"I have, in conclusion, to protest against this my attempt being considered as a revival of the follies and errors of humoral pathologists with their four fluid constituents of blood, phlegm, bile, and atrabile; and their cosmic elements, fire, water, earth, and air, their occult causes, and their facile explanations. It has taken nearly 3000 years to convince physiologists that the whole of a living body is alive, and consequently subject to all the impressions and re-actions of the vital power. At first the fluids were the sole seat of life, and then the solids became exclusively gifted; and each hypothesis furnished the root of a branching nosological tree. Latterly, the best modern observers have traced much of disease and morbid formation to disorder in the fluids." 111.

Dr. Ferguson candidly admits that "what he has done he does not consider as new, but looks on it as an attempt to demonstrate what has been hitherto a matter of pure conjecture, and mere opinion." "He has availed himself of the valuable hints and developments in various sources of information, and has endeavoured to probe the views and compare the facts with each other and with his own." He has thus endeavoured to arrive at that great desideratum-" a just theory of this most fatal and most complex malady." In this state then we shall leave the theory in question, in order that it may be put to the test of time and experience. This brings us to the most important chapter of all.

CHAP. V.-TREATMENT.

A statistical or numerical investigation of the various epidemics, in various localities and institutions, gives the melancholy result of one death in every three cases of puerperal fever.

I. PERITONEAL FORM.

Whenever peritoneal pain was evinced, a larger linseed poultice over the abdomen was found beneficial in the Lying-in Hospital, often affording decided and powerful relief.

It should be so thick as to retain warmth for four hours-and sufficiently large to reach from the sternum to the pubes. Where there is obvious indication for venesection, ten grains of Dover's powder may be given when the poultice is applied. A second visit should be made in four hours, when, if the symptoms have been alleviated, a fresh poultice and another powder may be prescribed. If, in four hours, after the second medication, the practitioner is not satisfied that the malady is yielding, depletion must be resorted to at once. The powder may be combined with mercury and aperients, according to circumstances. Numerous cases are detailed, some fatal, others successful. We shall give one as a sample.

"Case XX.-Charlotte Crisby, ætat. 18, February 12, 1829. 13th. On the evening of the first day, after a tedious labour, abdominal pain, extending from the umbilicus downwards, attacked her; the pain was constant, increased by pressure; the pulse full; the whole appearance that of a plethoric person; venæsectio ad deliq., about 3xx were taken away, she did not faint, but the pulse at the wrist ceased for ten minutes. The blood was flat, sizy, and not at all buffed. The crassamentum was firmish; grs. x, Dover's powder every four hours.

14th. In twelve hours from her attack she was free from all pain, but after a

few hours it returned in the right groin, extending all over the belly, up to the very pit of the stomach. It was increased by the slightest pressure, and was attended with painful paroxysms recurring every half hour. Milk and lochia copious; head-ache; pulse 130, feeble: twenty-four leeches. In six hours after this all pain had subsided. Two grs. calomel every two hours; fomentation and poultices.

15th. There was a little soreness; the gums were just touched, otherwise well.

16th. Gums still sore, but no pain any where; well. The milk and lochia natural throughout. MR. CATHCART. Remarks. This is an example of the use of mercury, combined with venesection; it is highly instructive." 147.

The following passage we deem it right to extract.

"The following is the sum of my own experience in bleeding as a remedy in puerperal fever:-Of all the means we possess of arresting this malady, I believe bleeding general or topical to be by far the most extensively applicable. The cases in which it is not so, are exceptions to the rule. Mercury, turpentine, emetics, opiates, sudorifics, &c., have a more limited range of utility than abstraction of blood. But while I admit this, I am equally certain, that large bleeding has not been borne in this malady, generally speaking, during the last twelve years.

Those who have borne it best and required it most, were-1. Those who were originally vigorous, and in whom no chronic ailment of the intestinal canal or lungs previously existed. 2. Those in whom the fever was accompanied by a general turgor of the frame: their aspect being that of a person who has been flushed by running, and forming a marked contrast with the pinched, shrivelled, and stricken looks of those labouring under the typhoid form of the malady. 3. Those in whom the disease seemed to be limited to one organ.

It may be asserted, with more hesitation, however, that they who are confined out of a hospital, exhibit greater reactive powers than those who are confined in one.

The pulse, as Gordon has remarked, is very deceptive; and the cases I have given, shew that painfulness is no sufficient criterion of the necessity of depletion.

Besides these general indications, epidemic puerperal fever, has, invariably, the character common to the ordinary fevers raging with it: if the latter require depletions, the presumption is, that the former will also.

It is curious, that in the majority of cases bled, the blood is neither cupped nor buffed.

The persons who do not bear large bleedings are those attacked by the ataxic or gastro-enteric forms: even though they be of originally strong constitutions : also those labouring under the complicated form, where many organs are, simultaneously, under the grasp of the diffusive malady. But in this last class there are so many shades of disease, that no absolute rule can be laid down.

If large bleeding be determined on, it must, to be beneficial, be resorted to, within the first twenty-four hours of the attack. In the second stage of the disease it is often, rapidly, fatal. If the bleeding be made early, it may be often repeated. It appears, where it does not remove the malady, to stop its progress, and make it continue lingering in its first stage, so that the repetition of venesection is late, only as to the lapse of time, but not tardy, as to the progress of the disease.

Of local depletion by leeching, it may be said, that the cases in all the four forms of puerperal fever, are very few indeed, which do not permit us to resort to it. It often removes a pain which will not yield to blood-letting. The num

ber of leeches required will, of course, vary with the case; in some, six is sufficient; in others, six dozen will scarcely be so. But the average cases will require from two to three dozen." 154.

II. GASTRO-ENTERIC FORM.

In this form the local inflammations are slight and transient, or nonexistent, whilst the general symptoms resemble typhus accompanied by intestinal irritation. Dr. F. considers the disordered secretions the result of vitiated blood, and not the cause of that vitiation. In this respect he differs from Dr. M. Hall, who attributes the disease to scybala and loaded bowels.

"For some of these cases which are not accounted for from the irritation of loaded intestine, Dr. M. Hall is obliged to assume the effects of loss of blood. But these effects, which that eminent pathologist has most ably traced to the impression made on the nervous functions, take place in this form of puerperal fever where there has been no hæmorrhage." 156.

Dr. F. agrees, however, with Dr. Hall as to the treatment of the malady. He thinks active purgatives inadmissible-and when an epidemic breaks out in the hospital, the usual routine of giving the "black-dose" on the third day after parturition, is abandoned. Where accumulations are suspected, castor oil is the safest aperient, guarded by hyosciamus or hop. General bleeding is rarely necessary. The topical inflammation is best relieved by leeches and even these sometimes cause fainting. The nervous system is greatly affected in this form of fever, and the constitution soon pulled down. The strength is therefore to be economized.

"The following I have found the most suitable treatment. Get rid of all local inflammations as soon as possible, by leeching or by moderate depletion, so as to reduce the malady into simple fever, with gastro-enteric irritation. When the skin is early dusky, and there is nausea or vomiting, begin with an emetic. If there be no nausea, nor vomiting, but intestinal flux, with a red tongue smeared with suburra, a large dose of calomel, from ten to fifteen grs. should be given. Small doses create purging, pain, and irritation, while the full dose produces one to six large pultaceous stools, after which the tongue is cleaned, rendered less red, and more moist, and the pulse usually falls. These stools, when examined, appear to contain the fæcal matter suspended in large quantities of mucus and greenish bile, as if the turgid capillaries of the irritated intestinal canal and liver had been freed from their load. In some instances, a repetition only, of the same dose is required to efface the main features of the malady, and to leave nothing but debility to support. In others, after a short respite, diarrhoea recommences, and soon is apt to become colliquative.

For this state, when the secretions are diseased, as well as copious, a treatment essentially alterative should be used, as a combination of Dover's powder, with a mercurial. When, however, the chief danger arises from the frequency and quantity of the flux, it will be requisite to resort to absorbents and astringents. If the debility be great, wine may be freely given with gruel or sago; where it is not, the strength should be supported by soup, thickened with any gelatinous substance, as thin fluids almost always cause immediate purging. At night, when delirium and night-mare, and fantastic visions torment the patient, a full dose of Batleys's sedative, in camphor mixture, strengthened by a few additional grains of camphor, should be given. After the intestinal irritation has abated, tonics may be used, and these are always better borne when ammonia is a chief ingredient." 160.

Several cases are detailed, and comments made by the author, for which we must refer to the book,

III. TREATMENT OF THE ATAXIC FORM.

Great disturbance of function will kill more rapidly than organic changes. The mysteries of the nervous system are yet locked up in Cymmerian darkness! Our author, and every practitioner, have seen death take place in this and other diseases, without any trace being left in the dead body to account for the fatal event. This state was designated by John Hunter"action without power"-it is evidently debility combined with irritability.

"Our practice, then, in the ataxic form of puerperal fever, if it be, as I believe, a malady to which the term action without power' is singularly applicable, is to sustain; where there is sinking, the support must be by stimuli, largely and frequently given. Where there is no visible sinking, then stimuli are not indicated, but sedatives, especially the Batley's laudanum, should be immediately given. When the action is equalized and reduced, nourishing food and tonics may be administered." 179.

Cases and remarks follow, with extracts from various authors.

IV. TREATMENT OF THE COMPLICATED FORM.

It is only in its slighter grades that this form is curable. "Where it is the leading characteristic of an epidemic, the vast majority will die." Fortunately this most fatal kind of puerperal fever rarely constitutes the whole of an epidemic.

"What treatment," says Cruvelhier,* "shall we oppose to purulent infection? To this question experience is as yet dumb, while theory would seem to point to diffusible stimuli and tonics; to ammonia, quinine, and to sudorifics; to hot external applications; to the vapour-bath; to purgatives, especially to emetics; to tartarized antimony, in large doses; to vesicatories, and to strong diuretics. Calomel has been extensively employed to create a fluxion from the intestinal mucous membrane; but all these means have failed as signally in my hands as in those of others. Yet when the injection of putrid matters into the veins of living animals has been followed by abundant, and very fetid evacuations, they have usually got well. It is a fundamental fact of pathology, that the intestinal canal is chiefly affected in diseases caused by any miasmata. The ancients expressed this truth by saying, that the intestinal canal attracted the poison of febrile diseases. I am certain that diseases, resulting from purulent infection, would not be stamped with the seal of incurability—and that nature, seconded by art, would triumph in the majority of cases-if the pus, which is incessantly renewed, did not incessantly renew the sources of infection." 200.

Dr. F. then enquires if there be no landmarks to guide us in discriminating between the fitness of various remedies, as mercury, quinine, emetics, stimuli, turpentine, sudorifics, blisters, diuretics, &c.? He then discusses the merits of each of these remedies allotting to them their due value, and endeavouring to ascertain the circumstances in which they may be advantageously or injuriously administered.

* "Art. Phlebite, Dict. de Med. et Chirurg. pratiques."

1. Emetics. These, he thinks, are most beneficial when the violence of the discase falls on the liver, and when there is early nausea and spontaneous vomiting.

2. Purgatives. "My own experience with regard to aperients is, that whenever they create tormina, there is the greatest risk of an attack of metroperitonitis succeeding. This so constantly occurs, that I invariably mix some anodyne-usually Dover's powder, or hyoscyamus, or hop, with the purgative."

211.

3. Mercurials. Here our author introduces a long dissertation on the action of mercury, derived chiefly from certain lectures delivered by Dr. Farre, and which, amongst some questionable speculations, are to be found many judicious remarks. The continental physicians, as Dr. Ferguson observes, have scarcely any just notions of the physiological effects of mercury on the human system.

"Mercurial action,' says Dr. Farre, is positively anti-phlegmonous. If it be pushed far enough, it produces an effect the exact reverse of this phlegmonous state, namely, the erythematous inflammation; the tendency of which is to loosen texture, while that of phlegmonous inflammation is to bind texture.'” 215.

Besides this, mercury opens and augments all the secretions and excretions, and thus reduces the whole bulk of solids and fluids. There is a period in most inflammations when we are obliged to desist from the lancet without having subdued the disease. Here mercury is an invaluable agent. The following are Dr. Farre's dogmas respecting mercury.

"1. Never to give mercury where there is an idiosyncracy against it.' The following case is illustrative of the danger of neglecting this advice :—

A patient of Mr. G.'s, of the Borough, desired him never to give her any mercury, as that drug was a poison to her whole family, to which he, without arguing the point, at once assented. In Mr. G.'s absence, the late Mr. C. was consulted as to some trifling disorder of the bowels, and not knowing the peculiarity of his patient's constitution, prescribed two grains of calomel. The next morning the lady shewed the prescription to Mr. C., saying that she was sure she had taken mercury, as she felt it in her mouth. In a few hours ptyalism ensued; in consequence of which she lost her teeth, her jaw exfoliated, and she ultimately, after a succession of ailments, died, in about two years.'

2. Mercury should be used in all active congestions-Pyrexia, phlogosis, phlegmon, ophthalmia, strabismus, cynanche laryngea, cynanche trachealis, pneumonia, and in all inflammatory diseases. In the adhesive stages of dysentery, in the phlegmasiæ, where there is inflammation with power, in tetanus, hemiplegia, paraplegia, neuralgia, in their states of active congestion.

3. Mercury is hurtful, or doubtful-In the malignant or asthenic forms of pyrexia, where there is low delirium; but in phrenitis, and in that peculiar form of it, the coup de soleil,' it is most effectual. It is hurtful in tetanus from punctured wound, and in all cases of irritable disease.

In idiopathic iritis, it is as effectual as bark in ague; but in the traumatic it is injurious, as it interferes with the closing of the vessels by adhesive inflammation hence in all hæmorrhage, where the orifices of vessels require to be closed, it is hurtful.

In the hemiplegia of lesion, in asthenic paraplegia, in the neuralgia of intation, it is bad. Poor Pemberton was three times salivated for tic douloureux, and three times the worse for it.