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A N 
 
 INAUGURAL DISSERTATION 
 
 PUERPERAL FEVER. 
 
9: i 
 
 -:- •-^^•" : ^^^,r^. 
 
 V #~ : * - *** 
 
 Of 5 
 
 H53 
 
TO THE 
 
 Honourable JOHN JAY, Efquire* 
 
 Chief Juftice of the United States, 
 &c. &c. &c. 
 
 WILLIAM SAMUEL JOHNSON, LL. XX 
 
 Prefident of Columbia College, &c> 
 
 JOHN CHARLTON, 
 
 Prefident of the Medical Society of the State of 
 
 New-York i 
 
 This DifTertation is further refpe&fully inferibed, 
 
 As a mark of regard and efteem, 
 
 For the attention fhewn to their very much obliged 
 
 Friend and humble Servant, 
 
 The AUTHOR, 
 
X O 
 
 The Right Reverend 
 
 SAMUEL SEABURY, D. D. 
 
 Bifhop of Connecticut and Rhode-Ifland: 
 
 1 HIS Diflertation is refpectfully dedicated, as a mark of that 
 gratitude and efteem which the Author muft ever have for 
 the Perfon who, in the mod kind and friendly manner, directed 
 him in his Medical Studies, during the time devoted to that 
 Science under his instruction. 
 
AN 
 
 INAUGURAL DISSERTATION 
 
 ON THE 
 
 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 PHTSId 
 
 ON THE FIFTH DAY OF MAY, 1 795. 
 
 By TIMOTHY FLETCHER WETMORE, 
 
 OF NEW-YORK. 
 
 Sitiui fit ancepi remedium experiri quam nullum. 
 
 Celsus. 
 Felix qui potult rerura cognofcere caufas. 
 
 Virg. 
 
 NEW- YORK: 
 
 PRINTED BY T. AND J. SWORDS, 
 
 Printer! to the Faculty of Phyfic of Columbia College. 
 
 -1795.- 
 
%M *•»* 
 
 "i i 
 
 c 3^La (l 
 
 K"<x 
 
 1.715" 
 
PREFACE. 
 
 A S this fever has been obferved in all ages, and has 
 been conjidered to be and aclually is one of the moft 
 dangerous difeafes incident to the fair fex\ and, as 
 many authors of eminence and great natural genius 
 and erudition have bejlowed much time in inveftigat- 
 ing it, with a view of determining the real caufe, and 
 rendering the method of cure more certain ; and as its 
 nature has remained to the prefent time a fubjecl 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 : — // cannot, therefore, be expected that IJhould 
 advance any thing new or definitive on thefubjeft, (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 Phy/icians, and defcrvedly demands their 
 greatejl attention. For this purpofe IJhall endeavour 
 to collefl and bring forward the moft received opinions, 
 B with 
 
( io ) 
 
 with fome remarks thereon, in hopes, by fo doing, 1 Jhall 
 not only fulfil a collegiate duty, but excite the attention 
 of fome future candidate to this wide field for invefii- 
 gation, and to a fubjecl of fuch 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 inteftines, uterus, &c. others have imagined it to 
 he the confequence of an ohflrucHon to the fecretion of 
 milk, while the greater number have been inclined (for 
 reafons equally if not more plaufible) to impute it to a 
 fupprejjion 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 necejfary confequence of any of the 
 taufes above mentioned. 
 
 AN 
 
A N 
 
 INAUGURAL DISSERTATION 
 
 PUERPERAL FEVER. 
 
 HISTORY OF THE DISEASE. 
 
 a 
 
 N the fecond or third day after delivery the 
 fymptoms of Puerperal Fever ufually begin to mew 
 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 CquCq of conftriclion on the extreme 
 parts of the body, followed by great debility,-f- 
 languor, lamtude, naufca, and other fymptoms not 
 unlike thofe produced in the cold ftage of intermit- 
 tent, which is fucceeded by heat : at this time 
 
 the 
 
 • Home. -f- Lcuke. 
 
( 12 ) 
 
 the head is fcarcely ever free from great pain, efpe= 
 daily 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 efpecialiy, accompanied with heat 
 and throbbing;, which is afterwards extended more 
 generally, and over the whole abdomen and its inte- 
 guments, and produces the moft exquifite 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 diftincl:, 
 full and perceptible— the fkin 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 deposits a dark coloured 
 fediment : fometimes the lochia undergoes no change, 
 either in quantity or quality, but are dark coloured 
 and foetid, and at other times they altogether difap- 
 pear. The fecretion of milk alfo undergoes fimilar 
 changes : in fome it is diminiihed in quantity — in 
 others it continues natural through the whole courfe 
 
 of 
 
( S3 ) 
 
 of the difeafe, and even to within a fhort time of 
 death. 
 
 On the firft 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 flighted impreflion. If preffure 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 moift and covered with a thick brownifh 
 fur, accompanied with great thirft, and in general 
 has a better appearance in the beginning than mod 
 fevers — the function of refpiration 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 comple&ion ; the pain in the abdomen, dif- 
 ficulty 
 
 • Lealcc. 
 
C 14 ) 
 
 ficulty of breathing, anxiety - ' and oppreffion about 
 the praecordia increafe, which is fucceeded by a 
 bilious and putrid diarrhea that fometimes evolves 
 contageous miafm.* This diarrhoea is fometimes, 
 though not always, of a dangerous and obflinate 
 nature, accompanying the difeafe through all its 
 ilages; 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 
 fbol) 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 •, 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 breads, 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; 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 mould continue fo 
 for a length of time, fhe finds herfelf but little 
 refreshed : during thefe dofes the eyes remain open, 
 the noftrils become enlarged, the face is commonly 
 much flufhed, the cheeks appear of a purplifh red, 
 and fometimes there is a circumfcribed red fpot on 
 the fame; the lips turn livid, the difcharges of 
 urine and Jiool become involuntary, and the partial 
 fvveats which now take place mew that death is at 
 hand. About this time the abdomen is not only 
 greatly fwelled, but begins to change to a greenifh or 
 even biackifh 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 moft commonly from the feventh to the twelfth 
 or fourteenth days, from which perhaps the refe- 
 rable patient flatters herfelf with hopes of recovery ; 
 but thefe are ill-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, maybe 
 often varied, (as I before obferved) according to 
 the conftitution of the patient, feafon of the year, 
 
 management 
 
 * Tiflbt. 
 
( tf ) 
 
 management of nurfes, the degree of the difeafe, 
 and its earlier or later invafion. 
 
 APPEARANCES ON DISSECTION. 
 
 FROM the appearances on dijfeffion of thofe 
 who have died of this difeafe, the caufes of their 
 death have been found very obfcure; fome relating, 
 that by diflection 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 offenlive air iflues 
 forth, followed by a very foetid humour, which is 
 fometimes yellow j it is found in a fluid flate in a 
 greater or lefs quantity : the interlines 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. J But 
 this does not appear to be the cafe, as obferved by 
 Home \ for he afTerts that the interlines are not only 
 a little but univerfally inflamed : but if there is any 
 diftinct inflammation, it is in that part of the 
 omentum which joins the interlines, for it has been 
 obferved to be particularly aifecl:ed.§ The ovaria 
 
 are 
 
 • Leake and Hulme. -J- Young, &c. 
 
 J Leake and others. § Leake° 
 
( *7 ) 
 
 are fometimes found inflamed, and in an indurated 
 and gangrenous ftate •* the abdominal vifcera are 
 alio 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 anatomiit John Hunter. 
 
 PREDISPONENT CAUSES. 
 
 IT evidently appears that the female fyflem un- 
 dergoes great changes during gejlation^ as the 
 naufea, vomiting, fvveliing of the breafts, and every 
 trifling circumftance affecting or disturbing the body- 
 in an unufual manner, and which more readily 
 takes place during parturition, clearly mews. 
 To prove that this difpofition to irritation chiefly 
 favours the production of this difeafe, it has been 
 advanced,-]- that pregnant women acting as nurfcs 
 to thofe who are lying-in, are never attacked with 
 this complaint until after parturition; and hence 
 C there 
 
 • Home and Med. Ccfnm. vol. iv. and vii. 
 f Leake. 
 
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 fb readily aflumes, affords ground to fufpect 
 a vitiated ftate of the humours to be the predijpo- 
 nent caufe ; for it is generally obferved to be moft 
 prevalent in unhealthy perfons, and among women 
 of weakly and fcorbutic conftitutions. 
 
 EXCITING CAUSES. 
 
 THESE are many and various; the principal 
 and moft 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, coftivenefs or the reverfe, excefs of joy 
 or grief, a moift 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 fufficiently ventilated, coftivenefs, too warm 
 a regimen, obftructed perfpiration, violence and 
 too great hafte in feparating the placenta, the ab- 
 domen being too much conftridled by bandages, 
 with the officious interference of midwives, every 
 thing which produces a plethoric diathefis, the too 
 
 foon 
 
C 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 circumftances 
 being favourable j) exceffive evacuations, efpecially 
 haemorrhages ; and finally, the abforption of acrid, 
 bilious or putrid matter from the alimentary canal, 
 uterus or vagina: thefe caufes being fufficient 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 
 caufes. This difeafe may alfo be produced by cer- 
 tain changes in the atmofphere, which elude our 
 refearches, and cannot be detected; for, if prevailing 
 as an epidemic, it acquires new ftrength, and be- 
 comes 
 
 * A remarkable cafe occurred in the month of January laft, in a 
 healthy woman, aged twenty-eight years, who wjs put to bed of her 
 fecond child, the labour perfectly r atural, and Arcngth but little diminifh- 
 ed ; flie was directed by her midwife in the free ufc of gin, (the weather 
 being cold,) of wkich fhe took fcveral pints. The excitement was fo great 
 at to produce indirect debility, typhus fever, ;md death. The collive 
 flate in which flic wa> differed to remain, might alone have produced 
 r tviR without the aid of fpiiituous liquors. 
 
( 20 ) 
 
 comes more mortal. It is more frequent in hospi- 
 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, which will be in any man- 
 ner fatisfactory j I mail, however, take a concife 
 view of the moft plaufible opinions, as delivered 
 by the mofr, approved authors, and endeavour to 
 examine them attentively, according to their re- 
 fpedlive 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 interlines and omen- 
 
 tum. 
 Moft fluids, after being retained a long time in 
 their refpective vefTels, receptacles or excretory 
 duels, 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 
 
 feldom 
 
( U ) 
 
 feldom happens, for we find that it comes on much 
 {boner from fuch a change firfl 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 -*xm not always nor at fixed periods 
 flow, we have already fhewn in the hiftory 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 interlines 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 22 } 
 
 organ Inclines to regain its former figure and origi- 
 nal ftate, becaufe the blood is not poured into it 
 any longer in fo great a quantity as it was before, 
 and which was requisite in a ftate of geftation. 
 Hence, fay they, the blood being determined to 
 another part, rufhes into thofe vefTels which make 
 the leaft refinance, to wit, thofe of the omentum 
 and inteftines, by which they fuffer a preternatural 
 diftention ; and this diftention or congeftion (in the 
 opinion of fome) is thought to be the origin of 
 this difeafe : but, at the time of geftation 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 vefTels of the 
 omentum can then be fo much diftended by blood 
 as to be productive of this fever. And if it is al- 
 lowed that the contractile force which the uterus 
 porTefTes is greater in the firft pregnancies than thofe 
 which follow, (for, in fad, the fudden contraction of 
 
 the 
 
 * White, p. 412. 
 
( n ) 
 
 the uterus with the very fmall, if any, paiiis which 
 are apt to follow the flrft: 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- 
 nifested 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 jomething deposited, 
 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 veSTeis of 
 the omentum and interlines producing inflammation 
 in thefe parts, is too fanciful and too much favour- 
 ing hypothecs to have much faith placed in it: 
 for it is not fufficiently fupported, nor do directions 
 prove the fame. 
 
 That kind of eryfipelas which is apt to appear 
 
 on 
 
 • Sir John Pringlt, Clcghorn and Lind. 
 
( 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 afthenia 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 preflure 
 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 
 
£ 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 increafing with the dif- 
 cafe; by flatulencies, coftivenefs or the reverfe. 
 
 This fever may be diflinguifhed from the miliary 
 by the rigor attending it being more violent, of 
 longer duration, and not interrupted ; the pulfe is 
 fuller and ftronger, 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 v 
 (though generally the latter) is not of a white but 
 brownifh appearance; the urine is alfo higher co- 
 loured. 1 he tsmmmtti m the beginning or the 
 puerperal is almoft always conftipated, which gives 
 another mean of diftinguiming the difeafe. 
 
 In the byjleritis, a difeafe that favours the puer- 
 peral, the pain is only felt in the uterus and about 
 the private-parts; but in the puerperal fever the 
 pains are felt in the ftomach and inteftines : nor is 
 the patient affected in the beginning of this difeafe 
 D with 
 
t 26 ) 
 
 -with violent delirium ; neither is the os uteri fo pain- 
 ful when touched as in hyfteritis. 
 
 To diftinguifh the puerperal fever from enteritis* 
 the pain is obferved to be more external, nor does 
 it affect the umbilical region only ; neither are the 
 bowels fo obftinately conftipated as in that difeafe. 
 
 When the original attack of this fever happens 
 to coincide with febrile commotions, excited in child- 
 i)ed 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 fhort 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 mooting from 
 the breafts to the arms, and back again 3 in the milk 
 fever 3 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 circumftanees many have expired 
 
 within 
 
( 27 ) 
 
 within twenty-four hours from the firfl: attack of 
 the difeafe; and there have been fome inftances- 
 where the rigor has clofed the fcene : however, the 
 cataftrophe is generally fufpended for a few days ; 
 but, for the moft part, fomewhere between the 
 fifth and eleventh, from the commencement, may 
 be fixed on as the decifive period ; but if it mould 
 be protracted beyond the eleventh day, there 
 wHI be more hopes of a recovery, although it 
 fometimes happens otherwife. The moil: favour- 
 able fymptoms are a gentle diarrhoea, which renders 
 the pains lefs acute ; the urine depofiting a dark co- 
 loured fediment, and efpecially if the lochia begin 
 again to flow, after being fomewhat fuppreffed, 
 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 diaphorefis 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 en the commencement of 
 the diarrhoea i if the refpiration is alfo attended 
 with a fenfe of anxiety and ftricture in. the thorax; 
 
 if' 
 
( 28 ) 
 
 if the ftrength is very much reduced, and at thefama 
 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 fo very fmall and frequent, that they 
 cannot be numbered ; if involuntary difcharges of 
 the foeces by ftool ; if a greenifh or blackifh matter 
 is ejected by vomiting ; vifcid eold fweats affect the 
 extremities, and there is a livid appearance on the 
 cheeks— ^tf/^ is near at hand. 
 
 PROPHYLAXIS. 
 
 "WOMEN, during the time of geftation, are 
 too apt to neglect the keeping their bowels open : 
 although this has been confldered a matter of no 
 importance, it is, however, often attended with 
 dangerous confequences, and renders the difeafes to 
 which they are liable in their lyings-in much more 
 fevere and obftinate 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 iituation of thefe women, muft be 
 had recourfe to, fuch as clyfters, gentle laxatives, 
 and that kind of diet which tends to keep the 
 bowels open, fuch as vegetables and ripe fruits. 
 
 An 
 
( *9 ) 
 
 An indolent, fedentary life not only occafions the 
 bowels to remain in a coftive ftate, but may be con* 
 fidered as predifpofing to this difeafej women 
 mould, 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 greatly 
 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 mould be light, nourifhing, and 
 eafy of digeftion; their cloathing mould fet eafy, 
 and be fuch as they have been accuftomed 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 
 adminifteredj but if, notwithftanding, the irrita- 
 bility of their fyftems becomes increafed, recourfe 
 muft be had to the Peruvian bark, mild calybeates, 
 and other tonics. The frequent ufe of the cold 
 bath during geftation has fometimes been attended 
 with the happieft effects; and it appears that the 
 fame treatment (if nothing forbids) is eflential in 
 removing that propensity to difeafes which is gene- 
 rally prefent in parturition-, and further, every 
 means muft be ufed that will tend to obviate a ple- 
 toric ftate of the fyftem. After parturition, every 
 
 meafurc 
 
( 30 ) 
 
 meafure muft ftill be had recourfe to, that will fecure 
 the fafety of the patient ; therefore, all irritating 
 caufes muft be avoided, cheerfulnefs promoted, and 
 both body and mind kept perfectly quiet, that the 
 patient may, for a few hours, enjoy Nature's fweet 
 reftorer, " balmy fleep." Nor is it of little mo- 
 ment that the bed-room mould be kept as clean and 
 neat as poffible ; the regimen mould be of a cooling, 
 vegetable kind, and.fuch as will not overload the 
 ftomachi cool drinks, and other liquids of the 
 acidulous and antifceptic kinds may be freely ufed. 
 The bowels, at this time, muft be well attended to, 
 that they be kept open. by clyfters and gentle laxa- 
 tives. Every principal caufe of difturbance muft 
 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 Is much oftener produced, 
 and in a greater variety of difeafes than is commonly imagined— that 
 is, a matter is generated or fecreted in veffels morbidly active, 
 which, when applied to other vcfTels, even in, a found body, tends to ex- 
 cite in them a fimilar action to that which originated itfelf. Hence clean- 
 linefs is neceifary in all difeafes; 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 operation is in analogy 
 with an infinitude of phsenomena in the human body depending upon this 
 general law in the fyftem — that the fluids in certain vessels 
 
 ARE AT ONCE THE PRODUCT OF THOSE VESSELS, AND THB A3- 
 JROPRIATE STIMULI TO THEIR FURTHER ACTION. 
 
 ProfefTor Smith's M. S. Lectures. 
 
( 5* 5 
 
 thought, in every inftance, the caufe of puerperal 
 fever ;* therefore, a free ventilation of the lying-in 
 room is highly neceffary ; nor is the officious inter- 
 ference of ignorant vifitants to be permitted ; nei- 
 ther is too rigid a treatment neceflary ; for in things 
 of an indifferent nature we may indulge our pa- 
 tients. Every lying-in woman is to be treated with 
 the greateft attention and the moft foothing indul- 
 gence, and whatever will render her pains more 
 eafy, mould moft readily be granted ; every degree 
 of violence mould 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 beft practitioners, and 
 fnould not be had recourfe to but in extreme danger 
 from floodings, &c.-j- The effect of opiates, gen- 
 tle compreffion of the abdomen, and afterwards 
 increafing it, ought firft to be tried. If the pati- 
 ent is expofed to contagion, every means mould 
 be carefully ufed that tend to leffen and moderate its 
 violence, or, if poffible, to render it inert. Fre- 
 quent change 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 
 
 • Young, <f Mawrlccau, 8te. 
 
( 32 ) 
 
 It Is alfo necefTary that every thing relative to 
 parturition mould be conducted in the moft fimple 
 manner*, the breafts fhould be drawn in due feafon; 
 the abdomen kept free from conftipation ; 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 otherwife 
 be injurious, were the difeafe to take place. 
 
 If the lochia mould flow in too great quantities,, 
 the infufion of bark and tinct. rofar. with as much 
 dix. vitriol, as will make it agreeable, may be had 
 recourfe to, together with abfolute reft in the hori- 
 zontal polition. 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 fbme- 
 thing emollient and antifceptic into the uterus. 
 Thefe are the moft general means of preventing 
 this dangerous and often fatal difeafe. I mall 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 arifing 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 mod 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 that 
 venefe&ion 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 fituation of women in child-bed : the 
 evacuations confequent upon delivery are ufually fuf- 
 ficient to diminilh any undue fuperabundance of the 
 fluids; and if, as frequently happens, the difeafe 
 be 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 affifled 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 ceconomy ; and every practical Phyfkian mull 
 Joiow how much the pulfe finks, and what a train 
 
C 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 pro- 
 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- 
 ftances, may palliate the fever; but that it often 
 fhortens the duration of it, appears to be a matter of 
 much doubt: on this account the practice becomes 
 {rill 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 
 
( z* ) 
 
 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 mould 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 afterted 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 bufiy 
 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 circumftances 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 ) 
 
 oh thefe at firft are founded our greateft hopes of 
 fuccefs ; for, by emptying the firft paffages, all dif- 
 tenfion from the contained foeces 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, me 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 coftivenefs or heat the fyftem) fhould be admi- 
 nistered j 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 ftimu- 
 btion. 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- 
 Jar 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 emmenagogue. 
 
 The vis vit^e 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 mould be frequently changed. 
 If the vomiting mould be troublefome, and fuch as 
 feems to arife from a fuperabundance of bile, mild 
 emetics and laxatives have been recommended to 
 reftrain 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 ftimulus -, for if the vomiting is not reftrain- 
 ed, or its violence leflened, difagreeable confequences 
 may enfue from the ftraining, &c. by the protrufion 
 of the womb, the ligaments of which are now in a 
 relaxed ftate. The moft proper drinks are thofe 
 
 which 
 >i 
 
 * In the Hotel Dieu, at Paris, fix or eight grains of Ipecacuanha exhibited 
 early, and repeated twice a day as long as neceffary, have been, it is faid, 
 attended with remarkable fuccefs. 
 
 Macbride and Lind have obferved, that vomiting is very ferviceable in 
 all fevers ariling from 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 ft ate 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 troui, 
 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 fhouldbe fomewhat reftrained by clyfters,* 
 with opium, and fuch medicines as have a gentle 
 reftringent operation j the Japonic confection is 
 
 ufeful 
 
 • Which fliould be emollient, diluting and nutrit'ou;, compofed of brothi, 
 beef-tea, cammomile inlufion with oil, and i1r.prc5r.aced with fixed air or 
 ytart. 
 
( 40 ) 
 
 ufeful at this time; the method of treatment juft 
 defcribed muft efpecially be ufed. If the ftrength of 
 the patient mould be greatly reduced by the diarrhoea, 
 it is cautioujly 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 retrained. 
 
 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. Befldes 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 aftringents feem to be indicated, fuch 
 
 as 
 
 * When the diarrhcea becomes critical and feems to be the means of 
 freeing the fyftem from puerperal fever, may we not fufpedt an analogy in 
 the ftate of the vefiels of the inteftines with that of the urethra, in 
 thofe cafe: of mild gonorrhoea where the difeafe goes off fponianeoufly ? 
 
( 4i ) 
 
 as the hsematoxylum, 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 aftiftance 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- 
 courfe to the faline draughts ; and if thefe mould 
 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 the abdomen, emollient cata- 
 plafms or fomentations are generally ufed with fuc- 
 cefs; but if they mould fail of affording relief, 
 epifpaftics, the rubifacients, camphor and opium 
 will not be ufed in vain. 
 
 To obviate or remove the dyfpncea, epifpaftics, 
 applied between the moulders, are always of fervice, 
 as alfo the fpermacasti 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 faid we may add, that the pa- 
 tient recovering from this difeafe mould be treated 
 as a convalefcent from any other fever ; and if me 
 mould not be quickly reftored to health, the cold 
 bath and various other tonics may become necef- 
 fary. 
 
 FINIS, 
 
errata; 
 
 Page 2 1, line 6, for 6 does,' read e do. 5 
 
 Page 25, line 18, for ' abdomen,' read < bowels.' 
 
(€6 
 
 211 
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 oil 
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