PUERPERAL FEVER. 
Chloroform as ah Ihterhal Remedy. 
By A. P. MERRILL. M. 0. 
REPRiHTSi’ F&QM THE AMERICAN PRAcTTTTTTVER FOR OCTOBER. 
LOUISVILLE 
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187 r. The American Practitioner. 
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DAVID W. YANDELL, M. D. 
Professor of Clinical Surgery in the University of Louisville 
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THEOPHILUS PARVIN, M. D. 
Professor of the Medical and Surgical Diseases of Women in the University of Louisville. 
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LOUISVILLE, ICY PUERPERAL FEVER 
Chloroform as an Internal Remedy. 
A. P. MERRILL. M. D. 
REPRINT ED FROM THE AMERICAN PRACTITIONER FOR OCTOBER. 
LOUIS VILLE. 
John P. Morton and Company, Publishers. 
1871. Puerperal Fever. PUERPERAL FEVER. 
The fatality of puerperal fever, which in many parts of 
the northern states appears to be scarcely less proportion- 
ally than that which attends upon yellow fever in the South, 
invites persevering inquiry into the pathology and treatment 
of the disease, and the more because of the variety and dis- 
cordancy of prevailing opinions. The devotion of a life some- 
what prolonged to the investigation and treatment principally 
of periodic diseases, often of the gravest form and character, 
has enabled me abundantly to verify the fact that the mys- 
terious principle, periodicity in disease, so universally preva- 
lent, besides its existence in much obscurity, may remain 
latent in the system for an indefinite period of time, always 
ready to be developed into activity upon sufficient provoca- 
tion. Proof of this is found in the oft-repeated observation 
that persons who have resided in malarial districts often 
carry with them upon their removal to a more healthy locality 
enough of this principle to subject them to an attack of 
periodic fever, upon the application of some exciting cause, 
months and even years after such change of residence. The 
liability of English people returning home from southern 
colonies, more than others among whom they live, to attacks 
of periodic disease has long been observed. The same is 
true also in regard to persons changing their residences from 
South to North in this country. Accidents and exposures 
producing a moderate shock of the nervous system have been 6 
Puerperal Fever. 
sufficient to elicit the periodic movement in these cases when 
no such tendency had been observed to exist, and while others 
similarly exposed have escaped. 
Now, to apply this doctrine to the puerperal condition, 
observation proves to us that during the whole period of 
pregnancy, while extraordinary powers are exercised to the 
accomplishment of one great purpose, often holding morbid 
tendencies in abeyance, there may be no sign of pathologic 
periodicity in the system, and yet its latent existence become 
evident from the readiness of its development as the effect 
of parturition. Surely if wounds and concussions, and even 
so slight a cause as change of temperature, may so disturb 
nervous function as to develop periodic disease long after the 
principle of periodicity has been imbibed, we might reason- 
ably expect a similar result from the violence of child-birth. 
Accordingly we do find that this event is often followed by 
well-marked paroxysms of fever at a period too early to allow 
for an original incubation or to be attributed to the influence 
of lactation. The susceptibility of the uterus at such a time 
determines the localization of the disease, and metritis be- 
comes the distinctive local lesion of the fever. This appears 
to be the more remarkable when we consider that idiopathic 
inflammation of the uterus, even after parturition, is a rare 
disease. Hyperaemia, congestion, hypertrophy, and nervous 
irritability of this organ are common; but inflammation, ex- 
cept as a lesion of fever, is unusual and exceptional. 
A difficult complication in puerperal fever is the existence 
of peritoneal inflammation as its frequent but not invariable 
concomitant. This is also uncommon as an idiopathic dis- 
ease, but it must not be deemed extraordinary that a vas- 
cular and sensitive serous membrane so closely investing the 
uterus and contiguous viscera should from sympathy partake 
of the morbid excitement of that organ. It is the more likely 
to do this, perhaps, because of the great distension it has 
suffered during the period of gestation, and its sudden relax- Puerperal Fever. 
7 
ation following parturition. Nor should it be a matter of 
surprise that the increased constitutional disturbance caused 
by a complication so serious as peritoneal inflammation often 
gives rise to the opinion that this is the primary and distinc- 
tive lesion of puerperal fever. Be this as it may, the fact is 
ever patent that the uterus is always the organ first to suffer 
in this disease, than which there is no febrile lesion more 
serious and more dangerous to life. Under strong epidemic 
influence, the first paroxysm is sometimes, and the second 
often, fatal. Remedial measures must therefore be prompt, 
decided, and skillfully applied, and without regard to the tem- 
porizing policy of expectant medicine. 
As in all other diseases which have ever proved exten- 
sively fatal, it has been contended that puerperal fever is 
propagated by contagion, and by some that contagion is the 
sole cause of the disease. The profession has been enter- 
tained by earnest and by bitter and vituperative discussions 
of the subject, contending even for the extreme view, appli- 
cable to no other disease, that the infection adheres to the 
person, and especially to the hands, of the accoucheur, in 
spite of ventilations, ablutions, and disinfections. It is said 
of small-pox, which is generally conceded to be the most 
contagious of all diseases, and believed by some to be the 
only disease which is uniformly so, that it has never been 
known to be conveyed from one patient to another by attend- 
ing physicians. Without any extraordinary precaution, the 
contagious matter which may adhere to the person and cloth- 
ing is supposed to be dissipated in the atmosphere. Proof 
has been given of the preservation of small-pox contagion in 
textile fabrics, but it has always been among such materials 
packed up and secured from ventilation. Upon inquiry at 
the great paper-mills, where imported rags in large quantities 
are used, I have not been able to hear of an instance of the 
communication of small-pox by them; and the explanation, 
several times given, has been that the rags were rendered 8 
Puerperal Fever. 
innocuous by a process of ventilation and drying, but without 
the application of the great disinfectant—artificial heat. 
This question of contagion must, as in other diseases 
supposed to be propagated by this agency, be settled by 
observation and experience. If it can be shown that puer- 
peral fever often occurs without the possibility of contagion, 
and without a suspicion of a communication of the disease to 
other puerperal subjects, it affords ground for the presump- 
tion that contagion has no agency in its production. Sporadic 
cases of this character are to be met with everywhere, and 
especially in cities and districts of country subject to malarial 
influences, and they excite no apprehension of contagion. It 
is only when the disease appears as an epidemic that this 
apprehension prevails, as it does in regard to every other 
epidemic disease; and men are slow to believe, while great 
numbers are suffering under similar circumstances, that the 
disease may be the product of a common cause independent 
of contagion. In my own judgment it is just as feasible to 
adduce proofs of the contagious character of common inter- 
mittents as of puerperal fever. Under epidemic influence one 
is not more likely than the other to attack all susceptible sub- 
jects, irrespective of intercourse, or the agency of physicians 
and nurses in conveying contagion. 
If my views on the pathology of puerperal fever be correct, 
it necessarily follows that antiperiodics must be principally 
relied upon as both preventive and remedial. During the 
latter months of pregnancy quinine may be given daily to 
eradicate the principle of periodicity, whether latent or ob- 
scurely developed. If judiciously administered it will nearly 
always prove successful, but in general large and sedative 
doses are to be avoided as tending to produce uterine con- 
traction and premature delivery ; but when the proper period 
for child-birth arrives this quality of sedative doses may be 
taken advantage of to facilitate labor, and to guard the woman 
against the dangerous development of fever. Nothing can be Puerperal Fever. 
9 
more appropriate than the production in this case of a con- 
dition of quininism which relaxes rigidity while it increases 
expulsive contraction. Upon the occurrence of post-partum 
fever, however, advantage must be taken of the first sign 
of remission to administer quinine in full doses to prevent 
a return of the paroxysm, which in times of an epidemic 
prevalence of puerperal fever not unfrequently proves fatal. 
There may be excessive uterine discharge as a consequence 
of the contrastimulation and the specific influence of the 
remedy over uterine function, but it is better to incur the 
risk of this than to forego the important advantage of effec- 
tive antiperiodic treatment. The bebeerine may also be given 
whenever the uterine discharges render restraining treatment 
necessary, and in this there may be also some antiperiodic 
power to make it an adjuvant to the quinine. 
The abortive treatment by chloroform internally is not less 
important and effective in this than in other forms of periodic 
fever. Upon this alone can reliance be placed to obviate the 
nervous derangements upon which the chill depends; but it 
is important that it be given in the inception of the chill, and 
in such dose as will produce gentle and healthful sleep. Few 
things are more difficult, however, than the enforcement of 
early and abortive treatment in fatal epidemic diseases, or 
even the preventive measures which might prove successful. 
I have often thought the puerperal-fever epidemic more liable 
to this difficulty than other diseases. During pregnancy 
women are slow to believe in the necessity of preventive 
measures, and upon the invasion of the chill after parturition 
it is apt to be attributed to some temporary nervous disturb- 
ance. Should the patient survive the first paroxysm, neither 
she nor her friends are likely to believe in the danger of its 
repetition; but this kind of infatuation belongs more or less 
to every epidemic disease, and is one cause of its mortality. 
Opium is highly esteemed as a remedy in peritonitis, and 10 
Puerperal Fever. 
to relieve this complication it has been recommended in puer- 
peral fever; but it often fails to afford the expected benefit, 
and sometimes, no doubt, it hastens on a fatal termination of 
the disease. The reason is, I apprehend, that inflammations 
of the serous membranes, whether they occur as lesions of 
fever or from other causes, are productive of nervous irrita- 
tions, which do not prevail to the same extent in the other 
tissues. For these irritations in the serous membranes opium 
is a useful and sometimes appears to be an indispensable 
remedy. In the treatment of pleuritis as a febrile lesion, for 
example, we find opium to be useful in the very stage of the 
disease which in gastric fever would preclude its administra- 
tion. In puerperal fever the close sympathy between the 
uterus and the stomach gives rise to gastric lesions simu- 
lating those of yellow fever, and the resemblance is increased 
not unfrequently during an epidemic prevalence of the puer- 
peral fever by its culminating in black vomit. In all such 
cases opium operates unfavorably, and facilitates the fatal 
issue so common and so dreadful in this class of diseases, 
involving the disorder of the mucous tissues of the stomach. 
I am not disposed to deny the efficacy of opium in idiopathic 
peritonitis, although I have found scruple doses of calomel 
given with turpentine and without opium, or with opium in 
moderate doses, to be equally successful; and I know of one 
remarkable case which was cured by calomel alone, given 
in very large quantity, the patient being restored to perfect 
health, and without salivation. 
Because of the commonly torpid condition of the bowels 
during pregnancy, and especially of the large intestines, 
cathartics are often necessary after confinement, and the 
more in case of the prevalence of puerperal fever. It is 
sometimes difficult to dislodge hardened fecal accumulations 
from the colon, and while they remain the irritations por- 
duced are a serious hinderance to successful treatment. It Puerperal Fever. 
11 
sometimes happens that watery dejections pass the hardened 
faeces, and deceive the patient into the belief that the bowels 
are sufficiently active, causing neglect of this important pre- 
caution. In this case mercurial cathartics are valuable as 
tending to the restoration of impaired secretion, and less 
than most other remedies of this class to prostration of 
strength by the production of watery stools. These may 
be alternated by aloes in aperient doses as operating mainly 
upon the large intestines, and sometimes by turpentine as 
conducive to healthy action in the mucous tissues, and also 
to a proper excitation of the kidneys. Were these women 
subjected to such intestinal treatment in the latter months 
of pregnancy, there are good reasons for believing it would 
save them from the evils of albuminous urine, and the con- 
vulsions so often its concomitant. 
I need not refer in detail to other remedies employed in 
the treatment of puerperal fever, all which are of small im- 
portance compared with the measures, properly timed, for 
warding off a returning paroxysm of fever, and without which 
it is certain to come. The disease, it must be borne in mind, 
is one of periodicity, and, like other fevers of this class, it 
manifests its violence in the morning paroxysm. The patient 
may have one, two, or three of these paroxysms in as many 
successive mornings, with many encouraging symptoms dur- 
ing the remissions, inspiring high hopes of a favorable result, 
when, for the want of effective antiperiodic treatment, there 
is an increase in the violence of the exacerbations of fever, 
and she unexpectedly succumbs. Such is the fate of many 
young mothers. Since the revival of the doctrine of debility 
in fever, contrastimulant measures are seldom used, either 
before or after confinement. The simile of the overburdened 
laborer, whose resiliency secures him from oppression when 
the crushing weight under which he was sinking has been 
removed, is no longer admissible; but debility is the common 
watchword, and stimulation the remedy. In no other form 12 
Puerperal Fever. 
of fever is this revival of an ancient error more frequently 
illustrated, and in none is it more to be deprecated, than 
in determining the treatment, both preventive and curative, 
of puerperal fever. The temporary exhaustion of physical 
strength by a painful and perhaps tedious parturition is too 
often met by injudicious measures of invigoration; and it is 
not uncommon that such errors in practice bring upon the 
woman a painful habit of vertigo and rush of blood to the 
brain, from which it is difficult to afford relief. 
But women of feeble constitutions are met with, and espe- 
cially women advanced in life, who have borne many children, 
in whom the principle of vitality seems to be impaired, with 
a defective nervous energy, who are benefited by measures 
of invigoration as the period of parturition approaches, and 
without which, should puerperal fever follow, we may reason- 
ably expect a tendency to an early collapse, reducing the vital 
power below the standard of health. The diagnosis is some- 
times difficult because of the similarity of symptoms presented 
by conditions of plethora and debility; but the asthenic con- 
dition may generally be determined by observing the exhaus- 
tion of strength and labored respiration which follow sudden 
exertion. The sensation of throbbing of the arteries, and 
especially of the brain, is also a diagnostic symptom indica- 
ting debility. Such cases bear and require tonic treatment, 
preference being given in general to iron and arsenic. We 
have no vegetable remedy equally reliable, or safer in respect 
of its immediate effects. Chloroform as an Internal Remedy. CHLOROFORM AS AN INTERNAL REMEDY. 
It is now nearly twenty years since I discovered the power 
of chloroform in congestion and chill, during all which time 
it has not failed me in practice; nor have I been able to hear 
of its failure, when properly administered, in the hands of 
others. I am therefore justified in recommending the treat- 
ment with greater confidence than in my earlier publications 
upon the subject; and I am the more willing to reiterate my 
former statements in a Louisville journal, because there are 
many persons in that city who witnessed my exhibition of the 
remedy to one of its prominent citizens in the public saloon 
of the Galt House, by means of which he was not only relieved 
of a violent ague without febrile reaction, but permanently 
cured of a chronic intermittent fever which had resisted an 
extended course of the common treatment. There is then 
no good reason to doubt that chloroform, given through the 
medium of the digestive organs in proper physiological doses, 
exercises a specific influence over the disordered innervation 
which causes congestion and chill, enabling us to arrest at- 
tacks of fever in the inceptive stage, and prevent the great 
mortality from this the most common form of disease. My 
oft-repeated experiments go to prove also that congestion 
caused by concussion is equally under the control of chloro- 
form as an internal remedy, enabling us to profit by the 
advantage of primary operations, one of the triumphs of 
modern surgery. 16 
Chloroform as an Internal Remedy. 
The proper and effective dose of chloroform given inter- 
nally ranges all the way from a single drop for an infant to 
one or two tea-spoonfuls or fluid drachms for an adult subject. 
I have rarely deemed it necessary to give more than one tea- 
spoonful, which in case of severe congestion, either with chill 
or from concussion, may require to be repeated. It may be 
given in water, milk, or cream; and in case of insensibility 
and excessive prostration, as in congestion of the brain, sun- 
stroke, etc., it may be poured into the mouth in a state of 
purity, when it will be swallowed without danger of strangu- 
lation. It may also be injected into the bowels, mixed in 
mucilage or starch. The mucous tissues suffer no injury 
from the application of chloroform in its purity. The sign 
of its full physiological action is sound and healthful sleep, 
and this is a safe guide in its administration. To secure the 
most beneficial results, this sleep, which is easily interrupted, 
should be prolonged as much as possible by rest, quiet, and 
the exclusion of light. There is no danger in such doses of 
chloroform in health; but females of excitable constitutions 
sometimes suffer from undue stimulation, but not when con- 
gestion exists in any vital organ, for which it is always a 
soothing as well as an efficient remedy. The American Practitioner: 
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