On the nature, signs, and treatment of childbed fevers; in a series of letters addressed to his class

Front matter

■A

ON THE

NATURE, SIGNS, AND TREATMENT

Letter V

Is there a, poisoned state of the blood? — Of conjectural putridity — Vitiated blood regarded by some as the cause of childbed fevers — In what way the blood can become changed — It is a dependent of the blood-membrane in disease, and not vice versd, 79

Letter VI

Contagion in childbed fever — Definitions — Contagions are both specific and incubative — Conditions of the problem — Common tendency to believe in contagion Dr. Holmes's pamphlet — Tonnelle's, Baudelocque's, Jacquemier's,

and Kiwisch's views — Von Busch and his hospital-epidemic — Collins's, Dubois's, and Scanzoni's opinions — Dr. Campbell's experience — Author's experience, with a table— Rutter's cases— Gooch a contagionist, and Armstrong Roberton's account of the Manchester Epidemic — Churchill . . .85

XIV CONTENTS.

Letter VII. Page

Childbed fever sporadic and accidental, or epidemic and unavoidable — Table of epidemics from 1652 to 1853 — It is not a fever, but a phlegmasia — Fever, what is it? — A group of various inflammations differing in character — Opinions of various authors as to the cause — Dr. Ferguson, Churchill, Dance, Tonnelle\ Ch. White — TonnelM's dissections — Case by Author — Gordon's work — Case by Author — Remarks on the so-called vitiation of the blood . 114

Letter VIII

Opinions of Gooch faulty from his having preceded Dance and Tonnelle' — Gasc — Raciborski on the veins — Uterine phlebitis — Putrescentia uteri — Serous or exo-metritis — Mucous or endo-metritis — Metritis parenchymatosa — Affection of the subjacent organs in peritonitis ........ 142

Letter IX

Description of a case of peritonitis in a woman recently confined . . . 149

Letter XI

Etiology — German notion of acute blood-dissolution ; Kiwisch's case — Sizy blood

of pregnancy — Febricula of gravid women — Case of Mrs — State of

the utero-placental disk — Undischarged lobuli of the placenta — Pressure — Contusion — State of cervix in labors — Over-distension of womb — Relaxation of abdominal walls and sudden withdrawal of textural tension — Torpor of bowels in the gravid — Exalted vital state in labors, analogous to intense hysteria — iEsthesis — Debility from labor — Cold — Unrest — -Indigestions — Seasons ; Tenon's table of them 174

Letter XII

Humboldt on climate — Epidemy — La Roche on miasm — Cosmic agents Filth

— Tenon's state of the air and the sick at Hotel Dieu — Influence of these on the nervous mass — Views of Oken, Cuvier, and Flourens on the nervous mass — The animal naught but nerve — Modifications of nerve crasis caused by epidemy— M. Cerise — Weakness of a cause that affects only one class out of many — Accidents ......... . iqq

Letter XIII

Collins cited to show that typhus fever is confounded with childbed fever— Pregnant women in cholera; Kiwisch's testimony — Typhoid fever not connected with childbed states— Smallpox and childbed fever— The womb compared to a stump in amputations— Remarks on the contagion of typhus and other zymotic diseases . 201

CONTENTS. XV

Letter XIV. Page

Erysipelas and peritonitis compared — Error to consider childbed fever an erysipelas, since it is a group of both phlegmonous and membranous inflammations — Dr. Philip Pitt Walsh's views on puerperal fever — Dr. J. Y. Simpson, of Edinburgh, on identity of erysipelas and phlebitis — Ontologists . . 206

Letter XVI

Diagnosis of childbed fevers by inquiries as to pain, rigors, the breathing, soreness or tenderness of the belly ; the mammary glands and milk ; intermittence of the pain ; the bladder of urine ; is it a urinary or a uterine pain? — The early phlebitis not painful — Date of the attack, and the time already elapsed — Milk fever; M. Chevillard's case — Remissions in the cases — One described by Tonnelle — -Milk fever with after-pains, or incipient childbed fever? — Touching, as a diagnostic proceeding in childbed fever — The tympanitis — Compare pains of phlebitis and peritonitis — The mind — Pusintoxication ............ 217

Letter XIX

On the treatment by means of bloodletting as the remedy-in-chief for childbed fevers — Estimate of the quantity of blood moved by the heart in given times, in health and in disease — The power of bloodletting as a controller of the circulation, and, consequently, of the innervations — Anodyne power of venesection — Instances in point from Armstrong, from Gordon, from Legouais, from Author — Puzos — Dr. Lee's tables of cases treated with and without venesection— Gordon — Rule as to time — How to bleed— Gordon's pupils — Late venesections — A fatal case — Two cases suddenly cured — A sudorific mixture — Case of venesection after violent hemorrhage .... 237

Letter I

motives foe writing these lettees — great diversity of opinions on the disease, and want of a better understanding of its nature and cube.

to the members of my class of 1850-51 :—

Gentlemen : —

1. It is a very remarkable thing that, in the present age of the world, there should, among medical men, exist such great differences of opinion concerning the nature, causes, and treatment of one of the most familiar, and at the same time, most terrible and fatal of disorders; I mean the disease or diseases grouped together under the denomination of childbed fevers — puerperal fever, puerperal peritonitis, peritoneal fever, metro-peritonitis, fever of lying-in women, &c. &c.

2. One might suppose that time enough has elapsed, even since the revival of medical learning in the fifteenth century, and more especially since the surer establishment of our medical philosophy after Harvey's discovery of the circulation, and the great enlargement of the circle of science by Pecquet, Eudbeck, and Aselli's invention of the absorbents at a later period of the seventeenth century, to have enabled our people to come to some certain conclusions on these questions. Many thousands of cases of childbed fever have been observed — many hundreds of dissections have been made to investigate its post-mortem appearances — yet all these, with books, essays, pamphlets, and conversations without number, have failed to harmonize the opinions of our brethren; for, it cannot be denied that, at this time, there is no medical subject on which we are less inclined to agree, than on our rationale of the malady, or our views as to the best way of curing it. Many good authors have complained of this diversity of opinion among us, and Delaroche in particular, after showing how wide is the gap between different classes of physicians on this topic, says it is not only a subject of astonishment to those who have never studied medicine, but a source of sad reflection to ourselves. "One is, at times," says he (p. 44), "led to suppose that all our attempts to cure consist in giving some kind of a shock to the disordered machinery ; that it matters but little what sort it may be, and that nature profits by the momentary shock to re-establish the equilibrium and mutual reactions of the organs."

3. Certainly, these differences of opinion among the doctors are very little creditable to them as a body of the learned; and, clearly showing that they have not availed themselves in a proper manner of all the means of knowledge within their reach, they at least evince that, with abundant sources of information on a special subject deeply interesting to the public, they have not exercised a due degree of diligence in searching after the truth, and so, prove us to be less learned and accurate, as a literary and scientific class, than we should be; — such short-comings are the proofs of our unworthiness as a scientific body. I have therefore earnestly desired that something might be done, with a view to harmonize our now discordant sentiments, since, in the event of the firm establishment of a clearly just doctrine, and right practice, as to childbed fevers, much good would accrue to society, whose servants we are, as well as to ourselves, who should expect to receive honor and reward only in proportion to our real merits and services to society. I confess that, while, on this subject, I do not consider the merits of the medical profession so considerable as they ought to be, I also believe they will never become so, until the time shall arrive when our whole corps shall be of one mind and opinion on these matters. That such a time is destiued to arrive, there can be no shadow of doubt, for there is a truth in regard to the nature and treatment of our disorder, which mankind must and will find out ; and whenever it shall come to be discovered, and made manifest, who is he that will be able to gainsay the truth !

DISEASE MISINTERPRETED. 35

4. The breaking out of an epidemic childbed fever, or even the occurrence of a single case, commonly excites a feeling of sharp interest and alarm, as far as ever the rumor of it extends : the public curiosity becomes speedily aroused; and among many physicians, whose opinions are taken, how wide is the diversity of their sentiments! The public curiosity thus left unappeased, the events, passing away, always leave a deep-seated conviction that, as the physicians disagree with each other, but little reliance is to be placed in them as a professional body, to this end ; and so the disquietude remains, and we are disparaged, and our estimation is lessened. If the public do become greatly alarmed on these occasions, it is because they know that any one of our women, seized with childbed fever, is at once placed in a most perilous position — and we know it even better than they ; and half our own distress and anxiety arises from this — that we are ourselves uncertain what we have to do, what to contend with, and by what principles to be guided?

5. The very name of childbed fever is a word of fear; to that degree, indeed, that smallpox, or yellow fever, when they attack an individual, or break out in a community, excite by the announcement of their onset scarcely greater apprehensions for the safety of the patients, or of society, than are aroused by the dreadful name just mentioned. Hence the subject is highly worthy of a Student's attention, and the more so from the diversity of the informations and numberless hypotheses in which he is to seek for the truth in relation to it. The works that have already been printed on the subject are more numerous, perhaps, than upon any single topic connected with obstetricy; and though it is true they contain an invaluable treasure of information, which the Student ought to feel himself bound by conscience to appropriate, and so furnish himself forth ready to combat against the dangers that threaten the persons committed to his watchful care, sagacity, and ability, yet the very number of those books renders the labor of reading them an almost endless task ; a task which, I fear, is undertaken and performed by very few of us. Besides, upon consulting the books, the Student's mind is apt to become confused in the maze of conflicting views presented to him ; so that when, at last, he finds himself, standing in the presence of the redoubtable enemy, called on to interpose his science and skill to defend the woman from threatened destruction, he knows not where to strike, or how to interpose his shield ; he gropes in thick darkness among his hypotheses, and what he does, being done without a clear understanding of what he should do, the victim is often lost through the physician's inefficiency.

6. Shall I then, while I complain that the books are already too many for us, shall I add to their number by contributing one more volume to the catalogue? Shall I add to the confusion I am so truly and so heartily ashamed of? No man ought to write a book unless he can set forth in it a new and useful thought, or place in a clearer view the thoughts of antecedent writers. This just sentiment I have derived from a writer who speaks upon the subject as follows : —

7. "Whatever may be the subject of a scientific work, the author of such a work must not conceive of knowledge in a mere historical fashion, and only as received from others ; but he must for himself, have spiritually penetrated to the idea of knowledge on some one of its sides, and produce it in a self-creative, new, and hitherto unknown form. If he be but a link in the chain of historical tradition, and can do no more than hand down to others the knowledge which he himself has received, and only in the form in which it already exists in some work whence he has obtained it, then let him leave others in peace to draw from this fountain whence he also has drawn. What need is there of his officious intermeddling? To do over again that which has already been done, is to do nothing ; and no man, who possesses common honesty and conscientiousness, will allow himself to indulge in such idleness. Can the age, then, furnish him with no occupation which is suited to his powers, that he must thus employ himself in doing what he ought not to do? It is not necessary that he should write an entirely new work on any part of knowledge, but only a better work than any hitherto existing. He who cannot do this, should absolutely not write. It is a crime, a want of honesty to do so, which, at the most, can only be excused by his thoughtlessness and utter want of any true understanding of the vocation he assumes."

8. These are the words of Prof. Fichte, which you may find at p. 126 of his Lectures on the Vocation of the Scholar ; and they

MY ENGAGEMENT TO WRITE. 37

are well worthy to be considered by every person who has the intention of writing a new book. I fully admit the justice of Prof. Fichte's condemnation of all those who, without due consideration, would add to the already heavy burden of our own peculiar literature, which, so abundant is it, has already become too vast for use, except by such as can give themselves up to a merely literary life. Yet, notwithstanding the philosopher's protest, which I have cited above, I feel impelled to write these Letters to you, partly in fulfilment of the promise I made at the close of my Course of Lectures — partly because I have felt obliged in this way to make up to you for the short-comings of my Public-instruction at the College, and, in a still stronger degree, because I think it would be a useful thing to set forth certain points that, though of the highest importance in our art, have not been adequately explained and enforced by those to whose labors we are indebted for the first suggestion and advancement of them. For example, in the use of venesection, as proposed by Dr. Gordon, while I look up to him as my real guide and teacher in this matter, I conceive that even he has in some respects failed to make his own wishes and sentiments clearly known. I should, I think, do a real service to my American medical brethren if I should be enabled to be a useful commentator on, and successful advocate of Dr. Alex. Gordon's great point of treatment.

9. Further, I am now sixty-two years of age, and first began to be conversant with medical affairs in the year 1809. I have had a very large and long experience in practice. I have written and published various essays, chapters, and lectures on this very subject. During many years I was connected with an establishment here for giving private lectures on Medicine, and it is now near fourteen years that I have had the honor to be one of the Professors in the Jefferson Medical College at Philadelphia. All these circumstances give me a warrant to speak, by this volume, on the subject of childbed fever; and as I conscientiously believe that another treatise is demanded, in the present state of our knowledge on this subject, I shall, therefore, keeping in view the warning and protest of the good German professor and philosopher, address myself to this task. If I have, indeed, attained to the full possession of the idea of childbed fever, both as to form and substance, my labor shall not prove to be vain ;

not that I suppose myself to be in possession of knowledge in this matter that other men have not dreamed of— for I have no such vanity— I only hope, and humbly trust, that my laborious life has not been in vain devoted to studies connected with this department of Science, and earnestly desire, before I depart hence, to make one further acknowledgment of that debt I owe to those American brethren who have sustained me by their good opinions during so many years — all that I am, and have, being due to them ; since I conceive that an American physician who is cast off and rejected by them is lost already.

10. In studying the subject of childbed fever, it will behove you to inquire what is its nature, its causes, tendencies, signs, and liability to modification and control by means of the medical art ; to know whether it will be always one and the same — or whether it is not rather a group of affections, classed together under this one appellation. You should strive to attain to the possession of the idea, or spiritual image and form of the disease, as it is, not in nature, but in the intelligence ; so as to create, as it were, a spiritual model, or eidolon, which you can denominate by this title — and which, once formed and perfected in your own understanding, might enable you to compare all the future possible events of your practice in this particular, with the true, absolute spiritual, intellectual standard, or idea of it. To attain to the possession of this idea, you should not rest content with learning what men of your own epoch have said on it — you must also have some clear notions of what was deemed and said in other times, and so, coming downwards from the beginning, make yourselves masters of its absolute identity, which consists not only in what is, but also in what was, and, to a certain extent, what shall be hereafter, as to childbed fever. I pray you not to make the mistake of regarding the Art and Science as already perfect — for, of a truth, Medicine is a thing always becoming, it has never yet become, and long ages must elapse ere it can reach such a stage of perfection. Hence, I propose in my next letter, to invite you to go back with me to an ancient date, that we may together for a moment contemplate this subject, as it was manifest, more than two thousand four hundred years ago.

Letter II. Reference To The Ancients

11. I AM in the present communication to invite your attention to certain very ancient views of childbed fever, and I heartily wish it were in my power to set before you, in these communications, such a full and comprehensive prospect of the disorder, as might make you acquainted with it as it was in all past time, as well as show you clearly what it is to-day, and under all possible circumstances and forms of it. The former, however, I could not do, even if I possessed learning sufficient, without violating the plan of this work. I must, nevertheless, beg you to take notice, that as childbed fever consists of certain affections to which only lying-in women are liable, you are to conclude that it must have been familiarly known to the most ancient nations, and cannot but still occasionally break out in all lands; so that it is by no means a new form of disease discovered in modern times, but one coeval with the pains and risks of the puerperal state, in all ages of the world. We have no right to doubt that the women of ancient Thebes, Babylon, Athens, Eome, Byzantium, Alexandria, Venice, and Genoa, were as subject to its seizure as those of London or New York, and that many tens of thousands of them, managed by their Shiphrahs and Puahs, must have perished under its sporadic or epidemic forms. Hence the reflection arises that the Medical Sciences are of very slow growth, since in some thousands of years they have not grown up to maturity, even on this most trite and startling subject; it being certainly true, that we are still left to grope our way amidst the treasured stores of human experience, and are still seeking in vain for that full and positive knowledge that we so much need and so earnestly desire.

12. It is not necessary in citing the writings of Hippocrates, or other ancient authors, to settle, even were this possible, questions as to their personal identity. Such ancient productions, as Hippocrates's writings, are precious to us, rather because they come to us as reflections of thought from ages long past, than because they represent the ideas of any particular individual ; for posterity always takes less interest in individuals, than in opinions, thought, rationales, dogmas, characteristic of times elapsed. It is sufficient for us to know that the books attributed to Hippocrates II. are among our most venerable records, and that they have for many centuries been the admiration of our class. Hippocrates II., the supposed author of the Books of Epidemics, lived at the same time with Socrates and Plato, and was therefore contemporary with many most illustrious and elegant scholars, in a day when admirable arts and important sciences sprung, as it were, perfect, upon the stage of the world, like Minerva fully armed.

13. Daniel Le Clerc, in EHistoire de la Midecine, page 113, informs us that this prince of physicians was born in the island of Cos, in the first year of the eightieth Olympiad, about thirty years before the breaking out of the Peloponnesian war, A. M. 3005. The Peloponnesian war, according to Sir Isaac Newton's Chronology, p. 40, began 431 B. C, so that Hippocrates was born about 451 before the advent of our Saviour.

14. Those among you who should feel any desire to peruse a very severe and very learned history and criticism of the man and his writings, will be both instructed and amused by the curious volume of Etudes Historiques et critiques, sur la Vie et la Doctrine a" Hippocrate, &c. &c, par M. S. Houdart, M. D. &c; 2d edition, 1840.

15. Among the many exemplifications of diseases on which he treated in his writings, Hippocrates has left us accounts of several persons who were under his care in childbed fever, and they are so clearly stated that readers at all familiar with the disorder at the present day, readily recognize the pictographic excellence of his representations. In Book I. Sect. V., De Morb. Mul., he already gives us a pretty clear account of childbed fever ; but it is in the Books of Epidemics that we must look for his cases. Among others, here is one which gives you an account of the illness of Dromeades's wife, which is numbered Case XL in the I.

CASE OF DEOMEADES'S WIFE. 41

Book of the Epidemics. Read it, and you shall not fail hereafter to meet with instances to convince you, not only of the fidelity of his relation, but show you that the disorder is one which was familiar in the most remote nations of antiquity : —

16. "The wife of Dromeades, recently delivered of a daughter, was doing as well as usual, when, on the second day after her delivery, she had a severe chill and a high fever. From the very first of this attack she complained of pain in the hypochondria, accompanied with nausea, rigors, anxiety, and sleeplessness, which continued for some days. The respiration was slow and sighing. On the day succeeding the chill, she had free healthy evacuations by stool ; the urine was heavy, white, and troubled, like urine disturbed after long resting, but without sediment. The night was sleepless. On the third day, about noon, a violent chill, high fever, and urine as before; pain in the hypochondria; qualmishness ; a bad night, without sleep : general sweat ; coldness, promptly succeeded by a return of the heat. On the fourth day the hypochondriac pain was less : she had gravative pain in the head ; lethargy ; a few drops of blood from the nostrils ; the toDgue dry ; thirst ; urine thin and oily : a little sleep. Fifth day, thirst, nausea ; same state of urine, no stool. About noon violent delirium, soon after which she became calm, and fell into a lethargic state. A slight coolness in the course of the night ; sleep ; delirium. Sixth day— in the morning a chill, followed by a prompt return of the heat. General sweat, cold extremities, delirium : slow, suspirious respiration ; soon after which, spasms, beginning at the head, and which speedily terminated in death."

17. Hippocrates, you see, speaks of pain in the hypochondria, by which you are not, I think, to understand literally the region of the body now so called, but the under parts of the abdomen, which is the usual seat of the pain in such cases as that he describes. Admitting this interpretation of his word hypochondria to be correct, then any person familiar with the incidents of a childbed fever will plainly perceive that the wife of Dromeades fell a victim to inflammation originating in the parts contained within the pelvis, and extension of that inflammation to parts above the plane of the superior strait, as well as into some of the larger veins or sinuses of the womb, for she manifestly exhibited during her illness, the proofs that she had infected the mass of the blood with corpuscles of pus, that could only have been produced by the inflamed tissue-surface of a vein or veins. I take this to be evident by the hysteroidal state, or pyajmic-intoxication condition of the woman on and after the fourth day. No such delirium is to be looked for in the pure peritonitic forms of the malady.

18. Case X. of Book III. contains an account of one of the servants of Pantimedes. This woman being prematurely confined, was, on the first day seized with intense fever, and other symptoms of disease, of which she died on the seventh day ; and doubtless with the same childbed fever we so often witness in the United States. As the details of the observation are quite meagre, I shall not quote them here.

19. The Xllth Case, Book III. contains the relation of another instance of the disorder. A woman, who in a laborious labor gave birth to a male child, was attacked with fever, thirst, nausea, and cardialgia, dry tongue, disorder of the bowels, marked by thin, small, liquid dejections, and insomnia. On the second day she had a slight chill, followed with smart fever. There was a moderate cool sweat about the head. On the third day, griping stools, that were copious, crude, and thin. The fourth day another chill, with general reaction and insomnia. The fifth day was bad ; and the sixth was similar to the fifth : she had copious, liquid stools. On the seventh day the chill returned, with smart fever, considerable thirst, and violent agitation : towards evening there came on a universal cold perspiration, followed by cooling of the whole body, particularly the limbs, which could not be kept warm. At night another chill; and the extremities continued to be cold. She got no sleep, and was slightly delirious, with frequent lucid intervals. At noon, on the eighth day, she had febrile heat, thirst, great heaviness, and vomiting of small quantities of yellow bile. The night was bad, with insomnia. She passed the urine in great abundance, but involuntarily. On the ninth day, there was remission of the symptoms ; heaviness in the evening, with vomiting of small portions of bile. On the tenth day, a violent chill in the exacerbation of the fever ; obstinate insomnia. In the morning, urine very copious, without sediment ; the extremities reco-

HIPPOCRATES'S EPIDEMICS. 43

vered their warmth. On the eleventh day, vomiting of greenish bile, soon succeeded by severe rigor and a return of the coldness of the extremities. Towards evening, sweat, chills, and frequent vomiting. The night was bad. On the twelfth day, the vomiting increased, and she brought up a great quantity of dark fetid matter, which was followed by frequent hiccough and excessive thirst. On the thirteenth day, bleeding at the nose, which was succeeded by her dissolution. The stools were always frequent, and were accompanied with continual rigors. The patient was about 17 years of age.

20. Few medical men, upon examining the foregoing relation, I suppose, would fail to discover in it the proofs that this woman died with a childbed fever, and that the fever was nothing more nor less than an open manifestation of such constitutional irritation and nervous perversion as might naturally be expected to arise from an inflamed state of parts shortly before concerned in the acts of gestation and parturition. I conceive it is not required, in order to satisfy our curiosity in regard to the causes and course of the phenomena, to suppose that the woman was first affected by the causes of a fever — properly so called — and that the local inflammations and degradations were accidents supervening during the fever. It is far more consonant with a spirit of right reason, to construe the circumstances in an opposite way, and consider that a certain area or areas of phlogosis being first established within the pelvis, the febrile phenomena were awakened by that cause. Galen, in his second commentary on the third book of Hippocrates, cites this very case, and says that Hippocrates would have mentioned the fact, had any external cause led to the premature delivery of the servant of Pantimedes. The illustrious commentator remarks : "Itaque ex morbo constat vitiosis collectis humoribus abortisse;" that is — "It is, therefore, clear that she miscarried on account of a disorder arising from a collection of vitiated humors." Galen, in a long comment, argues to show that the woman's delivery prematurely, was due to the bad state of her health, which he deduces from Hippocrates's description of the fever — thirst, dry tongue, disordered bowels, &c. &c. — but he also expresses a suspicion that these affections might be the ready results of an active atid distinctive phlegmasia ; yet I conclude from his words that he knew as little what was going on in the case as his great prede-