The Two Forms of Disease cannot always he Distinguished.—The differential diag- 
nosis of pelvic cellulitis and pelvic peritonitis cannot always be made, and, indeed, in 
many cases it is impossible, since both varieties of disease coexist. The elements of 
differentiation generally insisted on are, the greater general disturbance, nausea, etc., 
in pelvic peritonitis, with an earlier commencement of the symptoms after labor. The 
swellings of pelvic peritonitis are also more tender, with less clearly defined outline than 
those of cellulitis. When the cellulitis involves the iliac fossa the diagnosis is, of 
course, easy, and then a continuous retraction of the thigh on the affected side (an 
involuntary position assumed with the view of keeping the muscles lining the iliac fossa 
at rest) is often observed. When the inflammation is chiefly limited to the cavity of 
the pelvis, the distinction between the two classes of cases cannot be made with any 
degree of certainty. 
Terminations.—Both forms of disease may end either in resolution or in suppuration. 
In the former case, after the acute symptoms have existed for a variable time, it may 
be for a few days only, it may be for many weeks, their severity abates, the swellings 
become less tender and commence to contract, become harder, and are gradually ab- 
sorbed ; until, at last, the fixity of the uterus disappears, and it again resumes its 
central position in the pelvic cavity. This process is often very gradual. It is by no 
means rare to find a patient, even some months after the attack, when all acute symp- 
toms have long disappeared, who is even able to move about without inconvenience, in 
whom the uterus is still immovably fixed in a mass of deposit, or is, at least adherent 
in some part of its contour. More or less permanent adhesions are of common occur- 
rence, and give rise to symptoms of considerable obscurity, which are often not traced 
to their proper source. 
Symptoms of Suppuration.—When the inflammation is about to terminate in sup- 
puration, the pyrexial symptoms continue, and eventually well-marked hectic is de- 
veloped, the temperature generally showing a distinct exacerbation at night. At the 
same time rigors, loss of appetite, a discoloration of the face, and 
other signs of suppuration, show themselves. The relative frequency of this termination 
is variously estimated by authors. Duncan quotes Simpson as calculating it as occurring 
in half the cases of pelvic cellulitis, but states his own belief that it is much more 
frequent. West observed it in 23 out of 43 cases following delivery or abortion, and 
McClintock in 37 out of 70. Schroeder says that he has only once seen suppuration 
in 92 cases of distinctly demonstrable exudation, a result which is certainly totally 
opposed to common experience. Barker also states that in his experience suppuration 
in either pelvic peritonitis or cellulitis “ is very rare, except when they are associated 
with pyaemia or puerperal fever. ” It is certain that suppuration is more likely to occur 
in pelvic cellulitis than in pelvic peritonitis, but it unquestionably occurs, in this country 
at least, much more frequently than the statements of either of these authors would 
lead us to suppose. 
Channels through which Pus may Escape.—The pus may find an exit through various 
channels. In pelvic cellulitis, more especially when the areolar tissue of the iliac fossa 
is implicated, the most common site of exit is through the abdominal wall. It may, 
however, open at other positions, and the pus may nnd its way through the cellular 
tissue and point at the site of the anus, or in the vagina, or it may take even a more 
tortuous course and reach the inner surface of the thigh. Pelvic abscesses not uncom- 
monly open into the rectum or bladder, causing very considerable distress from tenesmus 
or dysuria. According to Hervieux, it is chiefly the peritoneal varieties which open in 
this way. Not unfrequently more than one opening is formed; and when the pus has 
burrowed for any distance, long fistulous tracts result, which secrete pus for a length 66 
PELVIC CELLULITIS AND PELVIC PERITONITIS. 
of time, and are very slow to heal. Rupture of an abscess into the peritoneal cavity, 
especially of a peritonitic abscess, is a possible (but fortunately a very rare) termination, 
and will generally prove fatal by producing general peritonitis. In one case which I 
have recorded in the fifteenth volume of the Obstetrical Transactions, suppuration 
was followed by extensive necrosis of the pelvic bones. Two similar cases are related 
by Trousseau in his Clinical Medicine, but I have not been able to meet with any 
other examples of this rare complication, which was probably rather the result of some 
obscure septicaemic condition than of extension of the inflammation. 
Prognosis. —The prognosis is favorable as regards ultimate recovery, but there is 
great risk of a protracted illness which may seriously impair the health of the patient, 
especially if suppuration result. Hence it is necessary to be guarded in an expression 
of opinion as to the consequences of the disease. Secondary mischief is also far from 
unlikely to follow, from the physical changes produced by the exudation, such as per- 
manent adhesions or malpositions of the uterus, or organic alterations in the ovaries or 
Fallopian tubes. 
Treatment.—In the treatment of both forms of disease the important points to bear 
in mind are the relief of pain, and the necessity of absolute rest; and to these objects 
all our measures must be subordinate, since it is quite hopeless to attempt to cut short 
the inflammation by any active medication. 
If the disease be recognized at a very early stage, the local abstraction of blood, by 
the application of a few leeches to the groin or to the haemorrhoidal veins, may give 
relief; put the influence of this remedy has been greatly exaggerated, and when the 
disease is of any standing it is quite useless. Leeches to the uterus, often recom- 
mended, are., I believe, likely to do more harm than good (unless in very skilful hands), 
from the irritation produced by passing the speculum. Opiates in large doses may be 
said to be our sheet-anchor in treatment whenever the pain is at all severe, either by 
the mouth, in the form of morphia suppositories, or injected subcutaneously. In the 
not uncommon cases in which pain comes on severely in paroxysms, the opiates should 
be administered in sufficient quantity to lull the pain, and it is a good plan to give the 
nurse a supply of morphia suppositories (which often act better than any other form 
of administering the drug), with directions to use them immediately the pain threatens 
to come on. W hen there is much pyrexia large doses of quinine may be given with 
great advantage, along with the opiates. The state of the bowels requires careful at- 
tention. The opiates are apt to produce constipation, and the passage of hardened 
faeces causes much suffering. Hence it is desirable to keep the bowels freely open. 
Nothing answers this purpose so well as small doses of castor oil, such as half a tea- 
spoonful given every morning. Warmth and moisture, constantly applied to the lower 
part of the abdomen, give great relief either in the form of large poultices of linseed 
meal, or, if these prove too heavy, of spongio-piline soaked in boiling water. The 
poultices may be advantageously sprinkled with laudanum or belladonna liniment. I 
say nothing of the use of mercurials, iodide of potassium, and other so-called absorbent 
remedies, since I believe them to be quite valueless, and apt to divert attention from 
more useful plans of treatment. 
Importance of Rest.—The most absolute rest in the recumbent position is essential, 
and it should be persevered in for some time after the intensity of the symptoms is 
lessened. The beneficial effect of rest in alleviating pain is often seen in neglected 
cases, the nature of which has been overlooked, instant relief following the laying up 
of the patient. 
Counter-irritation.—When the acute symptoms have lessened absorption of the 
exudation may be favored, and considerable relief obtained, from counter-irritation, 
which should be gentle and long-continued. The daily use of tincture of iodine until 
the skin peels, perhaps best meets this indication; but frequently repeated blisters 
are often very serviceable. This I believe to be a better plan than keeping up an open 
sore with savine ointment, or similar irritating applications. 
Opening of Pelvic Abscesses.—When suppuration is established the question of 
opening the abscess arises. When this points in the groin, and the matter is superfi- 
cial, a free incision may be made, and here, as in mammary abscess, the antiseptic 
treatment is likely to prove very serviceable. The abscess should, however, not be 
opened too soon, and it is better to wait until the pus is near the surface. The im- 
portance of not being in too great a hurrry to open pelvic abscesses has been insisted 
on by West, Duncan, and other writers, and I have no doubt the rule is a good one. 
It is more especially applicable when the abscess is pointing in the vagina or rectum, 
where exploratory incisions are apt to be dangerous, and when the presence of pus 
should be positively ascertained before operating. We have in the aspirator a most 
useful instrument in the treatment of such cases, which enables us to remove the DIET AND REGIMEN. 
67 
freater part of the pus without any risk, and the use of which is not attended with 
anger even if employed prematurely. If it do not sufficiently evacuate the abscess, 
a free opening can afterwards be safely made with the bistoury. The surgical treat- 
ment of pelvic abscess is, however, too wide a subject to admit of being satisfactorily 
treated here. 
Diet and Regimen.—The diet should be abundant but simple and nutritious. In 
the early stages of the disease, milk, beef-tea, eggs, and the like will be sufficient. 
After suppuration a large quantity of animal food is required, and a sufficient amount 
of stimulants. The drain on the system is then often very great, and the amount of 
nouirshment patients will require and assimilate, when a copious purulent discharge 
is going on, is often quite remarkable. A general tonic plan of medication will also be 
required, and such drugs as iron, quinine, and cod-liver oil, will prove useful. NEW MEDICAL BOOKS. 
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The title of this little book is well chosen, and Dr. Keating has written a work which should be read, and its 
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and practically upon. Dr. Keating has written a practical book, has carefully avoided unnecessary repetition, 
and, I think, successfully instructed the mother in the details of the treatment of her child as devolve upon her; 
he has studiously omitted giving prescriptions, and instructs the mother when to call upon the doctor, as his 
duties are totally distinct from hers.—Am. Journ. of Obstetrics, Oct., 1881. 
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The additions made by Dr. Keen are to be found on every page. They are always judicious, and leave one 
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LECTURES ON DISEASES OF THE NERVOUS SYSTEM, ESPECIALLY IN WOMEN. 
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. The cultivated, colloquial style assumed by the author, becomes the vehicle of a work of thought and expres- 
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