629 



PUERPERAL DISEASES. 



PUERPERAL DISEASES. 



630 



magister (promagislro), with numerous associates and assistants, in the 

 provinces. [PnovrxciA.] The revenues, which were chiefly leased to 

 the piiblicani, were tolls, harbour duties, and the scriptura, or the tax 

 that was paid for the use of the public pasture-lands. The publicani 

 had their under-lessees (portitores, TtXwmi, Luke v. 27, 29) and col- 

 lectors. Numerous slaves were also employed by them in collecting 

 the taxes ; and this body of men was comprehended under the term 

 of a familia pMicanvrnm. In our translation of the New Testament 

 these inferior officers are called " publicans," and are mentioned 

 together with " sinners," a distinction to which they might be partly 

 entitled for their occasional oppressive conduct, and partly to the 

 general dislike of all the world to tax-collectors. It appears that 

 Matthew, who was a Jew, was a publican (Matt. ix. 9), the only civil 

 employment held by a Jew under the Romans. 



The publicani undertook to pay fixed sums for the taxes of a par- 

 ticular district or place. The contract was often made by a single 

 person on behalf of himself and others. It was the business of the 

 censors to let the taxes. The publicani gave security to the state for 

 the due performance of their contract ; and their property, as well as 

 that of their sureties, was liable to the amount of their obligations. 



Among the remedies which the publicani had against those who were 

 bound to pay vectigal, was the pignarit captio, which seems to have 

 been a kind of distress (Qaius, iv. 23) ; but after the old forms of 

 action were changed, it was not usual actually to seize the property, 

 but a fiction was introduced into the formula, by virtue of which the 

 person who owed the vectigal might be condemned in a sum of money 

 equal in amount to what he must have paid in order to redeem his 

 property if it had been seized. 



PUERPERAL DISEASES. Under this term are included all 

 those diseases which arise out of the state of pregnancy : they are not, 

 however, as the name would seem to imply, peculiar to this condition, 

 but incidental only ; and they are DO far modified by it as to require 

 some allusion to their character and mode of treatment. Among the 

 most alarming of these diseases, and the earliest to make their appear- 

 ance, are puerperal convulsions ; they consist of epileptic seizures, and 

 their character differs in no respect from the ordinary epileptic fits 

 already described in the article EPILEPSY : we therefore shall merely 

 observe in the present place, that convulsions are liable to occur at 

 any time after the sixth month of utero-gestation ; but for the reasons 

 about to be stated, the majority of cases are met with during labour. 

 When they occur after delivery, they are generally connected with a 

 loaded state of the large intestine, or with a state of exhaustion from 

 hemorrhage. The cause of them attack* must be looked for in the 

 state of the viscera and large blood-vessels at this period : during 

 gestation, these parts are subjected to a constant and increasing 

 degree of pressure from the gravid uterus, the natural tendency of 

 which is to produce local congestion of the circulating fluid, and an 

 undue accumulation of the excretions within the intestines. At the 

 tune of parturition this pressure is materially augmented by the con- 

 tractile effort* which are made to expel the infant ; and the mechank-al 

 obstacle thus offered to the flow of blood through the abdominal aorta, 

 determines it in unnatural quantity to the brain. Hence this state of 

 thing*, if not remedied, may not only produce the disease we have just 

 been considering, but may even give rise to apoplexy. The treatment 

 is obvious, and consists in relieving the vascular system by general and 

 topical bleeding, and unloading the intestines by brisk cathartics. 



A recent writer attributes puerperal convulsion! to the presence of 

 urea in the blood. 



But by far the most important and the most dangerous of puerperal 

 distant is puerperal peritonitis [PERITONITIS], called also puerperal 

 inflammation, puerperal fever. It usually attacks women a few days 

 after delivery, and seems to have no connection with the duration or 

 the severity of labour. This fatal disease varies so much in the type 

 of the inflammation as to be scarcely recognised as the same affection 

 in different individuals anil at different periods, the accompanying fever 

 being sometimes strictly inflammatory, and at other times typhoid. 

 In its most dangerous form it is characterised by a remarkable pros- 

 tration of the vital powers, and by a countenance expressive of extreme 

 anxiety anil distress. The pulse is frequent and feeble ; the abdomen 

 tympanitis, anil unable to bear the slightest pressure ; the bowels are 

 constipated, and vomiting is not an unfrequent attendant. As the 

 disease proceeds, the lochial discharge and the secretion of milk are 

 suppressed; and towards its termination, a total cessation of pain 

 ! the patient dies, often in full possession of her 

 mi (if puerperal fvcr is most 



frequently epidemic, and many believe it to be highly contagious. The 

 lesions met with in this disease are chiefly manifest in the peritoneum ; 

 but in tho worst cases, the substance of the uterus itself, and the large 

 veins ill its vicinity, present evidences of inflammation. The treatment 

 of puerperal fever is peculiarly difficult; "every case," observes one of 

 our tmmt celebrated accoucheurs, " must be Isolated and studied alone, 

 and looked at by itself, and its management must depend upon its 

 type and it* stage." Bleeding, general and topical; counter-irritation, 

 by means of blisters or spirits of turpentine, applied to the abdomen ; 

 purging, by the exhibition of the last-named medicine, or by large 

 doses of calomel; and the latter, given to excite ptyalism, have been 

 the prineijial remedies used for combating this formidable malady. 

 But the prostration of the vital powers is in some cases so xh 



to afford us little chance of putting into requisition the only means 

 which we possess of combating the inflammatory symptoms. 



A form of disease sometimes occurs after delivery which from its 

 resemblance in some particulars to the one we have just alluded to 

 requires notice. It is due to stomachal and intestinal irritation and' 

 13 ushered in by rigors, followed by great heat of skin, a full and 

 frequent pulse, and loaded tongue. The abdomen may be tumid and 

 painful on pressure, and the head may bo affected by symptoms of 

 phrenitis, as intolerance of light, noise, wakefulness, and delirium. 

 The affection of the head and that of the abdomen frequently co-exist 

 or alternate in the same case ; and this conjunction of the two affec- 

 tions serves to assist in the diagnosis between peritonitis and the 

 present complaint. As it is of the greatest importance in a therapeutic 

 point of view to distinguish puerperal inflammation from intestinal 

 irritation, much may be learnt by the exhibition of large injections of 

 warm water, an examination of the evacuations, and an observation of the 

 effects thus produced upon the disease. In intestinal disorders, the faces 

 will be found to be scybalous, or at least offensive and dark-coloured, 

 and in large quantities ; and the relief obtained will be found to depend 

 upon the proper evacuation of the bowels. Another characteristic of 

 intestinal irritation is the susceptibility to fainting upon blood-letting. 

 The treatment of this disorder may be summed up in the words of 

 Dr. Marshall Hall. "In peritonitis," he observes, " the freest blood- 

 letting must be aided by purgative medicines ; whilst in intestinal 

 irritation, the freest and fullest evacuation of the intestines must be 

 aided by blood-letting ; for although both blood-letting and purging 

 are to be used in every case, yet the former is the remedy in in- 

 flammation, and the latter in intestinal irritation." In describing the 

 last-mentioned disease, we have alluded to the combination of cerebral 

 symptoms, which so frequently are present. This disturbance of the 

 intellectual functions is sometimes so great and so continued, as to lead 

 to the supposition that the brain is the seat of some active inflamma- 

 tory disease; and were we, acting upon this supposition, to have 

 recourse to antiphlogistic remedies only, we should probably lose our 

 p;itient. This alarming disorder has been termed puerperal insanity, 

 or puerperal mania. It comes on rather insidiously : there is a little 

 excitement during the day and sleeplessness at night ; then delirium, 

 and then actual mania ; the pulse is somewhat accelerated, the tongue 

 furred, the skin hot, the bowels costive, and the secretion of milk 

 diminished. It seems to arise from a combination of causes acting 

 upon an originally irritable temperament, but rendered still more so 

 by intestinal disorder and hrcmorrhage, or by tho debility consequent 

 upon suckling. Blood-letting in these cases is generally fatal ; the treat- 

 ment consists in regulating the bowels and preserving extreme quiet of 

 mind and body, with a nutritious but not stimulating diet. 



When speaking of puerperal fever, it was observed that the large veins 

 in the vicinity of the uterus frequently presented traces of inflammation. 

 Uterine and crural phlebitis, however, occurs as a distinct disease, and 

 has been described under the terms of phlegmasia dolens, oedema 

 puerperarum, the white swelling of lying-in women, &c. ; but it is 

 only within a few years that the true nature of this disease has 

 been fully understood, having been first pointed out to the pro- 

 fession by Dr. Robert Lee. It may appear as early as the fourth 

 day after delivery; but, in the majority of cases, it is not till tho 

 second or third week that it makes ita appearance; and, in many 

 instances, attacks women who are recovering from puerperal fever. It 

 is ushered in with rigors, and these are succeeded by heat, thirst, and 

 other symptoms of pyrexia. There is a sense of pain, first experienced 

 in the uterine region, and gradually descending in the course of the 

 iliac and crural veins down one leg, accompanied by swelling, and 

 great tenderness upon pressure along the course of the vessels, which 

 are hard as a cord, and roll under the fingers. In some cases an 

 erythematous redness of the integuments of the limb is met with ; but 

 in the majority they are smooth, shining, tense, and colourless. The 

 power of moving the limb is completely lost, and it is greatly and 

 uniformly swollen throughout its whole extent. Sometimes, after the 

 inflammation has subsided in one limb, the other is attacked in a 

 similar way. The pain and febrile symptoms usually diminish within 

 a few days after the occurrence of the swelling ; but sometimes the 

 pain is excruciating throughout the whole period of the acute stage of 

 the disease. The duration of the acute stago is various in different 

 individuals ; in the greater number of cases it terminates in two or 

 three weeks ; but the limb still remains powerless and cedematous. In 

 some women the limb does not return to its natural state for many 

 months, or years, or even during life. The appearances on dissection 

 which are met with in this disease are similar to those which charac- 

 terise inflammation of the veins generally. The causes of this aflection 

 are supposed to be owing to the orifices of the veins in the lining 

 membrane of the uterus being left open after the separation of the 

 placenta, by which a direct communication is established between the 

 cavities of these veins and the atmospheric air. The treatment of 

 phlegmasia dolens consists in the local abstraction of blood by leeches 

 applied to the groin, and in the course of the large venous trunks of 

 the limb ; hot fomentations to the part, and the administration of 

 diaphoretics and saline purgatives. After tho inflammatory symptom* 

 have subsided, the limb may be supported by a bandugo, and slight 

 frictions made use of. 



There u a disorder occasionally met with in the puerperal state, 



