Treatment. —This must be energetic, consisting of quinine, salicylate of soda, narcotics locally, and, especially, fixation in splints or immovable apparatus, perforated so as to allow of the application of medicinal sub stance& When the fever has passed, revulsives are to be used. The tinc ture of iodine, cotton saturated with iodine, vesicatories and the actual cautery may be employed. Trouseau used a poultice composed of four pounds of bread, six and a quarter ounces of camphorated alcohol and thirty grains of the extract of henbane. A poultice is thus made upon which is spread one hundred and fifty grains of the extract of belladonna, with which the limb, reposing on a splint, is enveloped. The poultice is only renewed once in eight days. To prevent it from drying, it is covered by a sheet of oiled silk. The whole is covered with cotton-batting and held by a bandage.
Alkaline baths and sulphur douches are useful, when swelling and stiffness of the joints are the only remaining symptoms. The patients are not to be kept quiet too long. It is, therefore, good, although the limb be left in the splint most of the time, to take it out morning and evening, when the acute attack has once passed, and to subject it to a few slight niovements, limited to the joint.
One sometimes sees, in pregnancy, true gonorrhceal rheumatism, syphi litic rheumatism, such as Dubois and Fournier have reported, and white swellings. White swellings may exist before pregnancy, or, as in a case of Labb/., quoted by Dubois, the white swelling developed in the left knee during the puerperal state of a preceding pregnancy, pursued its course and necessitated amputation during a subsequent pregnancy. The patient, already pregnant three months, submitted to amputation and recovered without an abortion. In another case, quoted by Richet, there was white swelling of the wrist and of the right knee. Richet em ployed igni-puncture. A month later the patient was attacked with acute tuberculosis. She was delivered at eight months and died forty eight hours afterward.
After Confinement.—Braunberger is very wrong in uniting, under a single heading, rheumatoid symptoms occurring after labor, although he carefully divides them into three distinct classes: 1. Articular locali zations in subacute infectious puerperal troubles; 2. Articular localiza tions in acute infectious puerperal troubles; 3. Localizations in non infectious chronic puerperal troubles. Here we have incontestable con fusion.
We must, indeed, carefully distinguish rheumatic disease—developed in the normal course of the puerperal state, and the arthritis of puer peral fever, which Lorain and Quinquaud have called the infections puer peral state. This arthritis, we consider, as do Lorain and Quinquaud,
as the manifestation of puerperal septimemia which attacks the joints as well as the lymphatics, the veins, the serous membranes, the heart and all the other organs, and is either primarily or secondarily developed. But these symptoms have no relation to rheumatism. This arthritis may become purulent, the same as puerperal peritonitis and pleuritis, but has no connection with puerperal rheumatism. Rheumatism may, of course, be developed in the puerperal state, just as in pregnancy, and, when it does so, it has characteristic features. It may be muscular, which is rare, or articular, which is common.
Afuscular Rheumatism.
This form attacks the muscles of the upper or lower limbs, localizing itself in the muscles of the arms or of the calves. To the two cases cited by Warmont and observed in Legroux's service, we e,an add two seen by ourselves, one of which is now under observation. Confined to the calf, in our two cases, the disease showed itself, each time, from the twentieth to the twenty-fifth day after labor, and we might have considered it phlegmasia alba dolens had not the absence of fever and of cedema, and the limitation of the disease to a small area, removed all doubt. We should prefer to call the trouble myodinia of puerperal women, as War mont and Legroux do. In our first case every symptom disappeared at the end of five days, by the application of belladonna and indulgence in rest. Our second patient has only been sick three days. We have just seen a third ease, where the rheumatism had settled in the muscles of the left shoulder after having affected the corresponding muscles on the right side for forty-eight hours. The patient had been confined twenty-four days before. Tha disease disappeared in eight days, under quinine and local narcotics.
Articular Rheumatism.
The characteristic of these cases is their tendency to suppuration. The joint symptoms, appearing from the second or third to the tenth or fifteenth day after confinement, are generally accompanied by a claret red, a blue, or a pale rose color, disppearing on pressure. to soon return. The swelling,unlike that observed during pregnancy, is generally slight,although the effusion be more abundant. The pain is excruciating. The pulse is very rapid, from one hundred and ton to one hundred and thirty-two per minute. The temperature usually keeps pace with the pulse, rising to 104° or even 106° F. Chills are frequent and recurrent. In fatal cases, there is adynamia and delirium, while meningitis is a frequent complica tion. Pericarditis and endocarditis are, also, complications.