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rosus. Comatose

Treatment.

Gen. IV. and obscurely delirious. Occasionally, however, it was Spec. III.

a direct lethargy, which continued for two or three weeks, y E. Syno

during which nothing but a violent noise would rouse

the patient; when after opening his eyes, and being synochal persuaded, perhaps, to take a little food or some medifever.

cine, he again fell into a sleep so profound, that Sauvages calls it a febrile cataphora. In some cases, however, instead of a lethargy, there was a low muttering delirium, in which the patient spoke incongruously and with fretfulness, with short snatchings of stertorous sleep interposed. The fever rarely terminated in less than fourteen days; and, when the lethargy prevailed, generally ran on to twenty-one or even thirty days. The first symptom of recovery was usually a capricious longing for some absurd kind of meat or drink. The head for many days still discovered great weakness, and even the muscles were incapable of supporting it in an erect position. Warm cordials were always mischievous : a free and repeated use of the lancet with brisk purgatives formed the best plan of cure, with diluting diaphoretics afterwards. Sauvages asserts that blistering the head was serviceable. Epithems of ice-water over the whole head, repeated as soon as they became warm, would probably have proved far more beneficial, as soon as the

vessels of the head had been sufficiently emptied. 8 E. Syno We find the same fever still more frequently comchus puer

mencing with a like tendency to the peritonæum instead Puerperal of to the head, which runs rapidly into a state of inflamfever, Child-bed mation, with an imperfect attempt at suppuration; and

especially where this membrane has been excited by a Procecding

sympathetic action with the uterus or any other adjacent combined organ, or by exposure to the atmosphere in consequence with, peri

of a wound through the abdominal integuments. And flammation. hence this disease occurs occasionally in cases of tap

ping for a dropsy of the abdomen, and still more frequently after labour : on which account it is commonly known by the name of PERITONÆAL, PUERPERAL, or CHILD-BED FEVER. From the days of Hippocrates to khose of Boerhaave and Van Swieten, the uterus was

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263 supposed to be the chief seat of inflammation when the Gen. IV. disease arises from this cause. But there is now no gesund question that it originates in the peritonæum itself, and chus puerthat the uterus is often very little affected; and this too,

ma mis vol, Puerperal though the inflammation should spread, as it often does, fever.

Child-bed to other organs in the vicinity.

The disease usually commences about the third day Uterus after delivery, or a wound made through the abdominal posed for

merly to be integuments by accident, or in tapping for a dropsy of the chief the abdomen; though sometimes it occurs rather later, seat of the

disease. and, according to Professor Frank, sometimes a little be- ;

Description. fore delivery*. It is marked by all the common symptoms of a severe febrile incursion, in combination with the tenseness and tenderness of the belly. The muscles of the back and hips are in great pain; the abdomen is tender, often acutely painful, and the pain is greatly increased by pressure, which peculiarly distin-guishes this disease from enteritis; and as the diaphragm is affected by contiguous sympathy, the breathing is also short and laborious, accompanied with most distressing anxiety. The head rarely suffers much at first, but in the progress of the disease is apt to become stupid and comatose. The flow of the milk and of the lochia are usually suspended, though the latter is not always so; but in this last case the discharge is thinner and more acrid. The stomach is sometimes, but not generally, troubled with sickness, and frequently discharges an offensive porraceous saburra; and a troublesome diarrhoea attacks the bowels. The disease appears also at times, and by practitioners Sometimes

compounded of deserved credit, to have been confounded not only with simple with enteritis but with simple irritation of the bowels in

the bowels. produced by a retention of scybala, indurated feces, or some other cause. In this last case, however, the abdominal tenderness is usually less diffuse, and, in the commencement of the disease, the pulse less disturbed and the head more disposed to be affected. There is also a

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Child-bed fever.

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Gen. IV. pretty full proof exhibited by the immediate and very senSpec. III. à E. Syno

moisible relief afforded by purgatives, and the very small chus puer benefit obtained by bleeding. Though there can be no Puerperal

eral question that if such intestinal irritation be suffered to fever. continue, it may in the end prove as perilous as perito

nitis itself, and even excite inflammation of the peritonæum, or intestines, or both.

To account for the inflammation of the peritonæum, it tion of the peritoneum

is only necessary to recal to mind the readiness with accounted which, in particular constitutions, or states of excitement for.

from various internal or external causes, inflammation

often takes place in interior cavities, and the rapidity Principle

with which it spreads over every part of them. It is to to be at tended to in this principle alone we trust in effecting a radical cure

for a dropsy of the tunica vaginalis of the scrotum. The cavity here is small, and we are not afraid of serious mischief; but were it as large as that of the peritonæum, he would be a bold operator who should venture upon a like mode of cure, notwithstanding that the process of adhesion, so much more easily effected in the scrotum than in the abdomen, might diminish the chance of

danger. Explanation In the opinion of Mr. John Hunter, the disease takes given by J.

place in consequence of an injury done to the peritonæum, as forming a cavity, by which its present state is either suddenly changed or rendered imperfect. The injury done to the peritoneum in the case of women after delivery, he ascribes, as his sentiments are delivered by Mr. Cruikshank, to two causes. Sometimes it proceeds from a want of disposition in the womb to recover itself after labour; by which the peritonæum, as a cavity must necessarily be affected. At other times from a too sudden emptying of the abdomen ; whence the peritonæum cannot always recover itself so as to be properly adopted to its new condition. This last cause, he observes, may also hold with men after the operation of the paracentesis. But, in them, besides the sudden emptying of the abdomen, there is the additional circumstance of a wound, which renders the peritonæum, as a cavity, imperfect.

Hunter.

SPECIII.

erarum.

Child-bed

tempera

When an inflammation of the peritonæum occurs, it Gen. IV. most frequently happens, as he still farther remarks, that

au E. Syroit spreads over all the cavity of the abdomen. An ex- chus puertravasation of fluids takes place into that cavity mixed

Puerperal with pus. The different viscera adhere by their perito- fever. næal coats. The intestines are distended with air. And

fever. the irritation, thus induced, kills the patient long before granulations or an obliteration of the cavity in the second method can occur *. Neither of these two causes, however, by themselves These

causes rarewill often, if ever, produce the fever before us, or even ly adequate peritonæal inflammation alone. For the uterus is perpe

of them

selves. tually exhibiting a morbid enlargement, without a disposition to recover itself; and the abdomen, sudden evacuation, while no such fever ensues. There must co- A peculiar operate a peculiar temperament, or a peculiar condition me of body at the time; and, in puerperal patients, there body neces

sary as an is especially the general pyrectic excitement which ne- accessory. cessarily follows, upon the very great change in various organs which takes place upon delivery, and the transfer of accumulated action from one organ to another. An- A peculiar other accessory is also frequently found in the constitu- ment of the tion of the atmosphere ; for whatever change is most atmosphere. calculated to produce fever from a morbid excitement of the abdominal viscera, cannot fail to co-operate in the production of this disease from a local cause. I have already observed that such a change most usually occurs in autumn, and have stated the grounds on which it depends, under the history of epanetus autumnalis, to which the reader may turn at his leisure t. And hence, so far Hence oc

casionally as I have observed, a tendency to peritonæal or puerpe- ; ral fever occurs more frequently at this season than at epidemy. any other: and on this account it is said by Dr. Douglas, of Dublin I, M. Vondenzande and some other wri

es an

. Edin. Med. Comment. Vol. 111. 322.
+ See Vol. 11. Cl. vi. Ord. 1. Gen. 11. Spec. II.

Observations pratiques sur la Maladie connue sur le nom de Péritonite, et de Fièvre puerperale. Anvers, 8vo, 1821.-J. P. Frank, De Cur. Hom. Morb. Tom. II. p. 197.

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Gen. IV. ters *, to occur occasionally as an epidemyt. There is Spec. III.

· much reason, indeed, for regarding it in this last view ; chus puer- for as most of the auxiliaries that unite in the production

of contagious miasm are present in a lying-in chamber,

such miasm is frequently the result; often indeed, as we Child-bed fever.

have reason to believe generated, after the manner of Contagious typhous miasm, and completely elaborated in the circu

lating and secreted fluids of the patient herself. Of this generated as in ty fact, indeed, we seem to have a striking illustration in the phus.

official report of the malignant puerperal fever that Proofs

raged so fatally in the lying-in department of the General of infection.

Hospital, at Vienna in 18197, circulated under the authority of the Baron Von Mastoschek ; but there can be no longer any question, after the accounts of the disease published by Dr. Gordon of Aberdeen, and Dr. Young of Edinburgh, as it appeared in the lying-in infirmaries of these cities ; in which woman after woman continued to be infected to a very great extent, and especially where they had had close communication with puerperal patients, or had even been attended by nurses or midwives who had previously attended the latter without sufficiently changing their malignant dress. This disease was only subdued by the ordinary means employed to exterminate contagious miasm, such as great cleanliness, repeated change of sheets and body-linen, free ventilation, and a total separation of those who were labouring under the disease from those who were about to be con

finedll. Contagious In all kinds of contagious fevers we find that some effects why limited to

persons are more liable to be infected than others from puerperal incidental circumstances; and, as I have already had patients.

occasion to observe in laying down the laws of febrile miasm so far as we are at present acquainted with them,

* Treatise on the Puerperal Fever, illustrated by cases which occurred in Leeds and its vicinity in the year 1809-1812. By William Hey, Jun., &c. + Clark, Edin. Med. Comment. Vol. 11.

Edin. Med. and Surg. Journ. No. LXXX. p. 83. | Compare Dr. Campbell's Treatise on the Epidemic Puerperal Fever, as it prevailed at Edinburgh in 1821-2. Edin. 8vo. 1822.

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