Thisis undoubtedly the most serious of all those maladies that so often follow labor. It appears from medical records that puerperal fever has been known from very remote times, and that it has frequently becomeepidemic, or has spread from one to another, like the Cholera. In hospitals this has often been observed, and also in cities, sometimes almost every female delivered in the place having been attacked while it prevailed. There is also no doubt but that it iscontagious, or capable of being transmitted from one person to another, like small pox. Numerous instances have been known where nurses and physicians have conveyed it to all whom they attended, during a long period after having been with a single case. One physician, after attending a case of puerperal fever, lost nine patients successively from the same disease, before he suspected the cause, and an old nurse assured me, that when she was a young woman, she was the unfortunate means of conveying it to two females whom she visited, by merely having been in the room a short time with one who was suffering from it. It is therefore highly important that all persons who may happen to be with a female so affected should not attend another case of childbirth for some time, and particularly that they should not wear any portion of the same clothing they had then on, and that theyshould bathe the whole body several times. If a case occurs in a hospital or other public institution, the female must be carefully isolated from all the others, and none of her attendants must be permitted on any account, to visit other puerperal patients, till after a sufficient time has elapsed, and every precaution has been taken.
The causes that produce this terrible disorder are not very well understood; some of them probably predispose to it before delivery, or even before pregnancy, while others are connected with labor and its consequences. Among the former may be mentioned, improper diet, an inactive life, anxiety of mind, bad air, a damp situation, a full habit, or great weakness, the frequent use of stimulants, andcertain excesses!The principal causes operating immediately are difficult labors, violent treatment, the use of instruments, tearing away the placenta too soon, retention of the lochia, cold, rising from the bed too soon, depression or excitement of the mind, over exertion in talking to and seeing company, and neglect of cleanliness. The most frequent cause probably is cold or damp, which checks the lochia and the perspiration, and leads directly to inflammation. It is on this account that the complaint is nearly always worse in winter than in summer, and prevails most in low damp situations, and in badly ventilated apartments, or in those insufficiently warmed. In most warm countries, and in those of an equable temperature, where the females remain much in the open air, and use regular exercise, puerperal fever appears to be but little known.
The nature of this complaint appears to be a severe and sudden inflammation, commencing either in the womb or some of the neighboring parts, which, if not arrested, rapidly extends to all the organs of the pelvisand abdomen, and hastens to a fatal termination with fearful speed. The precise seat, and place of commencement, of the inflammation, varies in different cases, but this makes little difference either in the symptoms, consequences, or treatment of the disease, and it is of but little use to give a separate name to all these various forms. Uterine Phlebitis, Metro Peritonitis, Puerperal Metritis, and Puerperal Peritonitis, are all essentially the same complaint, and identical with what is called Puerperal, or Childbed fever.
The disease generally appears from the second to the fifth day after delivery, but may be delayed as late as the fifteenth or twentieth day, or commences as early as two or three hours after; and has even been known to show itself before labor came on.
It usually begins with headache, general debility, uneasy feelings, creeping of the flesh, and chills: then follow tremblings, numbness of the limbs, cold feet and hands, with a burning heat in the body. The abdomen gradually gets tender, so that it cannot bear the slightest pressure, sharp pains are felt in various parts of it, and the patient continually complains of twisting and burning within. She prefers to lie on her back, with the head raised and the knees drawn up, so as to relax the abdominal muscles. Very soon she complains of great thirst, and cries out repeatedly from the sharpness of the pain; the headache increases, and the breathing becomes laborious. Hiccough generally occurs at an early stage, and is usually accompanied or followed by vomiting and diarrhœa, but sometimes by obstinate constipation. The abdomen continues to swell, and becomes still more tender, the face is pale, bathed with cold perspiration, and indicates in every line the anxiety andsuffering under which the patient labors. The features seem to be drawn upwards, and all together, orpinched up, and indeed the whole body seems toshrink. In general the lochial discharge either stops altogether or lessens very much, the breasts remain empty or nearly so, and the pulse is weak and irregular. In some few cases however, the lochia continues to flow, or even increases, and the breasts remain full up to the time of death. The urine is high colored and thick, and causes smarting and burning as it passes away. The tongue furs and becomes pointed, and pale colored. The eyes often seem much engorged, and the white part become yellow, as indeed the skin does over the whole body, owing to derangement of the bile, and alteration in the character of the blood. In most cases the mind retains its faculties nearly till dissolution, but there is frequently a vague sense of uneasiness and fear, with great depression of spirits and weeping. Some even feel assured, from the beginning, that they will never recover, and occasionally become delirious.
The duration of this disorder varies considerably, though in most cases it carries off the sufferer in a short time, frequently even in two or three days. It may however last five, ten, or twelve days, and has been known to do so fourteen.
The manner in which it terminates is also different in different cases. The fluid resulting from the inflammation may either be absorbed, or suppuration may ensue, and the matter be discharged, either from one of the natural passages or from an artificial opening; or it may not be discharged at all. Sometimes gangrene or mortification ensues, and sometimes the inflammation partly subsides and becomes chronic. When it terminates by resolution, whichis the most favorable mode, the patient begins to improve about the fourth or fifth day; the pains become less acute, the swelling and tenderness become less, and the milk, lochia, and other secretions that were suppressed begin to reappear. The patient is also able to lie either on the back or sides, and soon feels conscious herself that she is improving. But even when a turn for the better has decidedly taken place, too much confidence should not be prematurely felt, nor should there be any relaxation of attention, for the slightest causes may bring back all the symptoms with more than their former severity. When suppuration ensues, which is most commonly the case, a mass of fluid forms in the womb or abdomen, and is plainly indicated, either by its moving about or by a portion escaping from the body. In this case also the pain and tenderness decreases, and the abdomen seems less hard, but the pulse becomes weaker, a sense of weight is felt about the womb, the extremities become cold, chills come on, and gradually the powers of the system seem to fail till complete exhaustion ensues. When gangrene or mortification ensues, the termination is nearly the same, but more rapid, and all the above symptoms are more marked. When it passes into the chronic form, there is but little permanent abatement in the severity of the symptoms for some time; they partially lessen at intervals, but return again, sometimes with renewed vigor, and it remains long a matter of doubt whether the disease has really passed the critical period or not. Recovery takes place occasionally in this form of the disease, but more frequently the patient becomes daily weaker and more emaciated, diarrhœa and slow fever set in, the vital powers steadily sink, and at last death ensues. This fatal terminationmay however be delayed for an indefinite period, and may ultimately result from Consumption or Dropsy, both of which frequently follow chronic puerperal fever.
In regard to the probable termination of this disease, but little hope can be entertained that it will be favorable. Nor are there many indications that can be relied upon with certainty, as to what course it is likely to take. In general it is favorable when the swelling subsides, and the pains abate in severity, and particularly if the milk and lochia begin to be secreted again. The indications are also good in proportion as the symptoms are mild, and when there is no great sympathetic disturbance of other parts of the system. It is regarded as unfavorable when the pain and tenderness extends over a large portion of the abdomen, and when the attack commences very suddenly. The danger is also considered greater in proportion as the disease begins nearer to delivery; and when its first symptoms exhibit themselves before labor it is always considered mortal. It is likewise more dangerous with twins than with a single birth, and with first children than afterwards. It is seldom possible however to come to any probable conclusion till between the fifth and tenth day, and even then it is in general a matter of great uncertainty.
The best treatment of this fearful disease is one of the greatest problems in medical science. So many different plans have been adopted, and with such various success, that the history of past cases affords but little reliable data to guide us in future ones. In general the most powerfulantiphlogisticmeasures, or those thought most likely to reduce the inflammation at once, are immediately resorted to,such as bleeding, purgatives, and cold bathing. Bleeding is in particular the great agent depended upon, either from the arm, or by cups and leeches to the abdomen and vulva. Dr. Gordon, of Aberdeen in Scotland, who once met with a regular epidemic of puerperal fever in that city, assures us that nothing else succeeded in arresting the disorder but copious and frequent bleeding, at the very commencement. He carried it so far as to taketwenty-four ouncesat once, and he says that when he did so the patient was nearly sure to recover, but that at first, when he only abstracted about twelve ounces, she was as nearly sure to die. In about fifty cases to which he was called in time, he only lostfive, and taking the average of all he attended the recoveries were about two-thirds of the whole number, which is above the usual proportion.
It appears however, from the experience of the most eminent practitioners, that the bleeding must commence early; that the first abstraction should not be omitted beyond twenty-four hours after the first symptoms of the disease, and should be as much earlier as possible. With very few exceptions they also think Gordon's standard of twenty-four ounces not too much. Indeed it is generally admitted that if the blood be not drawnat firstand inlarge portions, it had better not be drawn at all. There may be of course many peculiar circumstances that will make bleeding improper, which nothing but experience and observation will teach a practitioner, but the number of such cases is thought to be small. The use of leeches meets with but few advocates, and certainly they seem to have had but partial success, compared with the lancet. Dr. Collins of Dublin depended chiefly upon leeches and Calomel, but hetells us that ineighty-eightcasesfifty-sixdied when so treated, while infifteenthat were freely bled from the arm onlyeightdied. In short it appears that the bleeding must be carried far enough,at the very beginning of the disease, to cut it short at once, or it will be of no avail, it being of little or no use merely tocheckit! In conjunction with the bleeding it is also usual to give enemas of starch and castor oil, or something similar, and to bathe the extremities in hot water.
I know that this practice of bleeding meets with strong opposition from many physicians, and that it is objected to by patients generally. I myself am as much opposed to it as any one reasonably can be, and I am well aware of the numerous evils which follow it, but still it cannot be denied that Dr. Gordon's plan has cured a greater number of cases ofpuerperal feverthan any other yet tried. It is true that many of those thus cured may have afterwards died of dropsy, convulsions, typhus and other diseasesproduced by the bleeding, but then the risk they run of dying from these was less than that from the puerperal fever, and in a choice of evils we ought to choose the least. It should also be remembered that some eminent practitioners assert, if this plan be adoptedpromptlyandfully, it willalways cure, or at least with very few exceptions.
Several other modes of treatment have also been adopted to dispense with bleeding, some of which have been much more successful than others, though none so much so as we could desire. Thus some practitioners resort immediately to hot fomentations and sweating medicines, or a hot bath if convenient, together with brisk purgatives, and injections. Some depend upon Calomel in large doses, with leeches tothe groins and vulva. Others again use cold fomentations, and cold injections both to the rectum and to the vagina. Others again use blisters over the abdomen, in conjunction with purgative enemas and moderate bleeding; but this mode seems to do but little good. Another plan is to give about six grains of ipecac, and to repeat the dose several times, at intervals of an hour or less, in conjunction with purgatives and warm fomentations. Turpentine has also been used internally and by enema, but seems to have accomplished little good. Perhaps the most frequent plan after bleeding, is to rub one or two drachms ofMercurial Ointmentwell on the skin, over the abdomen, every two or three hours, sometimes for several days regularly; eight or ten grains of Calomel being also given daily, at the same time. This brings on salivation, and in many cases the symptoms begin to abate in severity as soon as that commences. I am not aware however, that this treatment is any more successful than bleeding, nor do I think the consequences afterwards, in a case of recovery, are any less to be dreaded. It is difficult in fact to say what plan can be best recommended, even in the majority of cases, and certainly no one yet tried is applicable to all, on account of the peculiarities and varying circumstances of each. If the practitioner or patient is not decidedly opposed to the bleeding plan, that has undoubtedly the best recommendation, from former success. Next to that perhaps comes the mercurial treatment, which usually meets with as much opposition as the bleeding, but which certainly has been frequently found efficacious. The other plans have met with but little favor, though possibly they might sometimes succeed when the rest fail.
If I were asked what I should advise for those whowould notsubmit to the use either of the lancet or mercury, I should say, commence with a strong dose of Epsom Salts, or Jalap, and repeat it in about five hours after its full operation. Also apply warm fomentations to the abdomen, or put upon it a flannel bag full of hops soaked in vinegar, as hot as it can be borne, and put mustard poultices on the feet, and inside of the thighs. The hands must also be kept as warm as possible, and the head cool. The diet should be very spare, and contain nothing heating or stimulating, and cooling drinks, such as ice water, or cold lemonade, should be drunk freely. The purgative should be repeated at least every day, for two or three days, or more if the symptoms are not modified, and the mustard poultices may be regularly used to various parts of the limbs, for the same length of time. In conjunction with these means the breasts should also be kept warm, to promote the flow of the milk, and injections of starch and castor oil should be thrown up the rectum daily. The object being, as far as possible, to keep the surface of the body warm, and to cool the internal fever, at the same time that all the natural secretions are excited as much as possible to remove any morbid matter that may be formed. It should also be mentioned that the urine sometimes stops, or at least becomes very scanty and thick, in which case a little sweet nitre may be given, or if necessary the catheter must be used. Some bitter tea, as boneset or chammomile, should also be taken occasionally, and a James's Fever Powder with it once or twice a day, to promote perspiration; or if there be severe pains, a dose of Dover's Powders may be used instead.
If the disease passes the acute stage and becomeschronic, the same means must be pursued, and with strict regularity, or there will be danger of its again becoming acute. In all cases send for the most experienced practitioneras early as possible, and whatever his plan may be, if his past success proves it to be tolerably successful,submit to it, whether it be bleeding, salivation, or anything else. If there be no one at hand on whom dependence can be placed, follow the plan I have laid down as nearly as circumstances will allow, but practise it fully without delay, and till a change takes place. Those persons who make light of this disease, and pretend to say that this or that simple treatment is all-sufficient, either deceive themselves or wish to impose upon others. There are few affections more serious, as will be evident when it is borne in mind that, on an average,two females die out of every three attacked by it. To avoid all liability to it as far as possible, attend well to the general health during pregnancy, have everything comfortable, clean, and wholesome, during labor, and be careful to avoid cold, damp, and all kinds of mental and bodily excitement afterwards. The assistant also, whoever it may be, must be as careful and as gentle as possible, so as to avoid all violence or undue force, andnot to hurry nature. A want of attention to such simple details has, undoubtedly, brought on many attacks of this fearful disease that otherwise would never have been experienced.
The functions of the breasts are liable, from many causes, to become deranged, and such derangements may lead to serious results, both to the mother and the child. It is a common opinion that females whonurse are not so liable to suffer in this way as those who do not, but experience proves this opinion to be untrue; nevertheless, as it is the duty of mothers to nourish their own offspring, it should be a subject of careful study to relieve them of this liability as far as possible, or to assist them when necessary.
Galacterrhœa.This means an overflow, or excessive secretion of the milk, which sometimes takes place, particularly in those who do not nurse. At the commencement of the milk fever, Galacterrhœa needs but little attention, but if it continue to the second or third day, proper remedies should be applied to correct it. These consist in complete rest, both of body and mind, cooling drinks, and spare diet. If these do not correct it soon, a flaxseed poultice should be placed on each breast, and the patient should be made to perspire, either by warm teas and clothing, or by means of steaming. The bowels should also be freely opened with castor oil, or a seidlitz powder, and it will often benefit very much to give warm water freely to drink, with ten grains of nitrate of potash (saltpetre) to the pint.
In those that nurse it is very seldom the case that the secretion of milk is too profuse, unless the child has been kept too long from the breast. As a general rule it should be put to nurse in a few hours after birth, even if there be no milk, because its suction will materially help to bring on the flow. It frequently happens, when the child is kept away till the milk comes, that the breasts have swelled so that the nipple is buried and cannot be laid hold of well by the mouth, in consequence of which the child does not get nourishment enough, and the breasts not being well emptied become engorged, and their functions deranged. All this may be avoided byputting it too early. Sometimes however notwithstanding every precaution, the flow of milk is excessively great, and constitutes a real disease, which may cause great weakness and debility. In such cases it will generally be found that the diet is too stimulating or too rich, or that the bowels have been too inactive, and the first step towards an improvement must consist in correcting these faults. The skin should also be kept active by frequent bathing and good friction, and the quantity of nourishment taken should not be greater than the mere healthy support of the body requires. In particular no stimulating liquors should be used.
Agalaxy.—This complaint is the reverse of the former, as it consists in a deficient secretion of milk. The causes of this deficiency are various; sometimes it arises from a constitutional inertness of the breasts, sometimes from insufficient nourishment, and sometimes from profuse discharges in other parts. All excesses also tend to decrease the quantity of the milk,particularly those of a certain kind; and it is seldom so abundant or lasting either in extreme youth or advanced age. The appearance of the menses in like manner generally causes the flow to become less, and it ceases naturally in some much earlier than in others. Sometimes there is a deformity in the child's mouth, which prevents its sucking properly, and the milk may stop for want of being completely drawn. The breasts also may be diseased, or the nipple not sufficiently prominent, and the same difficulty be thus produced in another way.
In treating agalaxy, therefore, the first thing is to ascertain if there be no deformity or disease in either mother or child, which prevents proper nursing. If there be nothing of the kind, it must next be ascertainedwhether the mother has any excessive secretion elsewhere, such as diarrhœa, great flow of urine, or heavy sweats; if she have, these must be corrected. It must next be seen if she takes sufficient nourishment, and of a proper kind for her stomach and bowels. Sometimes a little spiced wine is excellent, or some porter, with white meats, and arrow-root milk. If she be of a full habit, however, and makes much blood, the contrary course must be pursued, and the diet be made low and unstimulating, while the bowels are kept free and the skin in good action.
In many cases when the nipple is small, it may be much enlarged by titillation, just before the child is put to it, after which the suction will increase it still more.
If the female be advanced in life, or very weak, or if she becomes pregnant, it may be better to procure a nurse than to attempt to stimulate the flow at all. The appearance of the menses need not occasion a suspension of nursing, unless it evidently deranges the secretion of the milk, or affects the health of the mother; in either of which cases the child should be weaned at once.
Engorgement of the Breasts.—The breasts are liable to become swollen, or engorged, from colds, blows, hard nursing from the child, over feeding, and from soreness or excoriations preventing them being fully emptied. This state may occur at any time, but is most frequent a few days after delivery. In general there is no danger from it, unless it be very bad or continues too long; it may then inflame and discharge, or become permanently hardened. To prevent such accidents the breasts should always be sufficiently emptied, either by the child or by artificialmeans, and every precaution should be used against cold or violence. Constipation must also be guarded against, and the diet and drink must be carefully observed, so that it be not too feeding, or too stimulating. Warm fomentations or poultices may also be used when the breasts are painful, and a Dover's Powder may be given at night, after bathing the feet in warm water, to promote perspiration.
Inflammation of the Breasts.—This is only a more advanced stage of the previous malady, produced by the same causes, and by want of timely attention. Like simple swelling, it may arise at any time during nursing, but is more frequent a few days after delivery. As soon as the inflammation commences the breasts become red, swollen, and excessively tender, particularly at one point, which soon begins to project like a nipple, if the disease is not stopped, and at last bursts and discharges the contained pus. Sometimes the inflammation is comparatively superficial, and extends only over a small portion of the surface, but at other times it goes deep and spreads wide. In proportion to its extent is the severity of the symptoms, which are those of inflammation in general, such as headache, thirst, fever, general uneasiness, and cutting pains in the part affected.
As soon as the abscess is formed and can be plainly discovered, it is usual to open it immediately, because the longer it remains the more extensive it becomes, and the larger portion of the breast becomes diseased. It is necessary however to becertain, before making an opening, that it is really an abscess on which we are going to operate, for sometimes a healthy part of the breast feels very much like one, and a mistake may easily be made; in fact such a mistake has often been made, and by men of experiencetoo. In the early stage of the inflammation every effort should be used to prevent an abscess from forming, by the use of purgatives, sweating medicines, low diet, cooling drinks, and warm fomentations over the whole chest. Some females practicecoldfomentations over the breasts, and with good success, in the commencement of the inflammation, but it may increase the difficulty with others, and, so far as I have seen, is no more generally useful than the other method. The warm bath all over the body is also very serviceable in a number of cases.
It usually happens however, in spite of every precaution, that matter will form, and its discharge become necessary. As soon as this is evident, it should be promoted as much as possible, by hot fomentations and poultices, till the head of the abscess is sufficiently distinct for it to be safely opened. While the swelling is going on the pain is often very severe, and it should be eased as much as possible, by using laudanum in the fomentations, or by putting on an opium plaster. After an abscess has opened and discharged, it should be kept open for some time, by little pledgets of lint, to prevent its closing up too soon, otherwise a portion of the matter may be shut in by the wound healing over it, and another abscess will form. Warm poultices and lotions should also be used afterwards, to promote the discharge as much as possible, but they should not be used after it has evidently begun to cease naturally. In short every means pointed out should be used energetically in the first stage, topreventthe gathering, but if it takes place in spite of them, then it should behastenedanddischargedas early as possible, to prevent its extending. After this, when it has evidently all escaped, the wound may be suffered to heal, and thepatient must be enjoined to be very careful in future, for the same accident will be very liable to reappear.
Sometimes these abscesses become very extensive, and remain for a long time. I have known ten or twelve on one breast, and I have known them to continue open for many months. When this is the case it is much to be deplored, as it is very likely indeed to destroy the breast, and may even lead to more serious results. Attention therefore cannot be bestowed upon them too early or too unremittingly, particularly if the female be scrofulous, or of a very full habit. Sometimes the inflammation attacks both breasts, and at other times only one, in which case every effort should be exerted to prevent its extending to the other. In many persons the same side is always affected, and becomes a scape-goat as it were for the other.
When the means used succeed in scattering the swelling, its dispersion is usually followed by some critical discharge, such as diarrhœa, or a great flow of urine, or even by profuse perspiration, which shows how nature operates in removing the diseased matter, and cautions us not rashly to check such discharges.
It is a very serious matter for the swelling toindurateor harden, as it sometimes will, without either scattering or dispersing, as it is then constantly liable to become worse again, besides destroying the structure of the gland. Every means should therefore be used to prevent this, by promoting its dispersion or discharge, in the way already pointed out. It is also very good in these cases to bathe frequently with alum water, or decoction of white oak bark, or even to rub on some of theOintment of Hydriodate of Potassa, diluted with an equal weight of fresh lard. A piece as large as a hickory nut may be well rubbedon twice a day, for three or four days, but it should be stopped immediately the swelling begins to subside, and not used again unless it still remains or again increases. In many cases pretty frequent friction, with the hand anointed with a little oil, will be all sufficient, especially if a hot fomentation be used afterwards.
Excoriations, or Cracks in the Breasts.—The annoyance from this cause is sometimes very great, the pain which is experienced when the child begins to nurse being so acute that it is impossible for the mother to allow it to remain. Frequently I have known it compel weaning much earlier than was desirable, and sometimes it has even been so bad, that the dress could scarcely be borne against the breasts. The precise cause of this liability to crack is not known, nor do we know of any certain means to prevent it. In many cases however I have known it prevented, to a great extent, by having the nipple gently sucked, very frequently, for six weeks or two months before childbirth. This hardens it, and if a wash of borax water be also used, after each time, it will be gradually prepared for its proper use. Our means of curing this troublesome affection are very limited, and frequently everything fails that is tried. The mucilage of Quince seed, prepared by bruising and boiling them in a small quantity of water, rubbed over the sores with a soft feather, immediately after nursing, often does much good. The mucilage from the tender tops of young sassafras sometimes succeeds better than that from the Quince, and a bruised leaf from the largehorse-shoe Geranium, laid on like a poultice, is sometimes better than either. A good lotion may also be made with a quarter of an ounce of borax, and a tea-spoonfulof laudanum, to half a pint of warm water, to be used frequently during the day. Some females use a wash made of saleratus, with considerable benefit, and others find relief from one made of nut galls, or white oak bark. Most of these means however are well known, and many others also, which, like them, sometimes succeed and often fail. The artificial nipple, orshield, should be tried if none of these means succeed, and frequently it will enable the mother to allow the child to nurse, though it may not altogether prevent the pain.
It not unfrequently happens that the child's mouth may be diseased, particularly withapthæ, or thrush, and this may possibly keep up the excoriations; in like manner the state of the breasts may also influence the mouth, and therefore the condition of each should be well ascertained when anything is the matter with either.
This is often observed in childbed, and sometimes even comes on during labor. It is usually attributed to cold, and no doubt it often does arise from cold, but more frequently it is owing to sympathetic derangement, and from violent attempts to swallow during and after the pains. Many females in fact cry out at those times, that something hasbrokenin the throat, and they fear they are going to suffocate. As a general rule the swelling gradually subsides in a short time, without any special treatment, but sometimes it increases and inflames, and an abscess forms which may become very troublesome, and even dangerous. To prevent this it should be frequently treated with warm fomentations and poultices, till the inflammation subsides, and then withthe same washes recommended for indurated or hardened breast, in the preceding section of this chapter. If the swelling becomes hard, and remains indolent, the ointment of hydriodate of potassa may also be prepared and used, as there recommended.
This is a painful tumefaction or swelling of one or both of the limbs, which comes on from the fifth to the fifteenth day after delivery. It generally commences with slight pain, or stiffness, or cramp, becoming more painful as it proceeds; but, sometimes, shooting, cutting pains, of great violence, are felt suddenly, at the very commencement. The swelling, also, sometimes comes on gradually, but, at other times, rapidly. In most cases the patient complains of a sudden pain in the groin and thigh, which is preceded by a chill followed by fever, and then the limb begins to enlarge. Most frequently the lower part swells first, and then it extends upward, sometimes, even to the hip. The skin, on the swollen part, looks white, shining and tight, as if ready to break; it is also extremely painful, so that pressure upon it can scarcely be borne. It looks in fact like a thin bag of skin filled with milk, and hence the namemilk leg, from an idea that it was really filled with milk, which had, by some means, reached there from the breast. This idea is erroneous, in the sense it is usually taken; the milk does not flow into the leg as many imagine, nor is anything like it to be found there, except a peculiar thin, white matter, when it breaks. Still, however, a sudden stoppage of the milk may cause such a swelling, like a sudden stoppage of any other secretion, but in no other way.It is, probably, most frequently produced by sudden cold, which checks that profuse perspiration into which females gradually fall immediately after delivery, and so drives the perspirable matter within, and causes inflammation and suppuration. A difficult or prolonged labor may also lead to it, by preventing, for a long time, the proper circulation of the blood through the large veins of the pelvis, and so engorging those below. Or the veins may become paralyzed, as it were, by the pressure they have sustained, and so become, for a time, unable to transmit the blood. In fact, both the veins and lymphatics become engorged, as if tied above the limb, and exhibit knots and bundles, like bunches of grapes.
Sometimes the fever will occur some days first, and the female cannot tell what it is owing to, till the swelling comes on; and even this may take place so gradually, and with so little pain, that the limb may be very large before it is observed. I have known females complain of a slight fever only, on going to sleep at night, and wake up in the morning with a confirmed case of milk leg; and I have known others start with a sudden pain in the groin, or hip, and be affected in the same way, in less than two hours.
The disease usually lasts from a month to seven or eight weeks, and terminates, either by a gradual resolution, or scattering, of the fluids, or by suppuration and discharge. When suppuration ensues, there will, sometimes, form one or more very large abscesses, which it may be difficult to heal, and which may lead to serious results, either from their extent, or from the constitutional irritation they produce.
The treatment, at first, consists in warm fomentations, such as those of poppy-heads, or hops, with cooling drinks, purgatives, low unstimulating diet, andoccasional doses of James's Fever Powder, to promote perspiration. This is intended to disperse the swelling, and, in general, it does so. If, however, the abscess forms and breaks, in spite of all the means used, it must be treated the same as abscess in the breast, previously described. In ordinary practice, it is the general custom tobleedat the commencement of the disease, or to apply leeches to the groin. This sometimes does good, but frequently is of no service at all, even if it does not make matters worse. I would, however, make the same remarks on bleeding here, as I did in regard to its use inpuerperal fever, to which milk leg has a resemblance, in some respects.
Another practice is to use tight bandages, the same as for varicose veins, but I think the plan is not, in general, a successful one, though it may be occasionally. Plunging the limb in cold water, or keeping it wrapped in cold wet cloths, has succeeded much more frequently, and is, with some, a favorite remedy. Stramonium leaves boiled in vinegar, and laid on hot, will also effect a cure sometimes; and so will bathing with hot lye or alcohol. A large poultice of hops, soaked in hot vinegar, has also been found useful.
The bladder, from its position, is very apt to be inconveniently pressed during the passage of the child, and to be temporarily affected for a short time after, in consequence. Sometimes, the neck of the bladder will beparalyzed, and the urine cannot be discharged. In this case, fomentations of warm milk and laudanum must be used, or awarm hip bath, if there be no danger of flooding, and the bowels must be freely opened. If this does not relieve, the catheter must be used, and always before the bladder is too full. To avoid its becoming so, the attendant should inquire of the female, during the first day, if she has urinated, or feels any inclination that way, so that he may know in time if the difficulty exists. In general, this paralysis passes off in the course of a day, but may endure longer sometimes; in which case the patient herself should speak of it. Cases have been known where the bladder has become so full as toburstthrough inattention to this matter. The contrary difficulty is occasionally observed, and the urine cannot be retained, but it flows away as fast as it is secreted. It is very seldom, however, that this state remains more than a single day and, more frequently only a few hours. A dash of cold water on the pubes, and against the meatus urinarius, has often corrected it at once, and so has a single purgative dose. If it remain after the first two days without amendment, it is customary to put a small blister on the abdomen, which usually relieves in a short time.
APPENDIX.ON PREVENTING PAIN IN CHILDBIRTH.
ON PREVENTING PAIN IN CHILDBIRTH.