UNITED STATES OF AMERICA * 11 En ^ r FOUNDED 1836 WASHINGTON, DC OPO 16—67244- .- --"vac AN INAUGURAL DISSERTATION ON THE PUERPERAL FEVE& ...''leO-^HI .1 J AN INAUGURAL DISSERTATION ON THI PUERPERAL FEVER. SUBMITTED TO THE PUBLIC EXAMINATION OF THE FACULTY OF PHYSIC, UNDER THE AUTHORITY OF THE TRUSTEES OF COLUMBIA COLLEGE, IN THE STATE OF NEW-YORK; WILLIAM SAMUEL JOHNSON, LL.D. Prefidcnt: FOR THE DEGREE OF DOCTOR OF P H T S I Cv ON THE FIFTH DAY OF MAY, 179$. By TIMOTHY FLETCHER WETMORE, OF NEW-YORK. Satius fit anceps remedium experiri quatn nullum. . Ciljus. Felix qui potuit rerum cognofcere ^auCas. / ^ VN f j»'-v ■- v/Y^— ' NEW-YORK: ^^L—~* PRINTED BY T. AND J. SWORDS, Printers to the Faculty of Phytic of Columbia College. —i 795— tO THE Honourable JOHN JAY, Efquire* Chief Juftice of the United States, isfc. i£c. itfc. WILLIAM SAMUEL JOHNSON, LL.D. Prefident of Columbia College, &c. AND JOHN CHARLTON, Prefident of the Medical Society of the State of New-York: This DilTertation is further refpectfully infcribed* As a mark of regard and efteem, For the attention fliewn to their very much obliged Friend and humble Servant, The AUTHOR. Hi:; c .ir.rl c r t PREFACE. A S this fever has been obferved in all ages, and has been confidered to be and aclually is one of the mofl dangerous difeafes incident to the fair fex\ and, as many authors of eminence and great natural genius and erudition have bejlowed much time in invejligat- ing it, with a view of determining the real caufc, and rendering the method of cure more certain \ and as its nature has remained to the prefent time a fubjeft of much difpute and uncertainty; for neither Leake, Denman, Manning, Hulme, White, Kirkland, Butter, Young, Johnfton, and other learned men before alluded to, have agreed on, nor fully determined the nature, caufe and method of cure in this fatal difeafe:—7/ cannot, therefore, be expefted that Ifhould advance any thing new or definitive on thefubjett, (this being only a collegiate exercife) although I am induced to take a view of the fame, as it is a difeafe that often perplexes Phyfuians, and defervedly demands their greateft attention. For this purpofe I fhall endeavour f a ;/.-;> ( io ) with fome remarks thereon, in hopes, by fo doing, 1 /ball not only fulfil a collegiate duty, but excite the attention of fome future candidate to this wide field for imcfli- gation, and to a fubjetl of fucb importance to the welfare of the female fex. The critical period at which this fever takes place, when febrile commotions are apt to be excited by various caufes, and the equivocal fymptoms which accompany it have afforded room for quefiioning whether it be a primary or fecondary difeafe: fome writers have confi- dered it as proceeding entirely from inflammation of the inteflines, uterus, &c. others have imagined it to be the confequence of an obflruRion to the fecretion of milk, while the greater number have been inclined (for +; reafons equally if not more plaufible) to impute it to a fuppreffion of the lochia. If this fever is examined attentively, according to its natural courfe, and inde* pendently of the accidental concomitant fymptoms with which it is not effentially connected, it may fafely be pronounced a primary difeafe of a particular type, and perhaps not the neceffary confequence of any of the caufes above mentioned. A'tf A N INAUGURAL DISSERTATION ON THE PUERPERAL FEVER. HISTORY OF THE DISEASE. #. V-/N the fecond or third day after delivery the fymptoms of Puerperal Fever ufually begin to fhew themfelves: they are not uniform but varied, for there have been inftances where they have come on within twenty-four hours after birth, and others of their not appearing till the fourth or fifth day, and fometimes later, and even not until the twelfth day :"* it is commonly preceded by a violent rigor, producing a fenfe of conftriction on the extreme parts of the body, followed by great debility,f languor, laflitude, naufea, and other fymptoms not unlike thofe produced in the cold ftage of intermit- tents, which is fucceeded by heat: at this time the * Home. f Leake. C 12 ) the bead is fcarcely ever free from great pain, efpe- ciilly in the fore part and over the eyes. In its early ftage it is attended with figns of inflammation—great pain is felt in the hypogaftric region, in the back, hips and pubes efpecially, accompanied with heat and throbbing, which is afterwards extended more generally, and over the whole abdomen and its inte- guments, and produces the mod exquifitc fenfibility, fo that the patient cannot bear to be touched. In the mean time the pulfe is fmall and flow, but after- wards becomes more quick, although fometimes, in plethoric patients, it is hard and full. Thefe fymp- toms are generally the fame from the beginning. The pulfe, after fome time, becomes more dilliruft, full and perceptible—the flan is generally hot and dry: a change in the quantity and quality of the lo- chia now takes place, with a troublefome tenefmus— the urine is voided with pain, fmall in quantity and high coloured, but not always the fame: in the ad- vanced ftages of the difeafe it depofits a dark coloured fediment: fometimes the lochia undergoes no change, either in quantity or quality, but are dark coloured and fcetid, and at other times they altogether difap- pear. The fecretion of milk alfo undergoes fimilar changes: in fome it is diminiflied in quantity—in others it continues natural through the whole courfe of . ( *3 ) of the difeafe, and even to within a fliort time of death. On the firfl: attack of this fever, the patient is feized with a vomiting of matter fimilar to that in cholera, to which the difeafe bears a ftrong refem- blance •, and when this fymptom takes place, and towards the fatal termination of the complaint, the vomiting fomewhat refembles coffee grounds : but inftead of this fymptom, there is fometimes only a naufea, with a difagreeable tafte in the mouth—the abdomen fwells to a confiderable fize, and, as before obferved, becomes fufceptible of painful fenfations on the flightefl: imprefllon. If prelTure is made be- tween the ftomach and umbilical region, the pain becomes intolerable, which is not the cafe when lower down.* The tongue is generally dry, though fometimes moifl: and covered with a thick brownifh fur, accompanied with great thirft, and in general has a better appearance in the beginning than moft fevers—the function offefpiration is performed with more or lefs difficulty foon after the commencement of the difeafe, attended at times with a fonorous noife. After a few days the fymptoms of inflam- mation ufually fubfide, and the difeafe acquires a typhoid complection; the pain in the abdomen, dif- ficulty • Leake, ficulty of breathing, anxiety and oppreflion about the praecordia increafe, which is fucceeded by a bilious and putrid diarrbira that fometimes evolves contageous miafm.* This diarrhoea is fometimes, though not always, of a dangerous and obftinate nature, accompanying the difeafe through all its ftages; and i am of opinion with the celebrated Home, that this affection is only fymptomatic. Each motion to Jiool is preceded by a temporary increafe of pain, which, on taking place (/. e. the ftool) there is an alleviation of the fame, the pa- tient naufeates all kinds of food and drink, except thofe which are cold and of the acidelous kind. In confequence of putrid exhalations, the teeth become covered with a brown or blackifh fordes j at length troublefome hiccough is produced, which greatly exafperates the pain of the abdomen, petechia;, vi- bices, and fometimes a miliary eruption alfo ap- pears, firft on the neck and breafts, and afterwards fpreads over the whole body, but which produces no mitigation of the difeafe. The patient, through the whole courfe of the complaint, is afflicted with a peculiar anxiety and dejection of fpirits, which now becomes increafed j the eyes no longer retain their ufual brightnefs, but become more and more languid, " White. ( i5 ) languid, and are funk in the head: if at any time the patient falls into a dofe, and fhould continue fo for a length of time, lhe finds herfelf but little refrefhed: during thefe dofes the eyes remain open, the nostrils become enlarged, the face is commonly much flufhed, the cheeks appear of a purplifti red, and fometimes there is a circumfcribed red fpot on the fame-, the lips turn livid, the difcharges of urine and fiool become involuntary, and the partial fweats which now take place fhew that death is at hand. About this time the abdomen is not only, greatly fwelled, but begins to change to a greenifh or even bbckifh colour •,* the pains of which entirely ceafe a few hours before death, which, when it takes place, is at different periods of the fever, but molt commonly from the feventh to the twelfth or fourteenth days, from which perhaps the mife- rable patient flatters herfelf with hopes of recovery -, but thefe' are iU-grounded, for very foon fubfultus tendinum, delirium, and hiccough come on, and death fpeedily clofes the fcene. Such, in general, is the courfe of the Puerperal Fever, the fymptoms of which, however, may be often varied, (as I before obferved) according to the constitution of the patient, feafon of the year, management « Tiflbt. management of nurfes, the degree of the difeafe, an J. its earlier or later invafion. APPEARANCES ON DISSECTION. FROM the appearances on diffetlion of thofe who have died of this difeafe, the caufes of their death have been found very obfeure •, fome relating, that by difleetion the difeafe feemed to depend on inflammation,* others that it was not.-f From either of which opinions we cannot determine the real feat and nature of the difeafe. On making an incifion into the abdomen, a very offenfive air i/Tues forth, followed by a very foetid humour, which is fometimes yellow; it is found in a fluid ftate in a greater or lefs quantity: the intestines are fome- times found ruptured, more or lefs inflamed, and at times proceeding to a fuppuration and inclin- ing to, or actually feized with gangrene.£ But this does not appear to be the cafe, as obferved by Home; for he aiTerts that the inteitines are not only a little but univerfally inflamed: but if there is any diltinct inflammation, it is in that part of the omentum which joins the inteitines, for it has been obferved to be particularly affected.§ The ovaria arc • Leake and Hulme. f Young, tec, X Leake and other.. 4 Lei!: ( i7 ) are fometimes found inflamed, and in an indurated and gangrenous ftate;* the abdominal vifcera are alfo found to be affected with inflammation and adhefions. There appears to be fcarcely any change in the nature and condition of the uterus, although fome have aflerted it. The inflammation is never apparently abfent in this difeafe; for even the pleura itfelf has not been found free from the fame, as has been made more clearly to appear by the indefatigable and unerring anatomist John Hunter. PREDISPONENT CAUSES. IT evidently appears that the female fyftem un- dergoes great changes during gefiation, as the naufea, vomiting, fwelling of the breafts, and every trifling circumstance affecting or disturbing the body in an unufual manner, and which more readily takes place during parturition, clearly fliews. To prove that this difpofition to irritation chiefly favours the production of this difeafe, it has been advanced,-f that pregnant women acting as nurfes to thofe who are lying-in, are never attacked with this complaint until after parturition; and hence C there * Home and Med. Comm. vol. iv. and vii. f Leake. ( IS ) there is no room of doubting that pregnancy and parturition are among the principle caufes which predifpofe to this fever. The putrid appearances, however, which this difeafe fo readily aflumes, affords ground to fufpect a vitiated itate of the humours to be the predifpo- nent caule-, for it is generally obferved to be moft prevalent in unhealthy perfons, and among women of weakly and fcorbutic constitutions. EXCITING CAUSES. THESE are many and various; the principal and molt remarkable during pregnancy, appear to be the intemperate ufe of fpirituous liquors, too great fatigue, or total want of exercife, too high or too low living, coltivenefs or the reverie, excefs of joy or grief, a moilt and warm atmofphere, impreg- nated with putrid effluvia. In lying-in, an overheat- ed and confined air, by breathing in a chamber that is not fufhciently ventilated, coltivenefs, too warm a regimen, obstructed perfpiration, violence and too great hafte in feparating the placenta, the ab- domen being too much constricted by bandages, with the officious interference of mid wives, every thing which produces a plethoric diathefis, the too foon ( 19 ) foon and too frequent ufe of animal food, fpirituous liquors* and other cordials. On the other hand, the exciting caufes of this difeafe may be the too long confinement of the woman to her bed, contagion, or putrid effluvia, which is fo often generated in hofpitals and elfewhere, with every thing which contributes to produce fever, (other circumstances being favourable;) exceffive evacuations, efpecially haemorrhages; and finally, the abforption of acrid, bilious or putrid matter from the alimentary canal, uterus or vagina: thefe caufes being fuflicient to produce fuch a condition in the body as, united with the predifponent ones, will produce the difeafe. To thefe may be added the various emotions of the mind, as fudden frights, &c. for all thefe (ef- pecially if the woman be predifpofed to the difeafe) may defervedly be reckoned among the exciting caules. This difeafe may alfo be produced by cer- tain changes in the atmofphere, which elude our refearches, and cannot be dete&ed; for, if prevailing as an epidemic, it acquires new strength, and be- comes * A remarkable cafe occurred in the month of January laft, in a healthy woman, aged twenty-eight years, who was put to bed of her second child, the labour perfectly r.atural, and ftrength but little diminifh- ed ; fhe was directed by her midwife in the free ufe of gin, (the weather being cold,) of which me took feveral pints. The excitement was fo gre it as to produce indirect debility, typhus fever, and death. The coftiv * ftate in which flie was fuffered to remain, might alone have produced fevxk without the aid of fpirituous liquors. ( to ) comes more mortal. It is more frequent in hofpi- tals than other places, and is more fatal in the for- mer than in the latter. PROXIMATE CAUSE. I HERE feel and muft confefs my inability to produce a fufficient explanation of the real nature and caufe of this difeafe, vvhich will be in any man- ner fatisfactory; I fhall, however, take a concife view of the molt plaufible opinions, as delivered by the molt approved authors, and endeavour to examine them attentively, according to their re- fpective merits, with fome inferences therefrom. The opinions concerning the immediate caufe of this difeafe may be reduced to three heads: I. The fuppreffion and retention of the lochia. II. A transfufion of the milk. III. An inflammation of the inteitines and omen- tum. Molt fluids, after being retained a long time in their refpective veflels, receptacles or excretory ducts, become acrid; it was fuppofed, therefore, that the lochia and milk, (for fimilar reafons) when long retained, might be the proximate caufe of this fever; but I am inclined to think that this fcldom ( 21 ) feldom happens, for we find that it comes on much fooner from fuch a change firit taking place in the lochia and milk; and moreover, it has often arifen when there was not a fufficient caufe (if we may reafon from thefe data) to expect its attack. That the lochia does not always nor at fixed periods flow, we have already fhewn in the history of the difeafe; for at one time they do not vary in quantity or quality, but continue a fufficient time, and are of a good kind: at another time they are fparing and of a putrid nature; and oftentimes, when the difeafe has advanced, they are almoft fuppreffed; therefore it remains, without admitting a doubt, that this alone can by no means be a fufficient caufe to produce this fever. Nor does it appear more reafonable to afcribe the caufe of this difeafe to a transfufion of the milk, for whether there be a transfufion or not, the occurrence of the difeafe is much the fame. Nor does it more clearly appear that the inflammation of the inteitines and omen- tum is the proximate caufe of this difeafe: how- ever, this opinion ought not equally with the others to be rejected: thofe efpecially who favour this lat- ter opinion contend that the uterus, after birth, is fomewhat inclined to be contracted; from whence they have formed their opinion, to wit, that that organ C » ) organ inclines to regain its former figure and origi- nal ftare, becaufe the blood is not poured into it any longer in fo great a quantity as it was before, and which was requifite in a state of geflation. Hence, fay thee, the blood being determined to another part, rufhes into thofe veflels which make the leait refiitance, to wit, thofe of the omentum and inteflines, by which they fuffer a preternatural diitcntion ; and this distention or congestion (in the opinion of fome) is thought to be the origin of this difeafe: but, at the time of geitation being gone through, and the birth at hand, the omentum has been found wounded when nothing like this difeafe has followed. From hence it is proved, that puerperal fever is not always the confequence of a wound in the omentum.* It cannot be denied that this fever has followed great difcharges from the womb, which fometimes happen after parturition: this being the cafe, it can fcarcely be fuppofed that the veflels of the omentum can then be fo much distended by blood as to be produ&ive of this fever. And if it is al- lowed that the contractile force which the uterus poiTelTes is greater in the firit pregnancies than thofe which follow, (for, in fact, the fudden contraction of the • White, p. 411. ( 23 ) the uterus with the very fmall, if any, pains which are apt to follow the firft parturition, feem to favour the opinion,) is not this fever then more to be ex- pected in thofe who ly-in of their firft children ? Why is there not danger alfo that this fever may follow the operation of the paracentesis ? Among all it is agreed, that the fymptoms ma- nifeited in this difeafe (producing death) are the fame which take place in putrid fevers :* and hence it may be concluded, that nothing determinate can be collected as to the real feat and nature of the difeafe. Sometimes, in various parts of the body, there feems to be a certain fomething depofited, which produces, as it were, a crifis; and from hence all the fymptoms have manifestly grown milder: but examples of this kind are rare, nor does the difeafe always ceafe on fuch a deposition. Upon a comparative view of thefe opinions, I think the one of congestion in the blood veflels of the omentum and inteftines producing inflammation in thefe parts, is too fanciful and too much favour- ing hypothefis to have much faith placed in it: for it is not fufficiently fupported, nor do diflections prove the fame. That kind of eryfipelas which is apt to appear on • Sir John Pringle, Cleghorn and LnJ. C 24 ) on the decline of this fever, ought to be confidered as fymptomatic only. To me it does not feem improper to clafs the puerperal fever among thofe difeafes to which Dr. Cullen has given the name of fynochus ■, for this dif- eafe, as far as I am able to judge, does not differ from fynochus, except in its attacking lying-in wo- men. That this opinion is not far from being right, the attack, progrefs and termination of the fever prove; for, generally, in the beginning it is at- tended with fuch manifeft fymptoms of inflamma- tion as to refemble fynocha, and then evidently re- quires blood-letting; but in the courfe of one or two days marks of aflhenia appear over the whole body, and then the difeafe refembles typhus. DIAGNOSIS. THIS difeafe is known by pyrexia, accompa- nied with great inquietude and violent acute pains of the abdomen below the ftomach; for on prefliire being made between it and the umbilical region, the forenefs is fo great as not to bear the gentleft touch. Thefe pains may be diftinguifhed from thofe called after-pains, by their uninterrupted con- tinuance through the whole courfe of the difeafe, though e 25 ) though fometimes they fuffer exacerbations; where- as, in the latter, they often wholly intermit. It is known by a dread in taking a full infpiration, which caufes much uneafinefs; by the refpiration being quick and fhort, the lungs themfelves not appear- ing affected, this difficulty increasing with the dif- eafe ; by flatulencies, coftivenefs or the reverfe. This fever may be diftinguifhed from the miliary by the rigor attending it being more violent, of longer duration, and not interrupted; the pulfe is fuller and stronger, the fkin more hot and freer from that itching fenfation which is felt in the mi- liary fever; nor do the eruptions in the puerperal produce a crifis as they generally do in the miliary fever; and the tongue, whether moift or dry, (though generally the latter) is not of a white but brownifh appearance; the urine is alfo higher co- loured. The abdomen in the beginning of the puerperal is almoft always constipated, which gives another mean of diftinguifhing the difeafe. In the hyfteritis, a difeafe that favours the puer- peral, the pain is only felt in the uterus and abou* the private-parts; but in the puerperal fever the pains are felt in the stomach and inteitines: nor is the patient affected in the beginning of this difeafe D with ( 26 ) with violent delirium; neither is the os uteri fo pain- ful when touched as in hyltcritis. To diftinguifh the puerperal fever from enteritis, the pain is obferved to be more external, nor does it affect the umbilical region only; neither arc the bowels fo obstinately conftipated as in that difeafe. When the original attack of this fever happens to coincide with febrile commotions, excited in child- bed women by the fecretion of milk, the nature of it may at firft be mifapprehended; but the conco- mitant fymptoms and great violence of the difeafe will, in a fliort time, diffipate fuch an error. In the milk fever the breafts are ufually tumified, but in the puerperal they commonly are not; nor are thofe pains which are frequently felt fhooting from the breafts to the arms, and back again, in the milk fever, felt in the puerperal. PROGNOSIS. WHEN the patient is naturally weak, her ftrength greatly reduced by immoderate evacuations after parturition, and when the difeafe is violent, and immediately follows delivery, its progrefs and termination are proportionably rapid and fatal: in thefe unfortunate circumstances many have expired within ( 27 ) within twenty-four hours from the firft attack of the difeafe; and there have been fome instances where the rigor has clofed the fcene: however, the catastrophe is generally fufpended for a few days -r but, for the moit part, fomewhere between the fifth and eleventh, from the commencement, may be fixed on as the decifive period; but if it fhould be protracted beyond the eleventh day, there will be more hopes of a recovery, although it fometimes happens otherwife. The moit favour- able fymptoms are a gentle diarrhoea, which renders the pains lefs acute; the urine depositing a dark co- loured fediment, and efpecially if the lochia begin again to flow, after being fomewhat fupprefled, together with the fecretion of milk being again re- newed. If there is alfo a gradual diminution of the fwelling, pain, and forenefs in the abdomen, and if after the bowels have been opened there is a gentle diaphoresis diffufed over the whole body, and if the vomiting, anorexia, and other febrile fymptoms begin to difappear; there will be reafon to hope a favourable termination of the difeafe. But if, on the other hand, the fwelling of the ab- domen does not fubfide on the commencement of the diarrhcea; if the refpiration is alfo attended with a kn(Q of anxiety and stricture in the thorax; if ( 2» ) if the ftrength is very much reduced, and at the fame time petechia appear, and the excrements are black and foetid, it is evident the patient is in imminent danger:—if the pains in the abdomen entirely ceafe, thepulfes become fovtry fmall and frequent, that they cannot be numbered; if involuntary difcharges of the fceces by ftool; if a grecnifh or blackifh matter is ejected by vomiting; vifcid cold fweats affect the extremities, and there is a livid appearance on the cheeks—^k is near at hand. PROPHYLAXIS. WOMEN1, during the time of geftation, are too apt to neglect the keeping their bowels open: although this has been confidered a matter of no importance, it is, however, often attended with dangerous confequences, and renders the difeafes to which they arc liable in their lyings-in much more fevere and obstinate than they would otherwife be if coftivenefs were prevented. To obviate this complaint, the cautious ufe of fuch remedies as are beft fuited to the situation of thefe women, muft be had recourfe to, fuch as clylters, gentle laxatives, a: ': that kind of diet which tends to keep the bowels open, fuch as vegetables and ripe fruir.9. An ( 29 ) An indolent, fedentary life not only occafions the bowels^to remain in a coitive itate, but may be con- sidered as predifpofing to this difeafe; women fhould, therefore, take gentle exercife, in the open air, as often as the weather will permit; they ought to avoid all fuch emotions of the mind as gready difturb and agitate their fyftems, by devoting fome part of their time to agreeable company, and by purfuing fuch means as will tend to promote cheer- fulnefs: their diet fhould be light, nourifhing, and eafy of digestion; their cloathing fhould fet eafy, and be fuch as they have been accustomed to, and that will keep them moderately warm. If they are troubled with naufea, vomiting, hyfteria, and the want of fleep, opium will afford relief, if cautioufly administered; but if, notwithstanding, the irrita- bility of their fyftems becomes increafed, recourfe mult be had to the Peruvian bark, mild calybeates, and other tonics. The frequent ufe of the cold bath during geitation has fometimes been attended with the happieft effects; and it appears that the fame treatment (if nothing forbids) is eflential in removing that propenfity to difeafes which is gene- rally prefent in parturition; and further, every means muit be ufed that will tend to obviate a ple- toric ftate of the fyftem. After parturition, every meafure ( 3<> ) meafure muft ftill be had rccourfe to, that will fccure the fafety of the patient; therefore, all irritating caufes muft be avoided, cheerfulncfs promoted, and both body and mind kept perfectly quiet, that the patient may, for a few hours, enjoy Nature's fweet reftorer, u balmy fleep." Nor is it of little mo- ment that the bed-room fhould be kept as clean and neat as poflible •, the regimen fhould be of a cooling, vegetable kind, and fuch as will not overload the itomach; cool drinks, and other liquids of the acidulous and antifecptic kinds may be freely ufed. The bowels, at this time, mult be well attended to, that they be kept open by clyfters and gentle laxa- tives. Every principal caufe of difturbance mull be avoided, fuch as violent emotions of the mind, with the rafh admittance of cold air to the body ; cleanlinefs muft be well attended to, for if it is not, contagion* may be produced, which has been thought, * It may be fufpe&ed that contagious matter it much oftener produced, and in a greater variety of difeafei than is commonly imagined—that is, a matter if generated or fecreted in vetted morbidly activr, which, when applied to other veireli, even in a found body, tends to ex- cite in them a fimilar action to that which originated itfelf. Hence clean- linefs ii necetfary in all difeafej; not becaufe the want of it produces the contagious matter, but becaufe it prevents an effective concentration of it. The general principle of this contagious operatten is is analogy «i'':i an infinitude of phxnomena in the human body depending upon this gen-Tit law in the fyft< m—that the fluids IN cert a in vii-.ii i ARE AT ONCE TKt PRODUCT OF THOSE VESSELS, AND THE AN ri.-Tr.:Azz ::;»:l_i to tmeib ruitiiee action. l'rjfctfor bu.i'.h's M. S. Lectures. ( 3* ) thought, in every instance, the caufe of puerperal fever ;* therefore, a free ventilation of the lying-in room is highly neceflary; nor is the officious inter- ference of ignorant visitants' to be permitted; nei- ther is too rigid a treatment neceflary ; for in things. of an indifferent nature we may indulge ouij pa- tients. Every lying-in woman is to be treated with the greateft attention and the moit foothing indul- gence, and whatever will render her pains more eafy, fhould moit readily be granted; every degree of violence fhould be carefully avoided; and, there- fore, the practice of tearing away the placenta can- not be too highly condemned, for it is not only a cruel but hazardous expedient, and at this day is generally condemned by the belt practitioners, and fhould not be had recourfe to but in extreme danger from floodings, &c.f The effect of opiates, gen- tle compreffion of the abdomen, and afterwards increasing it, ought firft to be tried. If the pati- ent is expofed to contagion, every means fhould be carefully ufed that tend to leflen and moderate its violence, or, if poffible, to render it inert. Fre- quent cliange of linen and air, the Peruvian bark, mild calybeates, gentle exercife, and that kind of diet which will give ftrength and vigor to the fyf- tem, are to be ufed. It * Yuun;. \ Mauriceau, &c. ( 3^ ) It is alfo necefTary that every thing relative to parturition fhould be conducted in the moft fimplc manner; the breafts fhould be drawn in due feafon; the abdomen kept free from constipation ; the bed- room muft be well aired as before mentioned; the diet light and fparing •, the drinks cooling and acidu- lous, and all kinds of fpirituous liquors and cordials carefully avoided, unlefs great debility has already taken place; for by obferving this mode of treat- ment in lying-in women, the difeafe (if it has com- menced) will not only be rendered more mild, but many things may be avoided that might otherwifc be injurious, were the difeafe to take place. If the lochia fhould flow in too great quantities, the infufion of bark and tinct. rofar. with as much elix. vitriol, as will make it agreeable, may be had recourfe to, together with abfolute reft in the hori- zontal pofition. But if the lochia have been long retained, and there is reafon to fufpect they have become acrid, it may not be amifs to inject fome- thing emollient and antifceptic into the uterus. Thefe are the moft general means of preventing this dangerous and often fatal difeafe. I fhall now proceed to the METHOD ( 33 ) METHOD OF CURE. NO difeafe has more divided the fentiments of Phyficians, in regard to the method of cure, than that of the puerperal fever. The apparent indica- tions and contra-indications of bleeding, and other remedies arising from the complication of inflam- matory and typhus fymptoms, the equivocal ap- pearances of the vomiting and purging, whether they be critical or fymptomatic, and the different caufes whence fymptoms fimilar to each other may arife in pregnant women; all thefe circumftances concur to involve the fubject in great obfcurity and indecifion: however, if we carefully attend to the feveral characteristics of this difeafe, fo as to be able to diftinguifh it from every other puerperal com- plaint, and obferve at the fame time the ufual man- ner of its declination, our judgments may in fome meafure be guided in the method of cure by the falutary efforts of nature. The method of cure which appears the moft proper to me, may be defcribed under two general indications. I. To diminifh or take off the fthenic diathefis. II. To obviate the debility and putrefcency which follow, and at the fame time to moderate all trouble- fome fymptoms. E To ( 34 ) To anfwer the firft intention, immediate recourfe muft be had to the fedative plan and regimen, a principal mean in which is blood-letting: but of its utility in this difeafe there appears nothing certain in the writings of Phyficians, fome contending thac venefection is proper, others that it is ufelefs and hazardous; but there have been fome inftances of critical haemorrhages, which would feem to confirm its utility. Dr. Denman thinks it may fafely be affirmed from experience, that for one who will be benefited by large bleeding, a much greater number will be injured thereby, and that even almoft irre- trievably. Nor can this feem furprifing when we confider the situation of women in child-bed: the evacuations confequent upon delivery are ufually fuf- ficient to diminifh any undue fuperabundance of the fluids; and if, as frequently happens, the difeafe he produced by too hafty a feparation of the pla- centa, the confequence of which is generally a very copious difcharge of blood, we can never fuppofe that nature will be aflifted in overcoming the febrile commotions, by the further evacuation of the vital fluid, through the defect of which fhe is now ren- dered unequal even to the ordinary fupport of the animal ccconomy; and every practical Phyfician muft know how much the pulfe finks, and what a train of ( 35 ) of nervous fymptoms is obferved to fucceed an ex- cefs of the difcharge above-mentioned: and, more- over, it is an axiom in phyfic, that a remedy which cures any diforder, will always prove fufficient to prevent it; and therefore, if bleeding were the pros- per cure in the puerperal fever, the difeafe ought to have been prevented by a large evacuation of blood when that happened previous to its feizure. Expe- rience, however, in this as in all other difeafes, is the only unerring guide we can follow; and whoever regulates his practice by facts and obfervation, will be convinced that venefection, efpecially in a large quantity, is in general very far from being attended with fuccefs; and, for my own part, I think it will feldom if ever be proper, unlefs in women of active, robuft and plethoric habits, and in whom fometimes the fymptoms of inflammation run high, and even in fuch perfons, it is not to be repeated but with the greateft caution, and when the fymptoms are moft urgent: Bleeding, when ufed in proper circum- stances, may palliate the fever; but that it often ftiortens the duration of it, appears to be a matter of much doubt: on this account the practice becomes itill more fufpicious and exceptionable, when we confider that by venefection being improperly ufed, the patient's ftrength may be fo far reduced as not to ( 36 ) to fupport the tedious diarrhoea by which the difeafe is generally removed. Whenever blood is to be drawn, it ought to be taken away at the commencement of the diforder, and the bleeding fhould not be in large quantities, left a dangerous ftate of debility be induced thereby; for it is worthy of remark, that whenever fevers incline to great debility, we are to avoid favouring it, by copious blood-letting.* Upon the whole, this evacuation promifes very little advantage; and it has been afferted by fome, that the difeafe is never mi- tigated by it—that the pulfes become lower after bleeding, although the blood be covered with a buffy coat; therefore, particular attention muft be paid to the ftate of the fymptoms before we make ufe of this remedy, and efpecially to that of the pulfe. Nor is the duration of the complaint to be neglected, for this and many other circumstances muft be at- tended to before the lancet is ufed. The ftate of the bowels is next to be attended to, and if they require opening, it muft be done either by clyfters or laxative medicines, fuch as the neutral falts, or the oleum ricini; which muft be repeated till a free difcharge from the bowels is ob- tained ; for ftools muft at all events be procured, as on • Cullen, ( 37 ) on thefe at firft are founded our greatest hopes of fuccefs; for, by emptying the firft paflages, all dif- tenfion from the contained fceces is taken off, flatu- lence leffened, irritation from the fceces avoided, and fome degree of freedom is given to the circulat- ing fluids of the parts affected: but this muft be done in the moft gentle manner, and by fuch medi- cines as will not create ficknefs, as the faline purges or emulfion of caftor oil. The firft evacuations are generally foetid; but, if afterwards they become lefs offenfive, and the patient feels herfelf generally re- lieved, fhe commonly falls into a fleep, which is fuc- ceeded by a gentle perfpiration. "Whatever pro- motes this perfpiration (which ought not to be pro- fufe or kept up by fuch medicines as may either pro- duce coltivenefs or heat the fyftem) fhould be admi- nistered ; the moft proper are the ipecacuanha, tar- tar emetic, or antimonial wine, in fmall dofes, every fecondor third hour, with the addition of opium, and in the intervals the faline mixtures will be found ad- vantageous: thefe alleviate pain, determine the fluids externally, are in a degree diuretic and antifceptic, and this without aftringency or fanguiferous stimu- lation. A determination to the fkin may alfo be folicited by fmall and repeated dofes of lukewarn diluents, as vinegar whey, lemonade, toaft and water, ( 38 ) water, a flight infufion of malt, or things of a fimi- lar nature. Stimulants, and the heating regimen, although they may be ufed for the purpofe of rendering the cold ftage fhorter, are very improper and injurious, and ought therefore to be rejected, efpecially thofe medicines which are called emmcnagoguc. The vis vita is to be fupported as much in this as in any typhus fever; cool air is, therefore, of fer- vice, and cleanlinefs, as before noted, muft efpeci- ally be attended to; for which purpofe the bed- clothes and.body linen fhould be frequently changed. If the vomiting fhould be troublefome, and fuch as feems to arife from a fuperabundance of bile, mild emetics and laxatives have been recommended to restrain it:* and if the fymptoms of inflammation are not prefent, a fmall quantity of opium may be given as foon as the vomiting will permit, to prevent further stimulus ; for if the vomiting is not reftrain- ed, or its violence leiTened, difagreeable confequences may enfue from the straining, &c. by the protrufion of the womb, the ligaments of which are now in a relaxed ftate. The moft proper drinks are thofe which * In the Hotel Dieu, at Paris, fix or eight grains of Ipecacuanha exhibited eirly, anH repeated twice a day as long as neceflary, have been, it is faid, a.tended with remarkable fuccefi. Macf r' !e and Lind have obferved, that vomiting is very fervkeable in all ]'e\er: arilin. fiom contagion. ( 39 ) which are mild, refrigerant and diluent; but the ufe of all fpirituous and fermented liquors muft be pro- hibited during the firft or inflammatory ftage of the difeafe. If, in purfuing this mode of treatment, there ap- pears to be a change for the better, we muft next attend to the ftate of the inteftines, and endeavour to reftore their tone and vigor. A free admiffion of cool air, with the ufe of the bark, and exercife in fair weather, will generally be fufficient to remove any remaining indifpofition. But, on the other hand, if the difeafe does not remit, but appears to increafe, and becomes more violent, verging to putridity, recourfe muft be had to our fecond indication, which is to obviate the debility and putridity about to take place. Of all the fymptoms ufually connected in this ftage of the difeafe, the moft remarkable and trou- blefome is that of diarrhoea, which, in the begin- ning of the complaint, is not injurious, and ought rather to be promoted than checked; but if immo- derate, it fhould be fomewhat restrained by clyiters,* with opium, and fuch medicines as have a gentle reftringent operation; the Japonic confection is ufeful * Which Should be emollient, diluting and nutritious, compofed of broths, beef-tea, cammomile infufion with oil, and impregnated with fixed air or yeail. ( 40 ) ufeful at this time; the method of treatment juft defcribed muft efpecially be ufed. If the strength of the patient fhould be greatly reduced by the diarrhoea, it is cautioufly to be checked, as it oftentimes proves critical and falutary.* By correcting the ftate of the fluids, we may render the irritating caufe in the inteftines lefs active, by which thofe profufe evacua- tions become restrained. Epifpaftics have been faid to be of fervice in this difeafe, when employed after venefection; but it is probable they can be of no other fervice in this fever than by removing topical pain. Although fpirituous liquors and a generous diet are injurious in the commencement of this difeafe, they now become very neceflary. Wine and water, cinnamon water, and other cordials may alfo be given. Befides thefe remedies, the Peruvian bark and columbo-root, either alone or joined with aro- matics and opiates, may be employed, which, in relieving this difeafe, have been very much ex- tolled, and defervedly fo, although they fometimes fail. If the diarrhoea fhould yet continue, ftill more powerful astringents feem to be indicated, fuch as • When the diarrhoea becomes critical and feems to be the means of freeing thefjftem from puerperal fever, may we not fufpedt an analogy in the ftate of the veiTelt of the inteftines with that of the urethra, in thofe cafes of mild gonorrhea where the difeafe goes off fponlaneouflr t ( 4i ) as the hasmatoxylum, kino, and others of this fort- —Can we expect any advantage from the cold bath, applied either by the fponge or in form of a fhower, or applied in any other way when great debility prevails ? An application like this is certainly wor- thy of attention, as it has been thought of fervice in the cure of typhus fever,* and I am informed, is the common practice at Vienna and fome parts of the Weft-Indies. It is further to be obferved, that the fuccefs in the means ufed for the removal of this difeafe, de- pends principally upon the immediate, early and conftant ufe of the remedies before mentioned, for we muft have recourfe to them even before any remiflion has appeared, as fhortly after the difeafe rejects affiftance from all medicines, and fpeedily terminates in death. Hence, whenever the vomit- ing becomes very violent and appears to aggravate the other fymptoms, we muft have immediate re- course to the faline draughts ; and if thefe fhould afford no relief, the infufion of columbo-root and liquid laudanum muft be tried : and whether the faline draughts are of fervice or not, we muft make ufe of the laft mentioned remedies, for from thefe we may expect relief with fome degree of certainty. F To * Gregory, ( 42 ) To relieve the pains of r'e.e abdomen, cmollit nt cata- plafms or fomentations are generally ufed with fuc- cefs; but if thev fhould fail of affording relief, epifpaftics, the rubifacients, camphor and opium will not be ufed in vain. To obviate or remove the dyfpneci, epifpaftics, applied between the fhouklcrs, are always of fervice, as alfo the fpcrmacseti mixture. It is, after all, very evident, that the nature of the puerperal fever, and much more the method of treating it, are not well underftood. To what has been find we may add, that the pa- tie; it. recovering from this difeafe fhould be treated as a convalcfcent from any other fever; and if fhc fhould not be quickly reftored to health, the cold bath and various other tonics may become neccf- farv. v i n i s. ERRATA. Page 21, line 6, forc does,' reade do.' Page 25, line 18, for £ abdomen,* read « bowels.' Med. Hist. wz 3/7 0 W5"*rii< ct -1 ' •-■>^-^": >l^l §l%-sseeS • '■X.lj.-ii,.