NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Service 7 i/,S P / <£* ■ {./.tar / DISSERTATION ON THE Puerperal. Fever, DELIVERED At a Public Examination for the Degree of BACHELOR IN MEDICINE, before the Reverend Joseph Willard, S.T.D. Prdident, The Medical Professors, AND The Governors Of the UNIVERSITY at CAMBRIDGE, In AMERICA. By PETER de SALES la TERRIERE, ^ From Canada. Cor dolet admonitu quoties rerninifcor amaras quas mife- randa fubit fasmlna faepa vices. BOSTON: Printed by Samuel Hall, at No. 53, Cornhill. MDCCLXXXIX. S* \ r ./ THIS DISSERTATION IS DEDICATED, WITH ALL RESPECT, \ I. TO JOHN WARREN, M. D. ProfefTor of Anatomy and Surgery ; BENJAMIN WATERHOUSE, M. D. ProfefTor of the Theory and Praftice.of Phyfic ; AARON DEXTER, M. D. ProfefTor of Chemiftry, and Materia Medica ; 9' Gentlemen not more diftinguifhed by their literary accomplishments,and their professional abilities, than refpected for their attention to students, and their talents for instruction 5 By their Humble Servant, PETER de SALES la TERRIERE. [ 5 ] -*->-s^i'^^MS;f^*ip%t*^^.-,--< « IT is not without diffidence that I appear before tin's honourable and reverend Assembly, In con- formity to the laudable cullom eftablifhed In ,the Univerfky. To produce a dlffertatlon in a language I have never pro- feffedly ftudled, before I entered thefe walls, Is not fo eafy a tafk as fome perhaps may imagine : but relying on that candor which diltinguifhes a polite education, I am em- boldened to offer you this fpecimen of my ftudles, hoping that every deficiency of language will be excufed. I (hall fay a few words for the information of thofc who may wonder to fee a perfon of my age engaging In the ftu- dy of Phyfic. The occafion of it is this ;—Canada, like moft provinces at a great diftancc from the mother coun- try, has become very deficient In medical knowledge. Not only the moft approved Englifn authors are unknown to mod of us, but even the late French writers on phyfia and furgery are fcarcely ieen among us. Ignorance and quackery having, from thefc and fome pther caufes, fpread among us, to the great detriment of the lives of his Britannic Majefty's fubjects, It excited the attention of the legiflature, and particularly of the hu- mane Lord Dorche/ler, who, touched with a tender feeling for the fufferings of others, IfTued an Ordonnance,obliging every C 6 3 every practitioner to undergo an examination before a com- mittee ofphyficians and members of the legiflative council. The refult of this plan was,—A certain number having been examined, wtre approved, and permitted to go on in practice : a number were rejected as unqualified, and prohibited praftifing ; and fome were paffed condition- ally, that is, they were recommended to pafs fome time at any univerfity, where medicine was taught with regu- larity, according to the moft improved Britifh fyftems. Finding myfelf included among the laft, I took from the regifter's office what concerned myfelf only, and fet off for the Univerfity of Cambridge, which had been ftrong- ly recommended to me as a medical fchool, where I could obtain every thing the ordonnance required of me. Although I had formed an high idea of the Univerfity of Cambridge, and of the medical lectures in particular, yet I am happy in declaring that they far exceed my moft. fanguine expectations, and I fhall account thofe circumftan- ces, which I once was ready to conceive as grievances, among the moft fortunate events of my life, inafmuch as they have made me acquainted with a fet of truly learned men, whofe urbanity, as well as abilities, I fhall never ceafe to revere. C 7 3' A DISSERTATION * ON THE Puerperal Fever. m TH E puerperal fever is a diforder peculiar to women in child-bed ; and although it is pro- bable it hath happened in all ages of the world, its caufe is ftill Involved in much ob- fcurity, and Its mode of treatment left, in a great meafure, undecided. The numbericut ofFby this difeafe, in Canada, have moved my compaffion, and excited me to enquire into its nature, and to try to afcertain the proper method of cure ; but alas ! I find even the moft celebrated Englifh phyficians, who have written on the fubjeft, differing in judgment with each other, and the fame appearances after death ex- plained in a different, and fometimes oppofite manner. Some practitioners doubt, whether it be a primary or a fecondary difeafe. Some confider it as arifing from an in- flammation of the uterus i others fuppofe it to be occafioncd C * 3 by an obftru&ion of the fecretion of the milk, while many others imagine it arifes from a fuppreffion of the lochia merely. It commonly begins, like other fevers, with rigour on the I ft, 2d, and 3d day after delivery, which is followed by great pain and forenefs over the whole hypogaftric region ; there Is a fenfe of heat and throbbing about the region of the uterus. There is much thirft, pain in the head, chiefly in the parts about the eye-brows, a flufhing In the face, anxiety, a hot, dry ikin, quick and weak pulfe, though fometimes It will refift the finger ftrongly, accom- panied with other figns of inflammation ; a fhortnefs in breathing, high coloured urine, and a fuppreffion of the lochia. A change in the quality of the lochia takes place, together with a tenefmus. Sometimes the patient vomits* from the beginning, a matter refembling what is difcharg- ed in the cholera morbus. When the fever has continued a few days, the fymptoms of Inflammation ufua-lly fubfide, and the difeafe takes a putrid form ; a bilious or putrid diarrhoea fupervenes, the flools become Involuntary, and the patient dies. Although this diforder begins fometimes like a regular fe- ver,and at others fhows fymptoms of genuine inflammation ; yet it feems to differ from both, and exhibits thofe fymp- toms of Irritation, with fudden depreffion of ftrength, quick and low pulfe, dizzlnefs, glazy eyes, and that fpccles of delirium which denote a diminifhed energy of the brain; the fymptoms are fuch as commonly arife when the mucous membrane Z 9 ] membrane of the throat, interlines, bladder or uterus are inflamed, which the fkilful practitioner knows to be very different from the fymptoms that arife when a thick, mufcular part is inflamed. I cannot exprefs my meaning better than by faying, that it is that kind of inflammation in which blood-letting is contra-indicated, and in which tonics are chiefly to be relied on. The puerperal fever may be dillinguifhed from the mili- ary, by the rigour being more violent, and without inter- ruption : and the eruptions, which are critical in the miliary fever, procure no mitigation in the puerperal. Phyficians hare differed nearly as much in their judge- ment refpefting the method of cure, as in the nature of the difeafe. Dr. Denman fuppofes it to arife from a re- dundancy or preternatural acrimony of the bile, the fecre- tion of which is irregular during pregnancy. Dr. Man- ning is of the fame opinion, only he lays much ftrefs on unwholcfome air and bad diet. Dr. Hulme differs from both thefe refpettable phyficians, fays it is owing to an inflammation of the omentum and inteftines, and maintains his argument by a variety of dif- fe&ions ; and the celebrated Dr. John Hunter is fo far of this opinion, that he thinks it is poffible even for men to have a diforderlike it, and fays that he ha3 known fimilar .appearances In the omentum and interlines of men, whofe abdomens have been diftended by dropfy. Dr. Hulme readily admits, that unwholefome air, and bad diet, may powerfully operate in caufing the difeafe. With this idea, Dr. Hulme proceeds to the cure by B emollient C 10 ] emollient injections, and, if the abatement of pain u not foon procured, he recommends fal catharticus a ma- rus, oleum ricini, and, in the intermediate fpaces, the fa- line draughts of Riverius. The complication of inflamma- tory and putrid fymptoms often puzzles the practitioner, who hefitates in doubt, whether he fhould bleed or not ; nay more, whether he fhould adopt an antiphlogistic courfe of remedies, or give the bark. The equivocal appearances of the vomiting and purg- ing, whether they be fymptomatical or critical, is another caufe of perplexity In the phyficlan ; for what are the fa- lutary efforts of nature, and what the ragings of a deflruc- tive diforder, he is unable to determine ; and this difeafe Is too acute to allow him time to hefitate long. As many women who die of a puerperal fever are af- flicted with a diarrhoea, fome have fuppofed this fymptom as the moft alarming, and have accordingly bent all their attention to rtftrain it ; and yet the experienced phyfician knows that numbers of women have recovered, apparently, through the intervention of this fymptom. Some inftan- ces have occurred of hasmorrage carrying off the difeafe, and this has been thought fufficient to juftify veuefecrion ; bvit Dr. Denman thinks we are warranted, by experience, to reject the practice as very hazardous, If not fatal ; and when We confider the fituation of child-bed women, wc fhould be apt, reafoning a priori, to conclude, that venc-• fectlon was unneceffary. Whether there may not occur cafes in the coldefl: feafons, in fiich a climate as Canada, where bleeding would be be- neficial, future experience muil determine. As C » ] As Dr. Denman and Dr. Manning fuppofe that acrid kile chiefly, fomeTits this difeafe, they begin with emetics, and then have recourfe to purgatives ; and they affcrt they have found this practice beneficial. Dr. Denman ufes the following formula. R. Tart, emetic gr. - - i Ocul. cancror. p. fcrup. i Intime mifceantur. The dofe is 6 gr. of this powdei ; aud if the firft does not produce any fenfible operation, lie repeats ft, in an en- creafed quantity, every two hours. He gives the faline draughts, which not only keep up the evacuation from the interlines, but'likewife promote the falutary difchargcs of urine and perfpiration. When a diarrhoea continues to fuch an alarming degree as to threaten a fatal termination*, he orders injections of chicken water, but to be conducted with great care, on account of the extreme fenfibility of the parts contained in the pelvis. He then adminifters the following draught : R. Pulv. Ipecac. - - - gr. i Confect. democrat, fcrup. i. Aq. alexit. fimp. vel. aq. cinara. fimp. unc. I m. Dr. Hulme, fuppofing that the proximate caufe of the puerperal fever is an inflammation of the omentum and in- teftines, fays, that the prcdifponent caufe is the preffure of the gravid uterus againft thefe parts. But Mr. White, another eminent Englifh practitioner, afks, if this were the cafe, whether the diforder would nottake place before delivery, and be mitigated immediately after that period? Seeing the puerperal fever is a difeafe, more frequent C 12 ] and more fatal, in large cities and in hofpitals, than in the country, and in private practice, fome have fuppofed, that it is a diforder very fimilar to the c'tnanche maligna, or ulcerated fore throat ? Allowing for the different feat of the diforder, they afk, are not the fymptoms very fimilar ? and may it not be fuppoffcd that it is an inflammation of the mucous membrane of the uterus and parts adjacent ? and do not the equivocal fymptoms before mentioned, in fome meafure, confirm this idea ? It may not be improper to obferve, that although Dr. Hulme fuppofes this diforder to arife from inflammation, yet he fays that bleeding is to be ufed with great caution. From the beginning of the year 1768 to 1770, the puerperal fever prevailed much In and about London. Dr. Leak publifhed the obfervations he made in that interval. It feemed to be occafioned, he faid, by catching cold, or by errors in diet, but oftener by anxiety of mind. He fays the deprefflon of Strength was fo fudden and fo great, that few of the patients could turn in bed without affift- ance, even fo early as the firft or fecond day of the attack. The lochia, he obferves, were not, from firft to laft, ob- ftructed, nor deficient In quantity, neither did the quality of the difcharge feem to be altered from its natural flate j and what Is remarkable, a confiderable preffure above the pubes did not occsfioti pain, while the fame degree of pref- fure between the ftomach and umbilical region produced a pain almoft intolerable ; and iu them that died, he fays the omentum was found-, fuppurated ; he therefore con- cludes, with Dr. Hulme, that an inflammation of that part and of the interlines, is the proximate caufe of the difor- der t n 3 der we are now treating of. In confequence of this idea, he advifes venefectlon, and recommends it from his own experience. But from the uniformity of the fymptoms, in the many cafes he relates, it has been fuppofed that it was a difeafe fui generis, then epidemic. Dr. Kirkland, who has written on this difeafe, recom- mends the peruvlan bark, and, if the diarrhoea fhould be- come very alarming, he does not hefitate to add fmall dofe* of laudanum to the bark. He warmly recommends, after Mr. White, the columbo root, as an admirable remedy to remove the Irritability of the Inteftlnal canal. Thus much have I been able to gather from authors, and from the lectures given in this univerfity, refpecting the nature and cure of this deftructive difeafe ; and have now to add a few obfervations I have made in my own practice in Canada. Is it not reafonable to fuppofe, that, In different cli- mates, the puerperal fever wears a different afpect ? In our cold climate, there moft commonly prevails that ftate of the arterial fyftem, which is known by the name of dia- thefts phlogtflica ; and I have generally found, that puer- peral patients bear bleeding better than we are led to fup- pofe, from reading thefe Engllfh authors. Dr. Leak's defcription of the difeafe comes the nearefl to what I have obferved in Canada of any of the Englifh authors. Dr. Thft's hlftory of the difeafe agrees with moft of the cafes I have met with, and his mode of treatment feems well [ 14 1 well adapted to our climate. I have found very beneficial effects from emetics and ecoprotics, and fometimes cathar- tics ; and in many inftances I have taken away 2 oz. of blood with evident advantage ; but In moft cafes, I am rather deterred from ufing venefection at all. The belt way of preventing this difeafe Is to obviate coft- ivenefs in the laft months of pregnancy, to keep the wo- man, after delivery, perfectly eafy in mind, ae well as in body. Her food fhould be light, and In fmall quantities ; her chamber fhould be properly aired, and every attention fhould be paid to cleanlinefs. However ignorant we may be of the nature of the puer- peral fever, of this we are certain, that the female fyftem is in fuch a ftate, on delivery, that errors in either of thefe refpects are apt to produce the difeafe ; too much heat will caufe it full as often as too much cold. That particular Jlate or predifpofition of their bodies, muft be inquired into, before wc can throughly underftand this diforder. And Indeed, from a view of the whole matter, I am in. duced to form the following opinion : That upon the nature of this predifpofition, the difeafe depends ; or, In other words, that the diforder, ufually known by the name of the puerperal fever, or that fever to which lying-in wo- men are more peculiarly Incident, affumes Its form princi- pally from circumftances pre-exifting in the fyftem. The circumftance of parturition, I would confider only as an exciting caufe. In C 15 ] In this view of the matter, let us examine in what form it may be expected to make it's appearance. The ftate of pregnancy may be confidered as having cer- tain effects on the vifcera of the abdomen In particular, and on the whole fyftem in general. The preffure of the gravid uterus is the principal agent in producing them. The evident confequences of this preffure are, 1. retention of faecal matter in the inteftlnts, and perhaps in the bladder j 2. diminished excretion of the bile, or difficult entrance into the duodenum ; 3. an obstruction to the free courfc of the chyle; and 4. Impeded circulation in the abdominal vif- cera. The laft of thefe may perhaps be confidered as the only one in which the vifcera in particular are Immediately interefted. The cfrcumftances affecting the fyftem In general, arc, " —Diftenfion of the fibres of the uterus, which, from an ex- tenfive fympathy of parts with this organ, muft nectffarily increafc the irritability of the nervous fyftem : — From an accumulation of putrid matter in the interlines, an abforp. tion of putrcfcent juices :—The collection of bile in the receptacles of the liver, which, by ftagnating, will be expo- ' fed to the abforption of it's thinner and moft diluting parts, and which will be the means of Inducing conftipation :__ Debility through the want of a nutritious, cooling fluid in the blood. A combination of thefe caufes with certain peculiarities of the habit may heighthen the predifpofition. The caufes dependent on parturition itfclf arc, 1. Irritation [ 16 ] I. Irritation upon the uterus. 2. Accelerated circulation, and Increafcd heat. 3. Sanguineous evacuation. 4. Sufpenfion of the requifite discharges. The firft of thefe may very readily be conceived as excit- ing difeafe, by means of the fympathy of parts wiih the uterus; and It will confplte with the already increafed ir- ritability. The fecond by giving activity to the retained ftagnant fluids, as the bile or thinner parts of the fasces. The third, by Increasing the abforption of thofe fluids, the vefftls of the receptacles being rendered more bibu- lous by the depletion. And The laft, by augmenting the quantity of colluvies, and by an application of putrid matter to the orifices of the uterine veffels, in addition.to that contained in other parts. That thefe may operate differently In different cafes of predifpofition, feems agreeable to the dictates of reafon and common fenfe. The degrees of violence in the attack arc allowed to depend much on conftitution and on predifpo- fing caufes ; and why may not the nature of the fymptoms be dependant on them alfo ? If it is granted that they may, are we not then jiiftified In concluding, that the forms of this difeafe may be various In different cafes, according to the predifpofition of the habit ? and may not the jarring opinions, and diffentieut theories which the Ingenious of our profeffion have advanced, be readily reconciled by thefe confiderations ? Of C 17 ] Of the two leading theories that have been advocated bjr phyficians, the one makes it an inflammatory, the other a putrid affection. Probably, in moft cafes, it is primarily inflammatory, and finally putrid ; but may it not eafily be conceived, that a puerperal fever which, in a plethoric habit, where the veffels being turgid are lefs difpofed to abforption, would In it's origin be highly Inflammatory, might in a thinner habit, where the Irritability is great| a flu me from the very beginning, a putrid type ? I hav- been Informed of an fnftance, in this Common- wealth, of two ingenious practitioners of eminence widely differing in fentlment on this difeafe, tenacioufly fuport- ing their opinions upon fact and experience, and yet fup- porting them in direct oppofition to each other. Might not both of them be in the right, and even the method of cure adopted by each of them be perfectly juftifiable, though the one recommended an antifeptic, and the other an antiphlogistic courfe ? Tbey both practifed according to the obvious fymptoms of the malady ; the one, under appearances actually putrid, prefcrlbed antifeptics ; the other, under thofe that were inflammatory, prefcribed antiphlogiftics. The many caufes of abforption indeed Should render us cautious of phlebotomy ; but I conceive, it may fometimes be indicated. It may, perhaps, be objected to what I have advanced, that if ray theory is right, there is nothing fpecific in the puerperal fever.—. To this I anfwer—That from the irritable ftate of the C nterus £ i8 ] uterus in particular ; from its vicinity to the fources of ab- forption ; and other peculiarities in it's fituation immedi- ately after parturition, I conceive fuch a variety in the character of the difeafe to be established, as may fo far render it a difeafe fui generis, as to require a treatment very different from that of either the fynocha, typhus or fynochus ; and, if I dared, I would venture to give It a name that fhould defignate it as a puerperal variety of the genus fynochus. Dr. Hulme's diffectlons have proved that in many cafes of what is called the puerperal fever, an inflammation of the omentum and inteftines was the proximate caufe. This might have been combined with a diathefis phloglftica ; and from fome of the remote caufes above mentioned, they affumed this form. It is to be prefumed, however, that Dr. Hulme did not mean to confider it as a fimple ente- ritis ; but as a difeafe, the character of which depended on the connexion of the parts which were the feat of It, with the uterus ; thus constituting a diftinct fpecies in a manner fimilar to that which I have adopted above. As to any inflammation of the uterus which may take placeinconfequenceof parturition, I have neglected to fpeak of it as connected with this diforder, for this is another dif- eafe, and it is that which has been confidered by Dr. Cal- len under the name of a hyfteritis. I fhall pay due attention to thisfubject, as cafes occur, and hope, fome time or other, to lay before you fome far- ther obfervations, in addition to this imperfect fketch. Erratum, in the title page, For fsepa read fsepe. Meet. Wist. WZ XI0 L35IJL