Gooch on some of the most important diseases peculiar to women; with other papers

Front matter

THE LIBRARY

OF

THE UNIVERSITY

Part I

The most fatal disease to which lying-in women are subject is known under the names of Puerperal or Child-bed Fever, Puerperal Peritonitis. Its essential symptoms are pain and tenderness over the abdomen, with a rapid pulse.* It begins a few days after delivery, with pain of the abdomen, shivering succeeded by heat, and a quick pulse. As the disease advances, the milk becomes suppressed, the belly tumid, and the breathing short ; when it terminates fatally, it does so commonly about the fifth day, but often in less than half that time. On opening the abdomen, the morbid appearances are not uniform, but the most common and remarkable are a copious effusion of lymph and serum on the surface and in the cavity of the peritoneum. Thus it is a fever essentially complicated, with an affection of the peritoneum. A better name than Puerperal Fever, or Puerperal Peritonitis, would be that which I have placed at the head of this paper — 'Peritoneal Fever' — for it would express the fact, that an affection of the peritoneum is an essential accompaniment of the disease, without defining what that affection is, because it is not uniform.

A remarkable circumstance about this disease is, that it is much more prevalent in some seasons than in others. In populous towns and cities it occasionally appears at any time, but the cases are few in number, mild in degree, and, if detected early, and treated properly, generally recover. Sometimes, however, it becomes ex-

* ' Dr. Lowder adopted a very good method to form an accurate definition of this 'disease. He read all the different authors of character who had written on the ' subject, and noted down all those pathognomonic symptoms which they agreed ' were necessary to constitute the disease, and, on comparing these with his own ' experience, he found them to be very few— fever, intense pain of the head, and 'intense pain of the abdomen.' — (Lowder, MS. Lectures.)

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traordinarily prevalent. In a lying-in hospital, in which there is commonly so little illness that the office of physician is almost a sinecure, cases of this disease sometimes become so numerous, that the physician finds it impossible to do his duty without visiting the hospital at least twice a day. In populous places so many cases occur, and so many of them are fatal, that the practitioner of midwifery goes about his tasks with unusual anxiety; and even in a thinly-peopled country, where the death of a lying-in woman is almost an unheard-of event, fatal cases have occurred in rapid succession, spreading terror among the pregnant women of the neighbourhood. Another remarkable circumstance about this disease is, that, when it is most prevalent, it is most dangerous. Each case is much more difficult of cure than when it occurs seldomer. The practitioner finds that, although the group of symptoms resembles what he was formerly accustomed to, he has now to deal with a disease far more obstinate and destructive, and Ins usual remedies are not so successful as formerly; he loses case after case in spite of his best efforts. When it has been thus raging for a considerable time, it at length subsides ; the cases become less frecpient and less severe ', the practitioner finds his treatment becoming more successful, partly because experience has taught him to detect it earlier and to treat it better, but probably also because the disease has itself become milder.

There is still another remarkable circumstance in the prevalent or epidemic form of this disease. It is not uncommon for the greater number of cases to occur in the practice of one man, whilst the other practitioners of the neighbourhood, who are not more skilful or more busy, meet with few or none. A practitioner opened the body of a woman who had died of puerperal fever, and continued to wear the same clothes. A lady whom he delivered a few days afterwards, Avas attacked with and died of a similar disease ; two more of his lying-in patients, in rapid succession, met with the same fate ; struck by the thought that he might have carried the contagion in his clothes, he instantly changed them, and met with no more cases of the kind. A woman in the country, who was employed as washerwoman and nurse, washed the linen of one who had died of puerperal fever ; the next lying-in patient she nursed died of the same disease : a third nursed by her met with the same fate, till the neighbourhood, getting afraid of her, ceased to employ her. The disease has occurred in some wards of a hospital, the others being free from it;

but after ventilating, cleansing, and painting these wards, they became as healthy as the others. Facts such as these have long led to the suspicion that the disease might be communicated from one lying-in woman to another in the clothes of the practitioner or nurse, or ihe furniture of a tainted chamber.

From the little I have already said about the symptoms of this disease, and the morbid appearances discovered after death, it is clear that it essentially consists in fever, with an inflamed state of the peritoneum ; but fever may vary, not only in degree, but in kind, or (as it is commonly called) type; and inflammation may vary, not only in degree, but also in kind or type. Hence, in investigating the nature of this disease, one of the first questions is, whether it is strictly uniform, differing only iu degree in different cases, and requiring only different degrees of the same treatment; or whether it differs so much in kind or type, that the mode of treatment which is necessary in some cases, is destructive in others. The latter is the conclusion to which we must inevitably come, at first sight, in tracing the history of tins disease in the works of those who have written about it. This I propose to do through the last half century, not for the useless purpose of raking up old and obsolete opinions, but because it is unsafe to draw inferences, except from a wider survey of facts than the experience of a single individual, or of a single epidemic, affords.

Puerperal fever was prevalent in Derbyshire, and the adjacent counties, between 1765 and 1775, and was described by Dr. Butter of Derby. His opinion was, that bleeding ought never to be used in this disease, unless when complicated with inflammation, and even in these cases bleedings of three ounces were sufficient ; that the best remedy was ten grains of rhubarb and ten grains of cordial confection every day, till the stools became natural; and that this mode of treatment never failed. He gives several cases, all of which recovered.

In 1787, that is about ten years after Dr. Butter wrote, a puerperal fever was prevalent and fatal in London, and was described by the late Dr. John Clarke. It generally began on the second or third day after delivery, and terminated fatally in a week — sometimes as early as thirty-six hours. Its essential symptoms were pain and tenderness of the belly, with a rapid pulse. As the disease advanced, the milk became suppressed, the belly large, the breathing short, the pulse quick and weak. The appearances on dissection were those of inflammation in some parts of the viscera of the abdomen; but this was never extensive, and sometimes there was none. The effusions of inflammation, however, were very abundant ; they often amounted to several pints, and appeared to be pus and lymph mixed with serum. The surfaces of the viscera were coated with lymph, but the peritoneum underneath was not red. The interstices between the viscera were filled with masses of lymph, which formed a cast of their shape. Of the patients attacked with this disease, more than two thirds died : bleeding was injurious ; leeches to the abdomen were useless ; emetics were hurtful ; bark and cordials, though indicated by debility, were inefficacious. Dr. Clarke suspected that the disease might be occasioned by the purge which is always given to lying -in women on the second day after delivery; but glysters were not more successful.

Now compare the accounts which Dr. Butter and Dr. Clarke have given of the results of their practice. The former seems to have lost none of Ins patients, and found a daily dose of rhubarb and cordial confection a never-failing remedy; the other lost more than two thirds of his patients, and nothing seems to have done any good. What can explain this contrariety of statement ? A perusal of their pamphlets at once solves the mystery; they are talking about two different diseases. That described by Dr. Clarke was a genuine puerperal fever, accompanied by an affection of the peritoneum, which occasioned the effusion of lymph and serum ; that described by Dr. Butter is quite different. Its ordinary duration was from ten days to five or six weeks. Whoever is familiar with the tremendous disease which I am considering, and knows that the patient is either dead or safe at the end of a week at longest, will instantly perceive that a disease so protracted cannot be the same; and a perusal of Dr. Butter's cases leaves no doubt on the subject. It was a slow remitting fever, not attended by any affection of the peritoneum. Its chief symptoms were sleepless nights, great depression of spirits, a quick pulse, one or two exacerbations of fever every day, and a very disorderly state of the alimentary canal. I have repeatedly seen it, but never as an epidemic ; and though it lasts a long time, I believe it never kills. Dr. Butter imagined that this fever, which he never failed to cure, was the same disease which he describes as so fatal in London.

I Siit the contrary statements of physicians do not always admit of so easy a solution. Dr. William Hunter, and Eichter, the professor of medicine and surgery in Gottingen, were two of the most useful minds that ever appeared in our profession. They were men of great talents and knowledge, singularly adapted for natural investigations, and remarkable for clearness of intellect and correctness of judgment. If any men could, such men might be trusted for giving accurate reports of a disease. Yet compare the accounts which these distinguished men have left of their experience in puerperal fever. Dr. "William Hunter used to say in his lectures — ' Of those ' attacked by this disease, treat them in what manner you will, at ' least three out of four will die. Upon examining the bodies, the 1 uterus, the viscera, and every other part of the abdomen, are found ' to be inflamed. There is a quantity of purulent matter in the * cavity of the abdomen, and the intestines are all glued together. ' T\ e tried various methods, (bleeding, refrigerants, stimulants, ' mithridate,) but everything failed/ Eichter, speaking of the child-bed fever, says, ' I have often seen the child-bed fever, and ' always treated it successfully. I have also seen cases, both near 1 and at a distance, in which the fever was treated differently from ' what I am accustomed to treat it, and the patients died. I there- ' fore think that I have a right to offer my opinion about the nature ' and treatment of this fever/

One woidd at first suppose that Eichter had committed some error like that of Dr. Butter; but the following remarks must remove this suspicion. ' It is plain/ says he, ' that it is not every ' fever which attacks a lying-in woman which is to be called child- ' bed fever. Its principal symptoms are debility ; swelling of the ' abdomen, colic-like pains ; pains in the abdomen, on external ' pressure ; pain of the head, especially in the forehead. The ' disease is commonly fatal in a few days. On dissection, the vis- ' cera of the abdomen are found inflamed, suppurating, gangrenous. ' The means for preventing the disease, or, if it has already begun, ' for curing it, are timely evacuations by purgatives/*

There can be no doubt that Hunter and Eichter both meant, thus far at least, the same disease — that it was the child-bed fever which is attended by inflammation of peritoneum, and which, if not cured, kills in a few days. But what shall we say to their very opposite experience ? the one, whatever he did, lost three patients out of four ; the other, by the gentlest aperients, never failed to cure

* Medicinische and Chirurgische Bemerkangen, von D. A. G. Richter, b. ii. s. 60.

fi PERITONEAL FEVERS.

the disease. Richter, at the time he wrote this statement, must have been sixty years of age. The inexperience of youth, therefore, will not explain it, and it is explicable only on the supposition either that, old as he was, he had never seen the epidemic puerperal fever, or that, if he had, the epidemics which he had seen were singularly mild.

The reader will feel curious to know the mode of treatment which in Richter' s hands was so successful. On the first symptoms of child-bed fever, he gave a purge two days successively, each enough to operate three times. On the following days smaller doses were given, enough to operate once, or at most twice, and this plan was continued till all symptoms had ceased.

Dr. Lowder, who, about thirty years ago, lectured on midwifery at the medical school of Guy's and St. Thomas's Hospitals, and who Avas esteemed by the best judges of those times as an excellent practical physician, gave the following account of this disease : That the pathognomonic symptoms were pain of the abdomen, pain of the head and fever; that it terminated fatally in a space of time between forty-eight hours and one week ; that the appearances on dissection were redness of the peritoneum, adhesion of the intestines, effusion of serum, mingled with pus and lymph. He thought that the inflammation was erysipelatous and the fever typhoid. "When the inflammatory symptoms were distinct, he permitted a few ounces of blood to be drawn ; but if the symptoms were typhoid, bleeding was positively injurious — he mentioned it as the assertion of many medical men, that all the patients who were bled died. Whenever the fever was typhoid, he recommended bark, and mentioned two cases, apparently hopeless, which recovered by taking daily a gallon of the decoction.

Among the London physicians, Dr. Denman was the chief believer in the inflammatory nature of puerperal fever, and in the safety and absolute necessity of bleeding, provided it was used early and actively. There can be no doubt he meant that puerperal fever, of which peritoneal inflauunation is an essential part ; and if I understand him rightly, he believed, that whenever the peritoneum was affected in that way which terminates in the effusion of serum and lymph, it was always with that form of inflammation which bears and requires bleeding. His mode of treating the disease seems to have been this : First, at the commencement of the disease, by a full bleeding from the arm, and if the effect of it was beneficial, by another bleeding after a few hours; if the constitution of the patient was feeble, he preferred cupping, or leeches to the abdomen. Next, by an emetic of ipecacuanha or tartarized antimony, so as to procure full vomiting, and after this had subsided, if the disease was not extinguished, the emetic was to be repeated. These emetics, generally, produced not only vomiting, but sweating and purging ; if not, sulphate of magnesia dissolved in thin gruel was given every few hours, till it procured several stools. Having succeeded in procuring these evacuations, he gave a full opiate. The rest of the treatment consisted in a saline aperient every morning and an opiate every night.

Puerperal fever was epidemic in Aberdeen more than two years, between 1789 and 1792, and was ascribed by Dr. Gordon, a physician of that place. He states, that the essential remedy was bloodletting employed early and freely; that when he took ten or twelve ounces away, the patient generally died, but when he took twenty-four ounces aicay at once, and during the first six hours of the disease, the patient commonly recovered. ' If practitioners/ said he, ' allow themselves to be guided by the pulse, they will run into ' a fatal error, because the pulse is more frequently weak and feeble, ' than strong and full, even at the beginning of the disease, yet I ' bled notwithstanding with great success. The pulse, instead of ' being thereby weakened, became more full and strong than before. ' This disease seized such women only as were visited or delivered ' by a practitioner, or taken care of by a nurse, who had previously ' attended patients affected with the disease/ His treatment consisted in a very early and very large bleeding, a bolus of three grains of calomel and two scruples of jalap, followed by a daily purgative and a nightly opiate. Of the patients whom he attended, twenty-eight died out of seventy-seven; and although his practice, when it had fair play, was much more successful, he yet confesses the loss of some.*

* Sprengel, in his History of Medicine, gives the following account of this work. ' The history which Alexander Gordon has given of an epidemic puerperal fever, 'which he considered as inflammatory, and which nevertheless he treated with ' drastic purgatives, such as jalap and sweet mercury, without resorting to bleeding.' — Histoire de la Medecine, par Kurt Sprengel, torn. vi. p. 343. If this is a specimen of the accuracy of this history, it will diminish the confidence with which we should consult this very learned and otherwise useful publication. The more, however, I look into compilations, and trace them to their sources, the more I suspect compilers find that, if they were very scrupulous ahout accuracy, they would never get on in

From the foregoing account of the experience and opinions of different physicians, who had opportunities of observing puerperal fever, what inferences are we to draw ? Supposing that each observed accurately the disease which he witnessed, and that no mistake was made in the formation of his opinion, the inevitable conclusion is this : — that puerperal fever, by which I always mean that fever which is accompanied by an inflammatory state of the peritoneum, is not one uniform disease, but may occur under different forms, — that sometimes it is so mild as to be curable by the gentlest aperients, and at other times it is very obstinate and fatal. That in this latter form it sometimes consists of acute inflammation of the peritoneum with inflammatory fever, which bears, and is curable only by, early and active depletion, sometimes of inflammation and fever of a low type, in which depletion is useless, and even pernicious.

Whilst these different opinions were formed and promulgated in England, some zealous and able physicians on the continent thought they had discovered a successful mode of treating tins hitherto intractable disease.

In 1782, the Royal Medical Society of Paris, being ordered by the Trench government, made a report on the mode of treating puerperal fever, which had been employed with unfailing success by M. Doulcet, one of the physicians to the Hotel Dieu. There can be no doubt that this disease was the genuine puerperal fever ; it began about three days after delivery, was attended by pain and distension of the abdomen, and a quick, small, contracted pulse; the milk was suppressed. After two days the pain diminished, or disappeared altogether ; there came on a cold viscid sweat, a weak tremulous pulse, delirium, and death took place on the third or fourth day. The abdomen contained two or three pints of fluid like unclarified whey, with flakes like curd over the surface of the intestines. After losing a vast number of patients, M. Doulcet happening to be in the hospital at the moment when a woman was seized with the disease attended by sickness, he ordered fifteen grains of ipecacuanha to be divided into two doses, one to be given directly, and the other an hour and a half afterwards. It produced vomiting and purging, and the latter was kept up by a potion made with two ounces of oil of almonds, one ounce of syrup of marsh mallows, and

their work. It is but fair to state, that I have used the French copy translated by A. J. L. Jourdan, who is very alert at exposing the ' erreurs grossieres' of his rival translator, M. Geiger. I hope that this is an ' erreur grossiere' of Sprengel.

PERITONEAL FEVERS. V

two "'rains of Kermes' mineral. In what closes and M'ith what frequency this was given, is not stated; was it a potion for one clay, or one close ? The same remedies wrere used the next, and every day until the symptoms of the disease had subsided ; the woman recovered, and the same treatment was employed in every subsequent case. From losing every patient, he now lost none. During four months nearly two hundred were cured ; five or six refused to take the medicine, and all these died. The success of the remedy depended on its being given at the moment of attack ; the loss of a few hours, however, was not always irreparable. When this account arrived in England, it produced, as may easily be supposed, a strong sensation, and the practice was tried by various physicians with different results. Dr. Walsh said it was infallible ; Dr. Denman that it was eminently useful ; Dr. Lowder that it disappointed him ; Dr. John Clarke that it was injurious ; and it soon fell into disuse. Was it ever fairly tried in tins country ? that is, not after the disease had established itself for several hours, but at the moment of attack, and with the potion of almond oil and Kermes' mineral.*

Dr. Boer of Vienna was for a long time physician to the large lying-in institution and director of the midwifery school in that city, and was much distinguished for his practical acuteness. Many years ago he thought he had discovered an almost infallible remedy for puerperal fever. Of this discovery he gives the following account. I might abridge it, but the reader will prefer his own interesting narrative.

' I once lost in one day two lying-in women from puerperal ' fever ; the one I attended alone, the other in consultation with ' the ordinary house physician. — At the same time I had also in 1 the practical school (of midwifery) two lying-in women ill with ' the same disease. The next day one of them died, and in the 1 other death was approaching. It was the seventh or eighth day

* Kermes' mineral, or the poudre fies Chartreux, was made by boiling four pounds of antimony, one pound of the solution of fixed nitre per deliquium, and three pounds of rain water, for two hours, and then filtering the boiling liquor through paper. This, on standing, deposited a yellow powder ; the liquor was poured off, and the powder washed and dried. ' This precipitated sulphur,' says Quincy, ' is really, as I am con- ' vinced from facts which have fallen within my own observation, the most certain and ' powerful antimonial medicine that can be given with safety. It has been recom- ' mended in fevers, but the use of medicines of this class is not yet enough authorised ' by experience to render such a practice eligible. The doses given have been from 'one grain to four, but it is best to begin first with the smallest dose, especially with ' young persons, as the force of its operation varies greatly in different constitutions.'

of her disease ; the belly was very prominent, tense, and so painful, that she could hardly bear the bed-clothes ; everything passed away from her unconsciously. She had an excessively quick pulse, starting of the tendons, and wandered in her talk ; her breathing was difficult and broken, and her countenance fallen : the milk of the breasts had gradually disappeared, and almost from the beginning of the disease no lochia were to be seen. With the death of these three lying-in women, to which I already in anticipation added the fourth, I was so depressed in spirits, that in the evening I sought for consolation in the society of two intimate friends ; but I could not divest myself of the fatality of these diseases. Among other thoughts it occurred to me to try a hitherto unemployed preparation of antimony, which I was assured in many kinds of fever had manifested an uncommon efficacy. In this case, thought I, there is nothing to be lost in the attempt. I went home, provided myself with a dose of it, and reached, about ten o'clock in the evening, the chamber of the dying woman. I found her worse than she was six or seven hours before ; but as one of the students and two of the female practitioners were waiting at the bed-side, I was obliged to take care not to be seen giving a dying woman a remedy out of my packet. I gave it, therefore, unseen to the midwife, who gave it to the patient, instead of one of the common camphor powders, mixed with tea. I then wished the poor creature an eternal good night.

' When I went the next morning, my first question was, when did the patient die? "Die?" answered the midwife. "Early in the morning she begged half a cup of coffee. She sat up in bed, and would not rest till the nurse combed out her hair. I thought her delirious." She seized me by the hand, and thanked me. I knew not at that moment whether what I saw was an improvement, or only a delusive lighting up from the insensibility of a fatal gangrene ; but it was a real amendment. She had in the night a profuse sweat, and passed much urine, after which she said she felt as if she had imbibed a new life. The pain and distension of the belly were gone; the pulse beat more freely and slower; the breathing was calm, the tongue naturally moist, the diarrhoea had almost ceased, and the lochia began again to appear. In short, all the symptoms seemed gone by magic. She longed for a little wine and water, which was given her. After four days, during which

' she passed a great quantity of uncommonly thick and turbid urine, ' with a mucous sediment, she became free from fever, and after ' eight or nine days she left the hospital.

' Although this unexpected recovery rejoiced me much, I was far ' from ascribing it to the medicine. I rather looked on the whole ' happy revolution as the effect of a natural crisis. It was not long ' before another lying-in woman, notwithstanding all the means used, 1 was in the same extreme circumstances. I gave her the same ' medicine with the same consequences, only the improvement was ' not so sudden. The patient had a profuse sweat, and passed mine ' which looked more like a dissolved bilious stool than urine. In ' five or six days she was perfectly restored. * * * *

' A tier twelve or fourteen such desperate cases, in which it always ' effected a cure in one and the same way, and after I had tried the ' common antimonial preparations without any good effect, and often ' with distinct injury, I began against my will to place especial con- ' fidence in it. After I was convinced of the efficacy of this medi- ' cine in cases where the disease had reached the highest degree, ' I proceeded to order it at the beginning of the disease. From that ' time, in our practice, the puerperal fever was never fatal; it never ' even reached a dangerous stage, for the medicine as certainly ' obviated the disease as it cured it when it was already fully ' formed/

For the truth of the foregoing statement, Dr. Boer appeals to those who accompanied him at the bed-sides of those patients. ' "When/ he remarks, ' on the one hand I consider the preparation ' and the component parts of this antimonial remedy, and on the 1 other the symptoms and nature of the disease in which it effected a ' cure, I can no longer reconcile myself with the common idea of the ' healing power of medicines. I am firmly of opinion, that either ' the succession of symptoms from which we conclude the presence ' of a disease are not sufficiently determined, and the true nature of ' most diseases is still hidden, or that certain substances must prof duce in our bodies an entirely different effect to what we commonly ' believe/*

The sequel of this narrative is very disappointing. Dr. Boer never explained what Iris antimonial preparation was. I have been told he would give it to any medical man with directions how to use

it ; but that the mode of its preparation was a secret which he never divulged. The above account was published in the year 1790 ; in 1806, he published a systematic account of the different forms of the puerperal fever which he had seen, in which he states that his subsequent experience had only corroborated his former estimate of the efficacy of the puerperal powder ; but the only passage which throws any light on the preparation of this medicine is one in which he praises 'the mild calx of antimony, or other preparation of this 1 medicine, more powerfully sudorific/* Boer thought higlily of M. Doulcet's mode of treatment, and it is not at all improbable that Kermes' mineral, which formed a part of that plan, was the antimonial preparation which constituted his puerperal powder.