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. 1. 267 the miasmic corpuscles are modified in a few of their pro- Gen. IV. perties by the accessories to which they are exposed, or ;
" ESynoby which they are produced. And by bearing these chus puerfacts in mind, we shall have no difficulty in accounting per for the limitation of this contagious fever to puerperal fever.
Child-bed women, and the exemption possessed by persons who are not under the same circumstances. For, operative as the miasm unquestionably is where the predisposition exists and the abdominal organs are thrown out of the balance of healthy action, it is inert where no such predisposition is to be found, and these organs are in elastic vigour. Dr. Douglas extends this view of the case fur- Facility of ther than many pathologists ; for he conceives that wo- the disease men whether pregnant or nursing, or for several months ass
by Douglas. after confinement, though not nursing, are susceptible of the disease upon the application of contagion *. But whether the miasm thus generated be the com- Whether
febrile mon febrile miasm we have contemplated in several of miasm mo. the preceding species, merely modified in its powers by dified or a
specific accidental circumstances, or a contagion specific and pe- contagion, culiar to itself, is a question which, at present, we have not the means of determining.
I have said that in the inflammation which takes place, Imperfect there is an imperfect attempt at suppuration. The fluid cu
"Euppuration. secreted or effused is usually a whey-like material, or milky ichor, or, as Mr. Cruikshank has described it, an extravasated matter mixed with pus. But Dr. Hulmet asserts that he has sometimes found genuine pus apparently secreted without ulceration; and Dr. Meckel informs Baron Haller that he has witnessed the same very extensively t. The nature of the fluid will, indeed, entirely depend upon the vehemence and rapidity of the inflammatory process. Where this is less violent, the secretion, as from the surface of other mucous membranes, may be purulent or even genuine pus, and has
* Report on Puerperal Fever. Dublin Reports, Vol. 111. p. 145,
Epist, ad Haller. Script. Vol. III,
Gex. IV. sometimes amounted to several pints; but, where more SPEC. III.
violent, it will be a milky, caseous, or whey-like serum. à E. Synochus puer. It is rarely however so mild and temperate in its march perarum. Puerperal
as to produce pus; often running on, as Dr. Hulme has
observed, to a state of gangrene at once: and in some Child bed
instances has been found to involve the intestines, omenfever. Intlamma
tum, and all the neighbouring viscera, in the common tory range mischief, as has been abundantly established by postoften very extensive. Obituary examinations *. And hence, the uterus itself
has sometimes participated in the inflammation, and has shown pus or gangrene according to the vehemence and rapidity of the morbid influencet. The secreted fluid, from its abundance is called by Professor Frank “acutus, purulentusque hydrops”, who further tells us that he has sometimes traced it in the lungs, pleura, cavity of the chest, and even in the pericardium, where these organs
have associated in the inflammation t. General
The general treatment of this disease should closely resemble that already laid down for the severer varieties of the malignant remittent, which it very much resembles, with the exception that the fever is continued instead of being remissive: and that the local irritation is seated in the peritonæum instead of in the liver or any other organ. This inflammation must be subdued, and that speedily, or the patient will perish; and hence, abstraction of blood and calomel purgatives are the arms on which we have chiefly, if not solely, to depend; and both should be employed decidedly and to as great an
extent as we dare. Venesec
Eighteen or twenty ounces of blood should be drawn tion.
from the arm, as soon as possible after the commencement of the disease, and repeated within twelve hours if necessary and the strength will allow : but if venesection have not taken place before the third day, the debility will have gained so high an ascendancy, avd the
* Hulme, ubi suprà. De la Roche, Recherches, &c. + Bang, Act. Soc. Haffn. I. | De Cur. Hom. Morb. Epit. Tom. II. p. 196. 8vo. Mannh. 1792.
general symptoms put on so putrescent a complexion, Gen. IV. that little benefit is to be gained from it. The bowels,
• E. Synoshould at the same time be moved by six or eight grains chus puerof calomel given in the form of a pill; and the same pre- Puerveral paration, to the amount of three or four grains--Dr. fever. Douglas advances the dose to not less than ten grains, to should be continued every six hours till the tension and Treatment. soreness of the abdomen have abated. And it will often Cathartics. be useful to accompany the calomel with one or more doses of castor oil, or the essential oil of turpentine, or both combined.
Dr. Vanderzande depends upon a free exhibition of Calomel. calomel without venesection, which, after the manner of Dr. Hamilton of Ipswich, he unites with opium; and he boasts of the certainty of success which this treatment has developed; though in conjunction with opium and calomel he sometimes employs mercurial friction *. There can be no question of the benefit of a liberal use of calomel in an early stage of the disease: but to let it supersede the use of the lancet, is to abandon our first chance of success, and to encounter an unnecessary peril.
It happens not unfrequently, however, that the pa- Neither adtient's frame is so weak and delicate that we should risk more by drawing blood generally than even by leaving the case to nature; as it does also that the stomach and bowels are from the first in a very high degree of irritation, with violent purging and vomiting, and will not bear any additional stimulant. Our wisdom is here to yield to circumstances, and let the general rule admit of particular exceptions. Instead of the lancet, we should have Local derecourse to leeches, and in this manner remove twelve pletion. ounces of blood at the least; and unite opium with smaller Opium. doses of calomel. It does not follow that calomel in such a combination will increase the irritation of the stomach or bowels; I have often seen the contrary; and
• Observations pratiques sur la Maladie connue sur le nom de Péritonite, ou de Fièvre puerperale &c., 8vo. 1821.
Gen. IV. that by the exhibition of two or three grains with one Spec. III. à E. Syno. Sramo prams, repeate
grain of opium, repeated every five or six hours, the irrichus puer- tation has yielded to the commencement of a new action.
It is also in such cases of extreme debility that the esPuerperal fever. sential oil of turpentine has often been found higbly Child-bed
beneficial when employed internally by itself; for while Treatment. it operates as a mild aperient, it acts as a counter-irriEssential tant, and hence directly influences the morbid state of oil of turpentine.
the peritonæum, while the pulse is supported by its stimulant power, and a pleasant moisture is sometimes diffused over the surface. It is in truth, with the exception of camphor, the only cordial we can safely venture to employ. For the purpose before us the dose should be about two drachms; which may be repeated every
two or three hours *. Fomenta Warm and anodyne fomentations to the abdomen are
usually prescribed at the same time, and are often found palliative, particularly the essential oil of turpentine, which may be used externally as well as internally; but
the common mode of applying them makes the bed wet Best and and gives great fatigue to the patient. And hence, I
have ordinarily prescribed a large piece of folded flannel mode of application. wrung out forcibly in as .hot water as can be borne, to be
applied over the whole of the pubes and abdomen, and covered by a broad flannel or linen swathe passed under the loins and folded over the epithem of reeking flannel, which is to remain for many hours, or till it becomes dry, as all that is wanted in this application, as in a common bread-and-water poultice, is warmth and moisture; the flannel answers the purpose as well as the bread; and whilst I do not recollect a single instance in which this application has not been soothing and serviceable, I have never met with a case in which a chill has been
complained of. Diapho In the mean time, a diapnoe or breathing perspiration
on the surface should be attempted by small doses of
* See Edinb. Med. and Surg. Journ. 1822. p. 538. Communication from Dr. Hy. Paine.
ipecacuan, or Dover's powder, and with the addition of Gen. IV. a solution of acetate of ammonia *; and if the debility be, very considerable, we may employ free doses of camphor, chus puerbeginning with half a scruple, and proceeding to half a
* Puerperal drachm at a time, every four or five hours, with great fever. advantage.
fever. If this plan should not answer, and the skin be still Treatment. hotter, drier, and more pungent to the touch, the pulse Camphor. quicker and more wiry, and the tongue deeper furred, it may be adviseable to exchange epithems of hot for those Cold epi
thems to of cold or even ice-water, as already recommended in the abdocases where the head is chiefly affected instead of the men instead peritonæum. I freely confess that I have not tried this plan myself hitherto, but it is strongly recommended by Loeffler and other physicians of great repute; and as it is a practice in common use in our own country in the case of flooding, without any evil resulting from it, we have no reason to expect any evil in the case before us; for the sensibility is here still more obtunded than in flooding, and nearly as much as in deliquium.