Remarks on puerperal fever

I A I REMARKS ON PUERPERAL FEVER. BY PEIRSON, M. A. L. D. Fellow of the Massachusetts Medical Among r Sbcfiety. the morbid affections pecu...

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A

I

REMARKS ON PUERPERAL FEVER. BY

PEIRSON, M.

A. L.

D.

Fellow of the Massachusetts Medical

Among

r

Sbcfiety.

the morbid affections peculiaf^xo^fhe puer-

abdomen is among the most dangerous and dreaded. The complaint makes its appearance in a neighborhood only at

peral

inflammation

state,

within

the

long intervals of time, so that a practitioner

become

largely experienced in other diseases without

This consideration, mainly, has

having seen a case.

induced

may have

me

drawn from

a few facts and observations

to offer

my own

two years. The opportunities of comparing the morbid anatomy practice for the last

of cases of puerperal fever with the symptoms in such cases, have

been exceedingly

rare,

and

to this

is

to

be traced the great variety of opinions promulgated as to its

proximate cause.

Mr. Hey of Leeds, who

cords his want of success in the

first

re-

cases which he

treated, in the epidemic at Leeds, in 1809, with

most

frank and honorable fidelity, gives us no light as to the morbid appearances by a single dissection.

seven

first

cases were

all

fatal,

and of

teen cases three only recovered. 1

His

his first four-

After witnessing

REMARKS ON PUERPERAL FEVER.

2

some good

from purging in the treatment

effects

this eighth case,

erdeen, Mr.

first

that recovered,

treatise of Dr.

Gordon of Ab-

which was the

and from perusing the

of

Hey began

to

doubt whether the early

and sudden sinking which occurred in these cases was evidence of a typhoid or putrid state, and ultimately used venesection and other remedies appro-

with almost complete success.

priate to inflammation

The

publication

of Mr.

Hey's book and some

others which followed, gave a decided character

Peritoneal inflam-

the treatment of puerperal fever.

mation was all

for the

the symptoms.

most part looked to Within the

to

last

for explaining

few

years, there

to

be a disposition to admit the occurrence of

cases in

which contra-stimulant remedies, especially

seems

bleeding are inadmissible, and that there are rous cases of a tion

mixed character

must be used

although they

The

in

which great cau-

in applying debilitating

may be

nume-

remedies,

required to a certain extent.

recent works of Marshall Hall, and Dr.

Gooch

upon the diseases of females are exceedingly

rich in

But

discriminating details. ease, especially in

from being settled, and

is still far

consider

the treatment of the dis-

regard to the use of blood-letting it

will be useful to

some circumstances on which

this indecision

depends. In

the

commencement of

this disease

there

often great depression and apparent debility,

out any tion.

marked pain

And

this is not

or increase

owing

is

with-

of vascular ac-

to a congestive state

of

REMARKS ON PUERPERAL FEVER. the blood-vessels, such as

On

the contrary, bleeding

tients faint

relieved by bleeding.

is

borne very

is

with a very slight

3

ill,

and pa-

The

loss of blood.

ex-

planation seems to be, that the nervous system

is

overpowered by sympathy with the morbid impressions

made upon a membrane

peritoneum.

witnessed in

all

distinctly

is

cases in which a foreign body

mitted to the cavity of the

symptoms

so extensive as the

This extensive sympathy

peritoneum

ad-

is

and the

;

in cases of perforation of the intestines

ulceration, and in those

where there

a sudden

is

by

effu-

upon the peritoneum of the confined matter of

sion

an abscess, are not unlike those of the puerperal peritonitis. There

is

the

first

stage of

same sunken coun-

tenance, the same small, frequent, feeble pulse, the

same

restlessness

There

heat.

is

and irregular distribution of animal

no condition of disease

in

which the

is more powerfully acted upon than which the contents of some part of the ali-

nervous system that in

mentary canal have been suddenly

let

in

upon the

peritoneum, in consequence of the intestine becoming perforated by ulceration or violence. brief relations, will recall

to the

many similar instances, and

will

The

following

experienced reader serve to illustrate

the shock by which the vital powers are prostrated in

commencement of

the

puerperal fever, and which

is

only to be met by cordials and stimulants. 1

.

A man

fering for

tum.

On

of about

fifty

years of age had been suf-

many weeks from

a schirro-contracted rec-

the day of his death he appeared feeble, but

REMARKS ON PUERPERAL FEVER.

4

suddenly he became not otherwise disordered, when all over attacked with severe pain and tenderness

had sense of sinking and faintness frequent, at the epigastrium in an extreme degree

He

the abdomen.

;

small,

and feeble pulse

tremities,

great restlessness

;

in twelve hours

and death

;

cold ex-

from the attack.

examined the body the next day in company with an ulceration his attending physician, and found I

through the rectum, just above the contracted part

through which had passed several balls of fcecal matter of

an inch

2. In the

in diameter.

following case the superior part of the

A

canal gave way.

young woman, a domestic

Autumn

family, in the

of 1829,

in a

was attacked with

vomiting and pain in the epigastrium.

She had a

very anxious countenance, rapid, small, feeble pulse coldness of the extremities, and great restlessness. visited her, in consultation, in the afternoon of the

on which she during

my

first

visit.

day, the stomach

;

I

day

gave up her work, and she died

On

examining the body the next was found perforated by a round

hole about three-fourths of an inch in diameter,

and

not surrounded by any marks of inflammation, by which the contents of the stomach had been let in

upon the peritoneum. stomach

is

The perforated portion of the preserved in a collection of morbid prepa-

rations in this

town and

closely resembles the

sentation of a perforated stomach in Baillie's 3.

Morbid Anatomy, (Fasc.

The

following

is

a case of

repre-

the plates to

3. PI. 5. Fig. 2.)

still

a different kind.

REMARKS ON PUERPERAL FEVER. producing analogous symptoms. years old

was

A

O

fine lad of fifteen

suffering under an inflammation of an

obscure kind, but evidently seated in the abdomen r

which was tender iliac region.

For

to the

touch, especially in the left

affection he

this

had been bled,

leeched, and blistered, with alleviation of the symp-

toms,

when

very suddenly, August 10th, 1828, at

four o'clock, A. rigor,

and at

M. he became

six o'clock

affected with a severe

was attacked with acute pain

and extreme tenderness of the abdomen, accompanied by great paleness, cold extremities, pulse 140, small

and

feeble.

Death took place nine hours from the

access of the rigor.

On

examination of the body,

I

found a considerable abscess had been formed by the

low down in the pelvis, bounded by the bladder and abdominal parietes, and

side of the rectum, in front

covered by the small intestines, which formed the

upper wall of the abscess.

The

cavity of the ab-

which was capable of holding a pound, was found partly empty, and pure pus in contact with scess,

the intestines, the peritoneal coat of which slightly altered

in appearance.

was but

The symptoms

just

previous to death were occasioned by the bursting of the abscess.

Every one who has seen the rapid

sink-

ing which occurs in bad cases of puerperal fever, will

admit the similarity between the symptoms cases and those of the cases

I

in these

have brought forward.

All practitioners perceive and admit the necessity

of active treatment in this highly dangerous disease.

But

active treatment

to

be useful, must be applied

REMARKS ON PUERPERAL FEVER.

6

early in the disease;

For the

culty.

frequently

—and here

the principal

lies

diffi-

peritonitis of the parturient condition

comes on so

and

insidiously,

confounded with many

is

so liable to

of the slight disturbances

be and even the usual phenomena of

this condition, that

however disposed the practitioner may be to strike a blow which will quash the disease at the outset, he is

prone to wait for some unequivocal

symptom

to

determine the diagnosis, which perhaps does not appear

the disease has gained a formidable

till

tage.

I

know

of no help for

advan-

except what

this,

is

to

be found in discriminating tact and experience on the part of the

There

physician.

certainly

is

symptom which can be depended on

no one

as a guide

to

The whole case, in all its circummust come under consideration, and even

active treatment. stances,

with the best opportunities to consult and deliberate,

he

is

a happy

man who can

say he never

was puz-

seldom a sure

criterion.

zled.

Tenderness on pressure

Almost every

woman

will

is

flinch

from pressure for

three or four days after suffering parturient pains.

And

in

more than one severe case of puerperal

tonitis, I

have

known

peri-

the patient refuse to acknowl-

edge that any pain or soreness was felt on pressure. Pain is a very uncertain mark, frequently not appearing

till

the last stage, if at

appear in the early stages,

is

all,

and when

easily

it

does

confounded with

after pains.

Rigor

is

very

commonly observed

to

precede the

REMARKS ON PUERPERAL FEVER.

my own

other symptoms, and

me

remind

experience does not

symptom was ab-

of a case in which this

But

sent.

and

coming of the milk,

also precedes the

it

in irritable habits precedes or

exertion,

little

7

accompanies every

and the performance of any function,

such as micturition, digestion, &c.

Pain of the head, which usually accompanies the

which we are speaking,

disease of tant of

many

the lochiae

slight

also a

concomi-

Suppression of

indispositions.

symptom which

not always a

is

is

were

the early stage of puerperal fever, and

exists in it

other-

much in different womuch diminished just before

wise, the discharge varies so

men, and the

is

usually so

appearance of the milk, that

it

is

not of the

highest value as a diagnostic symptom.

The sudden

retrocession of the milk

depended on, but

known till

in

one

at least

this secretion continue

is

more

fatal case,

to I

be

have

with variable quantity

death.

The tongue entirely clean.

is

usually coated, but in

Extreme

thirst

some cases

is

and a most pungent

heat of the skin, oftentimes accompanied with profuse perspiration, and in tions,

some instances with miliary erup-

me

have occurred to

among

as

the most certain

symptoms.

The

observation of the pulse

importance. at last, if its

it

becoming

This

is

is

of the very

always increased

be not so in the less frequent is

recovery that can occur.

first

On

in frequency

of the disease

among

first

;

and

the best signs of

finding a patient a

few

;

REMARKS ON PUERPERAL FEVER.

8

hours after delivery with a pulse of 100 and upward. I

am

immediately led to inquire

rigors,

if

she

she has experienced

has headache, heat of the

thirsty,

is

if

skin, interruption of sanguineous

ness on pressure of the

On

abdomen and

tender-

gastric sinking.

the answers to these questions a tolerably correct,

although not

The

infallible

diagnosis

may be

founded.

worst cases usually occur before the secretion of

milk has commenced, but

know

highly important to is

discharge,

if

milk has appeared

if its

it

is

secretion continues or

suspended.

Marshall Hall has described a set of cases under the

title

of a

*

Serious Morbid Affection,' in which

much tenderness of the abdomen, acute pain, and many other symptoms in common with puerperal

there

is

peritonitis,

and which he maintains do not depend on

inflammation but upon

by

irritation, principally

produced

the foecal contents of the large intestines.

These

cases arc aggravated by bleeding and drastic purges

and relieved by laxative enemata and mild opening medicines, while the patient

and

tonics.

Of

is

supported by cordials

the excellent adaptation of Mr. Hall's

remedies to relieve the symptoms,

have no doubt by no means follows, that these are not cases dependent on peritoneal inflammation, because they

but

I

it

require

forbearance from debilitating remedies.

not inflammation of the peritoneal coat often a cient reason

why

Is

suffi-

the fcecal contents of the alimentary

tube are retained

?

In fact,

is it

not a very

common

case, that large quantities of solid foecal matter will

REMARKS

V

PUERPERAL FEVER.

ch\

be parted with, so soon as the inflammatory state of

the peritoneum, which has retarded peristaltic action,

has yielded to bleeding and other remedies is

so, it

may

be that Mr. Hall, in at least some of his

eases, has transposed the cause

There

If this

?

and the

effect.

also a spasmodic affection of the uterus,

is

which may mislead us

in diagnosis, a case of

which

I

shall give in the sequel.

The

prognosis of puerperal fever

difficulties.

do

I

in

fatal

The

abdomen.

There

cases.

amendment, which occurs in the

not without

however, intend to point them

not,

out, but to call attention to one very

of mistake

is

common is

source

a deceptive

after effusion takes place

pulse,

tongue, countenance,

and sensations of the patient improve, and the friends

and oftentimes the physician, join with her This

pecting a recovery. lief

is

of the distended vessels,

in ex-

same temporary rewhich is found to take

the

place in croup and other inflammatory diseases, in

which serum or

The

fibrin are

poured out.

favorable termination of the disease

is

some-

times accompanied by diarrhoea, which although in part induced

by the medicine we

large doses of calomel,

taneously, and

is

is

probably

use,

especially

critical.

In speaking of the treatment of this disease

no reason

to dissent

by

nevertheless kept up spon-

I

have

from the established principles

adapted to the treatment of inflammatory diseases. In any case which rigor,

there

is °>

I

have seen, where, following a

abdominal pain, soreness, hard pulse,

.

REMARKS ON PUERPERAL EEVEK.

10

heat of skin, and coated tongue, a

bleeding will

full

do more to arrest the disease than any other remed) Cathartics, especially of calomel, large enemata, and

sinapisms

come next

blisters,

Leeches are of great value, especially is

importance.

in

where the pain

Cordials are usually administered

circumscribed.

by the attendants on the access of the have observed with good

far as I

occasional doses of opiates has

seemed

and as

chill,

effect.

to

The

use of

me

admis-

every case, and where symptoms of sinking

sible in

and depression

exists,

a combination of opium, ether,

and ammonia has been particularly

When

beneficial.

the bowels have been urged by purgatives to

some

degree of exhaustion, opiate enemata have been particularly

pain.

The

oil

when

Fomentations,

beneficial.

managed, have appeared

of turpentine

skilfully

co-operate in relieving

to

is

a singularly efficacious

purge in cases of accumulation in the large intestines.

Some

of

my

tensive experience,

medical brethren, of very ex-

and

in

greatest reliance, believe

on as the principal one ease.

My own

whose opinion I place the remedy may be relied

this

in the

treatment of the dis-

experience does not warrant

speaking so confidently of

its

good

effects.

me It

in

cer-

maintained the high character given it by Dr. Brennan, of Dublin, who called the attention tainly has not

of the medical public to analysis of his

its

A

critical

in the

London

use in 1814.

pamphlet may be found

Medical and Physical Journal, Vol. 32, page 403. In patients slowly recovering from puerperal fever

REMARKS ON PUERPERAL FEVER. the choice of a laxative

portance.

is

often a point of great im-

sometimes happens, that medicines

It

which are very mild and gentle succeed better in clearing the

more

brisk cathartics.

I

in their operation,

passages

first

have found

than

twenty

fifteen or

powder of rhubarb and magnesia

grains each of

syrup

11

of ginger

and

mint water repeated

distilled

every three or four hours

till

in

a most useful

effect,

and agreeable prescription.

The

early administration of tonics

The

called for in this disease.

particularly

is

frequent pulse, the

heat of the skin, and the general restlessness will

sometimes, in the late stages of the disease, is

when

it

disposed to a favorable termination, be increased

by the exhibition of evacuants, and yield kindly under the administration of tonics.

what

is

sometimes observed

This

in opthalmia

external inflammations, in which there

a

period

when

is

the treatment

may

is

similar to

and other frequently

be advantage-

ously changed from the debilitating to one directly

The

opposite.

sulphate of quinine presents an ad-

mirable article for a tonic prescription in these cases,

and may be combined with myrrh, with sulphate of and with

iron,

and

laxatives, so as to present very neat

efficacious prescriptions.

There fever,

share

is

one

subject

connected with puerperal

which has not yet received any considerable of philosophical

question of

its

examination.

contagious character.

minutely into the long discussion

I I

mean

will

this question

the

not go

would

REMARKS

12 call up, as

PUERPERAL FEVEB

Qtf

have not attempted

I

in

these remark

history of the disease, but only to call

the attention

of readers to particular points in the pathology and treatment of the disease, such as my own experience

has (painfully in

my own

upon

make on

instances) strongly impressed

many

The

mind.

this subject

is,

first

remark

have to

1

that nearly all the cases of

puerperal fever which have happened in this town,

and

the fatal cases, as far as

all

red in

my

which

first

know, have occur-

case of puerperal fever

saw was about the

ever

I

The

practice.

I

1st of January,

1829, at which time there had occurred in

hundred

tice

more than

fatal

on the fourth day.

The

after death. I

five

I

births.

my

prac-

This case was

did not inspect the body

two next cases of delivery which

attended were likewise fatal cases of puerperal

ver.

have annexed the dissection of one of these

I

which appeared

cases,

had

tended

These cases January.

the all

at

the time in the Boston

The two next women

Medical Intelligencer.

disease

severely

occurred in the

After this

I

first

March, when

I

and

recovered.

nineteen days of

my

patients,

a

fatal

of which

case occurred, the principal

have described

I

was brought

the 25th, disease

I

1

till

had two cases of moderate severity,

cured by a free bleeding, a purge, and blisters in July

at-

I

had no case occur, although

continued to attend the delivery of

tient

fe-

to

in

;

and

phenomena

the sequel.

This pabed on the 26th of June. On

attended another

woman who

with great severity and recovered.

had the

Up

to

REMARKS ON PUERPERAL FEVER. period,

ihis

am

I

had occurred

not informed

practice, although I

1

have attended in

have had no

I

twenty cases of fatal.

been any other case

I

may be

information

am

I

in

my

am

I

this disease, of

not aware that

town of

in the

puerperal peritonitis, although

my

fatal case

have had several dangerous cases. all,

which lour have been there has

ease

that a single

any other physician.

in the practice of

Since that period,

13

distinct

willing to admit

very defective on this point.

have been told of some

'

mixed

The

bid affections,' after delivery.

and

cases,'

'

mor-

very great im-

portance of this subject to every practitioner of mid-

my

wifery must be

apology

which can

I

may be

allowed to

easily be separated

from

offer

my own The

facts

is

opinion,

statements,

I

have settled

not contagious.

and considerations upon which

belief cannot

I

rest this

all

be brought up in this brief communi-

I

cannot reconcile to a belief in the

But

cation.

the disease

fairly

After the best

have been able to make,

I

belief, that

my

my

by those who do not agree with me. examination

matters of

Having candidly and

personal concernment. stated the fact,

for introducing

contagiousness of the disease, that consulting physicians,

and attending nurses, have never happened

communicate the disease

made

in the

with those

that minute dissections

;

presence of several practitioners have

never spread the contagion

been confined

to

in the

who

;

that

women who

have

same houses and the same rooms

died have not

long intervals elapsed

between

had the disease

mv

cases

in

;

thai

which

REMARKS ON PUERPERAL FEVEK.

'|

I

many

without the disease appearing

births occurred

;

minute that I had cases occur when I took the most precautions as to change of dress, &c, and the reverse

when

I

neglected

the explanation of

more

It

certainly true, that in the history of almost every

cases were attended

we

by one

strong remarks, (Ed.

all

leave

experienced practitioners.

epidemic puerperal fever

p.

I

howthem to

Still,

precaution.

are remarkable, and

ever, the facts

is

all

learn that most of the practitioner.

Med. and Surg.

Dr.

Arm-

Jour. Vol. 10,

446,) that in the epidemic in Sunderland, in 1813, the cases

were attended by one

practitioner,

This gen-

Gregson, with three solitary exceptions. tleman

lost four patients

one week.

in

Mr.

Dr. Arm-

strong attributes these facts to contagion.

The

cases

pressed as

which follow, and which

much

as possible, will

I

have com-

serve to exhibit the

mortem appearances, to give an instance of successful treatment by the usual remedies, and to call

post

the attention of practitioners to a case important to

be distinguished from inflammatory affections.

CASE

The

I.

subject of the following case

was a lady of

and previous good health, aged thirShe was brought to bed of her fourth

fine constitution

ty-one years. child

January 2d, 1829.

The

labor

was

easy, natu-

and no untoward circumstance occurred. Having been troubled with after-pains at the birth of her last child, she was ordered an opiate. Two doses of

ral,

REMARKS ON PUERPERAL FEVER.

lb

twenty drops Tr. Opii produced comparative case.

There was no unusual the abdomen.

pain, soreness, or distention of

In the afternoon of the second day,

she had a slight rigor, which was dispelled by some

warm

gin and water, and the secretion of milk in

These were the

usual quantity immediately followed.

customary symptoms of her previous confinements.

On

the third day she took half an ounce of

Salt,

which produced

On

bowels.

satisfactory

Epsom

movements of the

the morning of the fourth day, she

com-

plained of slight oppression at the stomach, and depression of spirits

;

she

was

relieved

by a

little

pep-

permint, and in the afternoon sat up for a short time,

and

told the nurse she

On

the morning of the

never

felt

better in her

day, she

fifth

life.

awoke with con-

siderable oppression and slight nausea, for

which the

nurse administered half an ounce of wine of anti-

mony, which was followed by

free vomiting of a pro-

fusion of green and yellow bile, and with great relief.

At noon of soft

this day,

and moderately

I

found her with a pulse of 80, a clean tongue

full,

;

she com-

plained of heat and burning of the throat, and

was

somewhat exhausted by the emetic, which had not entirely ceased infusion

ceased

chamomile,

of

till

it

after

which the vomiting

was renewed on taking a

medicine at night, and her death.

She took a draught of

operating.

it

diaphoretic

continued at intervals

At ten o'clock

at

night, the

pulse

till

was

144, soft and feeble, the respiration hurried, the voice feeble and indistinct, and the sensorium affected with

REMARKS OH PUERPERAL FEVER.

lb'

a peculiar kind of talkative delirium, resembling

phenomena of

The abdomen was now

These symptoms continued

of pain.

next day,

of the

till

ten o'clock

the sixth from her confinement,

she expired, exhausted, and with very

parent distress. lochias

lie

tumid and tender, but there was no complaint

slightly

when

ebriety.

I

The

were natural

little

ap-

secretion of milk and flow of

in quality

and quantity on the

fifth

The tongue continued clean and moist to the The patient had a careful nurse, who had been attendant in all her previous confinements, was

day. last.

her

surrounded with the comforts and conveniences of life,

was of a

no error

cheerful disposition, and

in diet or

management.

had committed

The second and

third nights and days after her confinement

coldest

we

have had

for

two

years.

were the

has been ob-

It

served, (Gardien Traite d'Accouchemens, torn. 2. p. 368.) that more cases occur in winter than in sum-

mer, and hence the influence of cold

among this

is

reckoned

the exciting causes of the disease.

But in was every way well protected, phenomenon of the effect of cold, di-

case the patient

and the usual

minished secretion, did not occur. Pathological phenomena,

Abdomen

two hours after death.

tumid, external appearance otherwise natu-

except purple appearance of back and nates, from gravitation of blood. On opening the cavity of the ral,

peritoneum, a quantity of limpid, straw-colored fluid escaped. About a pint of the same fluid, mixed with whitish threads of lymph, and having a

little

purulent

REMARKS ON PUERPERAL FEVER. sediment, was found in the cavity. distended with

17

much

Intestines

Peritoneum, both of parietes

flatus.

and intestines presented a mottled appearance, from a turgid state of the blood-vessels, apparently contain-

The omentum was

ing venous blood.

Patches of lymph were observed, espe-

contracted. cially

thickened and

on the surface of the

viscera, lying in the pelvis;

was found on the posterior Mucous coat of the bowels and

a large patch uterus.

exhibited no appearance of disease.

part of the the bladder

Liver natural,

Stomach contained a porand had on its mucous surface

except paler than usual. tion of yellowish fluid,

a

large

number of small purple

about the great curvature these

was about

was about

the

;

the

size of a

the size of a

common

principally

spots,

largest collection of

The

dollar.

cocoa-nut,

and exhibiting, as

uterus

its

walls

moderately

firm,

feeling, the

appearance which might be expected on

the sixth day from parturition.

was

Its

to

internal surface

lined with a gluey exudation, easily

The attachment

of the placenta

and there was a

slight purple

There were several purple

and

size

its

was

wiped

at the

appearance at spots at

off.

fundus,

this part

the os tincae,

larger but similar to those in the stomach.

The

right

ovarium was about the size of an almond, and darker of a deep purple. or appearance in

3

The

was There was no putrefactive smell any part examined.

colored than natural.

fimbria of this side

1^

i;i

puerperal fever.

oh

*rks

:m

CASE

The

II.

subject of the following case

was a lady pre-

good health and of a sound constitution.

viously in

She was delivered on the 26th of June, 1829, ofjiei third child, after a short labor, in which nothing un-

The

usual occurred.

secundines followed naturally

my

curred in

care,

and had been natural, and her

The

recovery rapid.

labors had oc-

Her former

within fifteen minutes.

delivery occurred at sunset,

She dreaded

and she passed a comfortable night.

which she had experienced with her last preceding confinement, and took two grains of opium after-pains,

After-pains, however, continued

during the night.

for forty-eight hours, the uterus feeling

The

tracted.

On the attributed

hard and con-

were very abundant.

lochiae

27th she experienced headache, which was to

She took castor

the opium.

oil

and

some diaphoretic medicine, and passed a tolerable night.

On

the headache

On

symptoms and

the 28th she had no remarkable

was not

severe.

the 29th after rather a restless night, she

com-

plained of more headache, with uneasy sensations at the stomach.

The

ant flow of milk.

mel, followed by

breasts

were

She had oil

this

tilled

with an abund-

day a purge of calo-

and leeches to the head, which

bled freely and instantly relieved the pain.

were on

this

day some

slight rigors,

buted to the flow of the milk.

There which were attri-

The

pulse not re-

markablv altered, the skin moist and warm.

19

REMARKS ON PUERPERAL FEVER.

On

was some headache,

the 30th there

which,

lor

although not severe, there were leeches applied, with

immediate usual

There had been no pain or un-

relief.

Although there

tenderness in the abdomen.

was some

shrinking

when

uterus

the

was

firmly

pressed upon.

On some

the evening of the 1st of July she experienced chilliness,

with a sense of oppression at the

epigastrium and slight nausea.

Chilliness

was

fol-

lowed by great heat of the skin and profuse sweating. Pulse

bled to § ipec.

Was

120, of moderate force and hardness. viij,

when

with ant.

tart,

she

became

Took

faint.

and vomited freely with

the gastric oppression

Took

and nausea.

of calomel, to be followed with castor

pulv.

relief of

ten grains in

oil

the

morning.

On

the 2d July complained of no pain, pulse 115.

Has had

several

dejections,

Complains of sense of heat ordered

emp. cantharid.

powders of calomel,

to

loose of natural color. at

the

the

stomach.

epigastrium,

pulv. antimonial.

Was and

and camphor

to

be taken every four hours, with a diaphoretic draught in the intervals.

On

the 3d the

symptoms continue.

Abdomen

of the bowels. pain, except

when

is felt.

without

pressure

applied distinctly to the uterus or

ovaries, especially of the

soreness

bears

Slight fulness

left side, in

The whole

below the umbilicus whs

which

surface of the

freelj vesicated-

which had hitherto been clean,

parts a

abdomen

Tongue

slightly coated

with

REMARKS ON PUERPERAL FEVER,

20

brown

back

fur at the

part.

Lochia; nearly disap-

Passed a

peared, flow of milk rather diminished. restless night partly

from being disturbed by the noise

Evacuations from the bowels rather

of cannon, &c.

frequent, small and fetid.

On

the 4th had

pulse

112,

some appearance of amendment,

cooler

skin

and

tongue

moist,

moist.

Passed a tolerable night, and on the 5th expressed

some

feelings of

rather

amendment.

and when pressure

full,

Pulse 108, is

of pain only from the vesication. side,

but prefers to

lie

abdomen

applied, complains

Can lie on either Has some de-

on her back.

gree of pain in the umbilical region.

On

morning of the 5th, at four A. M. was

the

seized with a rigor and coldness of the extremities,

extreme nausea, with sour and

bitter

eructations,

followed by severe pain in the hypogastric region, shooting up to the stomach.

and

feeble.

Pulse 160, very small

Countenance pale and sunken.

ten grains of pulv.

Took

ipec, and after vomiting,

120 had seven leeches applied to the hypogastric region, and renewed vesication of the superior parts of the abdomen. Pain was checked and by the opiate, ceased entirely after two hours.

drops of acet.

opii,

Nausea continued

in

considerable degree.

It

was

agreed, in consultation, that she should take sulph. quinine gr. ij. every four hours, and intermediately at the

same

to be

intervals, four

drops of Fowler's min.

allowed brandy and water

skin and fulness of ihe

till

the

puNe prohibited

sol.,

heat of the

Opiates pro

;

REMARKS

Under

re nata.

2J

PUERPERAL EEVER.

same

time, she

some-

this course, the patient rallied

At the

but without essential amendment.

what,

tr.

OlS

was ordered

a julep of carb. soda?,

cinnam., powdered charcoal and water, to correct

a sour and bitter taste of the mouth, with unnatural fetor of the alvine discharges.

On

can turn over and little

same appearances continue

the 6th, at sunrise, lie

on either

or no difficulty.

There

side, is

and breathe with

occasional hiccough,

and the convulsive action of the diaphragm

is

at-

At other times does not nor of much soreness upon pressure.

tended with sharp pain.

complain of pain,

She continued symptoms,

till

to sink

much change in A. M. when she died.

without

ten o'clock,

the

Examination of the body twelve hours after death. Abdomen more tumid than after delivery, but by no means tense. On opening the abdominal cavity the peritoneum lining the parietes was natural in appear-

Where

ance.

it

covered the intestines,

it

exhibited marks of recent inflammation. intestines

lymph.

The

small

were glued together with an exudation of

The omentum was

neal covering of the uterus this

uniformly

membrane

vascularity.

The

thickened.

was

the only part

perito-

where

exhibited by

The

ovaria

its redness any increased were enlarged and soft, and

were covered, especially the left, with lymph. The fimbriae were of a deep purple color. The abdominal cavity contained about a pint of serous fluid mixed

with

flocculi of

lymph.

The

surface of he liver 1

was

covered with an exudation of the same substanee, so

liEMAKKS

PUERPERAL FEVER.

<).\

smootli and uniform as to constitute a complete fac-

when

The

membrane.

titious

into

cut

was

inch in thickness. tity

Its

of dark, bloody

whence

substance

pale, firm,

and

mucus without fetor. was detached, was

the placenta

Its internal surface

of disease, and

its

The

size

free

The

part

plainly dis-

to be unnatu-

stomach and duode-

intestines as far as inspected,

from any marks of disease.

The mucous

were nearly empty.

uterus

exhibited no marks

was not thought

internal surface of the

num, and of the other

was

of the

walls about an

cavity contained a small quan-

tinguishable.

ral.

its

The

intestines

coat of the bladder

exhibited no mark of disease.

The most local

obvious remark in this case

actual severity and danger of the disease.

was never severe it

is,

that the

symptoms were greatly disproportionate the morning of the

till

to the

The pain sixth, when

lasted but for one hour,

and was quieted by twenty

The

lochial discharge continued

drops of acet. opii. freely for six days,

or four

;

moderate degree. at first

and was profuse

for the first three

and the day before death reappeared

The

secretion of milk,

in a

which was

abundant and regular, was never wholly sup-

pressed, although

its

quantity varied with the state

of thirst, perspiration, evacuations,

causes, and

at the

and other obvious

time of the patient's death the breasts were distended with milk.

REMARKS ON PUERPERAL FEVER.

CASE

III.

Mrs. C. aged about thirty years, was brought to

bed of a fourth

child,

Sunday evening, Nov. 14th,

after a very short, easy,

On Monday, had several

and perfectly natural

stools.

and

Nothing unnatural occurred

this

took

ol.

ricin.

commenced

day, and the flow of milk

On

travail. ss.

15th, she

§

at evening.

Tuesday, 16th, appearances were perfectly

fa-

vorable, as in her former lyings-in.

On Wednesday

at

my

morning

visit,

same

the

fa-

vorable state continued.

On Thursday

morning, 18th,

I

found hei

much

changed, and received from the nurse the following

During the afternoon of Wednesday, she some general uneasiness, and at eight, P. M. had

account. felt

a rigor, which was followed by moderate pain in the

abdomen. it

This pain increased

was most

till

midnight,

excruciating, and produced

There was considerable

inspiration.

degree of headache.

The

when

difficulty of

and some

thirst,

nurse had given some hot

tea and a cordial during the rigor, and in the morn-

ing a dose of

oil.

The

durable since midnight.

when

I

pain had

My

visit

become more enwas at ten, A. M.

found the pulse 120, rather

skin hot,

full,

sweaty, and the secretion of milk nearly suspended, the lochias not

domen moist

around

much diminished

or altered

rather tumid and exquisitely tender

and the

slightly

coated.

the

;

;

tongue

There was pain

abdomen, shooting up the

ab-

sides,

all

and

REMARKS ON PUERPERAL FEVER.

24

affecting the breath.

took sixteen ounces of blood

I

when some degree

from the arm,

of fainting

came

to on, directed six large leeches to the abdomen, and have the bleeding from their bites encouraged by a

warm

large

poultice.

I

directed twelve grains sub-

muriate of mercury to be taken immediately, to be followed in two hours by the following purging

R.

draught.

ana

g

i.

01.

misce.

5 ss.

s.

omn. 2d hora.

dejections followed the

Some

relief

exhibition of the

These were

dose of purging draught.

first

simp,

bites bled very

was obtained by the bleeding, leech freely, five

syr.

terebinth,

ol.

ricin.

and healthy looking, and each contained

At

tion of fecal stool.

five,

P.

M.

she

feculent,

some por-

was directed

to take half a grain of tart, antimon. every hour

some degree of nausea

is

produced, and to take once

four hours one of the

in

Subm. hydr. gr. 10.

10

blister



R.

following powders.

Pulv. opii gr.

ss.

Tart, antimon. gr.

Let a

xij.

5

till

Mix.

ij.

Pulv. digitalis

iij.

div. in chs.

10. be applied

to the

No.

abdo-

men.

At

ten, P.

M. took

fifteen drops acet. opii.

Friday, 19th Nov. seven, A.

night with considerable sleep

M.

Has passed the and without much pain,

except griping in the bowels, which she plainly distinguishes from the pain of inflammation. At about five,

A.

M. began

to

have pain in the right

gion, affecting the respiration, this pain has

come

quite severe.

strong.

Pulse 130, moderately

V. S. to fourteen ounces,

when

iliac

re-

now

be-

full

and

slight faint-

REMARKS OX PUERPERAL ness

came

Sinapism

on.

to

the seat of the

had

five

more

The

tity.

pow-

be continued as before.

Has

Let

dejections, rather small in quan-

fluid

and the tenderness of

blister rose well,

the

abdomen has somewhat lessened

tion

still

M.

A.

ten,

griping

the

tumefac-

its

;

increased from yester-

considerable, but not

At

day.

pain.

the

Has had no nausea from medicines. ders and the solution

$5

b'EVEtt.

continuing,

pain

with one or two small dejections, she w-as ordered an

enema, with seventy drops

tr.

This procured

opii.

considerable quiet rest and relief of the griping pain.

At eight and ing,

o'clock, P.

feel sore



let

M. gums appear

slightly swollen,

powders be omitted

the

continue solution.

till

morn-

Let her take twenty drops

acet. opii at ten o'clock.

Saturday, Nov. 20th, eight, A. erable night. as the

moist,

stomach

M.

Passed a

tol-

Did not take the antimonial

solution,

unpleasantly. Pulse 110.

Tongue

felt

Secretion of milk has re-

slightly coated.

turned, and breasts

Has had no pain and

are hard.

bowels not so tense.

No

two tablespoonfuls of

the terebinthinate mixture or-

dered on the only

at

first

night

morning.

Eight o'clock, evening. middle of the day. dejections.

and

The powders Omit

day.

and

Was

Pulse

Let her have

after its operation

the enema, not copious.

4

a

Had

to

be given

the

solution.

hot and restless in the

118, soft and

eommon

twenty drops

Sunday, Nov. 21st.

Let her have

dejection.

several

Pulse

full.

No

enema,

laxative

acet. opii.

dejections

110, rather

full

from

and

REMARKS ON PUERPERAL FEVER.

26

Gums

Passed rather an uneasy night.

soft.

Omit powders.

Let her have

every four hours.

Let her have

comfortably tender. infus. quassia?

§

ij.

un*

Let her have an opiate at night. tea. Monday, Nov. 22d. Had several dejections yesterday, and a good deal of forcing and ineffectual inbeef

Passed

very

a

uncomfortable

clination

to

night, in

consequence of the distended state of the

stool.

having passed

bladder, no urine

Three

hours.

pints of urine

Abdominal

100.

the

were drawn

much

distress

for

last

thirty

Pulse

off.

abated, and general

Continue infusion and opiate

appearance improved. at night.

Had two

Tuesday, Nov. 23d. erably large, in the tion to stool, tions. first

1

night,

dejections, consid-

and has frequent inclina-

with only small,

fetid

liquid,

evacua-

learnt to-day for the first time, that in the

stools

which the patient had had

finement, large quantities of raisins that occasionally since, the skins

The

continue to appear.

after her con-

were found, and

and seeds of

raisins

patient confesses that a fort-

night before confinement she had indulged in eating

a great deal of this

fruit.

She has to-day a good

deal of gastric sinking and faintness after every evacuation.

pressed.

Pulse

104, soft and

full,

and easily com-

Let her take a tablespoonful of the followtwo hours. R Camphor. 9 i.

ing mixture once in

Ammon. Carbon.

3

.

i.

01. Anis. gtt x.

Spt.

Sulph. 3i. Pulv. Acacia? si. Aquae Purae § vss. Mistura.

Omit

the

infus.

Ether.

M.

f.

and take one grain of

27

REMARKS ON PUERPERAL FEVER. of quinine

sulphate

in

a

little

Has had

Wednesday, Nov. 24th. P.

M. removed two

There has been a three days.

At

pints of urine with catheter.

Continue quinine.

slight secretion of

milk for the

Pulse 80, soft and feeble.

Thursday, 25th.

every three hours, rhei,

S ss.

Misce.

last.

Has Let

two tablespoonfuls of the following mix-

her take

R. Pulv.

last

Lochia nearly ceased.

had no alvine discharge since night before

beris

dejec-

several

during the night, but without faintness.

General appearance convalescent.

ture,

tr.

every dejection.

opii. after

five,

water

Let her have twelve drops

every four hours.

tions

brandy and

magnesia

Aq. menth

the bowels are moved.

till

ana 3

calc. virid.

§ iss.

i.

Syrup ZingiAq. purse

Afterwards to continue the quinine.

§

ij.

A small

quantity of urine has been spontaneously evacuated several times since yesterday.

Friday, 26th.

Three doses of the mixture have

been taken, and the bowels have been thrice moved.

Feces are of tolerable consistence and natural Continue medicine.

From

this

color.

period the catheter

was dispensed with, convalescence went on slowly, and at the end of three months the patient was fully recovered, the secretion of milk not having been entirelv lost.

REMARKS ON PUERPERAL FEVER.

28

CASE

IV.

Spasmodic pain of Uterus, simulating Puerperal Fever.

Mrs. C. T.

J.

was brought

to

bed

her seventh

oi'

one o'clock, A. M. of Monday, the 25th of

child, at

She suffered considerable flooding, which was checked by powder of ergot and moderate pressShe was made faint by loss of blood, and her ure. October.

The pains was much reduced in volume. brought on by the ergot were moderate, but sufficient During the to contract the uterus to its usual size. pulse

day of Monday, she was somewhat

thirsty,

restless,

and uneasy, had moderate after-pain, and some de-

She passed a

gree of tenderness of the abdomen. tolerable night, but sleep.

At

a dose of

At

tion.

six o'clock,

ol. ricini,

nine,

I

much

did not obtain

on Tuesday morning, she got

which operated well

made

refreshing

the

usual daily

one dejec-

;

when

visit,

1

found her with some degree of remitting pain low in the pelvis, moderate tenderness of the this region,

and the uterus hard and

small within the pelvis.

abdomen

firm,

in

and rather

She had experienced a con-

siderable degree of headache ever since her confine-

ment.

At one o'clock

1

was again

found that her pains had been

my

visit,

and were now excruciating.

described as cutting pains, as if a knife

some organ in the pelvis. abdomen was extreme, so

sent

for,

and

increasing ever since

The

They were was piercing

tenderness of the

that she screamed

on the

REMARKS first

OiN

PUERPEftAL

The

touch of the hand.

a hard contracted ball.

Had

uterus could be

felt in

Pulse very small, 120 in the

Headache increased, and

minute.

21*

IT.\ Kit.

extreme.

thirst

experienced no distinct rigors, but remembers to

have been chilly for a long time alter born.

her child was

administered twenty drops of acet. opii

I

:

directed a pint of hot water to be administered as an

enema, and the bowels to be fomented with water as

hot as could

opiate

equal parts of to

Half an hour

be borne.

she took one tablespoonful ol. ricin. ol.

terebinth,

be repeated every hour

moved.

1

till

after the

of a mixture

the bowels should be

when

her again in three hours,

visited

oi"

and simple syrup,

1

found her free from pain, dozing, her skin moist, her

headache relieved, and the tenderness of the abdo-

men

nearly

vanished.

felt, full, soft,

large as

has not

risen

The

uterus

up out of the

now

pelvis,

could be

and twice as

when contracted in the morning. The milk yet made its appearance, and the lochias are

abundant and have been uninterrupted

;

their

was rather increased during the paroxysms of

flow

pain.

The next morning, Wednesday, 27th, the sympmuch improved pain gone, soreness

toms were

;

slight, pulse 100,

more

full



and

soft.

Enemata were

administered, and several dejections followed.

Had

had several dejections on Tuesday night from the

A

oil.

coated tongue, and slight headache continued lor

twenty-four hours after mata,

with,

lescent,

this,

but

by the use of ene-

a very slender diet, she continued conva-

and on the eighth day from her confinement

/ REMARKS ON PUERPERAL FEVER.'

30

was

as well as ever she

had been in the same time.

The enemata which were exhibited every morning for several days brought away solid feces, but not in such large quantities as have sometimes been observed in parturient cases.

Salem,

May

11th, 1831.

I

I