A
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. President,
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 reminiscor amaras quas mise-
randa subit sæmina sæpa vices.
BOSTON:
Printed by SAMUEL HALL, at No. 53, Cornhill.
MDCCLXXXIX. THIS DISSERTATION
IS DEDICATED, WITH ALL RESPECT,
TO
JOHN WARREN, M. D.
Professor of Anatomy and Surgery;
BENJAMIN WATERHOUSE, M. D.
Professor of the Theory and Practice of Physic;
AARON DEXTER, M. D.
Professor of Chemistry, and Materia Medica;
GENTLEMEN not more distinguished by their
LITERARY ACCOMPLISHMENTS, and their
PROFESSIONAL ABILITIES, than respected
for their ATTENTION TO STUDENTS, and
their TALENTS for INSTRUCTION;
By their
Humble Servant,
PETER DE SALES LA TERRIERE. [5]
IT is not without diffidence that I appear before this
HONOURABLE and REVEREND ASSEMBLY, in con-
formity to the laudable custom established in the
University.
To produce a dissertation in a language I have never pro-
fessedly studied, before I entered these walls, is not so easy
a task as some perhaps may imagine: but relying on that
candor which distinguishes a polite education, I am em-
boldened to offer you this specimen of my studies, hoping
that every deficiency of language will be excused.
I shall say a few words for the information of those who
may wonder to see a person of my age engaging in the stu-
dy of Physic. The occasion of it is this;—Canada, like
most provinces at a great distance from the mother coun-
try, has become very deficient in medical knowledge. Not
only the most approved English authors are unknown to
most of us, but even the late French writers on physic
and surgery are scarcely seen among us.
Ignorance and quackery having, from these and some
other causes, spread among us, to the great detriment of
the lives of his Britannic Majesty's subjects, it excited the
attention of the legislature, and particularly of the hu-
mane Lord Dorchester, who, touched with a tender feeling
for the sufferings of others, issued an Ordonnance, obliging
every[6]
every practitioner to undergo an examination before a com-
mittee of physicians and members of the legislative council.
The result of this plan was,—A certain number having
been examined, were approved, and permitted to go on
in practice: a number were rejected as unqualified, and
prohibited practicing; and some were passed condition-
ally, that is, they were recommended to pass some time
at any university, where medicine was taught with regu-
larity, according to the most improved British systems.
Finding myself included among the last, I took from
the register's office what concerned myself only, and set off
for the University of Cambridge, which had been strong-
ly recommended to me as a medical school, where I could
obtain every thing the ordonnance required of me.
Although I had formed an high idea of the University
of Cambridge, and of the medical lectures in particular,
yet I am happy in declaring that they far exceed my most
sanguine expectations, and I shall account those circumstan-
ces, which I once was ready to conceive as grievances,
among the most fortunate events of my life, inasmuch as
they have made me acquainted with a set of truly learned
men, whose urbanity, as well as abilities, I shall never cease
to revere.[7]
A
DISSERTATION
ON THE
PUERPERAL FEVER.
THE puerperal fever is a disorder peculiar to
women in child-bed; and although it is pro-
bable it hath happened in all ages of the
world, its cause is still involved in much ob-
scurity, and its mode of treatment left, in a great measure,
undecided.
The numbers cut off by this disease, in Canada, have moved
my compassion, and excited me to enquire into its nature,
and to try to ascertain the proper method of cure; but
alas! I find even the most celebrated English physicians,
who have written on the subject, differing in judgment
with each other, and the same appearances after death ex-
plained in a different, and sometimes opposite manner.
Some practitioners doubt, whether it be a primary or
a secondary disease. Some consider it as arising from an in-
flammation of the uterus; others suppose it to be occasioned
by[8]
by an obstruction of the secretion of the milk, while many
others imagine it arises from a suppression of the lochia
merely.
It commonly begins, like other fevers, with rigour on
the 1st, 2d, and 3d day after delivery, which is followed
by great pain and  soreness over the whole hypogastric
region; there is a sense of heat and throbbing about the
region of the uterus. There is much thirst, pain in the
head, chiefly in the parts about the eye-brows, a flushing
in the face, anxiety, a hot, dry skin, quick and weak pulse,
though sometimes it will resist the finger strongly, accom-
panied with other signs of inflammation; a shortness in
breathing, high coloured urine, and a suppression of the
lochia.
A change in the quality of the lochia takes place,
together with a tenesmus. Sometimes the patient vomits,
from the beginning, a matter resembling what is discharg-
ed in the cholera morbus.
When the fever has continued a few days, the symptoms
of inflammation usually subside, and the disease takes a
putrid form; a bilious or putrid diarrhœa supervenes, the
stools become involuntary, and the patient dies.
Although this disorder begins sometimes like a regular fe-
ver, and at others shows symptoms of genuine inflammation;
yet it seems to differ from both, and exhibits those symp-
toms of irritation, with sudden depression of strength,
quick and low pulse, dizziness, glazy eyes, and that species
of delirium which denote a diminished energy of the brain;
the symptoms are such as commonly arise when the mucous
membrane[9]
membrane of the throat, intestines, bladder or uterus are
inflamed, which the skilful practitioner knows to be very
different from the symptoms that arise when a thick,
muscular part is inflamed. I cannot express my meaning
better than by saying, 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 distinguished 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.
Physicians have differed nearly as much in their judge-
ment respecting the method of cure, as in the nature of
the disease. Dr. Denman supposes it to arise from a re-
dundancy or preternatural acrimony of the bile, the secre-
tion of which is irregular during pregnancy. Dr. Man-
ning is of the same opinion, only  he lays much stress on
unwholesome air and bad diet.
Dr. Hulme differs from both these respectable physicians,
says it is owing to an inflammation of the omentum and
intestines, and maintains his argument by a variety of dis-
sections; and the celebrated Dr. John Hunter is so far of
this opinion, that he thinks it is possible even for men to
have a disorder like it, and says that he has known similar
appearances in the omentum and intestines of men, whose
abdomens have been distended by dropsy.
Dr. Hulme readily admits, that unwholesome air, and
bad diet, may powerfully operate in causing the disease.
With this idea, Dr. Hulme proceeds to the cure by
emollient
B[10]
emollient injections, and, if the abatement of pain is
not soon procured, he recommends sal catharticus ama-
rus, oleum ricini, and, in the intermediate spaces, the sa-
line draughts of Riverius. The complication of inflamma-
tory and putrid symptoms often puzzles the practitioner,
who hesitates in doubt, whether he should bleed or not;
nay more, whether he should adopt an antiphlogistic course
of remedies, or give the bark.
The equivocal appearances of the vomiting and purg-
ing, whether they be symptomatical or critical, is another
cause of perplexity in the physician; for what are the sa-
lutary efforts of nature, and what the ragings of a destruc-
tive disorder, he is unable to determine; and this disease is
too acute to allow him time to hesitate long.
As many women who die of a puerperal fever are af-
flicted with a diarrhœa, some have supposed this symptom
as the most alarming, and have accordingly bent all their
attention to restrain it; and yet the experienced physician
knows that numbers of women have recovered, apparently,
through the intervention of this symptom. Some instan-
ces have occurred of hæmorrage carrying off the disease,
and this has been thought sufficient to justify venesection;
but Dr. Denman thinks we are warranted, by experience,
to reject the practice as very hazardous, if not fatal; and
when we consider the situation of child-bed women, we
should be apt, reasoning a priori, to conclude, that vene-
section was unnecessary.
Whether there may not occur cases in the coldest seasons,
in such a climate as Canada, where bleeding would be be-
neficial, future experience must determine.
As[11]
As Dr. Denman and Dr. Manning suppose that acrid
bile chiefly, sometimes this disease, they begin with emetics,
and then have recourse to purgatives; and they assert they
have found this practice beneficial. Dr. Denman uses the
following formula.
R. Tart. emetic gr. - - I
Ocul. cancror. p. scrup. I Intime misceantur.
The dose is 6 gr. of this powder; and if the first does not
produce any sensible operation, he repeats it, in an en-
creased quantity, every two hours. He gives the saline
draughts, which not only keep up the evacuation from the
intestines, but likewise promote the salutary discharges of
urine and perspiration.
When a diarrhœa continues to such 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 sensibility of the parts contained in
the pelvis. He then administers the following draught:
R. Pulv. ipecac. - - - gr. I
Confect. democrat, scrup. I.
Aq. alexit. simp. vel. aq. cinam. simp. unc. I m.
Dr. Hulme, supposing that the proximate cause of the
puerperal fever is an inflammation of the omentum and in-
testines, says, that the predisponent cause is the pressure of
the gravid uterus against these parts. But Mr. White,
another eminent English practitioner, asks, if this were
the case, whether the disorder would not take place before
delivery, and be mitigated immediately after that period?
Seeing the puerperal fever is a disease, more frequent
and[12]
and more fatal, in large cities and in hospitals, than in
the country, and in private practice, some have supposed,
that it is a disorder very similar to the cinanche maligna, or
ulcerated sore throat? Allowing for the different seat of
the disorder, they ask, are not the symptoms very similar?
and may it not be supposed that it is an inflammation of
the mucous membrane of the uterus and parts adjacent?
and do not the equivocal symptoms before mentioned, in
some measure, confirm this idea?
It may not be improper to observe, that although Dr.
Hulme supposes this disorder to arise from inflammation,
yet he says that bleeding is to be used with great caution.
From the beginning of the year 1768 to 1770, the
puerperal fever prevailed much in and about London. Dr.
Leak published the observations he made in that interval.
It seemed to be occasioned, he said, by catching cold, or
by errors in diet, but oftener by anxiety of mind. He
says the depression of strength was so sudden and so great,
that few of the patients could turn in bed without assist-
ance, even so early as the first or second day of the attack.
The lochia, he observes, were not, from first to last, ob-
structed, nor deficient in quantity, neither did the quality
of the discharge seem to be altered from its natural state;
and what is remarkable, a considerable pressure above the
pubes did not occasion pain, while the same degree of pres-
sure between the stomach and umbilical region produced
a pain almost intolerable; and in them that died, he says
the omentum was found suppurated; he therefore con-
cludes, with Dr. Hulme, that an inflammation of that part
and of the intestines, is the proximate cause of the disor-
der[13]
der we are now treating of. In consequence of this idea,
he advises venesection, and recommends it from his own
experience. But from the uniformity of the symptoms,
in the many cases he relates, it has been supposed that it
was a disease sui generis, then epidemic.
Dr.  Kirkland, who has written on this disease, recom-
mends the peruvian bark, and, if the diarrhœa should be-
come very alarming, he does not hesitate to add small doses
of laudanum to the bark. He warmly recommends, after
Mr. White, the columbo root, as an admirable remedy to
remove the irritability of the intestinal canal.
Thus much have I been able to gather from authors,
and from the lectures given in this university, respecting
the nature and cure of this destructive disease ; and have
now to add a few observations I have made in my own
practice in Canada.
Is it not reasonable to suppose, that, in different cli-
mates, the puerperal fever wears a different aspect? In our
cold climate, there most commonly prevails that state of
the arterial system, which is known by the name of dia-
thesis phlogistica; and I have generally found, that puer-
peral patients bear bleeding better than we are led to sup-
pose, from reading these English authors.
Dr. Leak's description of the disease comes the nearest
to what I have observed in Canada of any of the English
authors.
Dr. Tissot's history of the disease agrees with most of
the cases I have met with, and his mode of treatment seems
well[14] 
well adapted to our climate. I have found very beneficial
effects from emetics and ecoprotics, and sometimes cathar-
tics; and in many instances I have taken away 2 oz. of
blood with evident advantage; but in most cases, I am
rather deterred from using venesection at all.
The best way of preventing this disease is to obviate cost-
iveness in the last months of pregnancy, to keep the wo-
man, after delivery, perfectly easy in mind, as well as in
body.
Her food should be light, and in small quantities; her
chamber should be properly aired, and every attention
should be paid to cleanliness.
However ignorant we may be of the nature of the puer-
peral fever, of this we are certain, that the female system
is in such a state, on delivery, that errors in either of these
respects are apt to produce the disease; too much heat
will cause it full as often as too much cold.
That particular state or predisposition of their bodies, must
be inquired into, before we can throughly understand this
disorder.
And indeed, from a  view of the whole matter, I am in-
duced to form the following opinion: That upon the
nature of this predisposition, the disease depends; or, in
other words, that the disorder, usually known by the name
of the puerperal fever, or that fever to which lying-in wo-
men are more peculiarly incident, assumes its form princi-
pally from circumstances pre-existing in the system. The
circumstance of parturition, I would consider only asan
exciting cause.
In[15]
In this view of the matter, let us examine in what form
it may be expected to make it's appearance.
The state of pregnancy may be considered as having cer-
tain effects on the viscera of the abdomen in particular,
and on the whole system in general. The pressure of the
gravid uterus is the principal agent in producing them.
The evident consequences of this pressure are, 1. retention
of fæcal matter in the intestines, and perhaps in the bladder;
2. diminished excretion of the bile, or difficult entrance
into the duodenum; 3. an obstruction to the free course of
the chyle; and 4. impeded circulation in the abdominal vis-
cera. The last of these may perhaps be considered as the
only one in which the viscera in particular are immediately
interested.
The circumstances affecting the system in general, are,
—Distension of the fibres of the uterus, which, from an ex-
tensive sympathy of parts with this organ, must necessarily
increse the irritability of the nervous system: — From an
accumulation of putrid matter in the intestines, an absorp-
tion of putrescent juices:—The collection of bile in the
receptacles of the liver, which, by stagnating, will be expo-
sed to the absorption of it's thinner and most diluting parts,
and which will  be the means of inducing constipation:--
Debility through the want of a nutritious, cooling fluid
in the blood.
A combination of these causes with certain peculiarities
of the habit may heighthen the predisposition.
The causes dependent on parturition itself are,
1. Irritation[16]
1. Irritation upon the uterus.
2. Accelerated circulation, and increased heat.
3. Sanguineous evacuation.
4. Suspension of the requisite discharges.
The first of these may very readily be conceived as excit-
ing disease, by means of the sympathy of parts with the
uterus; and it will conspire with the already increased ir-
ritability.
The second by giving activity to the retained stagnant
fluids, as the bile or thinner parts of the fæces.
The third, by increasing the absorption of those fluids,
the vessels of the receptacles being rendered more bibu-
lous by the depletion. And
The last, by augmenting the quantity of colluvies, and
by an application of putrid matter to the orifices of the
uterine vessels, in addition to that contained in other parts.
That these may operate differently in different cases of
predisposition, seems agreeable to the dictates of reason and
common sense. The degrees of violence in the attack are
allowed to depend much on constitution and on predispo-
sing causes; and why may not the nature of the symptoms
be dependant on them also? If it is granted that they may,
are we not then justified in concluding, that the forms of
this disease may be various in different cases, according to
the predisposition of the habit? and may not the jarring
opinions, and dissentient theories which the ingenious of our
profession have advanced, be readily reconciled by these
considerations?
Of[17]
Of the two leading theories that have been advocated by
physicians, the one makes it an inflammatory, the other a
putrid affection. Probably, in most cases, it is primarily
inflammatory, and finally putrid; but may it not easily
be conceived, that a puerperal fever which, in a plethoric
habit, where the vessels being turgid are less disposed to
absorption, would in it's origin be highly inflammatory,
might in a thinner habit, where the irritability is great,
assume from the very beginning, a putrid type?
I have been informed of an instance, in this Common-
wealth, of two ingenious practitioners of eminence widely
differing in sentiment on this disease, tenaciously suport-
ing their opinions upon fact and experience, and yet sup-
porting them in direct opposition 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 justifiable,
though the one recommended an antiseptic, and the other
an antiphlogistic course? They both practised according
to the obvious symptoms of the malady; the one, under
appearances actually putrid, prescribed antiseptics; the
other, under those that were inflammatory, prescribed
antiphlogistics.
The many causes of absorption indeed should render us
cautious of phlebotomy; but I conceive, it may sometimes
be indicated.
It may, perhaps, be objected to what I have advanced,
that  if my theory is right, there is nothing specific in the
puerperal fever.—
To this I answer—That from the irritable state of the
uterus
C[18]
uterus in particular; from its vicinity to the sources of ab-
sorption; and other peculiarities in it's situation immedi-
ately after parturition, I conceive such a variety in the
character of the disease to be established, as may so far
render it a disease sui generis, as to require a treatment
very different from  that of either the synocha, typhus or
synochus; and, if I dared, I would venture to give it a
name that should designate it as a puerperal variety of the
genus synochus.
Dr. Hulme's dissections have proved that in many cases of
what is called the puerperal fever, an inflammation of the
omentum and intestines was the proximate cause. This
might have been combined with a diathesis phloglstica;
and from some of the remote causes above mentioned, they
assumed this form. It is to be presumed, however, that
Dr. Hulme did not mean to consider it as a simple ente-
ritis; but as a disease, the character of which depended on
the connexion of the parts which were the seat of it, with
the uterus; thus constituting a distinct species in a manner
similar to that which I have adopted above.
As to any inflammation of the uterus which may take
place in consequence of parturition, I have neglected to speak
of it as connected with this disorder, for this is another dis-
ease, and it is that which has been considered by Dr. Cul-
len under the name of a hysteritis.
I shall pay due attention to this subject, as cases occur,
and hope, some time or other, to lay before you some far-
ther observations, in addition to this imperfect sketch.
ERRATUM, in the title page, For sæpa read sæpe.