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Puerperal -Fever, DEL I VERB l» At a Public Examination for the Degree ii£ BACHELOR IN MEDICINE, , BEFORE THE ReVERBUD - Joseph WiLLARD,^.7!Z). Pre'fideiitf The Medical Professors, The Gpv«RM0RS ^ Of t])l:l?sfTJ[5^SITr ^t CAMBRlbGE>J Iji i^ERiCA^ ETER DE^^ S^ LA IrERRIERli ! From Canada. ,Cor dolft tdthonttu quoties reminiTcor amarM ^|ii|. raoda fubit faemina fjfepa^victs. " ' ' ^'* • BOS T OH J ^ • * ■ 'ii Prmted by Samuil HALt,V at ^N«* I3, C^r * mDCtLXXXtt, i'Cf*v ^/' < ../^ 1 ?% I' ' M' % *iP*.-^ . /v-.^' -i': ■■' '-.7- .••': ■'iftlT'^r; - a; r;- %i « ft "-'i ^ 'iHi^ L. n; t. !r#* |i,v - * Jb 1\' " ■■ — -'TTT'ipTT^ ""'-^ .^•■■■*f. ) ■ ■■ ! i:*. #■ ^'^^:l.ft,-.... THIS DISSERTATION is DEDICATED, WITH ALL RESPECT, TO JOHN WARHEN, M. B. Profcflifr of Anatomy and Surgery ; BENJAMIN WATERHOUSE, M. D. Frofeflbr of the Theory and PraAice of Phyfic ; AARON DEXTER, M. D. Profeflbr of Chemiftry, and Materia Mcdica ; (Gentlemen not more diftinguifhcd by their LITERARY ACCOMPLISHMENTS^ and thcir PROFESSIONAL ABILITIES^ than refpcAcd for their attention to student§, and their talents for instruction j *^' By their ; Humble Servant} ' ^| PETER DE SALES tA TERRIERE. '■'■ f. f 5 3 »*<»» jt» « » jfairtiNw«»w, V IT Is not without diffidence that I appear before this HONOURAtLK and RiTERBND AssBMBLY, in Con- formity to the Ifiudable cuftom eftabliftied in the Univcrfity. To prodiice a differtation in a language I have neter pro* feffedly ftudied, before I entered thefe walU, is not fo eaff • laflc as fome perhaps may imagine : but relying on that candor Vrhich diftinguiflies a polite education^ I am em- boldened to offer you this fpecimen of my ftudicsi hoping that every deficiency of language will be excuKj^d. I (hall fay a few words for the information of thofe who may wonder to fee a pet fon of my age engaging in the ftu- ^y of Phyfic. The occalion of it is this ;— Canada, like moft provinces at a great diftance from the mother coun- try» has become Very deficient .' . medical knowledge. Not only the moft approved Engh.;. authdrs are unknown to inoft of us, but even the late French writers on phyfic ^nd furgery. are fcarcely I'een among us. Ignorance and quackery having, from thefe and fome Other caufes, fpread among us, to the great detriment of the lives of his Britannic Majefty's fubje£^s, it excited the attention of tlft legiflature, and particularly of the hu- mane Lord Dorcheflert who, touched with a tender feeling for the fufferings of others, iiTued an Ordonnance, obliging every C 6 3 every pradltioner to undergo an examination before a com* mutee of phyficians and members of the legiflative councit*^ The refult of this plan was,— A certain number having been examined, were approved, and permitted to go OA in pradlice : a nurnber were rcjeAed as unqualified, and « prohibited pradtliing ; and fome wece paffcd condition* ally, that is, they were recommended to pafs fome tim£ at any univerfity, where medicine was taught with regu- larity, according to the mod improved Britiih fyftems. Finding myfelf included among the lad, I took from the regider^s office what concerned myfelf only, and fet off for the Univerdty of Cambridge, which had been Ilrong* ly recommended to me as a medical fchool, where 1 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 Uflurcs in particular, yet I am happy in declaring that they far exceed my mod fanguine expectations, and I fhall account thofe circumdan- ces, which I once was ready to conceive as grievances* among the mod 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 (hall nevdr ceafc to revere. . «» itm mmmmm V-.V ^fm' 'm I \ I 1 2 ^*iJl!lH>'Jiif-r>yiiuj0^'^^^ . V DISSERTATION ON THE • Puerperal Fever. » - )• Vm 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 canfe is (till involved in much ob- fcurity, and its mode of treatment left, in a great meafurc, undecided. The numbej;9cut off by this difeafe, in Canada, have moved my compafliott, and excited me to enquire into its nature, and to try to afcertain the proper' method of cure ; but alas ! I find even the moil celebrated Englifh phyficians, vvho have written on the fubjed, differing in judgment with each other, ani the fame appearances after death ex* plained in a different, and fometimes oppoijte manner. Some practitioners doubt« whether it be a primary or a fecondary difcafe. Some confider it as arifing from an in- flammation of the uUrus i others fuppofe it to be occafioned ill //?■ t i 3 .- ,\)j an obftru£iion of the fecretion of the milk, wtiile many other! imagine ic arifei from a fuppreflion of the Mia 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 hypogaftrie ' region ; there is a fenfe of heat and throbbing about the region of th^ uterus. There 'is much ihirft, pain in the head, chiefly in the pares 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, accoo^- panied with other figns of inflammation ; a fhortnefs in breathing, high coloured urine, and a fuppreiUon of the lochia. A change in the quality of the lochia takes placCf together with a tenefmus. Sometimes the patient vomits^ from the beginning, a matter refembling what isdifcharg- ed in the cholera morbui* ' When the fever has continued a few days, the fymptoms of inflammation ufually fubfide, and the difeafc takes a putrid form ; a bilious or putrid diarrhoea (upervenes, the * ftools become idvoluntary, and the patient dies. • Although this difofder begins fometimes like a regular fe- ver, and at others fhows fymptoms of genuine infIa||imation ; yet it feems to differ from both, and exhibits thofe fymp- toms of irritation, with fudden depreflion of ftrecgth, quick and low pulfe, dizzinefs, glazy eyes, and that fpecies of delirium which denote a diminifhed energy of the brain ; the fymptoms are fucb as commonly ari/e wlien the mucous • membrane ■l*MM|H . t»- C 9 ] membrane of the throat, mtedinefi, bladder or uterus are inflamed, which the (Icilful pradlitlorler knows to be ver/ different from the fymptoms that arife when a thick, mufcular part is inflamed. I cannot cxpicfs 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 didinguifheJ from the mili- ary, by the rigour being more violent, and without inter- ruption : and the eruptions, which are critical in the miliary fev^r, procure no mitigation in the puerperal. - Phyficians hare differe3 nearly as much in their judge- ment lefpeftlng the method of cure, as in the nature of the difeafc. Dr. Den'man fuppofcs it to arife from, a re- dundancy or preternaroral acrimony of the bile, the fccre- tion of which is irregular during pregnancy. Dr, Man* ntng is of the fame opinioa, only he lays much (trefs on unwholefome air and bad diet* Dr. Hulme dTIffcrs from both thefc refpedlable phyiicians,^ fays it is owing to an inflammation o£ the omenttim and inteftines, and maintains his argument by a variety of dif- * fedtions ; and the celebrated Dr. John Hunter is fo far of this opinion, that he thinks it is poHible even for men to have'a diforderlike it, and fays that he has known ilmilar appearances in the omentum and inteitines of men, whofc 'abdomens have been diilended by dropfy. Dr, Httlnte readily admits, that unislrholefome air, and bad diet, may powerfully operate in cauflng the difeafe. With thrt idea. Dr. Hulme proceeds* to th« cure by B cmolllenc wteiS*. C lO ] t I I : I 1 ( I emollient' iiijeflions, and, If the abatement of pain it not foon procured, he recommends fal catharticus ama- rus, oleum ricini, and, in the intermediate fpaces, the fa* line draughti of Rivsrius, The complication of infiaiiima- lory and pu^crid fymptoms often puzzles the praftitionery who hefitates in doubt, whether he (houjd bleed or not f nay more, whether he fliould adopt an antiphlogiftic courf« of remedies, or give the bark. The equivocal appearances of the vomiting and jp>org- ing, whether they be fymptomatical or critical, is another caufe of perplexity in the phyfician ; for what, are the fa« lutary efforts of nature, and wha^ the ragings of a defiruc- tive difordur, he is unable to determine ; and this difeafc ii too'acute to allow him time to befitat'e long. • As many womeir yfrho die of a puerperal feve- are af- ^idled with a dianhcea, fome have fuppofed this irmptom . as the molt alarming, and hlave accordingly bent 11 their attention to redrain it ; and yet the experienced pi 'fician knows that numbers of wom«n have recovered, app? ently,^ through the intervention of this fymptom. Some nilan- ces have occurred bf hsfcmorrage carrying oflF the jii'eafe, and this has been thought fufficient to juftify veneiec.ion i but JDr. Denman thinks we are warranted, by experience^ to rejedl the practice as very hazardous, if not fatal ; and when we coniider the fituation of child-bed women, we Ihould be ape, teafoning a prion, to conclude, that vene- fe^ion was ^nneceifary. "Whether there may not occur cafes in the coldcft feafons, in fuch a climate as Canada, where bleeding would be be- neficial, future experience muft determine. As ■" y III* I c II ] >f As Dr. DenmaD and Dr. Manning fuppofc that acrid bile chiefly, foments this difeafe, tKey begin with emetics, and then have recourfe to purgatives ; and they a0ert they have found ihis praAice beneficial. Dr, Denman ufes the following formula. R. Tart, emetic gr. - - I Ocnl. cancror. p. fcrup. i Intime mifceantur. The dofe is 6 gr. of this powder; and if the firft does not produce any fenfible operation, he repeats it» in* an en- creafed quantity^ every -two hours. He gives the faltne . ^raughtSj which not only«keep up the evacuation from the inteftines, but lihewife promote the falutary difcharges of urine and perfpiratJon. • When a diarrhoea continues to fuchan alarming degree tl to threaten a fatal termination* he^^orders injedtions of chicken water, but to be conduced with great care, on account of the extreme fenfibiiity of the parts contained in ihe pelvis. He then adminifters the following draught : -R. Pulv. ipecac. - - - gr. i Confe^. democrat, fcrup. i. Aq. alexit. ilmp. vcl, aq. cinam. (imp. unc. i m. . • • • Dr.. Hulmet fuppq/ing that the proximate cagfe of the puerperal fever is an inflammation of the omentum and in* teftines, fays, that th£ predifponent caufe is the preflurc of the gravid uterus againft thefe parts. But Mr. White, another eminent Engh'fh pra6litioner, aiks, if this were the cafe, whether the diforder would not take place before delivery, and be mitig9ted immediately after that period ? Seeing the puerperal fever is a difeafe, more frequent and ! '■ ■' yM ii». / >f. C I* 3 and more fatal, iif large cities and in hofpitals, than in the country, and in private practice, fome have fuppofed« that it is a diforder very Hmitar to the ctnanche maligna^ or ulcerated fore throat ? Allowing for the different feat of the diforder, they afl<, are not the fymptonra very (Imilar \ and may it not be fuppofed that it is an inflammation of the mucous mepibrane of the uterus and parts adjacent I and do not the equivocal fymptoms before mentioned^ fQ fome meafurc, confirm this idea ? » ' ■>.••.' It may not be improper to obferve, that although Dr^ Hulme fuppofes this diforder to^rife from inflammation* yet he fays that bleeding is to be ufed wi.th great caution. From the beginning of the y.ear 1768 to 1770, the puerperal fever prevailed much in and about London. Dr. Leak publifhed tH^ obferyations 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 deprefpon of ftrength was foXudden and fo great, that few of the patients could turn in bed without aflift- alice, even fo early as the fir ft or fecond day of the attack. The lochia, he obferves, were not, from firft to lad, ob- ftrudled, nor deficient in quantity, neither did the quality of the difcharge leem to be altered foom its natural ftate ; and what is remarkable, a confiderable preffure above the pubes did not occafion pain, while the fame. degree of pref- fure betwfen the flomach and umbilical region produced a pain almoft intolerable ; and in them that died, he fays the omentum was found fuppurated ; he therefore con- V:lude8, with Dr. Hulme, that an inflammation of that part and df the intellines, is the proximate caufc of the djfor- <3cr ^ K \ J V. ^ \ 4er we are now treating of. In confequence of this idea^ he advifes venefed^ion, 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/M< generis, then epidemic. Dr. Kirkland, who has written on this dif^afe, recom- mends the peruyian bark, and, if the diarrhoea fhould be* come very alarming, he does not hedtate taadd fmalfdofes of laudanum to the bark. He warmly recommends, after Mr. White, the columbo root, as an admirable remedy to remove the irritability of ^he inteftinal canal. Thus much have I been able to gather from authors, apd from the led^ures given in this univerfity, refpe£|ting. the nature and cure of this de(lru£live difeafe ; and have now to add a few obfervations I have madb in my own pra£^ice in Canada, * Is it not reafonable to fuppjofe, that, in different cli* mates, the puerperal fever wears a different afpcft ? In our cold climate, there moft commonly prevails th?* ftatd of the arterial fyftem, which is known b]f the name oi dla- thejis phlogijika ; and I have generally found, that puer- peral patieqtsbear bleeding better than we are led to fup- pofe, from reading thefe £ngH(h authors. Dr. Leak's defcription of the difeafe comes the neareft to what I have obferved in Canada of any of the Englifh authors. ^ • Dr* Tlfoi*s hiftory of the difeafe agrees with moft of the cafes I have met witJi, and his mode of treatment fecmi . ' . •* . well * ? i -•<(«ii.j A I «4 3 vtU adapted to our climate. I have found very beneficial effefls from emetics and ecoprotics, and i'ometimes cathar* tic* ; and io many inftanees I have taken away 2 oz. of blood with evident advantage ; but in moft cafes* I am rather deterred from ufing venefedion at all. > The beft way of preventing this difeafe is to obviate coft- Ivenefs in the lad months of pregnancy, to keep the wo* , man^ after deliver y^ perfeAly eafy in mind, as well as ia body. . -Her food (hould be light* and in fmall quantities ; her chamber (hould be properly aired, and every attention fhonid be paid to cleanlinefs. ^ - However ignorant we may be of the nature of the puer- peral fever, o| this we are certain, that the female fyftem Is in flic]} a date, on delivery, that errors in either' of th'efe refpefls are apt to produce the difeafe ; too much heat will.caufe it full as often as too much cold. That particular JIate or predifpofttion of their bodies, muil be inquired into, before we can throughly underftand this diforder* And indeed, from a view of the wkole matter, I am in* duced to form the following opinion : That upon thf nature of this predifpoHtion, the difeafe depends ; or, in other words, that the diforder, ufually known by the name pf the puerperal fever, or that fever to which lying-in wo- men are more peculiarly incident, alTumes its form princi- pally from circumftances pre-exifting in the fyft^m^ The circuroftance of parturition, I would coirfider only as an excUinv caufe, • ' . Io •' •i •^ '^8^; M . C is 3 • . In this view of the matter, let us examine in what form It may be cxpe£fced to make it*» jippcaranc^. The ftate of pregnancy may be confidered as having ccjr- tain efFc6^s on the vifcera of the abdomen in particular, and on the whole fyftem in general. The preiTure of the gravid uterus is the principal agent in producing them. The evident confcquences of this prcffure are, i. retention of fsscal matter in the inteftines, and perhaps in the bladder; 2. diminifhed excretion of the bile, or difficult entrance into the duodenum ; 3. an obftru6lion to the free courfe of .the chyle ; and 4. impeded circulation in the abdominal vif- Cera. The laft of ihcfe may perhaps be confidered as the only one in which the vifcera in particular are immediately intercftcd'. • . The circumftances affediing the fyftem in general, are, •— Dideniion of the fibres of the uterus, which, from an ex- tenfive fympathy of parts with this organ, rouft neceifarily increafe the irritability of the nervous fyftem*: — From an accumulation of putrid matter in the in'teftines, an abforp- tion of putrefcent juices « — The collc^ion of bile in the receptacles of the liver, which, by (lagnating, will' be expo- fed to the abforption of it^s thinner and moft diluting parts, and which will be the means of inducing condipation :--* Debility through the want of a nutritious, cooling fluid in the blood. * A combination ofthefe caufes'with certain peculiaritiei of the habit may heighthen the predifpofition. Th{ caufes dependent on parturition 4tfelf are, 1. Irritation '•TW*:, - t. Ifritation upon the uterus. 2. Accelerated circulation, and increafed heat. 3. Sanguineous evacuation. 4. Sufpenfion of the requiCTte difcharges. The firft of thefe may very readily be conceived as excit<* ing difeafe, by means of the Tympathy of parts with the uterus; and' it will confpire with the already increafed ir- ritability. The fecond by giving a&ivity.to the retained ftagnant fluidsi as the bile or thinner parts of the fasces. The third, by increafing the abfocption of tbofc fluids, the vcflcls of the receptacles being rendered more bibu> lous by the depletion. And The laft, by augmenting the quantity of colluvies, and by an. applicatiou of putrid matter to the orifices of the uterine vefl*els, in addition to that contained in other parts. Thkt thefe may operate differently Tn different cafes of predifpofition, feems agreeable to the diflates of reafon and common fenfe. The degrees of violence in the attack arc allowed tS depend much on conftitution and on predifpQ- fing caufes ; and why may not the nature of the fymptoms be dependant on them alfo ? If it is granted that they may, ire we not then judified 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 diffentient theories which the ingenious of our profeffion have advanced, be readily reconciled by thefe confiderations ? • Of r '^f^ ',^ ,* ^ * • ^ , - mn wi fp i ^ l l|n ■il . |f ^ l n.f rr'--i irwl '•J(lt' *# iKv ^t Of the two leading theories that have been advocated by phyficians, theone makes it an inflammatory, the other t putrid affection. Trobably, in moft cafes, it is primarily inflammatory, atod finally putrid ; but may it not cafily be conceived, that a puerperal-fever which, in a plethoric habit, where the veflcls being turgid are lefs ^ifpofcd to abforption, would in it's origin be highly inflammatory* might in a thinner habit, where the irritability is great* aiTume from the very beginning, a putrid type \ I have been informed of an inftance, in this Common-- wealth, of two ingenious pradiltioners of eminence widely differing in fentiment on this difeafe, tenacioufly fuport- ing their opinions upon fa£i and experience, and yet fup- porting them in dire£l 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 antiphlogiftic courfe \ Tbey both pra&ifed according to the obvious fymptoms of the malady ; the one, under appearances a£tually putrid, prefcribed antifeptics ; the other, under thofe that were inflammatory^ prefcribed antiphlogiflics. « The many caufes of abforption indeed (hould render ui cautious of phlebotomy ; but I conceive, it may fometimei b^ indicated. • # It may, perhaps, be objefled to what I have advanced, that if my theory is right, there is nothing fpecific in thf puerperal fever.— To this I anfwcr— That from the irritable date of the C uterus I \ t »• 3 ittffn»lii-pMtieuliir ; frooi iu mcmkj to the fi»tirc«t of ab- Iwrptton ; and etlier peoaHari ties in tt't fitoattoo unmedi- •Itlf after partm-ftiant I coticetfc foeh a variety io the ;^ani6ter of the difitafe to be eAi^ltihed, as may fo £ir render it a difeafe fin generis $ as to require a treatment very di#erent from that of eicher the fynochat typhae or Jfuochus \ *and» if I dared, I would ventiive to give it » same that (honld dcfigwate it as a puerperal variety of the gentufynocbus. Dr. Hulnie^s diifl€6ttonB have proned that in many cafes of triiil is called the pnerperal fever, an inflamoiation of thi otttntnni and tntedines was the proximate cdufe. This might have been combined with a diatbeiis phlogiftica ; ind from fome of the remote cat^s above mentioned, they loomed this form. It is to be prefiwied, howrever, that JDr. Kulme did not mean to confider it as a £mple ente- ritis 5 but -sfe adiCeafe, the charader of which depended on the conncxion-of the parts which were the feat of it, with the sterns ; thus con*ftituting a diftinft fpocics in a manner fimilar to that which I have adopted above. -.1. ■'■;..■;-.■■■ '. * ■ As to any inflammation of the uterus which may take placeinconfequenceof parturition, I have ncgUacd to fpeak of h as conncaed with this diCorder, for this n another dlf- eafe, and it is that which baa been cpnfidcred by 3>. CuU )in under the name of a hyftcritis. «# t^««dl pay due attention to ^s fobje^, as cafts ^eur, >iiD^bope,-fome t«ne or*other, to lay before yoo fome far- ther obfervations, in addition to this impcrfea 0Betcb. ';t\ 'i***-: Zfk9,ATUVi,%jhtMpaie, For f«pa read f«pe. ''^'-•^-T ■ •■■• fc.-j*