A Dissertation on the Puerperal Fever/Dissertation

by Pierre de Sales Laterrière

A

DISSERTATION

ON THE

Puerperal Fever.

THE puerperal fever is a disorder peculiar to women in child-bed; and although it is probable it hath happened in all ages of the world, its cause is still involved in much obscurity, 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 explained in a different, and sometimes opposite manner.

Some practitioners doubt, whether it be a primary or a secondary disease. Some confider it as arising from an inflammation of the uterus;, others suppose it to be occasioned by an obtrusion 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, accompanied 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 discharged 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 fever, and at others shows symptoms of genuine inflammation; yet it seems to differ from both, and exhibits those symptoms 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 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 miliary, by the rigour being more violent, and without interruption: and the eruptions, which are critical in the miliary fever, procure no mitigation in the puerperal.

Physicians have differed nearly as much in their judgement respecting the method of cure, as in the nature of the disease. Dr. Denman supposes it to arise from a redundancy or preternatural acrimony of the bile, the secretion of which is irregular during pregnancy. Dr. Mannlng 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 dissections; 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 injections, and, if the abatement of pain is not soon procured, he recommends sal catharticus amarus, oleum ricini, and, in the intermediate spaces, the saline draughts of Riverius. The complication of inflammatory 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 purging, whether they be symptomatical or critical, is another cause of perplexity in the physician; for what are the salutary efforts of nature, and what the ragings of a destructive 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 afflicted 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 instances 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 venesection was unnecessary.

Whether there may not occur cases in the coldest seasons, in such a climate as Canada, where bleeding would be beneficial, future experience must determine.

As Dr. Denman and Dr. Manning suppose that acrid bile chiefly, foments 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, emeticgr.	1
Ocul. cancror. p. serup.	1 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 encreased 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. 1
Confect. democrat.	serup. 1.
Aq. alexit. simp. vel. aq. cinam. simp. unc. 1 m.

Dr. Hulme, supposing that the proximate cause of the puerperal fever is an inflammation of the omentum and intestines, 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 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 assistance, even so early as the first or second day of the attack. The lochia, he observes, were not, from first to last, obstructed, 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 pressure 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 concludes, with Dr. Hulme, that an inflammation of that part and of the intestines, is the proximate cause of the disder we are now treating of. In consequeuce 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, recommends the peruvian bark, and, if the diarrhœa should become 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 climates, 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 diathesis phlogistica; and I have generally found, that puerperal patients bear bleeding better than we are led to suppose, 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 adapted to our climate. I have found very beneficial effects From emetics and ecoprotics, and sometimes cathartics; 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 costiveness in the last months of pregnancy, to keep the woman, 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 puerperal 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 induced 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 women are more peculiarly incident, assumes its form principally from circumstanccs pre-existing in the system. The circumstance of parturition, I would consider only as as exciting cause.

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 certain 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 viscera. 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 extensive sympathy of parts with this organ, must necessarily increase the irritability of the nervous system:—From an accumulation of putrid matter in the intestines, an absorption of putrescent juices:—The collection of bile in the receptacles of the liver, which, by stagnating, will be exposed 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 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 exciting disease, by means of the sympathy of parts with the uterus; and it will conspire with the already increased irritability.

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 bibulous 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 predisposing 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 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 Commonwealth, of two ingenious practitioners of eminence widely differing in sentiment on this disease, tenaciously supporting their opinions upon fact and experience, and yet supporting 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 in particular; from its vicinity to the sources of absorption; and other peculiarities in it's situation immediately 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 interlines was the proximate cause. This might have been combined with a diathesis phlogistica; 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 enteritis; 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 disease, and it is that which has been considered by Dr. Cullen 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 farther observations, in addition to this imperfect sketch.

Erratum, in the title page. For sæpa read sæpè.