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AN
            INAUGURAL ESSAY,

                   ON THE


  PUERPERAL STATE OF FEVER.

                SUBMITTED TO

             THE EXAMINATION

                   OF THE

REV. JOHN ANDREWS, D. D. PROVOST, (Pro Tem.)
                     V
                     THE

    TRUSTEES  AND MEDICAL PROFESSORS

                   OF THE

        UNIVERSITY OF PENNSYLVANIA,

            On the 5th day of June, 1805.

             FOR THE DEGREE




      DOCTOR  OF   MEDICINE,
       By GEORGE E. MITCHELL, L. M.

             OF ELKTON^MAXrLAND.

HONORARY MEMBER OF THE PHILADELPHIA MEDICAL SOCIKTY.
" Errors in theory, seldom fail of producing- errors in practice."
                                    RUSH.
          PHILADELPHIA :
PRINTED FOR THE AUTHOR, BY JOHN H. OSWALD.
1805.   /£<?,-.-/  *— 

 
TO
  DOCTOR  ABRAHAM  MITCHELL,

             OF ELKTON, MARYLAND.


  Dear Sir,

        W HETHER  I contemplate your virtues as a citi-
zen, or your talents as a  Physician, I find you equally worthy
of the highest esteem and respect.

    My gratitude is eminently due to you for your kind and
generous patronage, and  particularly for the many  opportuni-
ties you have given me of becoming informed in my profes-
sion, and for the medical knowledge I have derived from your
private communications,  which I am conscious, being dictated
by your superior judgment,  will be of the highest importance
in the practice of my  profession.

    That you may  continue to enjoy health  and prosperity,
is the cordial wish of
                    Your affectionate Son and Pupil,
THE AUTHOR. 
TO
DOCTOR BENJAMIN RUSH,

   PROFESSOR OF THE INSTITUTES,

                   AND

       PRACTICE  OF MEDICINE,

                 IN THE

   UNIVERSITY  OF  PENNSYLVANIA.
  HONORED SIR,

        X  O YOU, illustrious as a Philosopher, a patriot,
and a citizen, this imperfect essay is inscribed as a small, but
sincere tribute of  respect due to your superior merit, and,  in
gratitude for the principles of my profession,  imbibed from
your  valuable lectures, and for the attention  and politeness
with which you have honored me, in sickness and in health.

    That bounteous heaven may continue to bless you with
prosperity, will ever be the wish of

            Your sincere Friend, and

                   Obliged Fellow Citizen,
GEO. E. MITCHELL. 
TO
DOCTOR JAMES HUTCHINSON,

                OF PHILADELPHIA.

          LATE HOUSE SURGEON,

                       OF

      THE  PENNSYLVANIA HOSPITAL.
         jL  HIS ESSAY is  also inscribed, as a tribirtc of
respect,  for your talents,  and as a mark of gratitude for the
attention and politeness which you honored we with, during m y
attendance as a student at the  Pennsylvania Hospital.....That
your health may be restored,  and fortune be over propitious,
is the sincere wish of

                         Your Friend,
THE  AUTHOR. 
s
PREFACE.
       ** In every work, regard the writer's end,
       u Since none can compass more than they intend™



 X HE  following essay is published in compliance with the
laws of the University of Pennsylvania, demanding an Inaugu-
ral Essay on some medical subject, previously to my receiving
the highest honors of my profession.

  The author is as sensible as the learned critic  will be, that
it abounds with imperfections.....to his friends he  hopes the
short time allotted for writing it.....and  being compelled to
write by the stimulus of necessity, will be sufficient apologies
for its incorrectness. 
           AN  ESSAY
                ON

PUERPERAL  FEVER.
      X HERE are no forms of disease, which demand the
sympathy and attention of physicians more, than those peculiar
to the fair sex.   Their conformation  subjects  them more to
disease ;  and although in the most early periods, as well as in
this enlightened sera, many successful exertions have been made
to alleviate their distresses, yet much remains to be done ; and
when we consider that their diseases constitute so considerable,
and important a part of the practice of medicine ; that physician
is culpable, who neglects to become acquainted with those forms
of disease, to which their peculiarity of structure and conforma-
tion expose them.

   The subject  of this Essay, is that disease which attacks wo-
men in their puerperal state ; hence it has obtained the name
of Puerperal Fever.  It  has been described  by very ancient
writers, under  different names ; some supposing it to bean in-
flammation of  the uterus,  others a suppression of the lochia ;
while others, still more extravagant, described it as being an im-
peded secretion  and metastasis of  the  milk.   And  although
we have many  lamentable proofs of its fatality and devastation,
recorded ;  yet  what is still more  lamentable,  it was seldom or
never treated with success.   On the authority of the ingenious
Doctor Gordon, we find this disease very fatal in Paris, as late
as the years 1746 and  1750, and that no one who was attacked
with it, recovered. 
(  8  )
  Doctor Hunter says, that in the Lying-in Hospital, of Lon-
don, in  the space of two months,  thirty two patients were af-
fected with this disease, and only one,  of that large number,
recovered.  And  in another Hospital,  nineteen were seized
with it,  during the epidemic season, of whom thirteen died.

  The yearly bills of mortality, for the cities of London, and
Westminster, (en the authority of Dr. Leake) are melancholy
testimonies of the inefficacy of our science, in  this disease.
From December  13th, 1768, to December 12th, 1769, died  of
this fever, one hundred and eighty five.  From December 12,
1769, to December  11th, 1770, died two hundred and seventy;
and from December 11th,  1776, to December 10th, 1771, died
one hundred and seventy-two.

  Doctor Gordon says, that one of the Professors of midwifery,
in the University of Edinburgh, declared the puerperal fever
incurable ; and another Professor, of the same University, con-
cludes his observations on it, in the following words.  " From
" the above cases, and from all that has been yet written upon
u this subject, we may, with great truth, conclude,  that we
" know little of the nature and still  less of the cure,  of puer-
" peral  fever."   And in the practice of Doctor Gordon, who
was most successful in this  disease, twenty-eight died, out of
severity-seven.

  I have perused no author on this subject,  who does not con-
sider it as a dreadful and fatal disease.   That a disease,  so re-
markable  for its  fatal termination, should excite  the attention
of the faculty, is not to be wondered at;  and consequently, in
eveiy age, we find some guardian of our science, endeavouring
to impede its progress ; a noble attempt, to meliorate the dis-
tressed condition of humanity, and alleviate the pains insepa-
rable from existence !  The intimate connection between the
body, and the mind, and their reciprocal dependence on each
other, prove health to be essential to the happiness of man. 
C  9  )
  Erroneous and  imaginary theories have been taught, and
received as orthodox, which have too long retarded  the pro-
gress of our science, and superceded a  theory formed on ra-
tional inductions from established facts.  " Errors in theory,
seldom  fail of producing errors in practice."   The great  ne-
cessity of a theory formed on the solid  basis of established
facts, which  would  guide to a successful  practice,  has been
acknowledged by some,  as the greatest desideratum  of  our
science.   Yet, how much has been said against theory in
medicine ?  Is it  not to a knowledge of the theory or  princi-
ples of  navigation, that  we are indebted  for the many  advan-
tages we now enjoy,  by  our  commercial intercourse with
different parts of  the globe ?  Great and important advantages
arise from just principles in medicine.  An American theory,
which teaches unity and simplicity  of disease,  will lead to a
successful practice.

  Puerperal  fever has  been the subject of great diversity of
opinion.  The erroneous  theory of the putrefaction  of  the
blood, as  taught by the great Boerhaave, induced many to con-
sider it  a  putrid  disease:  this is the offspring of ignorance ;
for putrefaction of the blood is incompatible with life.  Others
have considered it a highly inflammatory disease; this is mora
rational, and I admit, is frequently the case.  I  feel  happy in
having  my knowledge of this disease deduced from a theory,
which experience has taught, leads to a successful trei tment.
It is that theory which is taught by the Professor of the insti-
tutes and of the  practice of medicine,  in the  University ot
Pennsylvania, which teaches disease to be an unit, consisting
in a morbid, irregular,  and  convulsive  tction,  in the sangu:-
ferous  system, whether consisting  in an  excess or defect of
action.   It breaks the fetters of nosological arrangement, and
banishes the absurdity of prescribing for the name of a disease.
It confines the attention to the  pulse, the  Chronometer of
life ; the degree of morbid action in the system ; the sensible
                            B  * 
(  i©  )
qualities of the atmosphere ; a knowledge of the structure of
the human body, and the laws of animal life.

   The ingenious, but unfortunate, Dr.  John Brown,  and the
illustrious Professor Rush, declare animal life to be a forced
state, the effect of stimuli acting on a peculiar organization of
matter, which enables it to emit  life.  This susceptibility of
matter, to take on life, is properly  called excitability,  and the
effect of stimuli acting on it, is called excitement, which is life.

   In health, when all the functions of the body and mind are
performed with regularity,  there is a just ratio, between  the
action of stimuli, excitability and excitement*   An increase
or diminution of stimuli will produce  debility, which,  when
induced  by excess of stimuli,  is  called  indirect  or  debility
from action; when from an  abstraction of stimuli, direct or
debility from abstraction ; both of these are succeeded by in-
creased excitability ;  this is not  equally diffused through the
system ;  but  abounds in parts most debilitated ; hence the
concentration of irregular morbid excitement, that follows the
application of disproportionate stimuli.

   Puerperal fever generally makes its  attack  on the  evening
of the  second,  or commencement of  the third day, to the
sixth after parturition; a  time  when  the solicitous mother
anticipates alleviatioa from trouble and pain,  which she  has
borne with so much anxious fortitude ; but alas! her libera-
tion is often the exciting cause of a much dreaded disease.—
It generally commences suddenly, with violent rigours, which
are succeeded by a violent reaction of  the heart, and  arteries,
remissions, and exacerbations often alternating.   The  pulse
indicates much disease,  and is generally, at the  commence-
ment, Synocha, Syuochula,  or Typhoid. 
(  11  )
  The  abdomen is affected  with continued and excruciating
pain,  it is extremely  sore on pressure,  which characterises
it from after pains.   It often suffers tumefaction.

  Excessive pain in the back, and lower extremities, and swol-
len legs are often concomitants.

     Great nausea, and bilious  vomiting, often attend, and
sometimes the  alimentary canal  is affected  with profuse
diarrhaea, and not unfrequently tenesmus, and obstinate  cos-
tiveness.

    In the onset of  the  disease,  the  tongue  is furred and
white, but at  the close, it often assumes a dark brown color,
is rough and dry, accompanied with excessive and distressing
thirst.

   The face is often flushed, and  as the disease progresses,
the countenance becomes sorrowful, with great dejection  of
mind.
          " The cheerful, pure and animating bloom,
          " Dies from the face ; with squalid atrophy
          " Devoured, in sallow melancholy clad."

   The  skin is hot and dry, partial  sweats often occur, and
when cold, and confined to the face,  and breast, are harbingers
of imminent danger.

   A  great and sudden  prostration of strength,  accompanied
with  inability  to turn in bed, frequently  attends through  the
whole course of this disease.

   Respiration is laborious and hurried, attended  with  cou.;h-
and great pain. 
(  12  )
   The head sympathises ; on the commencement, the pain is
generally confined to the anterior part of the cranium,*nd when
the system is almost sunk under accumulated evils, the facul-
ties and operations of the mind become deranged.

   The lochia,  or  customary discharge from the uterus after
parturition, is seldom suppressed, and in proportion to the ad-
vancement of the disease, this uterine discharge often becomes
vitiated.

   The secretion of milk is seldom suppresscd,.....often lessen-
ed, and much altered in taste and color.

   The urine is often evacuated with great difficulty, which is
small in  quantity, and of a high color.

   The blood drawn indicates high morbid excitement. Hulme
and  Leak always found the blood sizy.  Doctor Gordon says,
that blood drawn in this  disease resembled  that  of patients
in  pleurisy and  rheumatism,  having  a  very thick inflam-
matory  crust.   I  have  seen blood  drawn  in  this disease
exhibit the  above appearance, and  in one oase  it was dis-
solved.

   The appetite forsakes the patient at the first attack. Sleep
is confused,  broken and interrupted with startings  and dread-
ful dreams.   In sleep the mouth often remains open,  and the
eyes half closed.

   The sweats now become  cold, viscid and clammy ; rigours
return, the  tongue  and teeth are covered with a dark  slimy
sordes; petechias, irruptions, singultus, facies hippocratica,
insensibility, derangement of mind, involuntary   discharge
of faeces,  and urine, cold extremities, loss of sight, and con-
vulsions close  the  melancholy  scene, and death  brings re- 
                         C   13  )

Kef to the  poor afflicted patient, who has suffered  indescriba-
ble torture.

   Thus the most prominent symptoms, which accompany this
disease, have been enumerated;  many of  them I have  wit-
nessed ; they will vary according  to the constitution of the pa-
tient, the grade and period of the  disease.

   If the distressed patient  withstands  the dreadful  conflict,
it is generally owing to the interposition of  some profuse  cri-
tical discharges ; profuse vomiting, and diarrhaea, perspiration,
hemorrhagias,  translation of  morbid  excitement to the ex-
tremities, or other parts, in form of erysipelas or abscess, have
all produced favorable terminations.

  This disease is  of  short duration,  when unassisted by art.
It  sometimes terminates in  twenty-four or thirty-six hours.
Gordon says more than one half die on the fifth day; this day,
u  therefore," says he  " may be  deemed the principal of the
^ fatal critical days, and it is likewise the principal  critical day
" when the crisis is salutary."  But death often terminates the
scene, at a more distant period from the attack ; and, when it
terminates in her favor, her recovery will be very  tedious, re-
quiring great attention to remove  the supervening debility.

  Many  of the customs and  modes of living, which result
from civilization, dispose  our  females  to many diseases from
which those in a state of nature are exempt; those are pecu-
liarly liable to this disease, who are of a very delicate confor-
mation, whose  minds have been saddened by the depressing
passions and emotions, and who have been subject to maltreat-
ment during pregnancy and parturition.

  The predisposing cause of this disease is debility : which,
whether from an excess or defect  of stimulus, is indispensably 
(  14   )
necessary to produce disease.   We often find it existing in an
eminent degree, after parturition, but more abundantly in the
contents of the abdomen and pelvis ; therefore, when morbid
or irregular excitement is produced by an exciting cause, they
must suffer a concentration of it.

   Exciting causes of this disease, are such as, acting on the
body when predisposed to disease, produce morbid or irregular
excitement in the system.

   In this disease, as  in  many others, the  effect has  been
considered as the cause ; hence we  find,  that  a suppression
of, or vitiated lochia, impeded secretion or metastasis of the
milk, inflammation  of the  uterus,  and of the peritoneum
and its  reflections, have all been considered as causes of this
disease.

   Doctor Leak says, that the lochial discharge often contin-
ues throilgh the whole course  of this fever, often of a natural
smell and appearance,  and frequently faetid, without produc-
ing disease.

   I  have attended several patients  in  this disease ;  in two,
the lochia, continued through the whole progress ; and in two
others it was not suppressed 'till an advanced stage of the fe-
ver.  Hulme paid no regard to obstructed lochia; he consider-
ed it the effect, not the  cause of this disease.

  This  disease is frequentlyproduced before there is a sufficient
time for the secretion of milk, or any morbid change in that
fluid. Many have a plentiful secretion of milk, which continues
till the fever is considerably advanced, and a suppression  of  it
seldom  produces  disease. 
(  J5   )
   The inflammation of the uterus, omentum,  and perito-
neum, which has  been considered as the cause of this dis-
ease, produced by a sympathy of the constitution with these
parts,  may, with  great  propriety, be considered  as the  ef»
feet  of an idiopathic, increased and irregular excitement in
the sanguiferous system, invited to those parts by accumulated
excitability.

   The causes of this disease  may be referred to  two general
classes.

     1st.  Those which occur previously to parturition.
     2d.  Those occurring after parturition.

   1st.  Many of the causes existing previously to parturition,
arc,  principally from the gravid  uterus, and are to be remov-
ed only by  delivery.....They may be alleviated by proper reme-
dies.....They are collections of indurated faeces, nausea, vomit-
ing, diarrhaca, suppression of urine, and stranguary, all of which
should be particularly regarded,  as  they predispose  much to
the formation  and violence of this  formidable complaint.—
Improper diet,.....improper exhibition  of stimulating and cor-
dial  potations,.....apparel too light and not accommodated to the
vicissitudes of the climate,.....want of cleanliness,.....a damp un-
healthy atmosphere,...alternation of heat and cold,...violent and
harsh treatment of the accoucheur during parturition,....injury
sustained by very laborious and preternatural labors,....violence
offered in extracting the placenta,....may be considered as cau-
ses of this malignant and fatal disease.

   2d. Causes  which produce this disease, after parturition,—
are, excessive Jieat from the pressure of bed-clothes, and con-
fined air  ; hence more common among the poor, and, in con-
fined hospitals. 
(  16  )
  Epidemic constitution of the atmosphere.  This fact jvas
known even to Hippocrates, and  Sydenham ; and every ob-
servant American physician, must have noticed the influence
of the constitution of the atmosphere, which produces our ma-
lignant fever, in puerperal women.

  Errors in diet, as well as free indulgence of spirituous li-
quors, are, too frequently, exciting causes of this disease.

  Tight bandages, or ligatures to the abdomen ; injuries done
to the uterus, by pressure, or difficult parturition ; or,  accord-
ing to Dr. William Hunter, too easy  parturition, whereby
there  is no reaction, to remove the disease of  the uterus from
gestation, by the depletion of the lochia.  This reaction is un-
necessary, where venesection and low diet had preceded.

  Many other causes  excite this disease, which is violent and
rapid,  in proportion to the predisposing  debility, and the force
of the exciting causes.
Appearances on  Dissection.
  Great information of the seat,  and violence of disease, may
be discovered, from an accurate investigation of  the  human
body, after decease ; and  it may be  justly said, that a negli-
gence, in this particular,  has much retarded  the progress of
medical science.

  Dissections of puerperal dead, have led to a pretty accurate
knowledge of this disease, and to a successful mode of treat-
ment. 
                         (  IT   )

   The contents of the abdomen exhibit  congestion, inflam-
 mation,  suppuration,  and mortification;  the certain effects
 of great excess of morbid excitement.  The abdomen  often
 contains pus,  and serous fluid, and emits,  when opened, a
 very  faetid  gas.   The peritoneum,  and its productions, the
 omentum, mesentery,  and  mesocolon, are  always,  much
 diseased.

   The  thorax generally exhibits marks  of high inflamma-
 tion.

   A dissection recorded by Doctor Gordon, of a patient who
 died on the fifth day, will give a  just idea of the violence of
 this disease.

    " I  found the peritoneum and its productions  ; the omen-
 "  turn, mesentery, and mesocolon, in a state of inflammation.
 "  The omentum had lost about half  its substance, by suppu-
 "  ration ; the  mesentery and mesocolon, and that part of the
 "  intestinal canal, with which they are connected,  were very
 "  much  inflamed.  But the disease appeared more especially
 "  to occupy the right side ; the right ovarium had come to a
 "  suppuration ; the colon, from its caput,  along the course of
 "  the ascending arch, was  much inflamed, and beginning  to
 "  run into gangrene.  A large quantity of pus, and  extrava-
 "  sated serum appeared in the cavity of the abdomen, which,
 "  when  taken  out and measured, amounted to two  English
 "  pints.   The peritoneal  coat of the uterus, was inflamed,
 "  and the organ itself not  so compact and  contracted,  as it
 "  ought  to have been.   Upon opening it, its cavity was found
 "  covered with a black coloured substance, which at first sight,
 u  had the appearance of mortification, but when wiped off, was
 (:  found  to be  nothing else than membrana decidua, in the
•< state in which it naturally is, about this time."  The  vio-
                           C * 
(  18  )
fence and rapidity of  this case,  as related by this ingenious
author, is a convincing proof, that it is often of a highly  in-
flammatory nature.

   It is observed  by the ingenious physiologist,  Mr. Hunter,
in his treatise pn inflammation,  " that when the attack upon
" these organs, which  are principally  connected with  life,
" proves fatal, the effects of inflammation upon  the constitu-
" tion, run through all  the  stages, with more rapidity, than
" when it happens in other parts ; so that at its very begin-
" ning, it has the same effect  upon the constitution, which is
" only produced by the  second stage of inflammation, in other
" parts."  This being a fact, and in this disease, a concentration
of morbid  action falling on parts so essential to  life, accounts
at once for its violence, fatal and  rapid termination  ; which
must be  much accelerated  by  the previous situation of the
sufferer.

   As was  before observed, many opinions are  extant,  with
respect to this disease.

  That which supports its putrid nature, is incompatible with
life ;  as has been proved by  the  ingenious Doctor Seybert  of
Philadelphia, in  his experiments on  the blood.  «And the
" symptoms which have been  supposed to designate a putrid
" fever, are  wholly the  effect of  mechanical action in the
" blood vessels, and  unconnected with the  introduction  of
" a putrid ferment in the blood."   That state of fever, which
has been  denominated putrid,  has been happily called by the
illustrious Professor of the institutes of medicine,  the gangren-
ous state of fever.  " For what appears  to some physicians,
" to  be signs of  putrefaction,  are  nothing but the issue of a
" violent  inflammation, left in  the hands of nature, or ac-
" celerated by  stimulating  medicines.   Thus the sun, when
« viewed at mid-day, appears to  the naked eye,  from the ex- 
C  19  )
« cess of its splendor, to be a mass of darkness, instead of an
« orb of light."

  Another opinion  of this disease being highly inflammatory,
I admitted to be rational and just;  for the pulse is often sy-
nocha, synochus and synochula.  The symptoms,  the appear-
ance of blood drawn, and successful remedies, prove it often
very inflammatory, or a disease of great morbid excitement.
But it often commences with the typhus form, and the inflam-
matory action quickly passes to  the typhus state;  which is
known by a frequent  and quick  pulse,  a great disposition to
sleep, a torpor  of the  alimentary canal,  tremors, partial and
clammy  sweats, petechiae,  singultus, and often a profuse
diarrhaca.

  Having  finished the history, symptoms,  and causes of this
disease, with the appearance on  dissection, I now proceed to
the curative indication, which must be divided into

  Remedies for the inflammatory, ...and

  Remedies for the typhus state of this disease.

  1st.  Remedies for the inflammatory puerperal fever. These
are, such medicines as lessen, by the abstraction of  stimulus,
the morbid and excessive action of the blood-vessels  ; and re-
medies which direct local congestion and serous effusions from
vital parts, to such as  are less  essential to life: viz. 1st. Blood-
letting.   2d. Cathartics.  3d. Emetics.  4th.  Blisters.  5th.
Sialogogues.

  When diversity of opinion exists, relative to the nature  of
a disease, the same diversity will exist in the modu3  medendi.

   1st.  Blood-letting, in this disease, has been violently op-
posed by many authors, and  practitioners in medicine. Others
have strongly advocated the propriety of using it.  Leak and 
(  20  )
Gordon have said much in its behalf.   The great propriety of
using it, is indicated by the pulse, the appearance of the blood,
and the success  which attends its proper use.  The long and
successful practice  of Dr. Rush, and a number  of eminent
physicians, in this  disease, establishes its efficacy,  beyond a
doubt.  Its indispensible necessity  is pointed out by the vio-
lence and rapidity of the  disease,  which demands  the most
prompt and powerful  remedies, to save the sinking,  suffering,
and  frequently,  lovely patient.   Dr. Gordon  seldom failed  in
effecting-a cure,  when he was permitted to follow  his inclina-
tions in the treatment of this disease.   Blood-letting  is the an-
chor of hope, in this, and many of  the most  fatal complaints,
which afflict mankind ; and when we hear and read of its want
of success, in the hands of many physicians, we  must attribute
it to an injudicious use, as  to time, and quantity.

  Botallus says, bleeding is more beneficial than  all other reme-
dies, provided it  be seasonably employed, and in due  quantity:
but I am of opinion, says he, it sometimes does no service, either
because practitioners are too late in having recourse to it,  or
use it too sparingly, or commit some  error in both these par- .
ticulars.  For,  if a disease, which requires four pounds of
blood to be taken away, in order to cure it, and only  one is
taken away, destroys the patient, it does not prove destructive
because bleeding was used, but because it was performed in
an improper, and perhaps, in an unseasonable manner. Dr.
Gordon says he found Botallus* observation  applicable  in the
puerperal fever.  Who can restrict the time and  quantity of
of blood to be effused in a  raging or malignant fever ? " Pro-
per remedies in  their proper places, constitute  the perfection
of medicine."   The state of the system  must  be  the lancet's
chronometer. This remedy supercedes all others,  when justly
proportioned to disease.  It renders, the  exhibition  of  other
remedies more  effectual: and knowing this fever to be an irre-
gular and convulsive action of the arterial system, the effects 
(  21  )
of proper bleeding,  will be as effectual in curing, as the re-
moval of mechanical bodies would be to lessen irritation, which
depended on them.                         '

   To fully contrast  the  practice of those physicians who are
opposed to blood-letting, and make improper use of it, with
the practice of those who employ it properly, would effectually
 convince the sceptic, of its transcendant efficacy :  but the li-
 mits allotted to this essay, will not permit:  let it suffice to say
 that success almost always attends its proper application ; want
 of it  is generally the effect of the neglect of its improper em-
 ployment.

   Several casesof this disease occurring, whilst I was engaged
 in writing this essay, I will  relate one,  in which this remedy,
 I  am convinced,  saved the life of the patient.

   This patient, Mrs.  V. was attacked, several days after a te-
 dious parturition, with violent rigours, succeded by excessive,
 irregular,  and convulsive  action  of the arterial  system: her
 head, back and abdomen were affected with  excrutiating  pain ;
 her face was much flushed ;  she was extremely restless ; her
 mind much agitated ;  her pulse,  synocha.   In this situation,
 I found her, on the night  of the  13th of April.   I bled  her to
 5 xxv. Her pains were much alleviated ; her pulse was not so
 much reduced as I had expected, from this evacuation : she
 expressed  herself much  relieved.  A cathartic of ol. Ricini
 was  ordered,  which operated well, during the night.  On the
 14th I visited her early in the morning: she had passed a very
 restless night: the state of her system was  nearly the same as
 I found it  the preceding night.   I  bled her this morning, to
 2- xxv. which had the desired effect.  Her  pains immediately
 left her ; her countenance  was more natural; and she said she
 was  much relieved ; her pulse was much reduced.   I ordered
 Other depleting.remedies. 
(  22  )
   In the evening of the same day,  I visited her, at 6 o'clock ;
her pulse was synochula;  slight pain in her abdomen: J vi. of
blood were taken  this evening, with  manifest  advantage.  I
now considered her free from the imminent danger I had found
her in, and that the diseased action, remaining in her system,
might now be trusted to milder remedies.  On the 18th, her
pulse was typhoid;  epispastics were applied to her arms, which
were effectual in translating^the morbid excitement.  The next
morning I found her free from fever, and thought it unneces-
sary to continue my attendance.   In  this patient,  the  lochia
was  discharged in  its usual quantity,  during her illness ; the
milk appeared at its usual time, and continued.

  This case, with  many  others which have come under my
immediate attention,  have convinced  me  that the theory and
practice I have recommended in this disease, are correct.

  The many cases of this  fever which  occur at the Philadel-
phia Dispensary, I am informed by my ingenious friend  and
fellow student, Mr. Samuel B. Smith,  of that institution, ter-
minate favorably, the consequence  of similar practice.

  Another case extracted  from my  note book, I  think well-
worth relating ; as further demonstrating the great success of
this remedy,  when indicated.  October 20th, 1804,  Mrs. S. a
woman of delicate constitution, was seized thirty-six hours after
delivery,  with a violent chill, which continued several hours ;
and was then succeeded by a very violent fever.  I  was called
to see her the next  day ; her  pulse was quick and very  tense,
in frequency about  100 in a minute ; her abdomen much tume-
fied, and  excessively  painful, excruciating pains in her loins
and  extremities.  I  bled  her to gxvi.  which much relieved
her;  other evacuating  remedies were  prescribed.   I visited
her  again  on the  22d, and found it necessary to repeat  the
bleeding, she was much relieved by it, and continued  better 
(  23  )
during the day.  A return of her complaint  with encreased
violence,  made it necessary for me to visit her in the night.
I then had recourse  to the lancet with very great advantage
to her ;  I ordered a continuation of other depleting reme-
dies.

  On the next day at three o'clock,  p. >r. it was necessary to
repeat the bleeding,  which was so effectual in subduing her
disease, that my further attendance was unnecessary.  Having
not mentioned the quantity of blood drawn at each bleeding,
I will just observe, that I was governed entirely by the pulse
and state  of the system : and I  am fully convinced that those
authors and practitioners, who are opposed to this safe and ef-
fectual remedy, have  done and will do much injury by neglect-
ing its proper use.

   Blood letting in this  disease must be assisted by other indi-
cated remedies ; good  attention from the attendants is of the
greatest importance,  without which, the most effectual reme-
dies prescribed by the most eminent Physician will be of little
importance.  A  case  which terminated in death, which the
ingenious Doctor  I. Stuart of Philadelphia, favored me with,
will evince the helpful tendency of this remedy, the violence
 of the  disease, and  the indispensible  necessity of proper
attention  to the  patient,  and to the directions  of the  Phy-
sician.

   On the 23d of July,  1804,1 was called to visit Mrs. P.......r;
she was apparently of a sound constitution, and about 24 years
of  age.   She  had been delivered by a midwife,  of a healthy
child, on the 21st of the  same month.   On the night of the
22d,  she was attacked  with a chill,  which  was succeeded by
fever, a pain in the head, back and abdomen,  and  considerable
thirst.  Her  countenance was  flushed,  the  eye watery,  and
the sclerotica a little  suffused  with  blood.   The respiration 
(  24  )
was  rather  short and oppressed.  The  pulse was full  and
strong.  The tongue  white and moist, and  the intestines
bound.  The lochia continued in a usual quantity.  She was
ordered to lose sixteen ounces of blood, and  to take a gentle
cathartic.   On the 24th, the medicine had  operated several
times, the pain of the  head was much relieved, but the pulse
continued active.  The  lochia were stopped.   She was direct-
ed to lose eight ounces more of blood, and to take some  ni-
trous powders.  On the morning of the 25th,  she had  had a
refreshing night's rest, was nearly free from all pain and fever.
She  was ordered to continue the  nitrous powders.   On the
afternoon  of the  26th,  I was sent for to visit her, in conse-
quence of a recurrence of the former symptoms, which  were
now  attended with a distressing vomiting, and anxiety  about
the precordia.   These symptoms had  taken place  about nine
o'clock in the morning of the same day.  She justly imputed
them to her having eaten plentifully of dried beef, and drink-
ing some anniseed cordial  on the evening of the 25th,  saying
she had soon after been seized with a burning sensation in the
stomach.  Her stomach was  so irritable, as to  eject  every
thing that was taken into it.  Her countenance  was flushed
and fierce.   The pulse was corded and active, she was affect-
ed with anxiety and sighing, pain in her head and back, with
great prostration of strength.   She was directed to lose twelve
ounces of blood, to have a blister applied to the region of the
stomach, and to take four grains of calomel every three hours.
At ten o'clock she had  an alvine discharge,  which was very
offensive, and dark colored. The vomiting had ceased  about
two hours before.  She sighed  much, and her restlessness and
anxiety were still distressing.  The skin was cooler ; the pulse
less active, but still corded and hard.   Blisters were now order-
ed to the extremities, and the calomel repeated.   On the 27th,
in the  morning, the blisters on the extremities had not  taken
effect.   The countenance was cadaverous, and the eyes glassy.
The extremities were cold, and bedewed with a clammy sweat. 
(  25   )
The pulse was tremulous, and at intervals,  scarcely  percepti-
ble.  She was affected with a low delirium, with a desire to
get out  of  bed ; harrassed with  a distressing hiccup, and
constant  inclination to vomit, without discharging any thing
except mucus,  and the liquids she had taken in.   The blis-
ters were removed, and in their places fresh ones with a quan-
tity of the oxymuriatx  hydrargyrus in  each, put  on.  The
calomel  was continued,  in doses of eight grains each.   This
was ordered to  be accompanied with large and often repeated
mercurial frictions, joined to sinapisms and jugs of  hot water
to the feet.  About twelve o'clock she vomited up a consi-
derable quantity of black matter, and at about 5 p. m. expired
 under that  discharge.

   If from an error of the nurse, in exhibiting her  misplaced
food and cordial, the exertions of a  successful and eminent
physician, were rendered ineffectual, how easy is it to account
for the bad  success of those physicians, who, influenced by  er-
roneous theories, or none at all exhibit  without regard to the
state of  the  system, opium, bark,  wine, their stimulating
draughts, boluses, &c. !
   Blood letting is  more effectual than all other  remedies,
 when the quantity, and time necessary for using it, are  re-
 gulated   by existing circumstances.   But when improperly
 employed,  is very injurious, and often fatal.
    " For the best medicines  improperly prescribed,  are  the
 greatest poisons, and the greatest poisons, properly prescrib-
 ed, are  the best medicines."

                    2d. Cathartics,
    Are the  next remedy which demand our attention in this
 disease. They " are useful in discharging acrid faeces, and
 « bile,  from the  bowels, in fevers.  They act, moreover,  by
 » creating an artificial weak part,  and thus invite morbid ac-
                             D * 
(  26  )
" tion from the blood vessels  to the bowels.   They likewise
" lessen the quantity of blood, by preventing  fresh  accession
" of chyle being added to it."

  This  disease terminating often favorably, through the  in-
tervention  of a profuse diarrhaea, early  induced physicians tq
place much confidence  in them.  They are of much advan-
tage in this disease, when prescribed properly, and much  ad-
vantage is to be expected from them, when used as  assistants
with other remedies.

                    3d.  Emetics.
  " They discharge offensive and stimulating matters from
" the stomach ;  they  lessen the fullness of  the  blood ves-
" sels,  by determining  the  serum  of the blood through  the
" pores ; and they equalize the excitement of the system,  by
" inviting its  excessive degrees from the  blood vessels to  the
" stomach and muscles."

  They have been used by  many  physicians as auxiliaries
to other remedies in the cure of this disease ; and some have
trusted the  cure to  emetics alone.  As  this  disease often
takes on the  typhoid form, emetics  will in  this  state be  of
peculiar service,  and  have  been  considered  by  Professor
Rush, as very effectual in untying the typhoid knot.

  Mr. Doulcet, doctor regent of the faculty  of medicine   at
Paris, and one of the physicians of the Hotel Dieu, depended
entirely on emetics of ipecacuanha in this disease ; he exhibit-
ed one immediately after the attack, and repeated them often ;
he was generally  successful.  As  assistants  in the cure   of
this disease, I consider them very valuable remedies.

  I am unable to attribute any specific virtues to ipecacuanha
in the  cure  of  this disease ;  but consider  other emetics
equally  as  efficacious,   when used  in  their  proper  place ; 
(  27  )
and they who trust to them alone, will often find them  an
ineffectual remedy,  and always improper in fevers of great in-
flammatory action.   They may be often exhibited with great
advantage in small and repeated nauseating doses, when, gene-
rally acting as diaphoretics, they abstract a portion of the fluid
parts of the blood, and reduce the morbid action of the blood
vessels.
                    4th.  Blisters.
    The great  advantage and efficacy of blisters in many
diseases, has  rendered  them a most important  acquisition
to the materia medica ; and when their time of application is
regulated by the state  of the system,  we have a very valu-
able remedy in this disease.   This state of the system  has
been judiciously called the blistering point.   Their application
is always improper, unless they are  able to counteract  the
morbid  action of the system.   They  are always proper in
weak morbid action.  They  have generally been  applied to
the abdomen, but  their  effect will be equally  efficacious, if
applied to the extremities ; and  the patients'  sufferings  will
not be so great.  They translate  morbid  action, and  con-
vert a centripetal into  a centrifugal disease.  Their  applica-
tion should be repeated often, according to circumstances.

                   5 th.  Sialagogues.
   Under this  class I  will confine my  observations to mercu-
 ry, which may justly  be considered  as  a most valuable re-
 medy in the treatment  of fever.   Experience has established
 its efficacy in curing the  most powerful forms of disease in
 the catalogue of human calamities, and I may  say with pro-
 priety, that  there is  no medicine in the  materia  medica
 more deserving of the panegyrics  which have been bestowed
 on it.
   Its  success in this,   and every form of disease,  depends on
 a proper exhibition as to time and quantity ; when given  as a 
                        (  28  )
                                                              i
3ialagogue in cases of high morbid action, its effects  are in-      ^
jurious, unless the system is reduced to the  salivating point
by  the most effectual  depleting  remedies. • It acts by in-
ducing a counteraction in the system, and " by  exciting and
" inflaming  the  glands  of  the  mouth  and   throat :  excite-
" ment and  inflammation  are abstracted from more vital
" parts."   In many instances  experience has proved this
medicine  very  effectual  in curing this disease, and when
milder remedies  fail, it ought always be  resorted  to  by
Physicians.
                                                              I

                      REMEDIES

                        FOR THE

    TYPHUS  PUERPERAL  FEVER.
  When this disease commences with, or assumes the typhus
form, which is known by the before mentioned symptoms ;
the indication of cure is to make use of such remedies, as by
" exciting action in  the  stomach,  bowels,  brain,  nerves,
" muscles and skin,  equalize the excitement of the whole sys-
" tem, and thereby  indirectly destroy a weak, but morbid ac-
" tion in the blood vessels, by imparting to them more vigorous
" and healthy action.

  These  remedies  are called stimulants,  and divide them-
selves into those which are used internally, and those which
are  applied externally.  Those which are used internally are
opium, fermented and distilled liquors, camphor, aether, Peru-
vian bark, Colombo,  rad. serpentar :  mercury and many other
valuable remedies under this class, which may be alternated
with advantage.  Much caution and attention is necessary in
the  exhibition of stimuli in this  form of disease ; they should 
(  29  )
be accommodated to the excitability of the system ; it is pro-
per (unless the excitability  is  exhausted) to  begin  with the
mildest stimuli,  and accommodate their exhibition to existing
circumstances.  Stimuli are always improper unless they ren-
der the pulse slower and fuller.

   Opium will be found very effectual in the typhus state of
this fever,  much attention is necessary to the pulse, and repe-
tition of this medicine  which ought always to repeated before
the exhaustion of the previous dose.

   Wine and porter will be  found  of great  importance ; and
should be given in large quantities, as the state of the system
will permit ; very  large quantities of wine may be given in
this form of fever without producing intoxication.  The Peru-
vian  bark, Colombo  root,  Virginia  snake  root, and their
many valuable substitutes may be used in rotation.   Much ad-
vantage is to be expected from pure air, and nourishing diet.
Mercury being a gradual and diffusible stimulant,  may be of-
ten used in this disease with great advantage : it ought not to
be given to produce a salivation, but just to excite and preserve
an irritation of the  mouth.

   External stimuli,  are,  blisters,  cataplasms, warm and hot
bath,  all  which in the  hands of physicians acquainted with
the principles of their science, may be used with advantage.
                     Prophylaxis.


  It is the duty of every physician to endeavour to prevent a?
well as to cure, this disease which, notwithstanding the inde-
fatigable exertions of the most eminent physicians, will often
terminate fatally. 
(  30   )
   rt should be guarded against by avoiding all the predisposing
and exciting causes.

   It may often be prevented  by  good  nursing,  cleanliness,
lenient cathartics, and blood letting, according to circumstances.
A costive habit of body, stimulating potations and diet, all sud-
den affections of the mind are particularly to  be cautioned
against.  Bandages applied to the abdomen too tight, confined
air, too much heat or cold, must be avoided with  care.  Too
much attention cannot be paid to  the prophylaxis of this dis-
ease, for by necessary attention previously to, and after parturi-
tion, one of the most fatal diseases which the female  sex are
subject to,  may be avoided.
  I now with regret,  bid adieu to you,*enlightened and illus-
trious Professors.  I should be  extremely  ungrateful and un-
worthy the numerous benefits I have received, if ever my re-
spect and esteem for your  superior talents and virtues should
be diminished.   Accept, Gentlemen, my sincere thanks,  and
that you may all enjoy happiness and prosperity, will ever  be
my wish.

  To Dr. Philip S. Physick," lecturer on Surgery,in the Penn-
sylvania Hospital, and to Drs. James, and Church, lecturers on
the theory and practice of Midwifery, I  must acknowledge
myself  greatly  indebted for information,  which their unpa-
rallelled knowledge of their professions enable  them  to  dis-
seminate with so much advantage to the student.

  It is also gratifying  to my feelings,  thus publicly to thank
my friend and fellow  graduate,  Mr. Joseph Hartshorn, house-
surgeon to the Pennsylvania Hospital, for his obliging attention
to me, during my  attending that valuable institution. 
M^<L> Hut.
  . WZ
  WO
 MWIi 

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