f GIFT OF WILMER COFFMAN University of California Berkeley A TREATISE ON THE MANAGEMENT OF PREGNANT AND LYING IN WOMEN, AND THE MEANS of CURING, BUT MORE ESPECIALLY OF PREVENTING THE PRINCIPAL DISORDERS TO WHICH THEY ARE LIABLE, TOGETHER WITH SOME NEW DIRECTIONS CONCERNING THE DELIVERY OF THE CHILD AND PLACENTA IN NATURAL BIRTHS, ILLUSTRATED WITH CASES. By CHARLES WHITE, ESQ. F. R. S. Man Midwife to the Lying in Hofpital, in Manchefter, in England, &c. &c PRINTED at WORCESTER, MASSACHUSETTS, BY ISAIAH THOMAS. Sold at his Bookftore in WORCESTER. Sold alfo by faid THOMAS, and ANDREWS, Fauft's Statue, ^cwbury Street, BOSTON ; and by faid THOMAS, Newhampfliire. MDCCXCIJI. f r n/u , ' . - I' 'A.-i-i' '' -';' P R F ACE. IHE intention of the following Treatife is to propofe proper means for pre- venting a numerous and fatal train of evils, in- cident to the moft amiable part of the creation j to combat a fet of pernicious maxims and opin- ions, built upon ignorance, and fupported by prejudice and obftinacy ; and to vindicate Na- ture herfelf from a charge of negled: or infuffi- ciency in her moft important work. I hayeno curious fingularities in theory to propofe, nor any fpecific remedy to extol j the only merit I claim, is merely that of having attended to, and followed Nature in her operations more clofely, and with a more religious obfervance than hith- erto perhaps has been done. At a time when reafoning from real fads and Accurate obfervation has taken place of idle theory in -viii PREFACE. in almoft every other fcience, and has with par- ticular advantage been applied to many branch- es of medicine, no apology feems neceflary for trying the fame method of reafoning, on this important fubjedt, which has hitherto been too much governed by arbitrary cuftom, and igno- rant prejudice. On reflecting upon the caufe why lefs prog- refs has been made in the prevention and cure of the diforders which fo fatally attack lying in women, than in many others, it feems moft ob- vious to impute it to preconceived notions rel- ative to the puerperal ftate, not founded upon fa6h For while a more rational general doc- trine of fevers, and the ufe of cool air and regi- men in their cure (ever 7ince~tHe"time~oF5yden- ham, and efpecially of late) has been advanced and fupported by the fpirited endeavours of many able men,* prejudices of ancient date have too much prevented the application of their principles to the febrile diforders of pu- erperal women, which were conceived to be of that peculiar nature of which every thing be- longing to this ftate partook. Every improve- ment in practice muft therefore take its rife from the eftablifhment of more juft ideas con- cerning * Friend, Glafs, Huxham, Pringle, Lee, Perkins, Huck, Dimfdale, Heberdenj Erockklby, Rufton, Watfbn, Baker, Kirkland, and many others. PREFACE. hi cerning the ftate itftif, and the caufes of the diforders accompanying it ; and by a proper attention to thefe, I an. experimentally con- vinced that not only the method of cure may be much advanced, but what i ftill more impor- tant, that thefe mifchiefs, fo dtftrefling and dan- gerous, may be entirely prevented. This then will be my chief aim in the fol- lowing Treatife ; and if in purfuing it, I may feem to pay more attention to fome minute cir- cumftances, than they really deferve, let it be remembered that the flighted remark drawn from real obfervation, is of more utility, and gives greater fatisfadlion to a judicious inquir- er, than the moft extenfive theory of caufes drawn from hypothecs alone. We are too apt to negled: what is fimple and ; evident, for the fake of thofe creations of the mind which may be produced at pleafure; but a fingle argument drawn from certain fad:, is a furer ground to reft upon than an entire fyftem of fpeculative invention. So important a law of Nature as the circulation of the blood, was deduced from a few obvious and eafy experi- ments, after the acute.fl fpeculation of philofo- phers had failed in the difcovery. Were x PREFACE, Were I, indeed, difpofecjto reafon in favour of the doftrines I have attempted to lay down, up- on any other ground thaft mere obfervation, vari- ous arguments, botfy priori and from analogy would not be wan^g. I might fay it is incon- ceivable that Nati/e fhould fufFer her moft impor- tant procefs to/oe the leaft complete, and that flie fhould need the help of art in an operation al- moft prior to art itfelf. In her inferior produc- tions we find, that, in fad:, fhe does not require it. Th? procefs of renewing the fpecies, in the vegetable creation, is performed entirely by her unerring power : and the fruit when it be- comes fully ripened, drops off fpontaneoully without the hand of art to feparate it. In the whole animal race this procefs is equally dif- tant from difeafe.* e Why then ftiould the human fpecies alone, her nobleft production, undergo her unkindnefs or negleft in fo ma- terial an objedt ? Though pain in bringing forth their offspring might be an unavoidable circumflance in the formation of mankind, .it is however overbalanced by many advantages ; but that this moil neceffiiry operation mould of itfelf be a difeafe, and fhould often be the fource of many dangerous and even fatal maladies, appears contradictory to the general plan of Na- ture * The author here does not mean to infmuate, that either the brute or the human fpecies are at all times exempt from preternatural births. PREFACE. xt fure in the fupporUnd prefervation of her crea- tures.* But however this drain of reafoning may pleafe a philofopVic mind, or may have turned my thoughts to a peculiar . way of con- fidering the fubject, I flioUd never have ven- tured to build practical rules apon fuch a foun- dation. I have offered nothing but what has been the refult of a long, extenfive, and I may fay, very fuccefsful experience among all ranks of women. How bold foever I muy feem in inculcating fome unufual practical dire&ions, the actual cafes which I have related, and which are only felected from a great number of fimi- lar ones, will, I hope, be my ample juflifica- tion. It was the experimental knowledge of thefe, and of the mifchiefs attending a contrary treatment, which alone influenced me to ad- drefs the public on thefe fubjedts ; and I defire to fubmit to a like experimental trial, what is here * Mr. Deparcieux at Paris, and Mr. Wargentin in Sweden, have obferved, that not only women live longer than men, but that married women live longer than fingle women. The regifters examined by Mr. Muret confirm this ; and it appears particularly, that of equal numbers of (ingle and married women between 15 and 25, more of the former died than of the latter in the proportion of two to one. Thereafon of this may be, as Mr. Muret acknowledges, that the wom- en who marry are a felefted body, confiding of the more healthy and vigorous part of the fex. But this probably is by no means the on- ly reafon ; for it may, I think, be expeaed, that in this, as well as in all other inttanccs, the confequences of< following Nature muft be favourable. Supplement to Price's Obferv. on Reverftonary Payments, p. 357. CE. Rk $;$ *if PJR E F A here offered to the judgment of the candid reader. I cannot conclude w/&out gratefully acknowl- edging the many ykligations I am under to thofe of my learnt friends, who have aflifted me in revifing/fid correcting thefe fheets, and to my medicaj^orrefpondents who have favour- ed me with/o many ufeful articles of informa- tion. Tli/ reader will at once fee of what im- portance^hefe have been in enabling me to de- duce the practical inferences which I have at* tempted to eftablifti. P. S. lam happy in the opportunity this fourth edition offers me, of exprejjing my fatisfattion for the reception this work has <*/reWr met with, and my hopes that its extenjive circulation may have f>een a means of accomplijhing, in a confide r able degree the purpofes it was intended to anfwer. Eejldes three pery large imp regions which have been called for at home, a tranjlation into French has been pubHJhed at Paris, and an Englifh edi-* tion was in the prefs at Philadelphia when the late troubles began in that country* THE THE CONTENTS. xv Page Cafe XI. Retention of tie Placenta occa- Jioning a fatal Miliary fever 2 1 3 Cafe XII. Retention of the Placenta cc- cajioning fatal F loadings - -215 Cafe XIII. do. - - 216 Cafe XIV. do. - ibid. Cafe XV. do. - - 217 CONCLUSION - - 218 POSTSCRIPT - 222 Appendix to the fecond Edit ion - 252 Sedt. I. On the ufe of the cold or temperate Eath - - 253 II. On the delivery of the Shoulders of the Child - - 254 f III. An Obfervation on the Manage- ment of Children at the time of Birth - 257 IV. On the Puerperal Fever audPo- fition after delivery 261 ADDITIONAL CASES, Cafe XVI. A Wound of the Omentum at the full period of Gejlation, which brought on labour * * 2 ^7 Cafe THE CONTENTS. Cafe XVII. A fatal Puerperal Fever with a Diffe&ion 238 Cafe XVIII. A fatal Puerperal Fever oc- cajianed by the Effluvia arijlng from foul Urine - 297 C^fe XIX. A total Inverfion of the Uterus, returned by a new mode of operation 299 Cafe XX. A fatal Puerperal Sever with a Diffeftion - 304 Cafe XXI. A remarkable Retention of the Placenta - - - 3^ Cafe XXII. A fatal Mortification of the U- terus, with Diffettion - - 3 11 CHAPTER CHAPTER L OF THE CAUSES AND SYMPTOMS OF THE PUERPE- RAL OR CHILD BED FEVER.f OMEN, during the time of ly- ing in, are fubjeft to this fever, which has frequently evident fymptoms of putrefcency, and which, if not properly managed has often fatal effects . That child bed women mould be fo liable to fe- vers, efpecially thofe of a putrid nature*, is not to be wondered t This diforder in the northern part of this Ifland is called the weed ; and in the fouthern parts by fome, the lochial fever. " Puerpera ex male affefti corporis vitio tanquam aurae peftilentiails ^^i putrida, feu potius TRtligngt ^uam nimium obnoxiz reperi- i *8 PUERPERAL FEVER. wondered at, if we corifidef every circumftance, and every inconvenience they lie under, owing to bad fafhions and cuftoms ; but to trace them up to. their original fource we mufl look back as far as the ear- ly months of pregnancy. At this period the tight- nefs of the flays, and petticoat bindings, the weight of the pockets, and of the petticoats, prefs the womb, already enlarged by the foetus, and its membranes, fo ftrongly againfl the lower inteflines, as to pre- vent the defcent and exclufion of the excrements. Thefe being retained, the thinner parts are abforbed by the la&eals, which caufe, or at lead greatly in- creafe, that obftinate coftivenefs of which moil wom- en complain during the whole time of pregnancy, and which is alfo farther increafed by a fedentary, inactive life, and improper diet. This excrementi- tious untur ; hujufce vero morbi labem hand omnes ex zquo fufcipiunt : etenim pauperes rufticx, aliseque duris laboribus affuetz, nee non viragines, & me- jretricesj quz clandeftina agunt puerperia, fine magna difficultate pariunt, & deinceps brevi a leftp excitatae, ad folita redeunt opera ; mulieres autem di- tiores, tenellae, & pulchrae, pleraeque vitam fedentiaram degcntes, quafi ma- ledifli divini graviori modo participes in dolorc pariunt t indeque mox a par- tu difficiles & periculofos fubeunt cafus." Willis de Febribus Puerperarum, Febres putridce Caput xvi. Willis's account would not have been liable to any material objefticn, if lie kad not excepted the poor in general, for it is now well known that they arr very liable to this fever, both in the holpitals, and in their own houfes, cfpecially if they are fituatcd in the middle of large manufacturing towns and cities ; but there is this to be faid in favour of the Doftor, that it is above a century fmce he wrote this Treatife on the Puerperal fever, at a time when there was no hofpital for lying in women in the Britifh dominions, our rr_an- ufaftories were then in their infancy, and the diet and mode of living amongJJ the poor people, were totally different from what they are at this time* PUERPERAL FEVER. 19 tious matter being abforbed into the circulation, undoubtedly occafions a great inclination to putrid- ity ; lofs of appetite foon follows, and the ftotnach and duodenum being no longer diflended with ali- ments, large quantities of bile are collected in the gall bladder, the cyftic and hepatic duels, and, by lodging there, foon acquire a putrid or putrefcent acrimony. When the woman is in labour, me is often at* tended by a number of her friends in a fmall room, with a large fire, which, together with her own pains, throw her into profufe fweats ; by the heat J of the chamber, and the breath of fo many people, the whole air is rendered foul, and unfit for refpira- tion * ; this is the cafe in all confined places, hof- pitals, jails, and fmall houfes, inhabited by many families, * Dr. Thomas Cooper, fpeaking of the lochial fever, fays, " This fever is moft common, and alfo more fatal in the hotter months." Compend. of Midwifery, p. 220. Lond. 1766. * It has been found by Dr. Stephen Hales (Statical Effays, Vol. 2, p. 324) that a pcrfon in health deftroys two gallons of air in two minutes and a half, fo as to render it unfit for refpiration. Dr. Percival informs me that a correfpondcnt of his, (a gentleman diftin- guifned for his knowledge of Natural and Experimental Philofophy) has lately difcovered " That air which animals have breathed is in all refpe&s the fame with air in which animals have putrified. The original quantity is equally di~ minifhed in both cafes ; which is found to be owing, in part at lead, to the precipitation of the fixed air it contained ; and they are r x e ftorcd by the fame procefs. One ufe of the lungs therefore muft be to carry off a putrid effluvi- um, without which a living body might perhaps putrify. as well as a dead one." B 2 20 PUERPERAL FEVER. Families, where putrid fevers are apt to be generat- ed, and proportionally the more* fo where there is the greateft want of free air. If the woman's pains be not ftrong enough, her friends are generally pouring into her large quan- tities of ftrong liquors, mixed with warm water, and if her pains be Very ftrong, the fame kind of reme- dy is made ufe of to fupport her. As foon as (he is delivered, if me be a perfon in affluent circum- ftances, me is covered up clofe in bed with addi- tional clothes, the curtains are drawn round the bed, and pinned together, every crevice in the win- clows and door is flopped clofe, not excepting even the key hole, the windows are guarded not only with mutters, and cu.rtain^ tuit euen with blankets,, the more effectually to exclude the freih air, and the good woman is not fuffered to put her arm, or even her nofe out of bed, for fear of catching cold. She is conftantjy fupplied out of the fpout of a tea- pot with large quantities of warm liquors, to keep up perfpiration and fweat, and her whole diet con- fifts of them. She is confined to a horizontal pof- ture for many days together, whereby both the ftools and lochia are prevented from having a free exit. This happens not only from the pofture of the pa- tient, but alfo from the great relaxation brought on by warm liquors and the heat of the bed and room, which prevent the over diitended abdominal muf* cles PUERPERAL FEVER, fti cles from fpeedily recovering their tone, whereby they are rendered unable to expel the contents of the abdomen, which lodging in the interlines many days, become acrid and quite putrid. The lochia ftagnating in the womb, and in the folds of the vagina, foon grow acrid, for it is well known that themildeft humours in the human bo,dy, if fuffered to Magnate, become fo, as foon as the air has accefs to them. Thefe are in part abforbed by the lymphatics in the womb and vagina, and the effluvia from them help to make the air in the bed, and in the room, more putrid ; this air in every act of infpiration is taken into the lungs, and is there again received into the circulation : Add to this that women are general!^ of 9. lei A, feldom of a rigid fibre, owing in fomemeafure to their periodical evac- uations, to their fedentary, inactive, and domeftic way of life, and likewife to their mufcles being fur- rounded with a much larger quantity of cellular membrane, than thofe of men ; hence alfo they ar- rive at their acme fooner than men. Amongft the poor people who live in cellars, and upon clay ground floors, the air is ftill made worfe by the dampnefs and clofenefs of their houfes, and the want of clean linen, and cleanlinefs in general. Thofe who live in garrets are alfo in no better a fituation, for the putrid miafmata of feveral B 3 families 22 PUERPERAL FEVER, families inhabiting the lower part of the houfe, afcend to them, already fufFering perhaps from the effluvia of a whole family in every fmgle room, the putridity of which is farther increafed, by the heat of the fun piercing through the covering of the houfe ; nor is it to be wondered at that they are ft ill in a worfe fituation in hofpitals*, where a number are * " II a regnc pendant Phiver de i746une maladie epidemique parmHes femmes encouche : M. de Juflieu a le premier obferve cette maladie ;elle corn- menjoitpar ledevoiemcnt, ou parunc difpofition audevoiement,qiricontinuoit pendant la couche : les caux qui accompagnent ordinaircment la naiflanee de 1'enfant, fortoient pendant le travail de Paccouchement ; raaisapres ce temps, la matrice devenoit feche, dure & doloreufe, elle etoit enflee, & les vffidanges n'avoient pas leur cours ordinaire. Enfuite, ces femmes etoient prifes de douleurs dans les entrailles, fur-tout dans les parties qu'occupent lesligamens larges de la matrice; le ventre etoit tendu, &. tous ces accidens etoient accompagncs atmc lauleur ds tete, & ouelquefois de la toux. Le troifieme & le quatrieme jour apres Pacouchcment, les mammelfes fe fletvifToient, au lieu qu'elles durciffent & fe gonflent naturellement dans ce temps par le lait qui s'y filtre alors en plus grande quantite : enfin ces femmes inoaroient entre le cinquieme & le feptieme jour de Pacouchement. Cette maladie n'a attaque que les pauvres femmes, & elle n'a pas ete aufli violente, ni aufli commune parmi les pauvresfemmesqui ont accouche chez elles, que parmi celles qui ont ete accouchees a 1'Hotel Dieu ; on a remarque que dans le moi de Fevrier, de vingt des ces femmes malades en couche a 1'Hotal Dieu, a peine en echappoit-il une : cette maladie n'a pas ete fi meurtriere dans le refte de Phiver. Meffrs. Col de Villars & Fontaine, Medecins de cet Hopital, nous ont rapporte qu'a Pouverture des cadavres de ces femmes, ils avoient vu du lait caille & attache a la furface, externe des inteftins, & qu'il y avoit une ferofite laiteufe epanchee dans le bas ventre ; ils ont meme trouve aufli de cette ferofite dans la poitrine de quelquis unes ; & lorfqu'on en coupoit les poumonsj ils degorgeoicnt une Jymphe laiteufe & pourrie. l.'cftomc, PUERPERAL FEVER. 33 are crowded, not only in one houfe, but in one ward? where the difeafe is conveyed from one to another by the putrid miafmata lodging in the curtains, bed clothes, and furniture, and by the necefTary houfes, which are either contiguous to, or fo near the hofpital as to occafion a moft dif- agreeable fmell, and muft of courfe convey that in- fection^ which cannot be more effectually com- municated, than by the excrements. This defcription may perhaps feem overcharged for a picture of that improved practice which is in- troduced by modern profeffors of the art; but up- on a clofe examination, I believe it will appear that many of the moft important errors do in reality prevail, and this I impute in great meafure to the large mare which nurfes have in directing the man- agement of lying in women, to whofe interference practitioners L'eftoinac, les inteftins & la matriccbien examinees, paroifibient avoir etc enflamm.es, & il eft forti, fuivant le rapport de ce.s deux Mcdecins, de* gru- meaux de fang a 1'ouverture des caneaux dc la matrice. Dans pleuficurs de ccs femnaes, les ovaires paroiffoient avoir etc en fup- Puration. '* Hift. de 1'Acad. Royalc des Sciences 1'an 1746, 410. p. 160. *' I am well informed that this fever and obftru&ion occur more frequent- ly in the lying in hofpitals, than in private practice. What can this arife from but from the different ftates of air ? This in my opinion is the caufe ; for though very great care is taken in thofe hofpitals, yet as the apartments and furniture will imbibe fome of the morbid effluvia, arifing from the pa- tients, >he air muft always be more or lefs tainted." Johnfon' Midwifery, p B4 4 PUERPERAL FEVER. pra&itioners muft in fome meafure fubmit, though contrary to their better judgment. Women have frequently many, and fometimes all of thefe difficulties to ftruggle with, even after the moil eafy deliveries ; but if there have been fuch violence ufed, either by inflruments or by the kand, in the extraction of the child or the placenta, as to bring on an inflammation of the womb, thefe difficulties will flill be farther increafed. The pa- tient may likewifebeput upon her labour too foon, by endeavouring to dilate the os internum, or be too frequently teazed with unfuccefsful attempts to deliver her, or after the head is born, the body of the child may be delivered too fuddenly, and too forcibly, without waiting for another pain, or giv- ing the moulders time to accommodate tkemf elves to the different dimenfions of the pelvis, the bad ef- fect of which I will explain more at large hereafter. In a few days after delivery the patient is perhaps feized with a fhivering fit, and the nurfe is furprif- ed, as me protefts fhe has not had the leaft waft of cold ; more clothes are heaped upon her : fpiri- tuous liquors, and hot fpices, are given her, to throw off the cold fit, which mofl certainly increafe the fucceeding hot one. A warm room, plenty of clothes, and warm drinks are continued to throw her into a fweat, but have frequently a contrary ef* feel;, by increafing and prolonging the burning fit, PUERPERAL FEVER. 35 which at laft terminates in a moft profufe fweat, continuing many nights and days without giving relief. ' The cold fit fometimes, like the paroxyfm of an ague, returns, but at uncertain periods, and at laft ends in a continued fever ; At other times no cold fit precedes the difeafe : It creeps on gradually, and firft Ihews itfelf by putrid fweats, attended with a naufea, or by vomitings of porraceous matter, and a loofenefs. What the patient vomits is generally mixed with large quantities of bile of a dark colour. The ftools are fometimes very copious and frequent, and fo exceedingly putrid as to be offenfive all over the houfe, and to convey infe&ion to the whole , family : At other times the patient is racked with a conftant tenefmus, and with frequent motions to make water, accompanied with fwelling, pain, and forenefs in the belly, and with pains in the head, back, breafts fides, hips, and iliac region, with a cough and difficulty of breathing; there is com- monly a wildnefs in the countenance, and the head feems hurried, and in fome cafes the face is flulh- ed ; the urine is voided often, with pain, and in fmall quantities, and is remarkably turbid. The tongue at nrfl is white and moift, and foon after is covered with a white fur, or elfe it is dry, hard, and brown, and afterwards covered with a brownifh fur ; a brown or blackifh fordes, the con- fequence *6 PUERPERAL FEVER. fcquence of putrid exhalations, adheres to the edges of the teeth. The patient ufually naufeates all kinds of food and drink, except what is cold and acidulated. The pulfe at the beginning of the dif- order is fometimes very little -altered, only fome- thing fuller and quicker, but as the diforder advan- ces, it never fails to grow quick, fmall, and creep- ing, and the patient complains of great anxiety, and oppreflion about the praecordia, attended with figh- ings, lownefs of fpirits, laffitude and great debility. The quantity of the lochia is frequently not at all diminifhed, at other times it is very much leffened: What flow are fometimes very foetid, and in fome cafes this difcharge is totally fupprefled. The breafls in fome grow flaccid, the milk abates in quantity, and if the diforder be not foon remov- ed, is entirely loft ; but this is not always the cafe, i If the hot regimen be continued, with vinous fpi- cy caudles, hot alexipharmic medicines, volatile al- caleous falts and fpirits, opiates, and a clofe room fo as to keep the patient in a perpetual fweat, vibices* or petechiae appear, or eruptions either of the white or * Cooper fpeaking of this fever about the fourth day, fays, " Now if nat before, fome violent pains come on, in the -arms, and thighs, fuccecded by a difcolouration of the fkin, occafioned by the blood corroding and ftagnating in the veflels." Compend. of Midwifery, p. 218. PUERPERAL FEVER. 2? or red kind, or both, firft upon the neck and breafts, afterwards extending themfelves all over the body, one crop fucceeding another till the patient is worn out ; but they give no relief, are not in any way critical, nor is there indeed any regular crifis in this diforder, except the loofenefs. The patient is generally eafier after every flool, and they feem to give relief. The ftools at laft are difcharged together with the urine, involuntarily ; colliquative fweats, hiccupings, convulfions, &c. come on ; and death, whickhappens fometimes foon- er, fometimes l^ter, clofes the fcene. There are fome who have died fo early as within twenty four hours after the firft attack ; but the eleventh from the firft feizure, is faid to be the day on which the patient moft commonly dies, though others have Jived many days longer without recovery. This difeafe was well known to Hippocrates*, and to numberlefs authors who have written fince his time, and has been filled either epidemic^, malignant, * Hipp, de Morb. Mulierum, lib. i..fet. 5. r on Epidemical Difeafes, cafe 4 and 5. *' \ During the prevalence of epidemic fevers, the recovery of women in child bed is much more precarious than in healthy feafons. This is obfcrva- ble in every fphere of life, but for obvious reafons, more remarkably in ly- ing in hofpitals ; it has been taken notice of by the induftrious Dr. Syden- bam ; and by Tho, Bartholine, and muft undoubtedly have happened invaria- bly fig PUERPERAL FEVER. malignant, putrid, or inflammatory, and by fome a compound of all four. It is generally malignant and putrid, when fuffered to run its courfe, and fre- quently at fome feafons epidemic, and in fome fitu- ations may properly be faid to be endemic. Nay, if the womb has been lacerated, or has received any injury in labour, it is fometimes undoubtedly com- pounded of all five. Some have reprefented it as entirely owing to the milk, fome to an inflammation of the womb t, and many to a fuppreflion of the lochia bly in all ages of the world, though it is now better underftood in this coun- try, fince fome of the moft ingenious of our phyficians have devoted their time chiefly to the ftudy and praftice of midwifery, and the management of thofe difeafes with which it is more particularly connected." Millar on the prevailing diforders of Great Britainj pt. 3, fed. 1. p. 332 of the puerperal fever. " Nonnunquam poft lochiorum fuppreflionem in febrem incidunt puer- peras, quas vel in earum qua? turn graflantur epidemicarum caftra tranfit, vel ab ea fola pendit origine." Diflert. Epift. ad. Gul. Cole, M. D. Sydn. op. p. 5gz. t Tiflbt in his Avis au Peuple, Eng. edit, by Kirkpatrick, p. 371, feeras to think that this diforder is an inflammation of the womb, and he mentions an extraordinary circumftance not taken notice of by other authors, viz. that the belly turns black. Seft. 370, he fays, The inflammation of the womb is difcoverable by pains in all the lower parts of the belly ; by tenfion or tight- nefs of the whole belfy ; by a fenfible increafe of pain on touching it a kind of red ftain or fpot that mounts to the middle of the belly, as high as the na- vel, which fpot as the difeafe increafes turns black, and then is always a mortal fymptom ;by a very extraordinary degree of weaknefs ; an aftoniming change cf countenance ; a light delirium or raving ; a continual fever, with a weak sod hard pulfs ; fometimcs inceflant vomitings j a frequent hiccup ; a mod* crate PUERPERAL FEVER, ^ jochia; fome have ranked it amongft hyfterical* diforders, and others have called it only a fymptom, but all have agreed in its fatality , and the uncer- tainty of every method of cure, both in the rich, and in the poor, who all acquire this diforder from fimilar caufes, though by means fomewhat different. I am informed that the appearances after death, are thofe of inflammation and gangrene in the intef- tines, or fome of the abdominal vifcera ; fometimes in the uterus || ; and in fome cafes, when the dif- eafe crate discharge of a reddifti ftinking fharp water ; frequent urgings to go to (lool ; a burning kind of heat in the urine ; and fometimes an entire fup- preflion of it." % * " Fcmina xxx. annorum temperament! fanguineo-melancholici, hyftcrici* paflionibus in puerperio, & extra illud, fsepins obncoria, tcrtium gravida, gef- tationis tempore nee venae feftionem admifit, nee exquifite fervavit praecepta diaetetica. Primis poft partum diebus non bene purgata eft utero : Sed de dolore lumborum, torrninibus ventris, alvo adftrifta, & fomno per aliquot no&es inquieto conquerebatur, A praftico, quern in confilium vocavit, val~ idiores effentias ad pellenda lochia fuerunt data: ; & ad alvum aperiendara uncia dimidia falis amari Sedlicenfis in aqua fimplici foluta eft oblata. Inde auftis torrninibus, nee fala per alvum, nee per uterum excretione, converfo fanguinis verfus fuperiora motu dcliravit, & accedentibus convulfionibus ex- tinfta eft," Hoffman, Tom, 3, feft, i. cap. 5, obf. 10 de nialo Hyfterico, As the difeafe which is the fubjeQt of this Effay occafions the doth of much the greater part of women who die in child bed, &c," Deuman on the Puerperal Fever, p. t. fl Pouteau in his Melanges de Chirurgie, p, i&a, upon opening two womn wh will be fen* fible PUERPERAL FEVER. 31 part will alfo operate in the fame manner in the liv- ing body, wherefoever there is a general putrefa&ive tendency ; nor need we be furprifed that the womb itfelf mould be found in a gangrenous flate when we confider the great diflenfion it has undergone, and that it has afterwards fuddenly collapfed, and has been kept fome time imbued with the ftagnat- ing, acrid, or even putrefcent lochia. It does not appear that this diforder can be af- cribed to fimple inflammation. The patients com- plain chiefly of a tenfion, forenefs and tendernefs of the lower part of the belly, and are not conftant- ly affected with thofe excruciating pains which gen- erally attend common inflammations of the bow- els ; but it frequently manifefls itfelf to be of a ma- lignant kind, occafioned by abforption of human effluvia, of acrid bile, and of a putrid colluvies through the whole inteftinal canal and organs of generation* Scarce any two authors have defcribed this fever alike, and yet I believe their defcriptions have truly been from what they have feen, but thefe different appearances have been probably owing to a variety of fible of the putrid ftate of the lungs by the offenfwenefs of the air that ia forced out of them." On the Difeafe* of the Army, Appendix, p, 84, ^to. edit. 3 2 PUERPERAL FEVER. of management, and to a difference in theconftitu* dons of the patients. Though a true puerperal fever is originally cauf- ed by a putrid atmofphere, or too long a 'confine- ment of the patient in an horizontal pofition, pro- ducing an abforption of putrid or acrid matter, and is not occafioned by either the heat of the air, or any hot things taken internally ; yet it may be much aggravated by thefe ; and many of the fymp- toms frequently attending it, are entirely occafion- ed by the hot air and a hot regimen. For inftance, if a woman of a ftrong conflitution, and of a pleth- oric habit of body, be feized with this fever, and fpiritucus liquors and hot fpices be given her, me will have a ftrong hard pulfe, and the fypmtoms cf inflammation will run fo high as to indicate the neceflity of copious bleeding ; and when the fever is farther advanced, a delirium ; fubfultis tendinum, &c. will come on. But if the patient be of a more relaxed habit of body, and be kept fweating in bed in a warm room, by warm liquids, eruptions will appear upon the fkin ; and if a woman fubje6l to hyfterical complaints be feized with this fever, and have any large evacuations either naturally, or procured by art, a train of hyflerical fymptoms will fucceed. And laftly, it muft be obferved that though all the fymptoms here enumerated have been feen in different patients, yet it muft .not be imagined PUERPERAL FEVER. gj imagined that all of them ever occurred in the fame fubjea*. * The opinion of the royal medical fociety of Paris, held at the Louvre, the 6th of Sept. 1782, as given in the report of a memoir of Mr. Doulcet oa the method of treating the puerperal fever -, which was, in 1783, tranflated into Englifh by Dr. Whitehead, phyfician to the London Difpenfary, with the addition of many valuable notes, confirms the theory I have endeavour- ed to advance on this fubjeft. " But without entering into long difcufiona *' oo this fubjeft, which would require deeper refeaYches than the time and *' limits of this report will permit, we will content ourfelves with obferving, <; that all the defcripdons we have of this difeafe, which are numerous, pre- " fent it under two principal characters, lB5t is> as an highly inflammatory, *' and as a putrid difeafe. The inflammation is announced by the tendon " and pain oT the belly; and the putridity is evidently marked by the " weaknefs and fmallnefs of the pulfe, the proftration of flrength, and the " exceiTiver foetid evacuations. The rriorc the putrid character prevails, the '* more rapid and dangerous the difeafe appears in general. The obferva- " tions of Johnfon, Johnftone, and De la Roche, reprefent it as being mre " of an inflammatory nature, and at the: fame time not fo alarming ; thofe *' rt'f White, Leakc, and Slaughter, as the molt putrid and moft fatal difcafe. Of four women who were attacked with this dife^fe in the Hofpice de t{ Vaugirard, three had a weak pulfe, remarkable profcration of flrength, ' l and extremely foetid evacuations ; and all three died. The fourth was " more robuftj and the fymptoms were fcr violent as to require feverai bleed- "*' ings, and fhe was the only one who happily recovered. This proftratioa " of flrength, therefore, which charafterifes the putridity, is one of th *' worft figns of this difeafe. It is chiefly in hofpitals that it affumes this t: characler, and it has no where been cither fo rapid, or fo generally fatal, <{ as in the Ho:el Dieu, for fome years pail. Does it in thefe cafes partak l< of the nature of the hofpltal fever ? This i *he fentiment of Mrj White,'* Vid. Whitehead's Tranf, p. 31. CHAP. 34 CHAP. II. ON THE MILIARY FEVER, HOUGH medical hiftory does not with abfolute certainty inform us whether the Miliary Fever was ob- ferved amongft the ancients, yet there is the greatefl probability that it was, from federal paffages in Hippocrates*, Cel- fus, * " O&avo fudor frigidus per omnia membra diffufus eft, cum puftulis rubentibus, rotundis parvis, varis non abfimilibus, quse permanebant neque abfceflum faciebant.' Hipp, de Morb. vulg, lib. i.feft. 3 ccg. 2. Per magnos sftus affatim & continenter compluit, idq; ab auftro magis* Sanies quidem pluritna cuti fubnafcebatur, quaj intro conclufa dum incalef- ceret, pruriginem excitabat. Deinde vero in puftulas erumpebat iis affines, qua in ambuftis fieri folent. Hip. de morb. vulg. lib. 2. fect i. In febribus autem seftivis circa feptimum, oftavum, & nonum diem, af- predines quzdam miliacee, culicum morfibus fere fimiles, quas tamen non a'dmodum pruriebant, in jfumxna cute fubnafcefeaatur & ad judicationem uf- que perdurabant. Ibid. lib. 2. feft. 3, - Euphjanorb M I L I A R Y FEVER. 35 fust, yEtius^, Haly Abbas , Fernelius||,Francifcus Valefius*, Petrus Forreftus t, Ballonius J, and Sen- nertus. Euphranoris filio, puftuls culicum morfibus non abfimiles erupcrunt,ve- rum pauco tempore duraverunt, poftridie febris invafit." Ibid. lib. 5. t p c puftularum generibus. At puftulas maxime vernis temporibus oriuntur. Earum plura genera funt, Nam modo circa totum corpus partemve afpredo quasdam fit, fimills his puftulis, quac ex urtica, vel ex fudore nafcuntur ; exanthemata Grasci vo- cant, exque modo rubent, modo colorem cutis non excedunt. Nonnunquam plures, fimiles varis oriuntur, nonnunquam majores. Purtulae, lividae fnnt,aut pallidas, aut nigrac, aut aliter naturali colore mutato : Subeftque illis humor. Ubi has ruptae funt, infra quafi exulcerata caro apparel, Phlyftaense helcodes Graeci nominantur. Fiunt vel ex frigore, vel ex igni, vel ex medicamentis. Cclfus, lib. 5. cap. 28. t Fiunt etiam aliqxiando puftulae rotundae inequales, fubalbidae aut fubru* brs, cum elevatione caronis. ^tii Serm, 5. cap. 129 De Puft. in feb. cur, ex Herod. ? . ' \ Haly Abb. Reg. Difpof. Theoric. lib. viij. chap. xiv. |j Exiguie & aquofas puftulas funt hidroa, id eft fudationcs. Emergunt fe- pente fparfim toto corpora, fed frequentius in manibus pedibufque, milii magnitudine, aqua pknas, fine rubore, fine ullo dolore. Fiunt cnim ex fu- doribus fub epidcrmide cocrcitis, per cujus fpiracula hi digeri minime pof- funt ; Unde a quibufdam fudorum papulae nuncupantur. Fernelii univerfa med. lib. 7, cap. 5. p. 242, * FrancifcusValefms in Hipp, de morb. vulg. com. lib. 2. left. 3. f Petrus Forreftus obf. 59. p. 205. lib. 6. vol. I. De Purpura intus re- percuffa. Obf. 60 De Purpura papulas rubentes habente, Obf. 61 De Muliere fudamina habente, & a medicaftris male traftata unde tandem mora fubfecuta eft. Ij. Antequam cahdis ifte invafiffet viris & majoribus apparcbant maculz, cchthymata, Miliares puftulae et caetera, id genus idque eftate maximi, fed nullum id adferebat perkulum. G. Ballon. Epid. & Eph. lib. 2. p. 202. Conftiiutio autumnalis. A. D. 1577. C e 3 6 M I L I A R Y F E V E R, nertus. It is evident that it was known to Riverr- us |l 3 who does not fpeak of it as a new difeafe. But we have no accurate defcription of it till the middle of the la ft century *, when it was fir ft obferved in the $ Verum cum Exanthcmatum genus duplex fit, unum,. quodcolorem cutis faltem mutat, ut fit in febribus petechialibus, alterum in quo tubercula quz- elam in cute erumpunt, puftularum & papularum nomen non utrique, fed pofteriori faltem generi congruere vidctur, et papulae ac puftulae faltem tubcr- eula fignificant, in quibus humor aliquis continetur. Senert. Tom. 3, lib. 5. p. i, cap. 22. p. 771. jl Exanthemata a maculis purpureis differunt ; ex eo quod maculae ad qualitates mutatas ipftus cutis, cum nullomodo emineant ; exanthemata vero ad tumorum genera refcruntur. Sunt enim varorum inftar aliquando alias vero minora, granis milii fimillima. Aliquando rubra funt a fanguine genita ; aliquando alba, a pituita, vel fero ; flava, a bile ; punicea, a bile exufta ; livida vel nigra, a maxima exuftione, vel mortificatione. Qu;s- 4$ MILIARY FEVER. eruption ; but that, on the contrary, the fuller and tfye earlier the eruption is, the greater is the danger. Allionius, a Phyfician of eminence at Turin, has treated of this diforder more fully than any other writer ; and from his account the following cir* cumftances are extracted, which prove the affinity of the miliary fever with putrid difeafes in general. " It may be traced to the fame caufes which pro- duce putridity in general, and the difeafes confe- quent upon it. C A miliary eruption often, accompanies putrid and other eruptive fevers. *' Though women in child bed are generally firft, and more univerfally attacked by it, it is not con- fined to them alone. : " Moft things that are ufeful and noxious m pu- trid fevers, are the fame in this." ) If we next confider the fymptoms of the miliary fever, we mail ftill find a great fimilarity with thjofe of other putrid difeafes ; infomuch that there feems to be no pathognomonic fign of this difeafe, except the eruption be allowed to be one. The great anxiety, vaft oppreffion, fighing and dejection of MI LI AX Y I EVER. of fpirits, fo much in fitted on by all author, tfee pathognompnic fymptoms of all putrid difeafes in general. They are the attendants of the low> nervous, the putrid malignant, and of all petechi- al fevers ; and fo indeed is the thrum, loofenefs, pale urine, and the quick and. weak pulfe. Some have faid that the tenfion and tendernejfe of the abdomen are pathognomonic fymptoms of thfc puerperal fever, but others have found them in the miliary*. The reft of the fymptoms, are common to all fevers whatever. The difeafes, or rather the fymptoms, which are faid to fucceed the miliary fever, are he&ic heats, lofs of appetite and of fpir- its, and fwellings of the legs, feet, and thighs; but thefe are nothing more than whatlfollow other pu- trid fevers. ' Thofe who have had this fever, are particularly liable to returns of it during their whole lives ; owing mod probably to the fkin being over relaxed, and its tone deftroyed, by a too liQt and forcing treatment. To * " The tenfion and tendernefs of the abdomen have been laid down as pathognomonic fymptoms of this difeafe. 1 myft confefs my doubts in this jppint, for I have met with them early in the month of child bed, the patient being feverifh at the fame time, and yet as appeared to me, the complaints arofe only from an accumulation of indigefted aliments in the primae vise ; fmce by giving a purgative, which brought away a large quantity of very putrid fceces, they were entirely removed. Befides, they are to be found in a miliary fever, as will be flicwn ia the next chapter." V Midwifery; p 35* 4*s MI LI ARY FEVER. To what has been already faid I muft beg leave to add my teflimony that I have frequently feen in puerperal women, miliary eruptions both of the red and the white kind, without any fever fuper- vening, a*id totally unattended with danger ; and I have feen all the fymptoms of the miliary fever (as they are generally defcribed by authors) except the eruption, and yet the diforder has terminated hap- pily, and in a fhort time, without that, or any other particular crifis. Some years ago this do&rine might have been treated as chimerical, but now I do not doubt I (hall eafily gain credit, as every inoculator knows that even the fmall pox itfelf, in which, of all eruptive fevers, the eruption feems moft critical, may be happily got over with little or no eruption, and at the fame time the patient be fecured from ever hav- ing the diforder again. That the miliary fever, like many other putrid fevers, may be generated by ill management 3 1 have not the leaft doubt ; and the relation of the follow- ing incident may help to prove the affertion. When Do&or Shebbeare, though no friend to the cool regimen, fays, " The moft effedual way is to fupport the vital heat by the gentleft means, and in an equable manner, otherwise the miliary eruption may be raiher a fymptom of the PhyQcian than of the diforder, as it is to be feared that fome, through miftaken practice, have difcovered a way of making miliary fevers, and may be called a kind of manufacturers of that difeafe ; increafed fweating, and long continued heat, often exhibit that phenomenon, where no ficknefs at- tends," Practice of Phyfic, vol. 2, p, 144* MILIARY FEVER. 43 When I began to praftife midwifery, a midwife (fince dead) had for a long time been in poffefiion of great pra&ice amongfl all ranks of women, and in other refpe&s was tolerably fuccefsful ; but a re- markable number of women under her care were affecled with the miliary fever, which proved fatal to many, particularly the wives of feveral of our principal tradefrnen, and became fo alarming and notorious, both in this neighbourhood, and in dif- tant parts of the country, as to acquire the name of the Manchefter fever. Her method was to keep her patients very clofe and warm, fo as fcarcely to admit a breath of air in- to the room, and to confine them many days fweating in a bed in a horizontal pofition. At the fame pe- riod of time, and in the fame town, other practition- ers who purfued a different plan met with no fuch fever. My Father informed me that he attended the third wife of a gentleman who had loft his two for- mer wives by miliary fevers in their firft lyings in. This lady being much alarmed at the fate of her predeceffors, was during her con- finement continually upon the watch, to fee if Die could difcover an eruption, which at lafl fhe did. This difcompofed her very much. She made a large quantity of pale urine. Both my Father and another Phyfician who was afterwards called in, 44 MILIARY FEVER. in, allured her that it would not be attended with either fever or danger, and that if fhe would keep up her fpirits, and obferve a cool regimen, it would be of no confequence, and accordingly fhe jfoon recovered How far fear might operate in this cafe I leave the reader to judge. My Father more- over faid. that this was the only cafe of a miliary eruption which he had met with in a child b^d woman, where he had attended.from the time of her delivery. Several ladies who have had dangerous miliary fevers during their former lyings in, and who have been in full expectation of them again, upon, tfee fame occafions have, by obferving the directions I have laid down in this Treatife, happily efcaped any kind of child bed fever. I have frequently feen miliary eruptions attend the fymptomatic fevers of perfons who have under- gone fome principal operation in furgery, though at that time they feemed to be in a perfecl flate of health, (excepting the local complaint, for which they underwent the operation) and no other reafon could be afligned for this eruption, but the patient's being of a relaxed habit of body, and fweatingin bed. I- have often feen- miliary eruptions at different peri- ods, and under different circumftances, but I can- not, upon the flri&efl inquiry, find that a miliary eruption 'was ever produced without a fweat, either ill MI LI ARY FEVER. in a greater or lefs degree ; and yet we know that mofl other eruptions will frequently come out with- out a fweat, as the fmall pox, meafles, fcarlet fever, chicken pox, the rafh which attends the ulcerated fore throat, and many other kinds of eruptions. I have often obferved that the miliary eruptions come out firft, and there is the greateft quantity of them in thofe parts which are the clofeft covered, efpecial- ly if covered with flannel. * A very ingenious Phyfician at Chefter informed me, that the miliary fever had been generally imag- ined to be endemic in the city and neighbourhood for thirty years before he refided there, and had car- ried off numbers of the inhabitants ; that the fever was frequently of a long duration, that he knew one perfon who recovered after having fucceffive crops of miliary eruptions for three months. That anoth- er Phyfician of the place had informed him, that he had a patient who lay ill of the fame fever for fix months, and died of it at laft. That he hadknown the miliary eruption often to accompany the rheuma- tifm, and many other fevers, but from obferving a *The fame gentleman has favoured me with the following note. ** I have frequently feen miliary eruptions unattended with either fever or danger, and feave had patients attacked with fevers of the low nervous kind, fighing, oppref- fion about the prxcordia, a propenfity to fweat, and other fymptoms ufually preceding miliary eruptions, and at a time and place where miliary fevers were common ; yet by a cool regimen, and guarding againft fweats which ap- peared rather to be fymptomttic than critical, the patients recovered any wiliar 46 MILIARY FEVER, a. different method of treating fevers in general^lie was fully perfuaded that this was a fabricated fymp- tom, and never had feen it evidently critical. The teftimony of Dr. De Haen, of Vienna, is fo important, fo flriking, and coincides fo intimately with the doctrine I mean to eftablim, that it is with great pleafure I quote the following paffages from his works. * During the fix years in which he had been Phylician to a hofpital that always contained a large number of fevers, he had only feen miliary or petechial eruptions three or four times as the primary difeafe, and once as a fuper- vening fymptom. If this faft be compared with in- numerable cafes of miliary and petechial eruptions in theBienniumMedicum of Dr. Storck,who attended another hofpital in the fame city the excellent ef- fects of cool treatment will be eminently confpicuous. In the fame place he allows that in private prac- tice he fometimes met with epidemic miiiary erup- tions, but thefe not often. He gives feventeen cafes of petechial and miliary eruptions, mofl of the latter : They are all brought to prove that thefe eruptions are not critical, that they arife fometimes from infe&icn, that the blood is often fizey in thefe cafes, that in fome cafes they are produced by clofe. bad air, and fwealing, and that. *Vol. I. Chap, 29. MILIARY- FEVER. 47 that the bark is an excellent remedy in thefe erup- tive feversj. Forty pages are employed in confuting his adver- faries concerning the caufe, &c. of miliary and petechial eruptions. He aflerts that hot medicines, regimen, and clofe warm rooms, are the caufes that thefe complaints are fo frequent at Vienna that they arife fometimes alfo from miafmata, or many patients lying in the fame room*. He quotes many authors to defend his opinion againft fweating, and hot medicines, efpecially Sydenham. From J ^Egri ergo numero 1 7 fpatio 6 annorum Petechias, aut Miliaria, aut utrumque, in nofocomio praftico habuerunt, adeoque quinque circiter omni biennio. Pars media horum, exanthemata, antequam ad me adfeirentur, jam habuerant ; pars altera iifdem in nolocomio praflico correpti funt ; ergo inibi fpatio trium annorum, exanthemata hzc quatuor duntaxat zsgris eruperunt. Omnium vero duo tantum fuere, quibus id fponte contigerit ; reliquis 15 aut contagium, aut pravum regimen, medendive methodus, aut combinata; has caufz, exanthemata produxere. In nemine vero illorum ea critica fuifle, ipfa cujufque morbi hiftoria abunde evicit. Concludo, fi plerifque asgris meis, citra exanthemata, integrae contingant, felicefque crifes ; tune exanthemata ilia, aliis medicis adeo frequentiffima, critica utique appellari non pofle. Vol. a. Cap* i. p. 13. " *Spatio decem fere annorum 24 homines exanthematici in nofocomio noftro fuere : O&o fcilicet exanthentate petechiali, quos inter cum variolis una ; xi folo miliari : V utroque ; eofque inter una cum peflimis variolis, affe6U : Horum. nemo criticae eruptionisnotam fuflinuit." Vol. 2. Cap. i . p. 395. '* Cramer, pluries mihi narravit, dum plura millia Boruflbrum captivorura anno 2757 & 1758 fu* cura demandati effent, inter 300 codem tempore, acute 4$ M I L I A fc Y FEVER. From the foregoing obfervations the following inferences may, I think, be deduced : t. The miliary eruption of child bed women is frequently a fymptom attendant on fevers, caufedby human effluvia, and by fweating, and never ap- pears without a fweat preceding it. 2 The precife time for the appearance of the eruption, cannot with tolerable certainty be fixed, It being common for one crop to be fucceeded by imore, and even fometimes to appear without any fever attending, or fucceeding ; and, as by removing the difeafe in its early flage the eruption may be to- tally prevented, it cannot be called critical. 3. The cooling and extinguiihing method of cure (as it is called) cannot prove prejudicial in the early flages acute ut plurimum, laborantes, vix quatuor aut quinque exanthemata pafroa cfl'c; illosvero quatuor vel quinque, aut nimium te&os, ant aifteconclufosfc *eperiffe, antequam fibi Jjemandarentur : Leuca autem a fe diftanti pago, ubt aib-imtiomorbi caiida methodus in ufuerat, vix zegrotafiequofquam, qui exan- themate non macularentur : A militibus in incolas contagium tranfiiffe ; pluref* ^uc,una cum medico fuo,exanthematumgenitore,inoT tern occubuifle." p. 421. Miliaria hoc anno in nofocomio nulla. An quod extinfta Viennic ? Mi&- trne^fcd quod eatlem non fabriceraus. Tom. 3* p. 43, Cap. iij. de Miliaribus 1765, Trai)i-i?:,cum bono Deo itcrnm, pro more, annus Academicusfine miliaribus, aut petechiis ; cum in nofocoinio, !um in urbe, &; fuburbiis npud zegros qui ihi ad rociilia vocato, obternpciaiunt in tuto regiminc in abftinentia a :r.3; & pncicytirrrin quctidian.i Iccii refeflione, Cap, :;:, p } 233. Impr. A. D. :76S, MILIARY FEVER, 49 flagcs by checking the eruption, if at the fame time it removes the caufe of the difeafe itfelf. 4 Puerperal women are not fubjeft to this dif- eafe from any othfcr caufe, but that of their being in a flate much inclined to putridity, attended with a relaxation of the (kin, from fweating in bed. 5. Therefore as the miliary eruption is never produced without fweat, and as neither the one nor the other can be faid to be ftriftly critical, may we not conclude that the eruption is occafioned by the cuticular fecretions being increafed by warmth and relaxation, and of courfe rendered more acrid, fo that by lodging upon the fkin, and communicat- ing with the external air, they muft foon acquire a putrid (late, even if the patient had no figns of putrefcency before ? In my lafl edition, I here added fome annotations from a manufcript copy of Dr. Cullen's le&ure on the miliary fever, as taken down by Mr. Bew, a very ingenious apothecary in Manchefterl At that time it gave me no fmall fatisfa&ion to find that my ideas of this fever correfponded fo nearly with thofe of a man, whofe great abilities, both as a pro- feffor and practitioner, have raifed him to the high- eft degree of reputation, and who, from a very ex- tenfive practice, has gained great experience : I am D happy g o M I L I A R Y FEVER. happy to find them fince confirmed by the doftors? late publications on the fubjecl;, in the Firft Lines of the Practice of Phyfic, vol. 2. p. 100; and in the fecond volume of his Methodical Nofology*. I muft alfo here return him my beft acknowledg- ments, for the handfome manner in which he has fpoken of me in the latter of thefe publications. * Speaking of the miliary fever, he fays, " Quod nunquam idiopathieus fit, praeter opinionem medicorum, a medio feculi decimi ad hunc fere diem, omnium, et contra fententiam medicorum hujus aevi, quorundam fpe&abil- ium, affirmare non aufim ; fed cum experientiam in haec re faepe fallacem, et medicos plerofque imitatorurn fervum pecusfuiffenoverim, dubitare cogor; et, utcunque fit, morbum miliarem plerumque fymptomaticum fuiflc, ex ob- fervantia propria, per multos annos frequenti, certo novi. Nunquam con- tagiofam, nee manifefto epidemicam, quibufdam lieet temporibus folito fre- quentiorem, vidi. Morbis febrilibus quibufcunque, turn inflammatoriis turn putridis, aliquando adjungitur ; in nullis tamen, nifi regimine calido,t fudo- ribms praseuntibus, ortum, &. in pluribus regimine temperato, et fudoribus vitatis, morbum^ alias expeftandum, prorfus vitatum obfervavi, &c." Vid, Synops, Nofol. Method, vol. 2, p. 14. CHAP. CHAP. III. OF THE MILK FEVER. HE PROXIMATE CAUSE of the milk fever is an accumulation of milk in the breafts, fo as to occafion eonfiderable tendon, tumefaction, pain, and heat ; and if a degree of force be ufed to extra6l the milk at a time that the breafts are fo tenfe and tu- mefied, inflammation and fever will be the confe- quence. The tumefaction will end, either in ref- olution or fuppuration, which may happen in the glandular or adipofe parts ; this will be preceded by pains in the head, in the breafts, and under the arms, by irregular Ihiverings, thirft, inappetency, heat, and quick pulfe ; the matter will either find its way externally, or will be abforbed, and produce he&ic fymptoms. I never knew it terminate in gan- grene, and feldom in fchirrus, except from mifman- agement Da The 5 2 M I L K F E V E R. The REMOTE CAUSES may be many and various; as cold, which conftringes the diameter of the vef- fels, and renders them impervious : plafters ; fpir- ituous, or hot applications to drive back the milk ; a hot room ; too many clothes ; error in diet, either in quantity or quality ; violent efforts to draw out the nipples from the breafts, when they are in fuch a faulty flate as to render this difficult ; and too fudden, or too early a floppage of the blood from the uterine veffels, which, by the analtomofmg of the epigaftric arteries, fills the internal mammary arteries too fuddenly, before the lactiferous tubes are become fufficiently pervious. ' The PREDISPONENT CAUSES of the fever are fuch a firmnefs and impervioufnefs in the lactiferous tubes, in an irritable habit of body, as to impede and obftrucl; the flow of milk into the breafts, whence alfo it is always moft violent in the firfl lying in. The fmall flat nipple which lies buried in the bread is generally occafioned by the. tight drefs, which has for fome centuries been fo conflantly worn in this ifland by the female fex of all ages, and of almoft all ranks, the moft laborious and neceffi- tous alone being excepted. This drefs, by con- ftantly preffing upon the breaft and nipple, reduces it to a flat form, inftead of that conical one, with the MILK FEVER. 53 the nipple in its apex, which it ought to preferve ; and the nipple is buried in the breaft. By being conftantly kept in thi's pofition, it contracts adhe- fions, it is prevented from coming out ; the whole breaft is deprived both of its beauty and ufe, and is even driven out of its proper place. Parents cannot be too cautious in this article of drefs. It is a matter of the greateft confequence to their daughters whenever they are in a puerperal Hate. The tightnefs of the flays is alone fufficient to do much harm, but they are alfo, often made hard and unpliable by packthread and whalebone, which muft greatly increafe the mifchief. I will here fubjoina fhort defcription of the breaft, for the benefit of fuch of my readers as may not yet have had proper opportunities of gaining information. The breaft confifts of a large conglom- erate circumfcribed gland, mixed with a confider- able quantity of fat. The glandular fubftance is compofed of a congeries of fmall convoluted arte- ries, veins, and nerves. The ultimate arteries, be- fore they terminate in their correfpondent veins, detach minute branches for the feparation of the milk, which uniting as they proceed to the nipple, form fmall canals, called the laftiferous tubes : thefe are about feven or eight in number, commu- nicating with the bafis of the nipple, and general- D 3 1 7. 54 MILK FEVER. ly opening at its apex by the fame number of duels, though fometimes two of them open by a common orifice. The duds adhere to a tough ligamentary elaftic fubftance, which is continued from the gland, and terminates with the du&s in the nipple. This ligamentary fub fiance and thefe dufts which it contains, are capable of extenfion and contraction to a great degree, and in their natural date are moderate- ly folded, curled, or corrugated ; by which mechan- ifm the place of valves is fupplied, and the invol- untary eruption of the milk prevented, unlefs the diflending force be very great, from the accumula- tion of too great a quantity. The whole fubftance of the nipple is fpongy, elaftic, and fubjecl: to dif- ferent changes, becoming fometimes hard, fome- times flaccid, fometimes flat, and funk into the breaft, and at other times prominent. Its outward furface is uneven, and full of fmall tubercles. The nipple is furrounded with a difk or circle of a dif~ ferent colour, called the areola, and on the infide of the {kin of the areola, are di Geminated little glands, known to anatomifts by the name of feba- ceous glands. Thefe fupply an oily mucus, to defend the areola and nipple from that abrafion which would otherwife be the confequence of fuc- tion, and likewife to glue up the mouths of the lactiferous tubes. The fkin upon thefe parts is extremely thin, and confequently the nervous pa- pilae lie very bare, and are very liable to irritation. From M I L K F E V E R. K From this ftructure of the breaft we are enabled to explain the reafons of the feveral phenomena of faction. Why the milk does not flow fpontane- oufly from the breafts in all fabjects. It is pre- vented by the convoluted pofition of the ducts, and their orifices are glued up by the febaceous juice of the glands. Why the milk flows with impetus af- ter the firft faftion. The tubes are elongated and unfolded, the febaceous gluten feparated from their orifices, the ftream of milk keeps the tubes ftraight, and their channels free from impediment. By faction the body of the breaft is increafed in length, and its breadth contracted, or in other words the whole is made more conical, and thereby the milk is prefled into the tubes at a time when they are ftraight and open. The operation of faction itfelf depends upon the principles of the air pump. The air being ex- haufted from the lactiferous tubes by the action of the child's mouth, the preffare on their fides pro- pels the milk towards the part whence the air is exhaufted, that is, the nipple, and occafions it to flow into the child's mouth, which is alfo exhauft- ed of air. Hence it will appear evident why women of rank, and thofe in the middle ftations of life, meet with difficulty in giving fuck to children, and have gen- D 4 erally 5 6 MILK FEVER. erally more or lefs of a milk fever, in their firfl lyings in, but if they fuckle their children, and meet wrh proper treatment, have never any afterwards. Hence it will appear why hard working, labouring women, who a^re obliged to go very loofe about their breads, generally make good nurfes, and that too with very little trouble. CHAP. CHAP. IV. GENERAL DIRECTIONS FOR THE PREVENTION OF MANY DISORDERS PECULIARLY INCIDENT TO THE PREGNANT STATE. H E prophylactic art, or the pre- vention of difeafes, particularly of fevers, is a fludy of the utmoft confequence to every one who pra&ifes furgery or midwifery. Without a perfect knowledge of this branch of phyiick, the pra&itioner cannot hope, at leaft was fuppofed to be the occafion of all fevers. Later obfervation has however found it prejudicial in many cafes ; and fome have gone fo far as to deny its utility in any. I (hall make quotations from fome of thofe au- thors * who have confidered this matter the moft clearly and particularly. From * " Hippocrates relates the cafes of fome patients, whofe fevers were ter- minated after the eruption of fweat, whether that fweat really put a period to the difeafe, or only appeared at its end ; as it happened in the inftances recorded, lib. i. patient 6, 7. lib. 2. patient 7. n, 12. in which patients the fever feems rather to be terminated by an eruption of blood than of fweat ; for fweat, fo far as I can perceive, is not by Hippocrates always pro- pofed as an inftrument by -which the difeafe is cured, but only as a mark or fign by which its event or termination may, with the greateft certainty, be prognofticated. For this reafon, in thofe books of his which are account- ed genuine, he no where mentions fudorific medicines ; and even in thofe -works which ar falfely afcribed to Hippocrates, there is only once mention made of a fweat procured or forced by medicines ; for the author of his fec- ond book of epidemics orders a fweat to be procured by carefully covering the patient with the bed clothes, and exhibiting meal, mixed in rich and generous wine ; nor does he even prefcribe thefe meafures as proper to be taken, except in thofe fevers which arife from laflitude, or fome other fimil- ar caufe, fuch as thofe commonly called diary fevers, " Internal medicines for producing fweats were fo little in ufe among the ancients, that Celfus has not a fingle word upon this fubjeft. If there- fore fweats are of any ad% r antage in fevers of this kind, they feem to derive the efficacy from nature alone. During thofe fweats, perhaps, the peccant frnatter might be eafily diflipated, and carried through the fkin, either on ac- count of the temperance of the climate, or by the good conftitutions of the patients, PUERPERAL FEVERS, Sec. 99 From the whole we may conclude, i. That fweating in bed in a confined atmofphere muft be very detrimental to a perfon in health, may bring on many diforders, but cannot prevent any. 2. That patients, -which were not yet corrupted by (loth tfn-d luxury : but in the pref* ent condition of mankind, we in vain expeft the folution of a difeafe by fweat, whether fpontaneous and natural, or procured by art : and I believe I may juflly venture to affirm, that in violent fevers the patients are rarely reftored by fweats alone. Friend on Fevers, Comment. 3. * But whereas the hot regimen is ftill too much in ufe, it may not be amifs to examine a little more narrowly how it comes to pafs that fo many ill confequences flow from it. " Nature then is fcarce ever able to expel the febrile matter by fweat, be- fore it has taken up a proper time for its maturation, except in the plague ; fo that fweats, which of their own accord flow largely in the beginning of a difeafe, do not carry off the fever, but prognofticate a long and dangerous diforder, and probably are the occafion of it. They likewife render the pa- tient coftive in the beginning, and in putrid fevers frequently caufe a diar- rhea towards the crifis, whereas thofe perfons generally efca-pe, and moil eafily get free from a fever, to whom the very contrary of this happens, ' In thefe climates there is no neceffity that perfons in perfect health fliould have a vifible moifture on their {kin, but in very warm countries, in hot days this fcems to be of great fervice. In Egypt during the fecond part of the fummer, every one fweats profufely feveral times a day, and at that feafon the inhabitants always enjoy the moft perfect health, *' Such an error is never more frequently committed than in giving what they call cordial and fudorific medicines in the beginning of fevers^for this method promifes an eafy and ple-afant cure, and is agreeable to the opinion of the vulgar. Cuftom has made it familiar, and the patient finds himfelf relieved when the fweats begin to flow, and i$ they ftop he is abundantly fcotter, more thirfty, and refllefs," " But G a loo PREVENTION OF 2. That fweats are particularly detrimental to K omen in the puerperal ftate, as they render them coftive, caufe a ftagnation and abforption of the lochia, relax and weaken the patients, and make them fo fufceptible of cold, that the air cannot be renewed, nor the common offices of life be per- formed without danger. 3 . That fweats are very detrimental in the be- ginning of all low nervous, or putrid fevers, but particularly ,thofe of lying in women, which if not in < { But fweats which are very eafily brought on in the beginning of a dif- rafe, will frequently quite difappear as it advances towards the height, fo as not to be recalled by the warmefl medicines ; and though they fhould con- tinue to flow, they will certainly bring along with them thofe bad fymp- toms which have been mentioned before. Although the ancients, the moft fludious of nature, never admitted this method of pra&ice, and the modems, more intimately inflru&ed in the facred myftery of phyfic, always rejected it, yet it is never to be expected that the old women, who have a licence of flaying mankind with impunity, fhould ever fuffer themfelves to be taktn off from their method of cure ; but it is to be wifhed that Phyficians, who follow the guidance of reafon, would throw afide their prejudices, and weigh the matter with that carefulncfs it deferves, and banifh this pernicious meth- od from that art which promifes health to mankind." gives the following quotation from Feu. Obfervatafideliaconfirm- averunt, putrida haec miafmata nocuifle puerperis, dum in nofocomiis de- cumbebant : Magnus enim illarum numerus peribat ; & fufpicari ceperant nofdcomii prsefecli, ignorantiam aut negligentiam obftelricandum in caufa effe. Plura fecabantur cadavera defun&arum, & corporis interiora abfcefli- bus plena fuerunt inventa. Sapiens medicus, omnia attente examinans, hanc caufam invenit, quod fub conclavi puerperarum. decumberent vulnerati. Confirmabattir ejus fentcntia inde imprimis, quod au&o vulneratovum de- cumbentium numero crefceret puerperarum ftrages, minuto pariter decrefce- rct. Aer humidus, tam calidus, quam frigidus nocebat ; ficcus autem prode- rat : Notum enim eft, humidum aerem putredini favere, praecipue fi fimul calidus fuerit. Dum autem puerperae locabantur in conclavi inferiori, non obfervabatur amplius haec ftrages : A.cr enim, putridis exhalationibus imbu~ tus, levior eft, unde fuperiora petit." Feu le pra^iq. des accouch. p. ^65. iss PREVENTION OF A Gentleman whofe veracity I can depend on, in- forms me that he attended a fmall private lying in hofpital in London, in the latter end of May, June, and the beginning of July, 1761 ; during which time the puerperal fever was very fatal there ; that to the beft of his recolle&ion they loft about twenty patients in the month of June ; that during this month he himfelf delivered fix women in a Ihort time in the hofpital of natural births, and they all died : He was fo mocked with the lofs, that he defired the gentleman who had the care of the hofpital to deliver fome of thofe who mould next be in labour, which he did, but they met with no better fate. They buried two women in one coffin to conceal their bad fuccefs. Several gentlemen of the faculty were invited to the hofpital to in- quire into the caufe of this great fatality ; but I could not learn that they were able to account for it in a fatisfa&ory manner*. Buildings might be raifed on purpofe for the reception of lying in women, and fo contrived that the * The following paffage from Mr. Doulcet's memoir before mentioned, is a further confirmation of the opinion I have advanced, " The memoir te upon which the Royal Medical Society has been confultedby government, " and of which we are now ordered to give an account, contains the defcrip- " tion and treatment of a difeafe which has attacked lying in women at the " Hotel Dieu at Paris ; and which has made its appearance in that hofpital *' at different times, but more frequently than ever fmce the year 1774. " The late Mr. Doulcet found a method of curing this difeafe, extremely " fimple, and which has never yet failed of fuccefs fmce it has been employ- " ed; although before this method was made ufe of, the difeafe had always *' been fatal to every woman who was attacked with it in that hofpital," . PUERPERAL FEVERS, Sec. 123 the air might be kept in conftant circulation, in fuch a manner that there would be no danger either of the creation or communication of this dif- order. The expenfe of fuch edifices would be rather greater than ufual. The rooms muft be lofty, open galleries with unglazed windows mould run through the whole buildings. The wards mould be all upon the centre floors, and they mould have no doors except into the galleries, and thofe doors mould be oppofite to the windows in the wards, that there may be a thorough ventila- tion of air when the windows are opened. In the upper part of the doors mould be feveral holes to let out the foul air. The ground plans mould ferve for offices, and the upper {lories be converted into lodging rooms for nurfes and fervants. An entire apartment ihould be allotted to every patient, or elfe if large wards were conftrufted the windows mould be placed very high, with the uppermofl fames made to let down. Large apertures mould be made as high as poilible in the partition wall which divides the walls from the gallery, after the manner of the Leicefter infirmary ; and in the upper partoffome of the windows the fartheft from the fire mould be fixed a few leaden lattices to admit frefh air, or what is ftill better circular, or, as they are called by fome, ^Eolian ventilators, I do not fuppofe that 124 PREVENTION OP that the fuperior advantages of thefe ventilators Over a leaden lattice conlifts in admitting more frefh, or extracting more foul air ; but by their circulatory motion they prevent the air from rum- ing dire&ly upon the perfons in the room, and thereby giving them cold. Thefe mould be kept open night and day, that a conftant circulation of air may be maintained : For it will not be fuffi- cient if a door, or even a window is opened a lit- tle in the middle of the day only, of which, who- ever will take the trouble to go into the ward of an hofpital early in a morning will thoroughly be convinced, the air having been rendered fo foul and difagreeable by a number of people breathing in it the whole night, as to make the atmofphere very unwholefome, not only to lying in women, but to any other perfon. Several air pipes made of wood of about fix in- ches diameter fixed in every ward, and paffing through the cieling and roof, have been found very ufeful in the Manchefler infirmary. I have been in a great number of hofpitals, but I do not know any fo free from foul air as that infirmary, which may, I think, be eafily accounted for. It is fituated up- on the higheft point of ground about the town ; the building is long and narrow, having no inner courts ; the principal wards are fifteen feet high, and the largeft of them do not contain more than thirteen PUERPERAL FEVERS, Sac. 125 thirteen beds. A large gallery runs through the whole length of the houfe, and that is interfered by the chapel and the great ftair cafe which lie open to it ; in thefe are windows, eaft, weft, north, and fouth, which are fet open every day as often as the weather permits. In the galleries, and in many of the wards lead lattices are fixed in the windows. Holes are cut in the upper part of the doors, and the doors are generally open in the day time. In the largeft wards are openings in the wall likewife to admit frefh air. As a proof of the advantages of an hofpital well ventilated, it may not be amifs to compare the fuc- cefs attending it, with that of a fmall crowded houfe, hired for the reception of patients at the fir ft inftitution of this chanty, before a proper building could be got ready. In the fmall houfe 403 patients were admitted in the fpace of three years, out of that number 22 died in the houfe, which is about the proportion of one in i8y. In the prefent infirmary between the 2^th of June, 1755, and the 24th of June, 1771, 6459 * n patients were admitted ; out of that num- ber 263 died in the houfe, which is nearly one in 24 j. This difference of fuccefs muft, I think, be principally owing to the plenty of room and free ventilation, for the perfons concerned when" this chanty 126 PREVENTION OF charity was in its infancy, were more careful both in regard to the admiflion and difcharge of patients than they have fince been, left a long lift of deaths Ihould have brought the infant charity into difre- pute. Poflibly it may be urged as an objection to thefe calculations, that many of thefe in patients were difcharged, or made out patients at a time when there were little expectations of their recov- ery ; which is certainly very true : But in anfwer to this, it muft be remembered likewife, that as all accidents are admitted without referve, many are taken into the houfe in a dying condition, and feveral have died before any means could be ufed for their relief ; and the calculations of thofe who died in the former, and in the prefent infirmary were made by the fame rule, therefore the objec- tion, if it be one, lies equally againft both. Befides air pipes carried through the roof, others may be let into the chimney of the ward above, as has been praftifed in St. George's hofpitaL* Moifture * " In wards which are clofe it nas been found that one or two fquare lioles of about fix or eight inches diameter, cut in the ceiling, and a tube mede of wood fitted to it, and carried up into the chimney of the ward above, fo as to enter above the grate, is one of the beft contrivances for procuring a free circulation of air, as the foul air, which is lighteft, and oc- cupies the higheft part of the ward, finds a free exit by thefe tubes. We lave fuch tubes now fixed at St. George's hofpital. A hole cut above the tloor of the ward, or in the upper part of the windows, and one of what are called chamber ventilators, fixed in it, will anfwer, where holes cannot be conveniently cut in the cieling." Monro on the Dif- of Military Hofpitals, p. 368. PUERPERAL FEVERS, &c. 127 Moifture * is more to be guarded againft than cold. Dr. Lind obferved that new Ihips were . more unhealthy than old ones, owing to the moift exhalations from the wood. I am afraid no methods will be effectual where feveral lying in women are in one ward. It will be very difficult to keep the air pure, dry, and fweet, and at the fame time to accommodate the heat of the ward to their different conflitutions and fymptoms. If feparate apartments cannot be al- lowed to every patient, at leaft as'foon as the fever has feized one, fhe ought immediately to be mov- ed into another room, not only for her immediate fafety, but for that of the other patients. Or it would be ftill better if every woman was delivered in a feparate ward, and was to remain there for a week or ten days, till all danger of this fever was over. I * " Heat and moifture become, when joined, the parents of putrefaction; to which if we add imprifoned animal fteams, we perhaps form no imper- feft idea of the efficient caufe of that ficknefs, which generally prevails in large new built {hips : And however fimple the inveftigation may be, the analogy it bears (the aggravating circumftance of difeafed perfpiration ex- cepted) to all experienced fickly climates, feems abundantly to confirm the folution. Thofe who have feen the effefts of unfeafoned timber on board, will not think the quantity of vapour arifing from the fappy wood trifling or innoxious. Thus, efpecially during the night, we, as it were realife the baneful dews of the torrid and other indifpofing climates, and create that very conftitution of air, whofe confequent difeafes prove fo often fatal to our fleets," Lind on the Health of Seamen, p. 77. PREVENTION OF I am not ignorant of the ufe of Hales's and Pringle's ventilators, which are exceedingly prop- er, and fhould, together with every other afliftance for clearing the wards of foul air, be made ufe of; but the beft of them alone is not to be depended upon. I have frequently been in an hofpital, in which, notwithflanding there is an extremely good ventilator, the air is foul and difagreeable, and the houfe is fcarcely ever free from the hofpital fever. In this hofpital, compound fractures, and fractures of the Ikull, though under the care of the ableft furgeons, are feldom fuccefsfully treated. In lying in hofpitals, and I may add in every hofpital, the bed flocks mould be of iron. [Vid. Plate II.] PLATE PUERPERAL FEVERS, & c . 129 PLATE II. Fig. 1. A perfpeftive view of an Iron Bedftead made at Birmingham, the invention of Do&or Vaughan, an ingenious Phyfician at Leicefter. It ferves every purpofe of a bed chair or dozer. The patient may be raifed and lowered in it to any pitch, with lefs fatigue than that which ufually arifes from other methods ; it is there- fore of great utility to fick perfons aud lying in women. a. b. The upper part of it, moving upon the hinge (a) to correfpond with which there is an* other hinge upon the other fide of the bed. c. A rack wheel, which is alfo anfwered by an- other on the other fide. d. The handle which gives motion to the arbor, pinions, and click wheel. e. The click wheel. f. The click* Fig. 2. The plan of the bedftead. d. The handle. e. The click wheel, fattened to the pinion. g.g. Pinions of twelve teeth each entering between the teeth of the rack wheels which are connected by an arbor from g. to g, : T..^ Mr. Alexander Brodie, Whitefmith, near Tem- ple Bar, has obtained a patient for a contrivance I fomething 130 PREVENTION OF fomething fimilar to this, which he calls his new- invented Bedfcrew Lever, calculated for the eafe of fick and gouty people, or childbed women ; which raifes them from a lying to a fitting pofcure, and lowers them again fo gently as hardly to be felt. His Lever, he informs me, is moved by a fcrew fixed at the foot of the bed. Whenever the patient has recovered from this fever and is removed into another room, the bed- ding and curtains mould be warned, the floor and wood work mould be cleanfed with vinegar, and it would ftill add to the falubrity of the apart- ment, if it were floved with brimflone, or what is much more effectual, if explofions of fmall quan- tities of gunpowder were made in it after the man- ner defcribed by Doftor Lind, which driving out the foul air, a frefh current immediately rufhes in to fill up the void fpace occafioned by the explofion. The Do&or feems to think that the good effects of it in purifying mips, or other infefted places, is owing to the antifeptic vapour ari ling from it; but, Is it not more probably owing to the explofion ? He fays he has found this method effectual in purifying the air, and that it is inoffenfive to the lungs. The fleams of warm vinegar applied to the patient's noftrils are very refreihing ; but fumi- gating the wards with it, as has been advifed by many authors, has not, I believe, proved fo anti- feptic PUERPERAL FEVERS, <&c. feptic as was at firft imagined ; which may be ow- ing probably to the following caufe : In diflilling vinegar it is very well known that what comes over at firft is moftly water, to the amount of a third or fourth of the whole qpanti- ty ; this is generally thrown away as ufelefs, and the very acid parts which are fuppofed to be pro- ductive of the greateft good, are not to be railed without a very confiderable degree of heat. So much watery fteam therefore being diffufed all over the room, may tend to increafe thofe com- plaints it was defigned to remedy ; for it is univer- faliy allowed that heat and moifture when joined are the parents of putrefaction. I have my doubts in regard to the utility o dry or moifl fumes*, or fprinklings in general > fuch * Doflie, fpeaking of the Murrain, fays, "But thefe fumigations, fre- quently repeated as they were for this purpofe, in clofe places where the beafls were confined, were not only ineffectual to that purpofe, but noxious in a confiderable degree, as being very conducive to the prevalence of the contagion. For being in general made with bodies that afforded an acrid fteam, fuch as fulphur, vinegar, tobacco, or terebinthinate fubftances, they injured the refpiration of the beafts, and thence diminifhirig the animal ftrength, rendered them more difpofed to be affefted by the contagion. A multiplicity of fals confirm the truth of this remark, as it appears frorri nearly all the accounts given, that the greater number of beafts have been loft where means of this kind have been rnoft employed, The medicating the cattle externally, by rubbing them with fulphur, gunpowder, tobacco water, and other fubftances, do lefs harm than the fumigations, but not inore good ? as experience has largely evinced* "A 1 a i 3 2 PREVENTION OF fuch as camphorated vinegar, tobacco, nitre, pitch, tar, refinous or aromatic gums, fulphur, or frank- incenfe, during the patient's flay in the room. Without the free admiflion of air I am apprehen- five they will operate to no good purpofe. If a fufficient quantity of free air be admitted they will feldom be neceffary. And if by their means the air is eifher heated or moiftened, they will certainly be prejudicial : But a!l thefe methods may be ufed with advantage if there be no patient in the room. If the lungs be inflamed, or the patient have any difficulty in breathing, the receiving fuch acrid fleams or fumes into the lungs would certainly be of bad eonfequence. *< A free refpiration of undepraved air is effentially neceflary to the ftrength- of the beafts, in order to their refitting the effects of the contagion. It has appeared from a number of obfervations which are recorded by the writers- on this fubjeft, that the cattle which have been kept out in the air, when the- weather was not inclement through too much cold or moifture, have been lefs fubjet to take this infection, and recovered in greater numbers when feized with it, than thofe which were houfed. In Denmark during the ter- rible vifitation mentioned above of this difeafe in the year 1 759, many of the boors attempted to preferve their cattle from the infection by the fumes of tobacco, which they continually fmoked in the cow houfe, even fitting, up the whole night in turns for that purpofe in the midft of them. But it was remarked that fcarcely any of the cattle Co treated avoided the contagioa and death in conference of it." M-emoirs of Agriculture, p, $89. PUERPERAL FEVERS, & c . 133 In puerperal women perfumes* have been known to bring on dangerous fymptoms, and I am afraid that all thefe methods can only tend to deceive by concealing, inftead of correcting the vitiated air. Heat, moifture, ftagnated air, and human efflu- via, fuch as fweat and the perfpiratory matter from the lungs and the (kin, &c. are the grand promot- ers of putrefaclion ; without thefe obftacles can be removed, every attempt to correfc the vitiated air will not, I am afraid, avail. A probable method is propofed by Dr. Alexander t of placing large quantities * * c Fragrantes odores, quibus multi adeo abut folent, ut etiam mutatis veftibus tota cutis illis imbuta maneat, turbant fajpe adeo puerperas ut mox fequantur enormes capitis dolores, dcliria lochiorum fuppreflio." Van Swieten. Comment. Sect. 1331. -r Alexander fpeaking of putrid diftempers, fays, " As the breathing of cool freih air feems above all other things a fine qua mm, directions to fupply tlie patient plentifully with it can never be too frequently, or too ftrongly inculcated : Where this is impoflible to be done, as in jails, the holds of fliips, &c. every method we arc capable of mentioning (hould be tried to correct and deftroy the virulence of thefe putrid particles, -which cannot poflibly be diflodged. Authors have from time to time contrived a variety of things for this valuable purpofe ; fuch as burning aromatics in, or fprink- ling the room with them, warning the room with vinegar, with fpirits, &c. It does not appear however upon the ftrifteft inquiry, that thefe method* have been attended with any remarkable, nor indeed with any vilible fuc- cefs. Their intention indeed is certainly a very rational one, viz. to im-* pregnate the whole air of a room with antifeptic matter, in fuch a manner that the patient may draw a good deal of it into his lungs, at every infpira- iu>n, But as their having hitherto done fo liiue good ? gives ground for a fufpicion 13 134 PREVENTION OF quantities of fermenting antifeptic mixtures in different parts of the room. In putrid fevers, and in the putrid fore throat I have frequently advifed patients to breathe the fixed air arifing from ef- fervefcent mixtures. In feveral the ufe of it was attended with manifeft advantages ; nor did the leaft inconvenience accrue to any, though fome of them were very tender people, and had weak lungs, and one in particular was a young lady who had a putrid fore throat, and had been fubjeft to a cough and fpitting of blood, and no other remedy was made ufe of, except gentle vomits, fait of worm- wood and juice of lemons taken into the ftomach during fufpicion that they have either in this way not been intimately enough blended with the air, or not blended with it in a fufficient quantity, I think, other methods ought to have a fair trial alfo, efpecially as there feem to be others better calculated for reruLering any antifeptic matter more light and fupportable by, and more diffufible through the air of a room. It was obferved before towards the beginning of this Effay, that Dr, Macbride had fweqtened feveral pieces of putrid meat by fufpending them in the fleams arifang from fermenting antifeptics ; and this me thinks fur- aifhes us with a hint how to endeavour to correcl the air of a confined place, and render it antifeptic, where patients with putrid difeafes are ; which is by placing large quantities of fermenting antifeptic mixtures in different parts of it. If this expedient fhould not be found to anfwer, a ftill farther trial may be made. Let a large quantity of a deco&ion of bark, camomile Cowers, &c. when in the aft of fermentation, into which it may be eafily brought, be put by the patient's bed fide, and his head fupported over it, fo as to breathe the fleam as often, and as long at a time as can be done. Should this method produce any good effect, it might very eafily be improv- ed by means of a machine contrived to convey the greateft part of the fleam jirifing from fuch a mixture, into the patient's lungs." Experimental Effays, p. 66, PUERPERAL FEVERS, &c. 135 during the aft of effervefcence, and antifeptic gar- gles. I have likewife ufed it with advantage ex- ternally in putrid ulcers, by receiving the fixed air arifing from fuch effervefcing mixtures upon the affected part. Notwithstanding what I have advanced for the neceflity of free air, and the cool regimen, yet I muft caution the young practitioner againft expof- ing his patients too fuddenly to the cold air, after being much heated, which would be apt to caufe obftru&ions and fevers ; and although great ad- vantages have accrued from the ufe of acids, acef- ent liquors, and fruits, yet il; muft be obferved that they ought not to be ufed where the bile is defi- cient, either in quantity or quality, where an acid acrimony abounds in the privies vice, or where the patients have found by experience, that they difa- gree*. * I muft refer thofe who would choofe to fee the affair of hofpitats fur- ther difcuffed, to a very ferifible pamphlet lately publifhed by my worthy- friend Dr. Aikin, entitled. Thoughts on Hofpitals. I 4 C H A P, CURE OF THE CHAP. VII. OF THE CURE or THE PUERPERAL FEVER. HENEVER a lying in woman is feized with a rigour or cold fhivering, fucceeded by a hot burning fit, and terminating in jaJWeat, we mould be very at- tentive to her, as much depends upon the management of the patient, during the continuance of thefe fymptoms ; for by a proper treatment the diforder may frequently be flopped in its firft ftage. and farther mifchief prevented. I do not apprehend the cold fit to be of the danger- ous confequence ufually imagined. I never knew it fatal*, and thofe authors who have mentioned it as * *' I never faw a pcrfon die in a cold fit (fpeaking of the ague) but have known feveral carried off in the hot one by ftrong convulfions, or delirium and other fyrnptoms, I am clearly of opinion that it is the hot fit, or fever, PUERPERAL FEVER. 137 as fuch, have not, I believe, fpoken from fah falling under their own infpeftion. If it have ever proved fo, it muft have been under very extraor- dinary circumftances. We need not particularly guard againft this fymptom by two warm a regi- men, much lefs need we do any thing when it is actually exifting that may be of pernicious confe- quence in the future progrefs of the fever and though the patient according to her own fenfations be colder than in health, yet fhe is feldom in real* ity fo. For by feveral experiments made by * Dr. Home in the cold, and even Ihivering fit of an in- termittent, it appeared that the heat of the patient by Fahrenheit's thermometers was 104 degrees, whereas that of a perfon in health feldom exceeds 98 f . In fome agues the thermometer applied to the patient's body finks below the ftarndard, as was found in the Edinburgh infirmary, but this hap- pens in very violent cafes only. In v/hich not only often endangers the patient's life, but alfo in the moft com- non cafes of intermitting fevers, by its continuance, weakens and impairs his whole habit of body." find's Advice to Europeans, Appendix, p. 31.3. * Med, Fafts, p, 221. -f During the cold fit of an ague, the heat is confiderably increafed, Swenke in his HaEmotologia, fays, " That the heat in the cold fit is lefs than the natural heat." But his experiments, perhaps, were made at the firft approaches of the cold fit, when the obftruftions in the capillaries arc fonfidenble, and the increafe of circulation inconfiderable. Ibid, p. 227, 138 CURE OF THE Jn the advanced ftate of moft fevers, patients are often very good judges of their own heat, and will frequently call out for cold air, which they find very refrefhing. But as this is not always the cafe at the very beginning of a fever, they ought to have fome perfon to feel their bodies many times, in a day, in order to regulate the heat of the room, and the quantity of clothes they are to hav 7 e upon them. During thefe fymptoms the patient fhould be al- lowed no fpiritous liquors, ale, wine, or wine whey, no broths, or animal food, no cordials, volatile falts, or ftimulating aromatic fpices ; and indeed the lefs food fhe takes the better, either liquid or folid, duritig the continuance of the cold fit. At the beginjfting of the fit, if (he be really colder than in -health, warm flannels, bags filled with toafled grains, bottles with hot water, or hot bricks, may be applied to the patient's feet ; but what is of more confequence, her limbs fliould be gently rubbed with a warm hand, or with flannel, to prevent the blood from ftagnatingin the capilla- ries, and fome additional clothes ihould be laid upon the bed, particularly upon the legs and feet. It muft however be remembered, that thefe clothes Ihould be taken away as foon as ever the hot fit comes on, at which time an emolient clyfter ihould be in- je&ed, and great care taken to fupply her with plen- ty of fmall liquors, fuch as' teas of all forts, thin wa- ter gruel, butter milk, tamarind, verjuice, or twomilk whey. PUERPERAL FEVER. whey, barley water, or decoft. pe&oral very H warmed, or even entirely cold*. The room fhould now be {applied not only with plenty of frefh, but of cold air. The bed curtains fhould be undrawn, that the bed as well as the room may be frequent- ly ventilated. To afcertain the degree of cold nee- effary is impoflible. The patient's fituation, the violence of the fit, and the mildnefs or feverity of the feafon muft determine it. It will however, in general, be good to reduce the degree of the pa- tient's heat as near as poffible to the ftandard of perfect health. The fooner this is done, and the nearer her heat is brought to this ftandard, the milder will the fucceeding fymptoms be, and the fooner * In the cafe of Georgias's wife in Lariffa, which Hippocrates has given us, who had a fever for the three firft days of her lying in, attended with great thirft and lofs of appetite, he fays, " The coldeft water was of fer- vice to her, but wine by no means," On Epidemics, Book 5, Cafe it. Doftor Kirkland relates the cafe of a women in the feventh month of her pregnancy, who was feized with a pleuro peripneumony, attended with many alarming fymptoms, when bleeding, bliftering, and other proper remedies, were employed to advantage ; but me received great relief from keeping out of bed feveral hours every day, in a large room, filled with cold air, by the windows and doors being fet open, and when fhe was fup- ported by pillows upon the bed, for fhe could not lie down, (he had but little more than a fheet to cover her. At firft fhe drank, cold water with a toaft, in moderate quantities ; but afterwards, when the violent heat abated, and fhe began to expectorate, the liquids fhe drank were very properly or- flered to be made rather warm. Reply to Maxwell, p, 86, CURE o* THE fooner will the fweating fit* come on ; which if it be fpontaneous, and not forced by hot air, too many clothes, hot liquors, or hot medicines, will in all probability terminate the diforder, but though liquors given perfectly cold are proper during the hot * Mr. Alexander, of Edinburgh, in his Experimental Eflays, has given us feveral experiments on fudorifics. He fays, " Thefe experiments feem clearly to prove, that there is a certain degree of heat, which may be called the fweating point, always abfolutely neceffary to produce that evacuation, and that the farther the heat of any perfon is advanced above, or reduced below, this ftandard, the farther he is removed from any poflibility of fweating. But, although there is a flandard degree of heat, at which, and perhaps at no other, a fweat can be produced, yet we may reafonably con- elude that this degree is not the fame in all perfons, nor in the fame perfon at all times, but that it rather differs, according to the difference of confti- tutioaal heat, and other circumflances," Experimental Effays, p. 166", " That profufe fweating is more deftruftive to the natural heat and itrength, than even pretty large blooding, is a truth which feems never to have been fufficiently attended to in practice ; and it is no very uncommon riling to fee a perfon thrown into a large and continued fweat, without any apprebeniion of danger, when at the fame time were he to lofe a fingle ounce of blood, it would be reckoned highly imprudent, as detracting from that flrength which ought to have fupported him in the difeafe. How far this is reconcileable to common obfervation, and the feelings of every one who has been in thefe circumllances, I fhall leave to the judicious to determine. " Dr. Huxham, that careful obferver of nature, is the only author I have met with who feems to have been fully aware of the fatal confequeaces of large fweating in low putrid diftempers, and accordingly exclaims againftit in the keeneft ami moft nervous manner, as havjng a very direft tendency toward the deftruftion of the patient. But I carry the matter flill farther, and affirm , that in all diftempers whatever, profufe fweating too long con- tinued, may have the fame effeft, and that it feldom or never can be ufeful, as all the puxpofes of it may be fully anfwered by a gentle mador on the fkin, PUERPERAL FEVER. hot burning fit, yet they muft not be given during the fweating fit. The heat of new milk will be the mod proper temperature. If nature be not in- terrupted, fhe ufually difcharges the morbific mat- ter &in, which may be much longer continued with lefs hurt to the ftrength of the patient." Experimental Eflays, p, 174, 175, " And we fee from the above experiment, that toward the end of a large and long continued fweat, a quick, weak, tremulous ptilfe comes on. When- ever we meet with one of this kind, we ought to confider it as a ftrong in- dication of the weaknefs of nature, and therefore, in my opinion, to be nearly as cautious of fweating, as of blooding." Ibid. p. 177. '* The following Corollaries, drawn from experiments and obfervation, siay perhaps throw fome light upon this fubjeft. Cc Coroll. i. When the velocity of the blood i* too great, and its mo- mentum too little in proportion, fweating will generally increafe the veloci- *y, and dimini/h the momentum. " Coroll. 2. When the velocity of the blood is too little, and its mo- mentum too great in proportion, fweating will generally diminim the veloc- ity, and increafe the momentum, *' Coroll. 3. When the velocity and momentum of the blood are both too great, fweating will weaken both ; but if it is continued long enough to exhauft the natural ftrength, it will then again increafe the velocity, but not the momentum* " From thefe corollaries we may form a fort of general plan, when fweaN ing is ufeful, and when not. Laying it down therefore as a poftulatum that the ftrength of nature depends more upon the momentum, than upon the velocity of the blood, whenever we find a fweat increafmg the velocity, and diminifhing its momentum, we are furethatitis weakening the patient, and therefore muft endeavour t flop it, Agaia when we find a fweat increafiog the 142 CURE OF THE ter of this paroxifm by fweat ; and this fweating/ which commonly ends in a few hours, may in foirie meafure be called critical. If it laft longer, it < weakens and relaxes the patient, quickens the pulfe, diminifhes the momentum of the blood, creates thirft and coftivenefs, leflens the milk and lochia, occafions their abforption, brings on, or increafes putridity, and frequently introduces eruptions of the white or red kind, and not uncommonly of both. If the patient be troubled with pains in her head, back, or loins, attended with a fwelling, pain and tenfenefs in the lower part of the abdomen, a nau- fea, vomiting, diarrhea, tenefmus, frequent mo- tions to make water, a quick pulfe, thrift, and a white or brown tongue, or with any of thefefymp- toms, it is neceflary to give her a gentle emetic, confifling either of ipecacuanha* in fubftance, or of the momentum, and diminifhing the velocity of the blood, we may be Cure that it is then emptying the overloaded veflfels, or opening fome obftru&ions, and in one of thefe ways adding to the natural ftrength. Farther, when we find a fweat diminishing the velocity and momentum of the blood, when they are both top great, we have reafon to believe it is then carrying off fome morbific matter, whic4i was the caufe of this augmentation, and therefore may go on with the fweat almoft as long as we find the momentum and ve- locity diminifh in an equal proportion to each other ; for we may be affur- cd, that while they do this, nature is never weak ; as very few, if any in- ftances ever happen, where great weaknefs is not attended with a very quick pulfe." Alexander's Experimental Eflays, p, 207, 8, 9. " The method of cure, therefore, eflablifhed at prefent in the Hotel " Dieu, and which has never yet failed of fuccefs fmce it was applied, con* " fills PUERPERAL FEVER. of fome antimonial preparation, emetic tartar for inilance, elfence of antimony, antimonial wine, or James's powder. The dofe mould be repeated once or twice a day, or as often as is found necef* fary to cleanfe the ftomach of phlegm, bile, gaftric, or pancreatic juice, with all of which it is gener- ally overloaded during the diforder. Whichfo- ever ** fifts in taking the advantage of the moment of attack, and giving, with- *' out lofing an inftant of time, fifteen grains of ipecacuanha in two dofes^ " at the diftance of an hour and a half from each other, and repeating them c< again the next day in the fame manner, whether the violence of the " fymptoms be abated or not : And if the difeafe fhould continue much " the lame, they are repeated again the third, and even the fourth day, ac " cording as the cafe may require. In the intervals between the dofes, the " effect of the ipecacuanha is kept up by a portion, compofcd of two " ounces of oil of fweet almonds, one ounce of fyrup of marfh mallows, *' and two grains of Kerme's mineral. The common drink is linfeed tea, " or an infufion of fcorzonera,* edulcorated with, fyrup of althaea ; and to- " wards the feventh or eighth day of the difeafe, the patient takes a milk " purgative, which is repeated -three or four times, according to the exi " gency of the cafe* ** It is evident, therefore, that the efficacy of this method of cure confilb " wholly in its early application, namely, in the very moment when the " difeafe firft commences : And though experience has fmce taught us that t( the Ibfs of a few hours is not always irreparable, yet it feldom happens ' that ipecacuanha has the fame complete fuccefs when the firft moment of " attack is loft." Vid. Whitehead's Tranf, of Doulcet's Memoirs, p. 10. The invention of the above method of curing this diforder, by giving vomits at the very firft at';ack of it, and frequently repeating them, cannot be afcribed to Mr. Doulcet, fmce Dr. Denman, in his Eflay on the puerpe- ral fever, publifhed in 1768, advifed the ufe of them with this difference only, that he refcpmmended tartar emetic, whereas Mr. Doulcet gives ipecac- uanha * Scorzonera latifolia, Cafp, Bauhin. Angl. Viper's Grafs, CURE OF T H i ever of thefe medicines is made ufe of, it mould b6 given at firft in a fmall quantity, and if no viable effeft enfue, if it neither affed the patient by flool or vomit, the fucceeding dofes mould be in* creafed, till their quantities are fuch as will anfwer their intentions* Frequent vomits are very ufeful In all putrid fevers, for the faliva* which is f wal- lowed into the flomach, and the other juices that are found there, and in the duodenum, contain very little or no fixed air, and therefore of courfe ab- forb the putrid miafmata, which cannot too often be evacuated. But if the patient have very vio- lent pains in the abdomen, purgatives are to be pre- ferred to emetics, as the a6lion of vomiting might increafe thofe pains. If cuanha the preference. But in this Treatife of mine, which was publilhed fn 1773, * recommended ipecacuanha in fub fiance, and as it was tranflated in^o French, and publimed at Paris in 1774, it is moft probable Mr. Doulcet muft have feen it, fmce he appears by his memoir, never to have ufed this mode o treatment till that time. We muft however allow that Mr. Doul- cet has very properly laid particular ftrefs upon the ipecacuanha being given at the very inftant of the attack ; and the public are much indebted to M. Viccj. .D'Azyr, and the gentlemen of the Royal Medical Society of Paris, for the report which they publimed. * " The abforbent quality ofthcfaliva moreover fhews, how apt it muft be to lay hold of infectious miafmata which oftentimes are in reality putrid %'apours, or fixed air, detached from bodies during putrefaction j and con- firms what hath been frequently recommended, namely, to (hake off infec- tion, and prevent the miafmata from getting into the mafs of fluids by imme- diate vomiting j and we may likewife fee, that the cautions given by authors concern; ng the fwallowing ottbcJaRva while in the places abounding with ic;eili(xis vapours, are founded in reafon." Macbride's Exper. Efiays, p. 268. By PUERPERAL FEVER. 145 If the patient be coflive, or have- a tenefmm, emollient clyfters, which hot only help to carry off the morbific matter, but are extremely ufeful as fomentations to the whole abdomen, mould be frequently injected ; but efpecial care mould be taken that they are not adminiftered too warm ; and if thefe be not fufficient, gentle purgatives muft be adminiftered in fmall dofes, and frequent- ly repeated, as cream of tartar, Glauber's, Ro- chelle, or Epfom falts, rhubarb or caftor oil ; if thefe mould fail, ftill ftronger muft be made ufe of. So foon as the ftomach and bowels have dif- charged their morbific contents, fpiritus mindereri, or the fait of wormwood neutralized with the juice of lemons may be given in draughts. This laft medicine mould be taken during the aft of effer- vefcence ; or it may be more agreeable to the pa- tient if the fait of wormwood be adminiftered in draughts of a fcruple each, and each draught wafh- ed down with a fpoonful of lemon juice ; and probably the taking it in this manner may be ful- ly as effectual, as they will e'ffervefce in the ftom- ach. Thefe dofes mould be repeated every two _-'- j hours By the precautions taken by Dr, Lind, and by immediate vomitings, on- ly five perfons died from among more than an hundred, who were feverally and fome of them conftantly employed, during eighteen months, in various Offices about the fick in Haflar hofpital, -where there conftantly was a great number of people ill of fevers that^were highly infectious. See his Difcourfe' on Fevers and Infcfliw, paper a, p, 74,, K 146 C U R E O F T H E hours or oftener ; they will corre& and fweeteri the acrid putrid bile, and will allay the feverifli fymptoms. Doftor Lind, who has prefcribed them frequently upon the acceffion of cold fits, tells us that they generally Ihorten the fits, and occafion profufe fw eatings. It may be neceffary perhaps to remind the reader, that though fweatings are in general very pernicious in this fever, yet they are indifpenfably neceffary at the termination of a rig- our, and may in fome meafure be faid to be critical in refpe6l to that paroxifm, though there be not a perfect crifis : that the beft method of procuring thefe fweats is to moderate and fhorten the burn- ing fit, for Dr. Alexander has proved that a per- fon may be too hot to fweat, and that there is a fweating point, in any degree of heat above or be- low which a perfon cannot fweat. Therefore if the patient be too hot to fweat, that heat muft be low- ered by cold air and cold water. By thefe means the burning ^fit will be moderated and fhortened, and fweats will natually fucceed, and will only continue a proper time, if they be not encouraged by warm liquors, a warm room, and many clothes ; hence the velocity and momentum of the blood which before were too great, will now be leffened, whilfl the morbific matter is carrying ofF, which was the caufe of the augmentation. Riverius PUERPERAL FEVER. Riverius* gave fait of wormwood and juice of lemons in obftinate vomitings attendant upon pu- trid malignant fevers. Sydenham adminiftered a fcruple of fait of wormwood in a fpoonful of lem- on juice, during the illiac paflion which fucceeded the depuratory fever, ahd in an intermittent fever attended with almofl continual vomitings, he gave the fame quantity fix or eight times in the fpace of two hours. I have prefcribed this medicine in the aft of effervefcence for many years during every ftage of the putrid malignant fever, both in preg- nant and puerperal women with every apparent ad- vantage; This practice has been recommended by Whytt, Barry, both the Linds, Pringle, and Mac- btide, who agree that the virtues of this medicine depend upon the emiflion of the fixed air, but they differ iri regard to the mode of its action ; fome are of opinion that it is owing to itsbrifk and unufual Jlimulus^ on the very fenfible nerves of the ftomach, others * " Salis abfinthii Bj. curii fucci limonum cochleari mixtus, remedium eft praeftantiflimum, praefertim in vomitu, qui febribus malignis folet con- tingere." Lib. 9. Cap. 7. de Naufea & Vomitu. f The draughts of fait of wormwood and juice of lemons are obferved " in a great meafure to lofe their power of flopping a vomiting when they are <* not fwallo wed in the ac~l of efFervefcence : And, ,1 Is not their fuperior an- tc tiemetic power in this ftate owing to their making a much ftronger impref- fion upon the nerves of the ftomach, while they continue to emit this fix- " ed air, and when all their parts are in violent motion, than after fa-turation, when they can aft only by their faline quality ? for while the nerves of " the- K2 14$ CURE "OF THE others to its antifeptic powers, by fweetening and deftroying the putrefa&ive acrimony. But which ever of thefe is the cafe, it certainly moderates the cold, the hot, and the fweating fit ; it allays thirft. vomiting and the febrile heat ; it keeps the intefti- nal canal open, and it raifes the fpirits without heating the patient. I have never known the leaffc bad confequence attend the taking of it, except that it has in fonie cafes caufed an uneafinefs at the ftomachj owing to its fudden diftenfion, from the quantity of fixed air fet at liberty. This effect may- be moderated by fuffering'fo much of the effervef- cence to fubfide before taking it, as may be judg- ed necelTary ; it is never more than a temporary inconvenience ; if the vapour be imbibed into the lungs it will fweeten the breath, which in its pureft Hate and in :health is feptic, but in putrid fevers moft remarkably fo. Notwithftanding the ingenious Dr. Macbride's experiment with the fparrow, and the general opin- ion that fixed air arifing from the union of the mildeft alkaline falts, and even the pureft vegeta- ble ** the ftomach are affefled with this briik and tmufuaI_/?z^M/ttJ, that difagreeable * f fenfation which pro^nced the vomiting muft be leffcned or deftro^'ed : " Ibid. p. 85. K 4 C U R E OF THE -- Free and even cold airf , an upright pofture, clean- linefs, fruifcj frefti, or preferved, a vegetable diet, and the ufe of cold acidulated liquors, fhould be ftri&ly enjoined, fuch as imperial, orange, or lem- onade, Sec. the vegetable acids * are to be prefer- red -f tl When the hofpital fever in the late war, was brought from England into the hofpital at Mahon, the houfe being found inefficient for the recep- tion of fo great a number of patients, tents were reared up in the fields for many of the men. Thefe poor fellows were thought to be badly accommo- dated, but it was very obfervable, that mofl of thofe who lay in the cold tents recovered ; when the mortality in. the houfe was fo great, that in fome wards not one in three efcaped." Ibid. p. 106. * " From thefe experiments may be deduced the great utility of acids in all difeafes which either proceed from, or are accompanied by, a redun- dance and depravation of the bile. And thisfeems to be the cafe with nioft autumnal fevers, and in general with the epidemics of all hot countries, efpecially where heat and moifture are conjoined. For the former promotes the generation, and the latter the putrefaction of the bile/' Percival's ExpmeAt on Aftringents, p. 155. " The difference between the acTion of mineral and vegetable acids QH putrid gall, as evidenced in the preceding trials, is deferving of particu- lar notice. From the ignorance of this diftinftion, or want of attention to it, I believe the elixir of vitriol is often exhibited, When vinegar, or the four juices of vegetables, would be much more ferviceable. For though it is the common property of all acids to correct the putrid acrimony, yet the power of fwectening it feems to be peculiar to thofe of 'the vegetable clafs. And as they are mildly aperient, at the fame time they will not only neu- tralifethc feptic comivies, which in lome difeafes lodges in the ftomach and flexure of the duodenum, but will alfo tend to evacuate it : An advantage not ?o be expefted from the mineral acids." Ibid. p. 158. - * c . Acids correft the bitternefs and acrimony of the bile ; and volatile bitters correft the acidity and tenacity pf. the phlegm. If vin egar PUERPERAL FEVER. 153 red to the mineral, they not only correct, but fweeten, the putrid bile, and are mildly aperient, and above all, we muft remember to keep the al- vine tube open. Every method recommended in the preceding chapter as preventive of this diforder, mould now be enforced in a higher degree, in order to its cure ; particularly the patient mould have clean linen every day, and her hands, face, and teeth mould be daily warned in cold water*, except (he be in a fweat ; me mould alfo fit up in bed as often as fhe can bear it, and be got out of bed every day. If cgar be mixed with ftrong decoftions in water, of wormwood, gentian root, camomile flowers, centaury tops, and buckbean, the mixtures will have neither bitternefs nor acidity, if they be mixed in juft proportions. Hence acids and bitters correft each other, when either happens to abound too much in the body. If bile abounds, as it commonly does in fummer and hot countries, acids and cooling acidulated liquors will be proper to correct it ; and if phlegm abounds, as it does in winter and cold countries, volatile al- kalious fpirits and warming fermented liquors will be proper corre&ors." Robinfon on the Virtues and Operations of Medicines, p. 168. " Ex aceti partibus quatuor, & bilis recentis part^bus quinquc, miftura fata, neutrius faporem prdebebat, fed medium quendam, mamfeftedulcem." Robertus Ramfay Differt. Med. Inaug. de Bile, exper. xvii. ** Miftura aceti & bilis, ut in exp. xvii. fa&a, lacli reccnti affufa, coagulum hujus non induxit, etfi eadem aceti copia, per fe affufa plus quam fufficiens ad coagulum inducendum fuiffet." Ibid, exper, xix. * " Frigus, quatenus corporis calorem & cerebri vel nervorum energismt minuit, fedans eft, Si calor nimius fit, frigus ad eundem compefcendum utile 154 CURE o F T H E If thefe dire&ions be timely made ufe of, before any confiderable abforption has taken place, or any matter depofited in the cavity of the abdomen, I have no doubt but they will generally prove fuc- cefsful. I have always found them fo, except in cafes wherein the womb has fuffered damage at the time of parturition ; but I mult inform the reader that I never attended a woman in a lying in hofpital. A diaphorefis or gentle fweat, is rec- ommended by many authors, who yet allow that a diarrhea is critical, that it is the way which nature takes to difburden herfelf of the morbific matter, and that it ought by no means to be checked. It is an axiom in phyfic, that the increafe of one evacuation leffens all the reft ; ^ Why then fhould an evacuation be encouraged which relaxes and weakens the patient, increafes the velocity, and de- creafes the momentum of the blood, creates third, leffens the milk and lochia, promotes putrefaftion and ^> * ~i mile eft. In plerifque morbis febrilibus, caloris ftimulus movbum exacer- bat,' adeoque frigus ad gratam fenfationem fere femper neceffarium eft. Si aec inflammationis topicae, nee diathefis phiogifticz periculum fit, aer & po- tus frigidi/lib'ere concefli, multum juvant. In ephemera puerperarum aqua: frigidze hauftum vel manus immerfionem ut remedium eximium laudat Pro- feffor nofter Young, et, faepe omnibus aliis anteponendum, cenfet." Differt. Med. Inaug. T. Tucker, p. 45. For a more particular account of the great advantages, and even neceffity, of cold air, in fupprefiing and extinguishing fevers, I muft beg leave to re- fer the reader to two very fenfible pamphlets publifhed by Doaor Ki.kland, the one entitled, An E/ay on the Cure o/Difeafes casing fcccrs, the other, A Rt- p ) to Maxwell. PUERPERAL, FEVER. and abforption, and checks that loofenefs which certainly ihould not be removed, except by taking away its caufe ; I mean by the admiflion of free air inftead of foul, by the prevention of heat and moiflure, by abflaining from fuch foods as have a putrefcent tendency, by frequently clean (ing the ftomach and bowels of the corrupted colluvies, by correcting and fweetening its putrefcent acri- mony, and by an upright pofition preventing a lodgement of any kind of offending matter, either ;n the uterus, vagina, inteftines, or bladder ? I do not deny that many perfons have recovered who have been kept in gentle fweats ; but inflances of the recovery of patients may be adduced, un- der alrrioft every kind of erroneous practice. That many have recovered without fweating. or where the fweat has only come on at the termination of the paroxifmof a rigour,! myfelfcan teftify. Ex* cepting at this period, I am equally confident that the patient's recovery, without fweating in the fmalleft degree, is not only more expeditious, but at- tended with greater certainty, and though we often fee a gentle diaphorefis upon the ikin when the fever goes off, yet we ought not to confider it as the caufe, but the confequence of the amendment; and I believe I may venture to fay, that in thofe few cafes where fweating has proved ferviceable, the 156 CURE or THS the fweats have come on fpontaneoufly, and were not the effe& of art. Nitre* is a very improper medicine in this fever, and in all difeafes where putrid bile abounds. In regard to phlebotomy, efpecially at the be- ginning of this diforder, authors are much divid- ed ; fome of them obftinately infilling upon its efficacy, and others as warmly rejecting it.t That fome women may be fubjeft to fuch in- flammatory diforders during their lyings in as may require bleeding, cannot be denied ; but cafes of this kind are not very common in the prefent age, efpecially amongft thofe who inhabit large towns. In the puerperal fever, however, which generally, fooner or later, affords linking fymptoms of pu- trefcency, we fhould be extremely cautious how \ *_^ , >t 4 we * Sir John Prihgle, in making fome experiments upon gall to preferve it from putrefaftion, fays, " Only nitre failed, -which though four times " ftronger than fea fait in preferving flefh, is inferior to it in preferving ' gall, and much weaker than fal ammoniacus ; which, again, is forhewhat " lefs powerful than nitre in keeping flefh fweet. The nitre was faon tC opened by the gall, and emitted much air, which arofe as from a fer- '* menting liquor, and when this happened the gall began to putrefy. But " the falinc mixture generated no air, and oppofed the putrefaction of the ** gall more than it did that of the flefh. Perhaps this may be the reafon " why, as far as I have obferved, nitre difagrees with .the ftomachin, putrid *' bilious cafes." Append, to Difeafes of the Army, p. 27, i Leveret fays he had never feen one woman efcape after Aphorifm 995, PUERPERAL FEVER. we do any thing to debilitate the vis vitas , to weak- en the circulating powers by unneceffary evacua- tions, or wafte the ftrength which may be wanted to fupport the patient under loofenefs and vomit-- ings. It has been lately obferved by DoQor Den- man, " that thofe who have recovered have feem- " ed generally to owe their fafety to a happy " flrength of conftitution, able to withftand the " continuance of a long loofenefs, by which the " difeafe appeared to be gradually wore off, or to *.-' Blifters* are generally difapproved by all writ- ers upon thisfubject. The flimulus they occalion in * " Si qui puerperio morbi fupervenerint, in his omnibus adhibita veficato- ria inter trcs primos dies periculum Temper, faepe mortem afferunt." Manningham Aph. Med. p. 153. Baglivy relates the hiftory of a puerperal fever unfuccefsfully treated, where blifters were attended with a manifeft difadvantage to the patient. " Mulier ofto menfmra gravida, juvenis, &. gracilis, integro oftiduo doloribus vcntris mokflata, PUERPERAL FEVER. in the bladder and uterus, and the bad effeft they fometimes have in putrid and bilious fevers, when applied too early, are fufficient reafons to condemn their application in the beginning of this fever, ef- pecially if foon after delivery. The moleftata, demum infantem peperit. Poft partum adhuc continuabant dolores, cum infigni ventris tenfione. Quoniam vero omne genus remedio* rum fpreverat, vel potius neglexerat, demum a quodam medico quatuor vefi. cantia fibi apponi permifit. Lochia quz primum fluebant exinde fupprefla funt. Faucis poft diebus denuo apparentibus lochiis, abdomen graviter con* velli csepit cum infigni dolore, adeo ut ne digito quidem premi poffet ; ex- inde fudores frigidi, cum refrigeratione extremorum apparuerunt ; pulfus & refpiratio erant diminuta, & fere ad extremum vitas redafta fuit patiens. Elapfis paucis diebus in melius aliquant ulum procedebat ; derepente tamen fupervenientibus graviffima fpirandi difEcultate ex genere convulfivarum, & interdum in delirium fe commutante, nee non alvi fluxu flavo, & fcetido, qui per ofto dies continuavit, demum decima feptima die morbi, obiit pa- liens," &c. Baglivi oper. p. 599. Etherington, fpeaking of the low, nervous, and hyfteric fever, fays, " For although bliflers in general are very ferviceable where this diforder happens, yet, to lying in women, they prove of the worft confequence, by inflaming the womb, and fometimes bringing on mortifications and death. For which reafon we cannot too earneftly forbid the ufe of blifters in all diforders of puerperal women, in the early days of their lying in, while the veffels are fo full, and the parts from whence the placenta was feparated fo very tender, and liable to be injured by the cauftic falls of the cantharides. Many fatal inflances attending the application of blifters at this time have been obferv- ed." General Cautions in the Cure of Fevers, p. 41 . " 1 do not know any worfe practice than bliftering in the beginning of fe- vers, particularly the putrid and bilious ; blifters increafe the inflammation, and greatly exafperate the acrimony of the morbid matter : in th6 early part of the bilious conftitution, they promote the propenfity to fymptoniatic fweats, and hinder the excretion by the bowels." Grant on Fevers, p. 344. " Neither do blifters feem to be always of fervice in fevers ; for fome of the putrid kincj djjjjplve the Wood, and turn iato a dark corrupted fanies." Glafs'iCom. 275. *6o CURE OF, &c. The whole clafs of ftimulating medicines, callect enimenagogues, which are faid to promote a dif- charge of the lochia, are equally to be avoided. They irritate the womb, increafe the fever, and do not anfwer the end for which they are adminiftered. In the laft flage of this diforder, when the pa- tient Teems to fink under it, wemuft endeavour to fupport her by ftrong infufions and tin&ures of the Peruvian bark, by wine and other cordials, and to ftimul.ate and roufe her by volatile falts and blif- ters; and in this (late of the difeafe they may even be applied to the abdomen. I mufl not omit to mention, in this place, the good effe&s I have experienced from emollient or antifeptic injections into the uterus, by means of a large ivory fyringe, or an claftic vegetable bottle. In thofe cafes where the lochia have become acrid or putrid, and by being abforbed into the circula- tion, havefefved as a conftant fomes to the difeafe, I have by this means known the fever much affuag- ed, and in many cafes wholly extinguimed ; for though, as I have before obferved, the quantity of the lochia is not to be much regarded, the quality of this difcharge is a matter of infinite importance* CHAP, CHAP. VIII. OF THE CURE OF THE MILIARY FEVER. N the fixth chapter I have laid down the prophyla&ic treatment of this diforder. If I can pro- nounce with certainty of any medical facl;, it is, that the milia- ry fevers of puerperal women may be prevented ; and I am equally confident that they may, in their firft ftages, be totally extinguifh- ed, without any of thofe bad confequences which too frequently attend them when they are fuffered to take their ufual courfe. As foon as any fymptoms of the diforder appear, whether they come on with or without a rigour, a gentle emetic will be neceflary. This remedy may be adminiflered at any time, except during the par- oxifm. If there be a cold fhivering fit, fucceeded by L burning " life CURE OF THE burning and fweating, thefe fymptoms are to be treated in the mariner explained in the laft chap- ter. A quarter or half a grain, or where the con- ftitution is remarkably ftrong, a grain of emetic tartar may be given twice a day or oftener, in draughts ; but if it be intended to aft as an emetic, neither cream of tartar nor any other acids mould J be given along with it*. If thefe dofes do not oc- cafion gentle vomitings, as the flomach in this dif- order is generally relaxed, and abounds with heavy phlegm and mucus, 'a few grains of ipecacuanha mould be adminiftered every, or every other day, and neutral draughts in the aft of effervefcence mould be given every other hour. If the patient be coftive. emollient clyfters Ihould Jbe every day injefted. They allay the febrile heat .and prevent loofenefs, which is often occaftoned by the feces lodging and thereby growing putrid and acrimonious in the interlines. An upright pofture, with cold liquors and free, pure, and even cold air, accompanied with the greateft cleanlinefs, are abfolutely neceflary. If thefe and the direc- tions given in the preceding chapter be properly purfued, I have no doubt but they will prove ef- \ feftual in totally extinguifhing the fever. Bleed- ing * u Cream of tartar and acids check the operation 01 vomits, but more 'efpeciajly ojf antimonial vomits." Robinfon on the Operation of Medicines, p. 169, MILIARY FEVER. ing and other evacuations, except gentle emetics and emollient clyfters, will be unneceffary. There can be indeed no objeftion made to a mild purga- tive at the beginning of the diforder, provided it be not" given immediately after delivery. Great care and circumfpe&ion is required in conducing the patient through the fecond ftage of this difor- der, when there is a large crop of miliary puftulee, efpecially if they be of the white kind, attend- ed with a quick uneven pulfe, a dry tongue, and a continual fweat. Though it be in this cafe abfolutely neceffary that the patient's linen mould be frequently changed, that the bed curtains mould be undrawn, and the room ventilated, and though it may fometimes be expedient that a current of frefh air mould pafs over the patient, yet thefe things ought not to be done fuddenly or raihly ; cautioufly, and by de- grees they may be performed with fafety. The de- gree of cold admitted mould be fuch as will reduce the heat of the body as near as poflible to the ftand- ard of health, fuch as will prevent the patient's burning or fweating. Intenfe cold is feldom nec- effary ; but where it is, by proceeding with proper care, it may be admitted not only without hazard, but with the greateft benefit. Evacuations are in general followed with the word of confequences. A few loofe ftools (in fome L 2 cafe CURE OF THE cafes fpontaneous, in others produced by art) have funk patients beyond recovery, and bleeding has been attended with as bad fuccefs. . I remember, not without great concern, that in the earlier part of my practice, when my ideas of phlebotomy in puerperal cafes were very differ- ent from what they are at prefent, I was called to a puerperal woman in this flage of the miliary fe- ver. She had a plentiful eruption of the white kind, was in a fweat, and her pulfe was fo quick, fo full and flrong, that I was prompted to believe this evacuation neceffary. She did not feem to be in immediate danger, I took eight or ten ounces of blood from her arm, but was inftantly convinced of my error. Before I flopped the blood me began to droop, and in lefs than half an hour expired. The making a large quantity of pale thin urine, a common fymptom in this diforder, always weak- ens the patient to a great degree. All diuretics muft therefore be pernicious. I have known the hot fweating mode of practice carried on to that extreme, that the feather bed has rotted beneath the patient ; by this method me has been fo much exhaufted, that the higheft cordials have been neceffary to fupport her, nay I have been credibly informed that under thefe circumftances a patient has fometim-es drank a gallon of zuine, in MILIARY FEVER. a fingle day, exclujlve of brandy, and of the cordials from the Apothecary sjhop, and all this too without intoxication. Many have fallen viclims to this practice, and thofe who have recovered under it, have in general been fo much enfeebled, and have had their conftitutions fo far broken, that during the remainder of their lives they have been liable to frequent returns of the diforder *. When the patient has been kept fweating in bed for many days in a fupine pofture, her fuddenly getting * Etherington fpeaking of the miliary fever fays, c< The ufe of fudorifics has been found to be fuccefsful neither in the beginning, middle, nor end of this fever ; although the foftnefs of the pulfe at the beginning might feem to demand the warmeft cordials ; or its weaknefs during the eruption to make ftimulants necefiary. Neither is promoting at lafl the natural fweat, which appears to be a crifis, beneficial. " The forcing out and keeping up fweats, upon every fufpicion of cold or eruption, I know is warranted by vulgar practice. But I am convinced from repeated examples, that fweating in all eruptive difcafes is attended with bad confequences. Probably from carrying off the thinner fluids, which mould fupportand keep up the eruption." General Cautions in the Cure of Fevers, p. 52. (t I have more than once known patients fink under this fever, after hav- ing been kept in a fweating method for five or fix weeks together, and after . . having gone through three or four fucceflive crops of miliary eruptions, as they are called, they all the while melting away, and weltering in their own fweat, and the bed rotting under them." Huxham on Fevers, p. 87. e How exceedingly pernicious hot alexipharmic medicines are in the mil- iary fever, experience hath too frequently taught us ; by which it appear* that O ' i66 C U R E o P T it getting out of it has fometimes been attended with difagreeable confequences. Thefe have not been owing to the cold, but have arifen from her change of poflure, and from the feeblenefs of the mufcular fibres of the heart, which profufe fweats had great- ly debilitated. I have known feveral perfons who, under thefe circumftances, notwithftanding the greateft care to prevent the effe&s of cold, could not bear this fudden alteration of pofture. All evacu- ations, and whatever tends to weaken the tone of the veffels, has the effect of fweating. Sir John Pringle has remarked, " That nothing can be low- (( er than the fick are in the advanced ftate of the " jail or hofpital fever, and that therefore Hoff- " man rightly advifes in all fuch cafes that thepa- " tient may be kept conftantly in bed, and not be " permitted even to fit up in it. In the lafl ftage " of this difeafe, as well as in that of the fea fcur- * ( vy, it fhould feem that the force of the heart is " too frnall to convey the blood to the brain, ex- " cept when thfe body is in an horizontal pofture *." But as an horizontal pofition is very bad in all fe- vers to which puerperal women are fubjecl;, I al- ways that by means of fuch medicines, and keeping the patient too warm, almoil all died when the difeafe made its firft appearance ; whereas at prefent, num- bers under a temperate regimen efcape. In a neighbouring town this year, a great many in the petechial fever were treated with hot alexipharmics,'>and Kept in a continual fweat, of which fcarce a third part recovered." Glafs's Comment, on Fevers, Eng. edit. p. 235. p. 3*4 i to ' MILJARY FEVER. ways advife the patient, if %e .c^nn^t fit up in bed, to have feveral pillows, or bolfters fo applied to her head and moulders, as to raife them as high as ihe can bear without inconvenience. Bliftering is fo far from doing good in the firft or fecond flages of the miliary fever of childbed women, that it is often productive of much mif- chief. It increafes both the fever and the number of the pu Mules, attenuates the blood, increafes the urine, promotes putrefaction, caufes thirft, drynefs of the tongue, watchings, deliriums, tenefmus, fub~ fultus tendinum, hiccoughs, arid convulfions. Nitre, efpecially if given alone, though an antifeptic, hath no place in this diforder. In weak and delicate ftornachs k caufes too great, a chillnefs, it aug- ments the patient's anxiety, adds to the vaft op- prefiion of the precordia, 1 lowers the pulfe, and is exceedingly diuretic. Volatile alkaline falts, though likewife antifep- tics to the dead fibre, increafe the heat, liquify the blood, and promote putrefaction in living bodies. Emmenagogues mufl be avoided. They heat and irritate the patient, and are never produ&ive of good. Camphor has been held in great eftimation in inflammations of the uterus, in acute and malig- L 4 nant CURE OF THE nant fevers attended with heat, thirft, watching, de- lirium, and phrenzy, in all putrid diforders, and even in the plague itfelf ; but in fome conftitutions, when adminiftered in large dofes, it has been known to produce ftrangury, coftivenefs, heat, thirft, fpafms, and even convulfions. * The ingenious Dr. Alexander, after making fev- eral experiments with this drug, fome of which were near coding him his life, concludes with tell- ing us that he does not know whether to rank it amongft heating or cooling medicines, and that no certain rule can be laid down to ascertain the ex- a6l quantity which may be adminiftered with pro- priety. M. Pouteau, in his Melanges de Chirurgie, fpeaks highly of it in the puerperal fever, but Doc- tor Denmant fays he was informed by a phyflcian who * De Haen (in Hift. Morb. Vratifl.) fays, the Phyficians of Breflaw found that camphor in the malignant fever did more harm than good. Ratio Medendi. p. 150. t{ Does experience fufficiently warrant that virtue fometimes afcribed to camphor of preventing a ftrangury ; two fcruples of it given to a woman in a clyfter, proved fo irritating as to bring on pains refembling thofe of la- bour. Another woman was feized with a ftrangury foon after {he had taken a camphor bolus, which me herfelf imputed to the camphor, and no other probable caufe of it could be afllgned. Camphor in its nature is nearly allied to fpirit of turpentine, ne drachm of which taken internally brings pn a ftrangury as certainly as cantharides." Med. Tranf. vol. j. p. 470, Art t 2K by Dr, Heberden, t Effay on the Puerperal Fever, p, 2, MILIARY FEVER. tfg who converfed with him upon this fubjeft, that he afterwards altered his opinion. Whenever it is thought neceflfary to give it, I would advife it to be adminiflered in fome acid vehicle, in lemon juice as directed by Hoffman, or in the julep, e camphor of the College, prepared with vinegar in- flead of water in the manner recommended by Huxham and Mead, or with a fmall quantity of nitre,* Opiates fhould not be given except in cafes of great irritation : They tend to relax the patient, and whenever they are neceffary they ought to be accompanied with fmall dofes of ipecacuanha. Broths, butter, cheefe, eggs, and animal foods of all kinds fhould be avoided as the encouragers of putrefaction. Acid, or acidulated liquors, fuch as whey made of verjuice, tamarinds, or buttermilk, water where- in * Dr. Lyfbns, in his Effay on the effects of Camphor and Calomel, extols the virtues of nitre and camphor when given together in epidemic fevers ; but many of the cafes he has brought to confirm his opinion appear to be ephemeras only, and might have gone off without that or any other medi- cine ; and what confirms me in this opinion is, that he was often difappoint- ed in his expectations from it, when it was not given in the beginning of the fever. [Vid. p. 16.] But notwithftanding this, 1 am of opinion that thefc two medicines are better given combined than feparate, as they correct each other ; and though I cannot fay pofitively, that I have feen them of fervice ; .in fevers, yet I am very certain, that I have prefcribed them, in the manner directed by Mr, Rowley, with very good effeft to perfons afflifted with ul- cers of the legsv 170 CURE OF THE in current jelly has been diffolved, lemon and orangeade, imperial, or Glutton's febrifuge julep, may be drank, provided they do not occafion grip- ings ; infufions of antifeptic herbs, fuch as camo- mile and buck bean, bohea and green tea (if it has not been found to difagree) thin panada, gruel, fweet milk, bu f te? milk, and wort, are alfo proper. If the bowels be in too lax a ftate, rofe leaves, baluftines, or Pomegranate t>ark, may be added to the wort. Salep, barley water, or cold water with- out any thing added to it, mould be often given to the patient. Where fhe labours under great languors, wine either alone, mixed with water, or made into whey, provided they are perfectly cold, may be adminif- tered occafionally ; if the patient be troubled with the heartburn or acidities wKick render wine im- proper, brandy or rum may be fubflituted in its room,. Ipecacuanha given in fmall dofes, fo as only to occafion a gentle puking, is of great fervice. $ ' not only cleanfes the ftomach of that glafTy phlegm with which it fo much abounds in this fever, but is preventive of diarrheas by difcharging acrid bile, pancreatic juice or corrupted faliva taken into the ftomach by deglutition, or any other putrid collu- vies. If a diarrhea come on and fink the patient, it mufl be fuppreffed or moderated by aftringents, feich MILIARY FEVER, fuch as gum, rubr. aftring. lign. campech. fang, dracon. terr. japon. jelly of Englifli ftarch given in draughts and clyfterwife, &c. but chalk, abforb- ent calcareous earths, and the teftacea muft gener- ally be avoided as great promoters of putrefaction. However, when acidities abound in the primes i)ics^ which may be known by four eru&ations, vomit- ings, or by green ftools, the chalk julep with tinc- ture of bark may be given with advantage, and the white decoclion may be drank for common drink. Neutral draughts may be continued through this ftage of the diforder, giving along with them oc- cafionally fuch cordials as the rad. ferpent. contray- erv. and confe6t. cardiaca, or any of the compound, waters, according to the ftrength of the patient. The pulv. contrayerv. compof. of the College is an improper medicine in this fever, as it contains fo large a proportion of the teftacea as will overbal- ance the antifeptic powers of the contrayerva root. Elix. vitriol, dulc. given in draughts, and moft preparations of the bark, beginning with the {lender ones, fuch as cold infufions of it, bark tea, and Huxham's tin&ure, are of great fervice in bracing and ftrengthening the fibres, preventing fweat, and refilling putrefaction. If the patient's ftomach will not bear the bark ? it may be adminiftered in clyfiers,* The * Dr T. hwell relates the cafe of a woman -who had a fever in her lyinj jp vhi-s tue bark was of great fervice given in clyfiers. {T, Phyf, & Lit. vol. 2. p, 418. CURE OF THE The apthae attending this fever are generally re- lieved by the bark, by acids, and acidulated gar- gles, and by borax given in the form of a linclus. The third or laft ftage of this diforder is very hazardous. I have frequently known muflc of great fervice in watchings, deliriums, the fubfultus tendmum, hiccoughings, and convulfions ; but it is often given in too fmall dofes ; and hiccoughings have often been relieved by a few drops of oil of cinnamon. If the patient's pulfe fink, and (he become le- thargic, blifters and linagifms muft be applied to ftimulate and roufe her, and the highefl cordials, particularly wine in confiderable quantities, and even the fal c. c. are neceflary for her fupport. During the whole treatment of the miliary fever in puerperal cafes, the greateft circumfpe&ion and delicacy are required. The patient can frequently neither bear to be raifed nor deprefifed. She can endure but few evacuations. Bleeding, purging, and even bliftering, except as a flimulus in the laft ftage of this diforder, are hurtful. Neither fudorifics nor diuretics mould be adminiftered, No animal food, nothing that is feptic, nothing weakening, nothing heating, irritating or difTolving the MIUARY FEVER. the blood, fhould be given, except in the laft ftage. She can at all times bear gentle vomits, and emoll- ient clyfters to clear the prime? vice. Pure, free, and cold air is ufeful if it be let in by degrees and ad- mitted cautioufly. Cold liquors if given with pru- dence a\e beneficial, and too much ftrefs cannot be laid upon acid and aftringent antifeptics. V All irregular difcharges muft be reftrained, and the patient properly fupported. We muft remem- ber there is no particular, and indeed feldom any crifis in this difordfcr ; wherever there is it is the aft of nature, not of arVjj and I muft add, that critical eruptions, or difcha s (ges are fo far from be- ing prevented by cold a*r or cold liquors, that they are promoted by them*. The nearer the heat of the body is brought to the ftandard of health, the fooner and the eafier will nature be enabled to throw off her burden; CASES. * " Several patients labouring under eruptive fevers, who have happened to keep out of bed a little time every day for feveral days together, have conftantly found that the eruption was greater while they were up and cool, and th^t' it began to fade as foon as they were hot in bed. ,t Is it owing to 1 experience or hypothefis that eruptions ar,e believed to be thrown out more vigoroufly by warmth and lying in bed ?" Queries by Dr. Heberden, Med. Tranf, vol. i. p. 470? 6 A S E CASES CASE L ANUARY 14th, 1761. Betty Rigg, aged 2 1 , died in the Mancheiler in* firmary of aperipneumony after three or four days illnefs, being about fix months gone with child, and I had an opportunity of infpe6Hng the body. The tho- rax contained a good deal of water, and the right lobe of the lungs was mortified, the womb and the reft of the vifcera appeared to be in a found and ^natural ftate. The womb was contiguous to the peritoneum, the inteftines chiefly occupying the epigailric region, being fupported by the diftended uterus. Upon opening the womb and difcharging the waters, I had a full view of the fituation of the fetus, which lay upon its right fide, the head to the os uteri, the right ear to the os facrumj the left to the os pubis, the breech and feet to the fundus ute- CASES. ri, the knees drawn up to the belly, and the chia down to the breaft. The placenta adhered to the anterior part of the womb. The womb was not much altered in thicknefs from an unimpregnated Hate. Her friends coming prevented any further examination. R E M ARK. Till within thefe few years it has generally been imagined that the fetus from the time of concep- tion to the 8th or 9th month, or even till the la- bour began, was placed in crable effe&. I gave her ten grains of ipecacuanha, which vomited her very well, and brought up a great deal of glaffy phlegm. A blifter was applied between her fhoulders ; (lie was ordered to drink milk and water, cold water, or buttermilk and wa- ter, plentifully ; fhe fometimes took water gruel and barley water; a window was kept open during the day time, and a clyiler was given her. Friday the 8th of the fever. The blifter was ordered to be taken off, and the part was warned with milk and water to prevent a ftrangury. She was delirious, the miliary eruption was dying away, and another vomit was given her. Upon this, and the fucceeding days tfee window was opened, and the clyfler was daily repeated. Saturday the gth. No alteration appeared. Sunday the loth day. She had frequent retch- ings to vomit, attended with flight labour pains, and took every three hours a fcruple of fait of worm- wood in half an ounce of lemon juice during the a6l of effervefcence, which was mixed clofe under her mouth, that fhe might breathe the fixed air. Monday, Sept. gth, the eleventh of her illnefs. She this day mifcarned in the beginning of the feventh month of her pregnancy. Tuefday, CASES, Tuefday. She flill remained delirious, the fub- fultus tendinum continued, her tongue was covered witk a brownifh fur, her urine was flame coloured, her pulfe was quick and fmall, her fkin was dry and parched, and the difcharge of the lochia was trifling. The window and door were now ordered to be kept open day and night. She was raifed up in bed as often as (he could be prevailed upon, drank nothing but what was cold, and took every three hours fait of wormwood and lemon juice during the a 61 of effervefcence. The vomit and clyfter this day repeated. Wednefday. The difcharge of the lochia was very fmall, fhe had no appearance of milk, but feemed fomething better. Thurfday. Much better, very fenfible, but deaf, Friday, Sept. 13th. No material alteration. Saturday. Her fituation much like that of the two preceding days ; the clyfter repeated, the lemn on juice and fait of wormwood continued, and her drink buttermilk and water, &c. as before. The door and window ftill kept open. Sunday, Sept. 15th. She remained in the fame ] flate till evening, when fhe began to be a little de- lirious* ig CASES. lirious. The night was frofty, but the door and window were ftill kept open. Monday, i6th, the i8th day of the fever, and the 8th from her delivery. I this morning found upon her a plentiful eruption, which was evidently not of the miliary kind. The puftules were as large as peas, perfectly diuincl;, but not pellucid, and mod nearly refembled thofe eruptions which are commonly termed fcorbutic. They were chief- ly upon her legs and the out fides of her arms, though (he lay conftantly with her arms out of bed, and expofed them as much as poflible to the cold air of the window, clofe to which the bed was placed; none of them appeared upon her body. This eruption was attended with a violent itching in the (kin. Her tongue was moift, but had a whitifh fur upon it : She took another vomit, and parted with a great quantity of glaffy phlegm. The night was very rainy, and the window continued open. Tuefday, ijth. The puftules were more numer- ous, and had run together. She was quite fenfible, but deaf ; her pulfe regular, her tongue moift but while, her urine of a natural colour, with little or no fediment ; fhe complained of a flight forenefs In her breads, but there was no milk in them. Wednefday CASES, ig t Wednefday the i8th. This fecond eruption was dying away, her pulfe was flow and regular, her tongue moift, the itching in her fkin continued. Thurfday. She continued to recover. Friday, September 2Oth, the 22d from the commencement of the fever, and the i2th from her mifcarriage. She had no complaints, except thofe of weaknefs, and of an itching which the eruption had left behind it. / ' In this cafe it is worthy of obfervation that there were two eruptions, totally differing from each other ; the fir ft what is generally called the red miliary, and by fome a ram, evidently produced by profufe fweating, and in the greateft quantity upon thofe parts of the body which were kept the warmeft ; the other of a much larger kind, attend- ed with violent itchings, came out upon thecoldeft parts of her body, when fhe had been twelve en- tire days without fweating, after a frofty night, in which the window had been kept conftantly open. This eruption, though it had all the appearance of being critical, for the fever feemed to have no other crifis, was not at all checked by the cold air, or wet night, which fucceeded its appearance. Upon CASES. Upon the whole, I think this cafe helps to prove tbat ei-uptions of the miliary kind are promoted by fweating, that they are not critical, that cold air and cold water are afllflant in fupprefling them, and that cold air and cold water will not prevent eruptions of a more critical nature. N. B. Upon inquiring of her, fmce (he recover- ed, (he informs me that fhe does not recollect the leaft circumftance about her mifcarriage. CASE vr. r-pi IHE fubjeS; of the following article is a lady of an extremely tender conftitution. Her appetite is bad, flie fleeps ill, and has during the greateft part of her life been fubjel to frequent returns of the bilious cholic, with fevers and diar- rheas attended with an univerfal yellownefs of the flun, and pains in her right fide. Thefe complaints have prevented her taking that exercife which was neceffary, and for many years have rendered her incapable of riding on horfeback. She was always fo impatient of cold when in perfect health, as to require a fire during the heats of fummer. She had borne feven children ; five of her labours were natural, and two of them preternatural. To * fix CASES. fix of her children fhe had been herfelf a nurfe. During thefe lyings in file never was once in a fweat, nor was fhe troubled with the flighteft fever- ifh fymptom. In the firft week fhe feldom got much deep. This, together with a poor appetite, prevented her gaining ftrength fo faft as many others do, but fhe was generally down itairs at the termination of the month. She was continually hot and feverifh for feveral weeks at the latter end of pregnancy of her eighth child, and during that time was frequently troubled with falfe pains. - On the 23d of Augufl, 1771? fhe received a fright as fhe was riding in her chariot, and ori Sunday the 25th was feized with a mivering fit, and was fo extremely cold that fhe was obliged to order a large fire to be made in her chamber. In this ftate fhe continued the greater part of the day. About five o'clock in the afternoon fhe began to flood, her falfe pains continued, fhe was much alarmed, and as yet there feemed to be no prepara- tion for labour, fhe now took twenty drops of the Theban tin&ure, with as many of the acid elixir of vitriol. In a little while the mouth of the" womb began to dilate, and the child might be per- ceived to be in a natural petition. Her legs and. N feet 194 CASES. feet flill continued cold, but as her labour advanc- ed her flooding abated, and fhe grew gradually warmer. After the cold fit came on fhe never per- ceived the child to move, though before that time it had been remarkably a&ive. About ten o'clock the fame evening fhe was de- livered of a fmall boy. In lefs than a minute af- ter the head was expelled, another pain came on, and the whole child was produced in the manner I have before defcribed, one moulder coming from under the pubis, and the other pafling along the facrum. The infant did not cry, it fcarcely ftirred, but the pulfation in the navel firing was very flrong. Before I cut it I waited to give the child time to recover. In about five or fix minutes the pulfa- tion flopped. I divided the umbilical chord with a pair of fciffars, and the child gradually recover- ed. No effufion of blood followed the divifion, though I did not make a ligature till fome time af- ter the child was feparated from its mother. I thought it however prudent to make one before the child was dreffed, left the warmth of the clothes might occafion it to bleed. As foon as the child was removed the fecundines came away without any affiftance, The CASES. i 95 The firft night my patient got no fleep. Though there was no fire in the room, me was too hot the morning following. She complained of pains in her head, betwixt her moulders, and of a general laflitude, but had no afterpains. The child was laid to her breafts early the next morning. She fat up feveral times in bed. In the evening fhe was removed to her chair, whilft her bed was made, and clean linen laid upon it. Her own linen too was changed. The chimney was never flopped, and the door was opened to let more air into the room. She drank barley water, eat toaft and butter, and a few plumbs and apri- cots. The fecond night fhe had very little fleep. On the third day, Tuefday, fhe continued hot and thirfty. Her pulfe was too quick. The noife of company in the houfe, and of carriages in the ftreet, diflurbed her. She frequently fell into pro- fufe fweats. Her fpirits were low, and fhe was much troubled with flartings and twitchings all over her body. She ate a little chicken and French beans at dinner. Her drink was imperial, aired with a piece of toafted bread ; and a window and a door were opened in an adjoining clofet. The third night fhe was alrnoft fleeplefs ; and on the fourth day, Wednefday, fhe remained hot N * with ,,;. sg CASES, with pains in the head, back, loins, ftomach, in the right fide, and in the left moulder. She had fre- quent ftartings, and broke out into fweats, and her urine was turbid and high coloured. From thefe fymptoms I was apprehenfive of the bilious colic, but was unwilling to diflurb the acrid putrid bile by either vomits or purges, choofing rather if pof- lible to correcl it by fruit and acids, and to ex- tinguifh the fever by cold air and cold liquors. A clyfter was however given her, which procured a ftool. The door into a gallery was opened, and another window there was thrown open. A ftuff quilt which lay upon the bed was exchanged for a flight w;ifhing one. She was taken out of bed and ftaid up an hour. Her ufual liquor was cold im- perial, fhe eat dry bread, with plumbs, pears, and grapes, and drank two cups of coffee and one of tea morning and evening. On the fourth night fhe flept ill. On Tuefday the fifth day fhe had flufhings in her face, and her other fymptoms remained much the fame' as in the preceding days. The doors and windows were kept open. Another clyfter was given with fuccefs. Her diet was the fame as the day before, with the addition of about half a About * CASES, About midnight, being very hot and reftlefs, {he ordered the fervant to open a window of the room in which ihe lay. The remaining part of the night and all the next day, this window, together with thofe in the clofet and gallery, and the doors which communicated with thofe apartments, remained open. The curtains of the bed and windows were undrawn. There was a current of air through the room, and only a flight quilt with one blanket re- mained upon the bed. My patient's drefs was a half fhirt and a thin linen fkirt. She had no bedgown or waiilcoat on, except when {he fat up. On Friday the fixth day {he had a ftool natural- ly, and me feemed cooler and better. Her diet had not 1 been much varied for feveral days. She had coffee twice a day with toaft and butter, puddings and fruit dumplings to dinner, and bread dipped in imperial for fupper. She was ufually three hours out of bed, often fat up in bed, and drank cold im- perial, and eat fruit plentifully whenever it was agreeable to her. On the feventh day, Saturday, {he continued bet- ter. She had a ftool procure*, by clyfter. She fat up four hours, had free air and the ufual diet, and this night hejr fleep was a little more frieudly. N 3 ** 198 CASES. On Sunday the eighth day (he was much cooler, and in all refpefts better. She had a flool by the afliftance of a clyfter. She fat up five hours, and no alteration was made in her diet. This evening all the windows and doors were ihut for the firft time. She had a good night, and on Monday the ninth day all her complaints were vanifhed. She got up before dinner and ate a whole partridge, a very unufual quantity for her when even in the bell ftate of health. During this whole time her lochia were in prop- er quantities. Her milk though not fo much as upon former occafions, was more than fufficient for the child ; on the fourth and fifth days her breafts were hard and knotty, but {he was relieved by having them well rubbed with a foft hand, up- on which a little oil had been poured to prevent their chafing, i Excepting a little cold water or rue tea the child tafted nothing befides its mother's milk. It flept eight, nine, or ten hours every night in a crib bed in another apartment, without any kind of food whatever, had the breaft only four times a day, and never feemed griped or uneafy except upon the fecond day and night,whilft the firft milk was purging off the meconium. It was in every re- fpeft as well as an infant could be, neither fretful CASES. nor uneafy as thofe children are apt to be whofe itomachs are overloaded by largp quantities of im- proper diet. In the courfe of the firft week my patient eat eighteen Orleans plumbs, fifteen green gages, ten apricots, four pears, one apple, four large bunches of grapes, and the greateft part of a large melon. Except the firft day me drank every day two pints of imperial, but never tafted cordials, wine, ale, or any kind of fpiritous liquors. Broths were never given to her, nor did me, the third day only ex- cepted, tafte any animal food. I knew her confli- tution well, and was certain that fruit and acids would agree with it ; I was therefore fo far from refuiing her the free ufe of them, that I encouraged her in it. Inclination prompted her to this kind of diet, and experience had convinced her of its u-< tility ; but I muft own I was greatly furprifed that me could bear fo much cold air, a thing fo very unufual to her, and that too without taking cold. This circumftance I fcarcely could have credited had I not been an eye witnefs to it. The cool air was let in cautioufly, by degrees as (he was found to want and as me perceived herfelf capable of bearing it ; but me was fo fenfible of the relief it afforded, that me frequently called out for it herfelf. It is very evident tfcat had not this meth- od been purfued, a bad fever, the fymptoms of N 4 which $00 CASES. which appeared before her delivery, would have been the confequence ; and I have no doubt but that the fruit and the imperial corrected the bile and prevented a loofenefs. The room fhe lay in was upon the firft chamber floor. It was eighteen feet fquare, and twelve feet high, and had three doors and three windows into it. One of the windows faced the north, the oth- er two the eafl, but thefe lail were fo far fhaded by another part of the houfe, that the fun did not mine upon them after nine o'clock in die morning, and indeed there was fo little fun during the morn- ings of this week that I could not difcover the room to be at any time affe&ed with it. For the feafon of the year, the heat of the air was very moderate. The quickfilver in . Farenheit's ther- mometer generally flood at about fixty degrees, and riever rofe higher than fixty fix. \ .;],- \ During the fecond week fhe continued to recov- er, and by degrees returned tQ her ufual way of living, eating animal food once every day and con- tinuing her fruit and vegetable diet. The third week fhe fat in her drefiing room every day, and her heats had fo entirely left her, that a fire was very acceptable to her. As this cafe, in which the method of treatment I would recommend was followed to its utmoft ex- tremity, CASES. 20* tremity, may appear fo very extraordinary to fome perfons that they may imagine I have been impofed upon in feveral particulars, I think it proper to ob- viate any fuch objection, by declaring, that by conflantly redding in the fame houfe during the whole time, I was an eye witnefs of every cireum^ fiance I have here related. CASE VIL MARY L O R D of Manchefter, a poor woman, aged 31, was delivered on the 25th of May, 1772, in the morning, by a midwife in the neighbourhood. She had an eafy labour, and the fecundines came away without difficulty ; this was her third lying in. She had a fhivering fit that evening, and another the next day, and on the third day fhe was feized with a fevere vomiting and looienefs, together with pains in her head, loins, hips, and lower part of her belly, which was a little fwelled, and fo exceedingly tender that fhe could not bear it to be touched. Thefe fymptoms continued, and fhe gradually grew worfe till I firft faw her, which was on the fourth day in the even- ing. I found her hot and thirfty, with a white tOHgue and a quick pulfe ; her milk was much di- minifhed, and the lochia flopped. The whole family lived in the fame room in which fhe lay, being the only one they had ; it was very warm. having A S E s; having a large fire in it, and fmelt very difagreea- bly. I defired the fire might be lefiened, and more air let into the room, accordingly the window was fet open and remained open all night. She had fcarcely fitten up in bed fince her delivery, but had lain in an horizontal pofition all the time. I advifed her to fit up frequently in bed, and to get out of it once every day, to put on clean linen, and never to fuckle her child or take any food in an horizontal poilure ; to abftainfrom ft rong liquors, broths, and all kinds of animal food, and to drink buttermilk or buttermilk whey ; and I directed her to take half a grain of emetic tartar with five grains of calx of antimony every four hours. On the fifth day the room was much cooler, and did not fmell fo difagreeably. She had complied ftri61> ly with my directions, and was much better in eve* ry refpea. On the fixth day all her complaints were vanifhed. CASE VIII. ON the gd of April, 1772, I was fene for to Mrs. of W H , a few miles from hence. She had been delivered of a fine child, as Jhefat upon the knee of an ajjiflant, by a young Sur- geon about five hours before I faw her, and this was her fecond lying in. The CASES, . The placenta ftill remained behind. She flood- ed much, and had feveral fainting fits, which came on in fuch very quick fucceffion as to threaten im- mediate danger. I was defirous of getting the pla- centa away, as the mofl effectual method of put- ting a flop to the flooding. To effecl; this I pull- ed gently at the navel firing, defiring the other gentleman to make at the fame time a compreffion upon her belly, and directing her to aflift herfelf by forcing and encouraging what little pains me had. Thefe means were ineffectual, as fhe had loft much blood. As flie flill continued bleeding, and was reduced very low, I did not think it pna- dent to wait any longer ; I therefore introduced my hand into the uterus, and eafily brought away the fecundines. The flooding immediately ceafed, and I left her to the care of the gentleman who had delivered her, but who likewife lived at fome di fiance. ;. I heard no more of her till the afternoon of the ninth day, when her friends fent for me to come over with all expedition, as they then thought fhe was dying. They informed me that upon the third day after her delivery fhe had had a cold ftiivering fit, followed by a hot one terminating in a fweat, that fhe had likewife a fecond upon the fixth day, and that fhe laboured under a naufea, Attended with vomiting, thirft, and total lofs of appetite. 204 CASES. appetite. Her pulfe was quick, and fmall, her tongue was very white upon its fides, and had a brown dry flreak of abouf the breadth of half an inch down its middle. She gave fuck to her child, had very little milk, and complained of great pain in her belly, which was fo extremely tender that fhe could not bear me to touch it. Her lochia fuffiou nt in quantity, but very putrid. She not had a ftool fince her delivery, though a : or iiad been given her upon the fif^h day ; nor haa hie ever got out of bed during the firft week. To thefe circumftances I muft add, that fince that time fhe had drank no lefs than fevcn bottles of made wine, each bottle containing about a quart, in gruel, whey, &c. The houfe me was in was an olcl country hall, was fhuated in a low marlhy ground, and was moated about with a large piece of water,. I directed emollient clyfters to be inje&ed every half hour, half an ounce of Glauber's falts to be taken immediately, and the dofe to be repeated a few hours after, fait of wormwood and juice of lemons to be taken in the aft of effervefcence every two hours ; and as I apprehended I had very little time to Me, I ordered her a pill containing three grains of calomel to be taken early in the morning, if flie had not a plentiful evacuation by ftool be- fore that time. In the night Ihe had feveral ftools, and as I found her much better in th~ morning, the calomel CASES. 205 calomel was omitted. I now dire&ed her to take half a grain of emetic tartar twice a day, to con- tinue the fait of wormwood and juice of lemons as before, to repeat the Glauber's falts occafionally, to fit up often in bed, and once a day to get out of it. By thefe means the inteftinal canal was kept fufficiently open, her fever difappeared, and the pains in her belly foon left her. She however con- tinued very weak, and her legs and thighs fwejled much, owing, no doubt, to the great lofs of blood fuftained before the placenta could be got away ; to remedy which I prefcribed the bark and rhu- barb, with eight or ten drops of the elixir of vitri- ol to be taken twice a day ; but her ftomach could not bear that, or fcarce any other medicine except the tincture of columbo, which agreed with her perfectly well : by this medicine, together with a folid diet, and gentle exercife, me gradual recovered flrength. CASE IX. MA RYWRIGLEYof Colly hurft, near Manchefter, aged 28, was delivered by a coun- try midwife, upon the 2Oth of May, 1772, as Jht fat upon the knee of an affiflant. This was the fourth lying in ? Her delivery was natural, and the pla- centa &o6 CASES. cents, came away without difficulty. On the third day (he was feized with a rigour, grew afterwards hot, and then fell into a cold clammy fweat, which was of a long duration ; fhe had violent pains in her head, back, loins, hips, and the lower part of the abdomen, which was fo exceedingly tender that Ihe could not bear to have it touched. She had frequent vomitings, the pain and forenefs in her belly made her breathing quick and fhort, and fhe Bad a cough which added to the pain and forenefs. In her ftools fhe had been tolerably regular. She Iiad been three or four times taken up whilft her bed was made, but could not bear to continue out of it. This was the account her friends gave me when I was fir ft called in, which was upon the ninth day, early in the morning. I found her in a copious fweat, which had continued a day or two, but all her fymptoms were evidently growing worfe. Her face was flufhed, her pulfe was quick, lier tongue had a white dry fur upon it, and the middle of it was red and dry. She was much troubled with thirft. Her urine was high colour- ed. Her lochia, which for fome time were few and very offenfive. had entirely ceafed. She gave fuck to her child, but her milk was almoft gone. She lay with her head and moulders lower than the reft of her body, and fhe informed me that fhe had never fat up in bed fmce her delivery, but had taken all her food in that difagreeable pofture. This CASE S. 207 This I apprehended to be one caufe of her difor- der. She had conftant fire in the room, and the door had never been fet open to give frefh air ad- mittance. I opened the door, advifed her to cool herfelf gradually, to let the fweat abate by degrees, and as foon as it was abated, to fit up in bed. I alfo directed her to fit up whenever me either took nourimment or fuckled her child, and when (he lay down ordered her head and moulders to be raifed by bolflers. I prefcribed for her a fcruple of the calx of an- timony, and two grains of emetic tartar, to be di- vided into four papers, one of which I directed to be taken every three hours. She was ordered to ufe water poflet, by fome nurfes called two milk whey, for her conftant drink, to abftain from ftrong liquor, broths, and animal food, and I di- rected an emollient clyfter to be injected. I faw her again in the evening. I found her much cool- er, but (he ftill complained of pain and forenefs in the lower part of the belly : Her complaints in general continued, but upon the whole fhe thought herfelf fomething better. She had taken the four dofes of antimonial powder, and they had brought up a great deal of bile ; the clyfter too had been given her, but as it had not procured a (tool, I or- dered a fecond to be adminiftered. I now pre- fcribed a fcruple of fait of wormwood to be taken in CASES. in a large fpoonfu! of lemon juice during the afit of effervefcence. This I ordered to be mixed un- der her mouth, that me might breathe the fixed air arifing from it, and this mixture I directed to be repeated every three hours. In an adjoining room I fet a window open. When I vifited her next morning I found her much better. In the night me had two large ftools, exclufive of what had come away with the clyfter. The pain, fwell- ing, and forenefs of her belly were almoft gone, and me faid me was in a manner well. The door of her bed chamber, and the window of an adjoining , room had been kept open all night, and there had been no fire in the chamber. She fat up frequently in bed. and in the evening got out of it, and was able to walk with a little afliflance. On the i ith day fhe was confiderably better ; the lochia returned without any offenfive fmell ; the milk increafed in quantity, and her urine was of a more natural colour. The door of her cham- ber and the window in the next room were kept ot>en night and day, and the fame medicines and regimen were continued. Her fever and the pains in her belly, c. had left her, and fhe feemed quite vrcl], except that her tongue remained white and furred, &nt me was not the lead thirfty. She con- el to recover, and when I faw her upon the fifteenth CASES. fifteenth day her tongue was of a natural colour, and me had no compjaints except ,a little pain and weaknefs in her groins when Ihe walked, which the was not able to do without afliftance. Upon the 1 8th day fhe had a return of her com- ints, which gradually grew worfe, but her friends [id not fend to acquaint me immediately, and when they did I was abroad, therefore did not fee her again till the morning of the twenty fecond. She had lain in bed for the greateft part of feveral days 5 , and was very coflive. She complained of great pain in her loins, hips, and lower part of her belly, particularly about thejimfhyfisof the ospubis, which was fo extremely tender that fhe could not bear to have it touched. She had frequent motions to make water, attended with confiderable pain, and could not make a fpoonful at a time, which was very high coloured : her pulfe beat 120 ftrokes in a minute. Tongue dry and parched ; breathing quick, fhort, and difficult, which fhe faid was occafioned by the pain in her belly. Her lo- chia flopped ; her milk diminifhed. She fweatecf prpfufely, and her face was flufhed. I ordered the ^hUmonial powders to be repeated every four hours, an emollient clyfler to be injected, and directed the nurfe to raife her up frequently in bed, and to keep 'Open the doors and windows. The powders puked her a little, but fhe had no ftool. In the evening O I* aio CASES, I ordered her another clyfter, and the fait of worm- Wood and juice of lemons to be taken every three hours during the aft of effervefcence, and me re- turned to the fame kind of diet and regimen which had been at firft prefcribed. She had a loofe black fetid ftool in the night ; and on the 2gd day in the morning, me made wa- ter rather more eafily, and there was a fmall ap- pearance of the lochia, but in other refpefts flie was much the fame. In the afternoon ftie was ve- ry hot, and fo delirious that they could fcarcely hold her in bed. This I mufl obferve was a very- hot day, and the room me lay in faced the fouth, which certainly contributed to increafe her com- plaints. In the evening me grew cooler and more calm, and in the night made with eafe a tolerable quantity of clay coloured urine, which depofited a copious fediment. Windows and doors kept open. - i* 24th. In the morning me had a fmall quick pulfe, which beat 116 ftrokes in a minute, but in- termitted after every 5th or 6th ftroke, her pains were fomething eafier. This was likewife a very hot day, I therefore advifed her friends to move her into another room, but me was fo ill they thought fhe could not bear it, and it was omitted. In the afternoon her delirium returned, but not- with fo much violence. The effervefcing mixture ; was t A S E S. 211 was given every two hours. In- the evening ftie had a large black fetid ftool. ' 25th. In the morning her pulfe was flower and ftronger, and more regular, beating 96 ftrokes in a minute, but fhe complained of very great pain iri the hypogaftric region. I directed her to take half an ounce of Glauber's fait immediately, and the fame quantity in an hour or too after, and to have the clyfler repeated, but they did not procure a ftool. Early in the afternoon, when the room was the hotted, her delirium returned, but went ofF again as the heat of the day abated, but her pain continued with fuch violence as to make her quite impatient. I ordered another clyfler to be injecl> ed, and a pill to be given immediately, containing three grains of calomel and half a grain of emetic tartar. Thefe procured her feveral very loofe of- fenfive ftools in the night, and with them, great eafe* 26th. I found her much better, the pain, fore- nefs, and fever, having almoft left her ; pulfe calm and regular, beating only 88 ftrokes in a minutCi Effervefcing mixture continued. This day was- rather cooler than the three preceding ones ; fhe had no delirium ; but her pulfe was quicker in the afternoon; beating i do in a minute. Had not flept much in the night, but was cool in the morning ; pulfe 8, did not com- O 2 plain 212 CASE S. plain of pain except when {he moved, but the fore- nefs at the lower part of the belly ftill continued. I preicribed her the bark with a little rhubarb to keep her gently open. She was removed into an- other room which faced the north, and in the af- ternoon her pulfe was reduced to 82 ftrokes in a minute. The bark and rhubarb procured her feveral ftools in the evening, which were of a more natu- ral colour, and not fo offenfive. She had a good night. 2 8th. In the afternoon her heats returned a little, and her chief complaint was pain in making water. Bark and rhubarb, and the effervefcing mixture were ftill continued, and I defired her to take a teafpoonful of the fwcet fpirit of nitre, and to drink plentifully of milk and fmall liquors. ; '. ', t r> 6th. After a very good night, had no com- plaints remaining. CASE X, MARY BURGESS of Carrington in. Cheftiire, aged 38, was delivered September 2Oth, 1770, of her firtl child, by the affiftance of the crotchet^ C A S E S. crotchet, having a very laborious birth. No at- tempts were made to extraft the fecundines that night. The next day the gentleman who delivered her deiired I would vifit her along with him. I found her very hot, and her rkilfe quick and ftrong; ihe had frequent returns of pains, which feemed to be efforts to expel the fecundines, and during every pain a difcharge of blood. I took hold of the navel firing, pulled gently at it, defiring her afc the fame time to encourage her pains, and in about a quarter of an hour the fecundines CaTne away. Though only about twenty three hours had elapfed betwixt the delivery of the child and the fecundines, yet they were in a very putrid flate, as was evident both by the fmell and their being remarkably difcol- oured. I took my leave of her, defiring her to keep cool, have frefh air frequently admitted into the room, and to fit up often in bed ; and I had the fatisfa&ion afterwards to hear that me recovered without any farther difagrceable fymptams. . e A-S E -XL i Extracl of a Letter from Mr. to Mr. White, ri* ~ :vb - ' \O 01; SIR, MARY DAVENPORT of Bariow- Moor, in the County of Lancafter, a ftrong health* O 3 i ui CASES. ful country woman, about 36 years of age, was de<* v livered January 27, 1771, of her fixth child, asjhe Jat upon a woman's knee, and had an eafy natural la* bour. I ufed all the gentle methods I was acquainted with to bring the placenta away, but in vain. Af- ter waiting fome time without effect, her friends growing uneafy, I defired you might be fent for, which was done, but you was otherwife engaged, and could not attend. The next day I made fome further attempts to extract the placenta by gently pulling at the funis, but with no better fuccefs. On the third day I laid hold of the navel firing, with an intention of making another attempt to bring away the fecundines, when the navel firing feparated from the placenta without any force be- ing ufed, and was in a very putrid ftate. This day her milk began to come, but difappeared a- gain in the evening. The difcharge of the lochia was in proper quantities, but exceedingly ofFenfive. i I do not recollect that fhe had any cold fit, but (he had frequent hot burping fits fucceeded by fweats, ' On the fifth day (he had a clyfter given her, which procured a ftool, and foon after the fecun- came away in a very putrid ftate, On CASES. 215 . On the 6th day fhe complained of great oppref- iion about the precordia, had a quick pulfe, a white dry tongue, and her breath was the moft remark- ably offenfive I ever obferved. I afked her friends whether it had been ufually fo, but they allured me, that before her delivery, fhe had as fweet a breath as any woman in England. On the i2tha large quantity of white miliary puflules appeared, particularly about the bread. On the 14th a hiccoughing came on ; the miliary eruption continued out till the day of her death* which happened on the 2 ad from her delivery. CASE XII. JVlR. , a gentleman of abilities in his profeffion, has informed me, that in the month of March, 1772, he delivered Mrs. , as /he fat upon the knee of an a/iftant. The pofition of the infant was natural, the placenta remained be- hind, and the mouth of the womb contracting it- felf, rendered it unfafe, at leaftat that time, to ex- tracl; it. Another very able accoucheur was confulted, and they both agreeing that it was prudent to leave nature to herfelf, no attempts were made, On the fourth day the fecundines were excluded without affiftance, and foon after fhe began to flood P 4 exceflivetyv CASES, exceffively. The flooding could not be fuppreffed, and fhe died the fame day. CASE XIIL i JVlR. , an ingenious furgeon, told me he delivered a ftrong, healthy, country woman, of a fine child, asjhefat upon the knee of an ajjijlanti He made no attempt to bring away the placenta, having been inftru&ed by a teacher of midwifery, whofe le&ures he had attended, that leaving it behind was never productive of difagree- able confequences. After waiting a confiderable time in vain for its exclufion, no bad fymptoms appearing, he left her as he thought, in perfect fafety ; but in the middle of the night fhe began to flood Extremely, and lie was again fent for, Jle made what hafle he could, but living feveral miles from his patient, he came too late. She was dead, and the placenta unexcluded. --:- T C A S . E XIV. 1 H E fame gentleman has alfo in- formed me, that in the beginning of March, 1772, he was fent for to a woman who had five days be- fore been delivered of a child fry a country mid- wife, CASES. wife, asjhefat upon the knee of an ajjijlant : fhe had flooded extremely, he found her dying, and the fecundines unexcluded. CASE XV. rj. 1 HAVE been told by a Surgeon in Chefhire, that having delivered a healthful woman, who had a very eafy labour, he made no attempts to bring away the placenta, but left her, in full ex- pectation of its being expelled without danger. On the third day he was again fent for upon account of a violent flooding. He lived only three or four miles from the patient,, went as foon as poflible, but found her dead without the exclufion of the placenta. - CONCLUSION. 2l8 CONCLUSION. .BEFORE I draw any inferences from the cafes I have related concerning the management of the placenta, in order to ft ate the matter fairly, it will be neceffary to inform my readers that I have likewife known many misfortunes arife from the manual extraction, when it has been improper- ly or untimely performed; fuch as inverfions of the uterus, and death in confequence of it, lacera- tions of the neck of the womb, and inflammations of that organ, which have frequently ended in fter- ility or death. The advocates for leaving the pla- centa entirely to nature, certainly a6l upon the moft laudable plan, and no pe^fon has a higher opinion of the powers of nature than myfelf ; but they have ended where they mould have begun. They fet out with art, and end ,with nature. It would have been better if they had reverfed their practice, We CONCLUSION. We do nature great injuftice, if by taking the reins into our own hands, we fir ft interrupt her,, put her out of her courfe, and then leave her to berfelf. ~~- ' Woman in a Mate of nature was never deliver- ed in a hot room, nor with many clothes upon her : By heat, and a multitude of clothes, the mufcles lofe their contra6lile power. Woman in a flate of nature would not think of being delivered in an upright pofture, or upon the knee of an affiftant. Woman in a ftate of nature would not have the child dragged from her ; it would be gradually ex- pelled by the contractile power of the uterus ; the fame progreflive contractive power would expel the fecundines ; and, Woman in a ftate of nature would not after de- livery lie in an horizontal pofture, in a warm bed, drinking warm liquids for a week, or even a day. We fhould be confiftent in our pra&ice ; we fliould imitate nature through her whole progrefs, and not in the latter part only ; but we muft alfo make proper allowances for thefc times and this country, CONCLUSION country, where women are fo far removed from a liate of nature. We may however, in my opinion, draw the fol- lowing conclulions : - ift. Putrid fevers, floodings, and death, have been occafioned by retentions of the fecundines. sdly. Floodings occafioned by a retention of the placenta generally ceafe by a timely removal of it. gdly. The manual extra&ion of the placenta mould never be attempted whilft there are any fpafmodic contractions either in the neck or acrofs the middle of the womb. 4thly. Opiates will generally remove thefe con- tractions. rr"'^ 5thly. Though many cafes have happened when the placenta lias remained fome days in the uterus after the delivery of the child, without manifeft in- jury, yet it is not generally fafe for a woman to be left by the accoucheur before it is removed. Laflly. When every, part of the child is expell- ed folely py the contraftile power of the uterus, in fuch CONCLUSION. 221 fuch a manner that the flioulders are permitted to make their proper turns, the woman having been kept in an horizontal pofition, and the cool regi- men having been ftriclly obferved, there will fel- dom or never be occafion for the manual extraction of the placenta. POSTSCRIPT. 222 I i POSTSCRIPT. OINCE the foregoing papers were compleated, I have with great pleafure perufed a Treatife on the Puerperal Fever by the learned Dr. Hulme, which contains many excellent prac- tical directions for the management of lying in women. He appears thoroughly convinced that Miliary fevers are the offspring of heated air and warm regimen, which opinion is ftrongly fupported by the following fa6l : He fays,* " I have at- " tended more than fourteen hundred women in " the London lying in hofpital, yet I do not re- " member ever meeting with an inftance of the <( Miliary fever in that houfe. This I attribute " partly to the cool regimen that is ftriclly enjoin- " ed to be obferved there, but above all to the ad- " miflion of cool air, which is ordered to be let in- " to * Page 9& POSTSCRIPT. 223 " to the wards every day, at an opening in the wm- " dows. And probably it is for the fame reafon, " alfo, that I never have obferved in that excellent " afylum for pregnancy any petechice, vibices, exam* " themata, veficulce, punfticultz, or any other febrile " eruptions, joined with the fever which we are {C now treating." But although this method was effectual in preventing Miliary and other eruptive fevers, yet he did not find it fufficient for the pre- vention of the Puerperal fever. In fa ft, a cool regimen, and opening the windows in the day time, cannot alone prevent this fever in a ward which contains feveral lying in women, where the efflu- via from breathing and perfpiration, and from the lochial difcharge, becoming putrid by ftagnation whilft the patient is in an horizontal pofture, muft, by being pent up during a whole night without ventilation render the air very foul and ofFenfive. The juices that are extracted from meat by boiling are the moft alkalefcent parts of it, and of courfe the moil improper in putrid difeafes. Of all ani- mal diet, the leail alkalefcent are white meats of young, tame, lean animals, which have fed upon vegetables, are frefh killed by bleeding to death, and have been well boiled. The great quantities of broth allowed in the hofpital diet, and that too often made with water replete with particles of pu- trid animal or vegetable fubftances, may contrib- ute 224 POSTSCRIPT. ute toincreafe a putrefcent difpqfition, and give evry flight feverifh complaint a difpofition to- wards putridity. But as 1 have already given at large my ideas of the caufe of this difeafe, I mail now confine my- felf to a few remarks upon Dr. Hulme's opinion concerning this matter. And I mufl firft premife, that the Doctor, fpeakirjg of the caufe of this dif- order arifmg from preflTure, fays, ." As I am no " practitioner jri midwifery, I have not ha(J an op- < portunity of attending fo minutely to the differ- to tne 3*ft of October 1775, there have been delivered POSTSCRIPT. 237 delivered in the hofpital 10726 women, of whom 152 have died, which is nearly one in 70. In this hofpital, fa the year 1768, 633 women werq delivered, and feventeen died, which is nearly one in 37. In the year 1770, 6i6 were delivered, and only five died, which is one in 135. Therefore, though it appears that the year 1770 was very fa- tal to the women in fome of the lying in hofpitals in London, yet it was remarkably otherwife in the lying in hofpital in Dublin, and the year 1768 was the moft fatal in that hofpital. It is worthy of obfervation of two hofpitals, both fituated at nearly equal diflances from the centre of the fame city, viz. London, both inftituted a- bout the fame period of time, and both under the direction of men of confiderable eminence in the profeflion, and nearly the fame number of women having been delivered in both hoiifes ; that in one of them, they mould lofe in the proportion of one in 36, and in the other only one in 131 2-3. In order to inform both myfelf and the public of every matter relative to fo important a point, I have made farther inquiry into the caufe of the great fuccefs of this particular hofpital, and I am favoured with the following account by a gentle- man who has eminently diilinguimed himfelf for bis knowledge in this branch of practice. He in- forms 238 POSTSCRIPT. forms me, that " This Jhofpital is fituated neai% "and open to the fields; no particular care is " taken of their diet or regimen in any refpeft, " but there are fcarcely ever more than f6ur in the 11 fame room, commonly two only ; and it is to " the open air and the confinement of fo few in " one room that we impute the fuccefs. " Whereas in another hofpital there are eighteen " or twenty in a room, which ought only to re- " ceive eight." Perhaps there are fome other particulars relative to this hofpital which may contribute very materi- ally to its fuccefs. It was inftituted for the pur- pofe of inftru&ing young gentlemen, and not only unmarried women, but even thofe of the mod a- bandoned charalers are admitted. It is not to be fuppofed that in an hofpital of this kind unnecef- fary expenfes of any fort are fuffered to be incur- red either in nurfing or diet, and the patients are therefore obliged to do a good deal for themfelves ; add to this, that thefe fort of women^are of great fpirits, impatient of confinement, and will not fub- znit to it longer than they can poffibly avoid. I have endeavoured to form a calculation of the proportion of women who have died in childbed to thofe who have been delivered, in different towns,. POSTSCRIPT, 239 towns, viz. London, Northampton, Manchefler r Holy Crofs in Salop, Chefter, Warrington, Liver- pool, Ackworth near Ferrybridge, Yorklhire, and feveral places in Germany ; it is not in my power to do this with precifion, as we cannot exactly deter- mine the number of women who have been delivered every year in each town : However, from compar- ing the number of chriftenings with the number of women who have died in childbed, as taken from the bills of Mortality of thefe different towns for feveral years laft paft, we may form fome proba* ble conjecture. Yet if we make proper allowance^ for the ftillborn and chrifoms, we mall find that the number of women delivered each year will greatly exceed the chriftenings, therefore the fuc- cefs of general practice will be much greater than is here reprefented. In Manchefter, regifters of particular difeafes have been kept no longer than eighteen years, and in the collegiate church only. Thefe I have di- vided into three periods, in order to mew that though the town has in ; creafed in fize and number of inhabitants, yet the danger attending childbed women has been diminifhed, which muft chiefly be owing to the improvements in the management of them. It is to be lamented that thefe regiftevs have not been longer kept, a the fatal period I have alluded to in the former part of this treatife when POSTSCRIPT. when the fatality was occasioned by mifmanage- ment, was prior to that time, during which period from my own recollection, I am very certain the misfortunes attending childbed women would greatly have exceeded the following calculations. In London, from the beginning of the year 1737 to the end of the year 1753, being 17 years, there were 254252 chriftenings, and 3552 women died in childbed, which is the proportion of one in 71^-. In the ilaft- eighteen years there were 281304 chrift- enirigs; and 3905 women died in childbed, which is in the proportion of one in 72. The moft fatal years were 1761, when 289 women died in childbed, and there were 16000 chriftenings, which is in the pro- portion of one in 55 ; and the year 1762, when 272 died in childbed, and there were 15321 chrift- enings which is in the proportion of one in 56. The year 1771 was the moft favourable, when 172 women only died in childbed, and there were 17072 chriftenings, which is in the proportion of one in 99. In Northampton, ifi the parifh of Allfaints, from the beginning of the year 1737 to the end of the year 1753, there were 1535 chriftenings, dif. fenters included, and 20 women died in childbed, which is in the proportion of one in 76^. In the laft eighteen years there were 1602 chriftenings, and P O S T S C R I P Tt and 20 women died in childbed, which i* in the proportion of one in 80. In the parifh of Holycrofs, in Salop*, from Michaelmas 1750 to Michaelmas 1760, there were 331 chriflenings, and 4 women died in childbed, which is about the proportion of one in 82. From that time to Michaelmas 17701*, there were 382 chriflenings, and 4 women died in childbed, which is about the proportion of one in 95. In Manchefler, at the collegiate church, from the beginning of the year 1754 to the end of the year 1759, there were 41 17 chriflenings, and 44 women died in childbed, which is about the pro- portion of one in 93. From that time to the end of the year 1765, there were 4432 chriflenings, and 40 women died in childbed, which is about the proportion of one in nof. In the lafl fix years there were 5251 chriflenings, and 47 women died in childbed, which is nearefl one in 111^. In the year 1770 there were 897 chriflenings, and eight women died in childbed, which is in the propor- tion of one in 112. In the year 1771 there were 1001 chriflenings, and 6 women only died in child- bed, which is one in 167 ; this and the year 1759 were the mofl favourable to lying in women, and the * See Phil, Tranf.vo.l. LII. p. i. Art. 25, -Ubid.vol. LXf.p, i,Art,6, Q POSTSCRIP T. the year 1757 was the moft unfavourable, for there were only 593 chriftenings, and 9 women died in childbed, which is in the proportion of one in 66. Thefe calculations are not however entirely to be depended on, as I find that more families have their children chriftened at the collegiate church than what bury there, but in the years 1772, 1773, and 1774, very accurate accounts were taken at all the churches and chapels in Mancheiter and Sal- ford, by which it appears that there were 4035 chriftenings, and 44 women died in childbed, which is nearly in the proportion of one in 91-J. ' At Chefter, in the years 1772, 1773, and 1774, there were 1238 chriftenings, and 13 women died in childbed, which is in the proportion of one in 95. At Warrington, in the years 1773, 1774, and 1775, there.were 1124 chriftenings, and 10 wom- en died in childbed, which is nearly one in 112. At Liverpool, in the year 1772, there were 1108 chriftenings, and 1 1 women died in childbed, which is nearly in the proportion of one in 100. At Ackworth, a fmall village near Ferrybridge iti Yorkfhire, from the 8th of December 1744 to the gift of December 1773, being 29 years and a few days, ' ' POSTSCRIPT. 243 days, there were 559 chrilknings, and 6 women died in childbed, which is nearly in the proportioa of one in 93. In Leipfic,* from the beginning of the year 1720 to the end of the year 1725, there were 5237 chriflenings, and 107 women died in childbed. In Lobau, in 1720, 160 were born, and 4 died in child- bed. In St. Annabergh, 105 were born, and one died in childbed. At Schnubergh, 89 were born, and one died in childbed. At Rawits, 134 were born, and 15 died in childbed. At Ratifbon, in 1721, 250 were chriflened, and 2 died in childbed. At Coburg, in 1725, 206 were chriflened, and 2 died in childbed. Total 6181 chriftenings, and 132 women died in childbed, which is about the proportion of one in If we confider that the poor will be found to conftitute the bulk of the people in almoft every town ; that many of the poor women when in la- bour have very ignorant widwives, forne of them much worfe than none at all ; and that very few of them can be attended by regular, or even by a- ny mirfes, but are obliged to take care of them- felves, deflitute of proper affiftance, and of even the neceflaries of life, and perhaps affli&ed with dan- gerous diforders ; if under all thefe difadvantages it O 2 mould * Martin's Abridgment of the Phil. Tranf, vol? 7. fart ^ 244 POSTSCRIP T, fhould be found that the fuccefs attending them jfhould be greater than that of fome private pra&ice among the affluent, or even the pra&ice in fome lying in hofpkals, where all proper affiftance is fuppofed to be at hand, we have great reafon to apprehend mifmanagement in fome department or other. It may perhaps be thought neceffary to make fome apology for thefe calculations and compan- ions, efpecially thofe relating to hofpitals, which are given with no other view than to the improve- ment of this branch of medical knowledge. I en- tertain the highefl opinion of hofpitals and infirma- ries, efpecially thofe which are maintained, by vol- untary fubfcriptions. They are the nobleft of all charities, the lead liable to abufe, and if it happen that fome of them have not been fo fuccefsful as others, the evil needs only to be pointed out, and I have no doubt but it will be remedied. The buffy or lizy appearance of the blood in the puerperal fever is brought to fhow that it is an inflammatory diforder ; but fometimes the blood drawn from fuch patients does not coagulate ort being expofed to the air, as in the cafe which Mr. Hewfon * mentions of a patient in the Britifh ly ing in hofpital. The blood was drawn three days before * Experimental Inquiry, p lit.. , POSTSCRIPT. 245 before her death, and Mr. Hewfon has been fo kind as to inform me that this patient was judged to have a true puerperal fever, as was evident both from her fymptoms and from diffe&ion : and pof- fibly the blood might oftener have the fame ap- pearance if patients were bled late in this diforder. Mofl pregnant women have iizy blood where there are no fyrnptoms of inflammation. Sir John Pringle, Dr. Huxham, and others have obferved that in putrid fevers the appearance of the blood is very various : fometimes, efpecially in the beginning of the difeafe, mowing an inflam* matory cruft, and very foon changing to a famous and diffolved ftate, fo that no certain indications can be drawn from it. With refpecl: to bleeding in the puerperal fever, I cannot upon the ftri&eft inquiry find that thofe who have bled the moft copioufly have had the beft fuccefs, either in private or in hofpital prac- tice. Dr. Hulme fays, " Bleeding mould only be " looked upon as a fecondary help, though it '-' fhould always be firfl in point of time." Thus far he is certainly right, if it be advifeable at all; but I muft own I have great doubts even about that in all cafes indifcrimmately. Emetics, cathartics, and clyfters are certainly proper to cleanfe the primx via?, and likewife fuch medicines and diet as Q 3 246 POSTSCRIPT, will correct the putrid colluvies ; but an upright pofture and free ventilation are at all times ufeful, and abfolutely neceffary, both in the prevention and cure. My patients generally fit up in bed in a few hours after delivery, fome of them get out of bed the fame day, moft on the fecond, and none exceed the third ; and left any inconvenience fhould be fuppofed to arife from this early upright pofture, I think it neceffary to declare that none whom I have delivered, are troubled with any prolapfus vag- ina;, or any other complaint which I have the leaft reafon to fufpeft could pofiibly arife from fuch treatment. Several difficulties which arife concerning the puerperal fever may, I imagine, be more confiftent- ly and fatisfa&orily anfwered from the ideas I have attempted to give of it than from any others. <; Why is this fever more common and fatal in fome fea- fons than in others, under the fame management of lying in women ? This muft proceed from the different difpofition of the air to favour putrid dif- orders which from various obfervations we know frequently takes place. Why in the very fame ward of an hofpital, and under apparently fimilar circumftances, fhould fome be fatally attacked with fever, and others entirely efcape ? This is no more POSTSCRIPT. 247 more than what we fee every day to be the cafe even in diforders which are the mofl infectious, which fhows us that all perfons are not equally lia- ble to the fame difeafe, nor the fame perfon at dif- ferent times and feafons. <; Why does not the foul air affect patients in the lying in hofpitals before delivery as well as after ? This feems nearly to re- femble what happens in ill ventilated hofpitals where patients with large abfceffes, white fwellings of the joints, and the like, frequently efcape fevers till the abfceffes are opened or the limbs amputated, and are then immediately feized with putrid ones which foon deftroy them ; both probably are ow- ing to the fame immediate caufe, viz. the admiffion of air to the difcharges, which are either already putrid, or will foon become fo on the accefs of the air, in which cafe the putrid matter will be readily abforbed by the lymphatics, now open to receive it. I am informed, that in an hofpital in London much crowded with patients, the furgeons obferved that all thofe who had large lumbar abfceffes, as foon as a confiderable opening was made into them, were immediately feifed with putrid fevers, and died in a few days, though they were in tolerable health before the opening was made ; this put them up* on an experiment of letting off the matter gradu- ally by a fmall trocar, and fome days afterwards introducing a feton : The event was however the fame in the end, only with this difference, that 9 4 thefe POSTSCRIPT. thefc laft named patients were not attacked fo fud- denly, and lived fomething longer ; but as foon as the foul air had free admittance, the fame putrid fever came on with the fame fatal effects. Differ- ent degrees of putridity will affect perfons in differ- ent ftates. Lying in women are injured by a fmall quantity of foul air fooner perhaps than any other patients ; a fecond degree will affect thofe who have wounds or ulcers internally or externally : A further degree will give a putrid fever to perfons in perfect health, as frequently happens in jails, hof- pitals, and crowded barracks ; and there is a high- er degree that will prove fatal in a few hours to the ftrongeft conftitutions, as in the cafe of our unfor- tunate countrymen at Calcutta. From hence we may infer why the puerperal fever is always attend- ed with pain and tendernefs in the hypogaftric or iliac regions, and frequently upon the fymphylis of the pubis. Becaufe thefe parts lie neareft to the uterus and inteftines, and are therefore moft likely & * *- to abforb the putrid matter. ^ Why is the lower part of the omentum generally mortified ? Becaufe it lies in contact both with the uterus and in- teftines, and from its adipofe nature foon acquires a gangrenous date. Upon the whole, I am difpofcd to conclude, that though inflammation and mortification in fome of the yifcera have often been difcovered, upondif. fection, POSTSCRIPT. fefiion, in thofe who have died of this fever, yet thefe appearances fhould rather be confidered as the effe6t, than the caufe. That the immediate caufe is the abforption of aerid matter from the intef- tines and uterus ; and frequently a depofition of it upon the omentum, peritoneum, or fome of the vifcera ; and the predifpofing caufes are accumu- lations of feces in the inteflines ; a flagnation of the lochia occafionedby a horizontal pofition, and want of free ventilation at a time when the woman ftands moil in need of it : Under thefe circumftanc- es it may happen either to the rich or the poor. As much, therefore, may depend upon the nurfes, both in public and in private practice, it is earneflly to be wiflied, that accoucheurs would be very explicit in their directions, and that patients would not pay too blind a deference to the nurfes when they aft contrary to the advice of thofe whofe knowledge is certainly fuperior, and whofe province it is to di- reft. I had finifhed this poftfcript before two papers containing fome important information came to hand, the fubftance of which I am therefore obliged to infer t here. The firft was a MS. copy of Dr. Hunter's ex- cellent ledures on the gravid uterus, which I fliould very gladly have referred to in the body of my 250 POSTSCRIPT. my treatife to fupport, by fo refpeftable an author-* ty, my ideas of the power of nature in accomplifh- ing the work of delivery in moft cafes without the help of art, and the neceffity of clofely attending to her operations in laying down rules for the fafeft and eafieft pra&ice. The Do&or, however, gives his pupils a dreadful account of the puerpe- ral fever. He informs them that he has unfortu- nately feen a great deal of it in the hofpital, par- ticularly in one year, when it was fo fatal that all the gentlemen attending, and all the patrons of the charity, held a confultation to debate whether the houfe mould not be (hut up. That in two months thirty two patients were feized with the fever, of whom only one recovered. That various methods of treatment were put in practice ; fome from the beginning of the difeafe were bled, fome were treated with cooling medicines, others with warm medicines and cordials, but every thing proved equally unfuccefsful. In private practice the fa- tality was very great, and at lead three in four who were attacked with the fever, died. The other piece of information I received was contained in a letter with which I was favoured by Prof e {for Young of Edinburgh. It relates to the lying in ward at the infirmary in that city, and when compared with the account before given of the fuccefs attending it, will ferve to confirm the dire&ions POSTSCRIPT. dire&ions I offered concerning the conflruftion and mangement of thefe hofpitals. The lying in ward at Edinburgh infirmary is a very large room which holds ten beds. There is but one fire place, which is at one end of the room ; and the door, which is almoft always open, and is on the head of the ftaircafe, where there is a conftant ventilation, is placed at the oppofite end. As the ward is fubjecl: to fmoke, a window near the door is frequently open. There are ten win- dows, and the height of the room is about fourteen feet. The women have all lingle beds at fome diftance from each other. They generally get up on the fecond or third day, and are difmifTed about a fortnight after delivery, fometimes fooner where they have families which require their care. Other circumftances attending this ward may deferve notice. No patients are received from the middle of July to the i2th of November, by which means it is fufficiently purified every year. None are admitted but fuch as will fubmit to be deliver- ed by the fludents ; therefore the fame reafons may concur here which are mentioned in page 238, as probably contributing to the fuccefs of a particu- lar hofpital in London. APPENDIX. APPENDIX TO THE SECOND EDITION, *" | ~* 1 HE moft material improvements which the preceding Volume has, I flatter myfelf, been a means of introducing into the management of pregnant and lying in women, are the follow- ing : ift. The ufe of a cold or temperate bath dur- ing the flate, of pregnancy, and that of giving fuck, sdly. Permitting the fhoulders of the child to be expelled by the labour pains only, inftead of hur- rying them away forcibly in one direction without fufFering them to accommodate themfelves to the dimenfions of the pelvis by making their proper turns. sdly. Allowing the circulation between the child and placenta to ceafe fpontaneoufly, in- ftead of immediately intercepting it, as foon as the child APPENDIX, 2 53 child is delivered, by tying the navel firing. 4thly. Placing the woman in an upright pofition as early after delivery, and as frequently, as poffible. Thefe are all points which deferve an attentive confider- ation ; and as an additional experience of four years has enabled me to fpeak of them with ftill greater confidence, and to enforce them by later obfervations, I mall include what I have farther to communicate on thefe fubje&s, together with fome additional remarks upon the puerperal fever, in an appendix. I. In the body of this work I have flrongly rec- ommended the ufe of the cold, or rather temper- ate bath, in preventing mifcarriages, and many other diforders incident to the pregnant ftate. I can now confirm the efficacy of this preventive remedy from ample experience, in a great number of different conflitutions. So efficacious, indeed, it has proved, that I have not known a fingle in- (lance of its failure, except where the patient has- received fome violent injury. This was the cafe with a lady who mifcarried in confequence of a fall down flairs ; but returning afterwards to the ufe of the bath, me conceived again ; and continu- ing the bathing the whole period of geftation, be- came the happy mother of a fine child, though fhe had before met with frequent difappointments. i * 5 4 APPENDIX. I muft here likewife confirm what I before ob~ ferved concerning the excellent effects of the fame remedy in increafing the fecretion of milk, and preferving the health during the time of fuckling ; and particularly in preventing the colds to which nurfes are fo liable. Several ladies of my ac- quaintance are fo fenfible of thefe benefits, that they con (lantly bathe three or four times a week while pregnant and giving fuck, intermitting it on- ly during the month of their lying in, and fome icarcely fo long. It is a jufl and important obfervation which Dr. Hunter makes in his le&ures, that " although women ufually mifcarry at eleven or twelve weeks, the fetus has generally been blighted, or removed out of the circulation at feven or eight weeks." This fafc fuggefts an effential remark concerning bathing, that if it be not begun before the term at which the uterine fruit is generally blighted, no good can be expected from it in preventing mif- carnage. II. The common practice of pulling at the child's head the inftant it is born, and thereby pre- venting the moulders from making their proper ^urns, is produftiveof more bad confequences both to the mother and child than might at firfl be ap- prehended. The child is a fufferer, as well by overftraining APPENDIX. 255 overftraining the mufcles of the neck in the aftion of forcibly dragging it forwards, as by the pref- fure of the fhoulders againft each fide of the cheft, whilft they pafs through the bones of the pelvis in a wrong direction. It is obvious that by thefe means its fhape will be greatly altered, perhaps fo as never perfectly to recover itfelf ; which may lay the foundation of various difeafes. The effe&s on the mother are probably more pernicious in ftretching and relaxing the ligaments of the womb, the internal coat of the vagina, and the other parts fubfervient to generation : Whereby prolapfufes of the vagina and anus, and a train of other difagreeable complaints may be occafioned. But there are, I am perfuaded, more immediate bad confequences accruing to the mother. By foreftalling nature in the expulfion of the child, the pains are fo weakened as to be rendered infuf- ficient to expel the placenta. Before I became fen- fible of the abfurdity of this mode of practice, I was frequently obliged to extra 61 the placenta by manual operation ; but for many years pad this has never happened to me in any cafe where I my- felf had delivered the child. Gently pulling at the funis has always proved fufficient for the purpofe ; and from analogical reafoning I (hall conclude that even this flight afliftance would be unneceffary, were not the generality of women in our age and country in a ftate very unfavourable to the full ex- ertion 256 APPENDIX. ertion of their natural powers. By the too hafty delivery of the child likewife, afterpains are occa- fioned, as by this means the mouths of the finufes or uterine veins are permitted to clofe too fuddenly. III. In the year 1775, a gentleman in London, of deferved eminence in his profeflion, printed a ihort paper which he intended to put into the hands of every practitioner of midwifery with whom he was acquainted. Its purport was to rec- ommend a method, which he fuppofed to be new, of managing the navel firing at the time of deliv- ery. He had communicated his obfervations on this head to his pupils the winter before ; and had Ihewn the paper in manufcript to feveral medical gentlemen, who all approved of it, as inculcating a new and ufeful mode of praclice. A few days after the paper was printed, he was much furprifed when fhewn by a ftudent that I had recommended in fuch explicit terms, and from,umilar motives, the fame practice. He immediately wrote me a very friendly letter, with a relation of the matter, and inclofed one of the papers. As many of my readers may not have feen this little tra&, and the point propofed is very ingenioufly maintained by the author, I (hall without apology reprint it entire. . .AN A-P T PE N-D-I-X. AN OBSERVATION ON THE MANAGEMENT OJT CHILDREN AT THE TIME OF BIRTH. ' : T ' : : 'J :c IT bath been a matter : of the molt ten- ous confideration to thofe who have had the care of very young children, to fee fo great a number born dead, or die after an imperfect exiftence of a few hours or days. Witlx,,a view, of preventing thefe accidents, which, though fometimes unavoid- able, have more frequently fcerned to be owing to mif management, I prefurue to recommend a method, which, as far as my experience enables me to judge, is much preferable to that which- is ufually followed/' " To explain my opinion, I will call the life of a child in utero fetal life, and the life which is con- fequent to refpiration, animal life. I 9. I Prafilicai Obfervations on the Childbed Fever, fecond edit. p. 59. APPENDIX. 267 " body, which were a long time in coming to fup- " puration, and, when broke, difcharged a fanious ' " ichor. Again, " Thofe who were feized with this fever " Were not fubjeft to abfceffes of the breafts ; and " of thofe who happened to have fuch abfcefles, " I have never known one die ; neither are they " fubjecl; to a diarrhea, or much fymptomatic fe- " ver, although the pain attending a fuppuration " of the bread is often very acute." If to thofe confiderations we add, that as the pu- erperal fever is more fatal in large cities and crowd- ed hofpitals than in places where the air is more open and pure, fo is the fever occafioned by -ab- forption of matter that as the former is more fa- tal in fome peculiar conftitutions of the air than in others, fo is the latter that as the puerperal fe- ver does not appear till after delivery,* fo neither does * Till fuch a change is produced, women are not " fuh|eft to this fever ; <{ for I have obferved, that thofe with child, who affifted the nurfes in at* " tending the fick, were perfectly free from it, evea when it wasmoft rife; " but being delivered, feveral of them fickened foon after, and were affecled t; with the fame fymptoms as the reft," Leake, p. 88. Some are of opinion that there are not wanting inftances of the puerperal fever being formed before delivery : But, ,. May not thefc fuggeftions arife \ from fometimes observing cold fhiverings before and during the time of la- bour ? And if a puerperal fever come on foon after delivery, ^ Might they rot 8 APPENDIX does abforption of matter from an abfcefs till it bd opened and the air have accefs we may, I think, with a good degree of certainty conclude that the abforption of matter is the immediate caufe of the puerperal fever, as well as of that confequent up- &* abfcefles and ulcers. This matter is either carried off by fome of the emuriclories, as by ftool, which is the moft frequent, by a frefh flow of the lochia, or by fweat ; or elfe it is depofited upon fome part of the body. If in the cavity of the abdomen, upon the lungs,* the liver not conclude that thofe cold fhiverings were fymptoms of that fever ? But thefe I have fo frequently fecn without the puerperal fever fupervening, or the leaft bad confequcnce enfuing, that I am certain they are not to be de- pended on. Women however before delivery are not exempt from other fevers, and after delivery thofe fevers may chang their type and degenerate into the puerperal ; nay, I even think it more than probable that if there be a fever of any kind at the time of delivery, it may occafion an abforption after delivery, and fo bring on one of the puerperal kind. ^ns 1 -,"' 11 ' 111 . t -~~'f~~' * A cough, fhortnefs of breathing, together with pleuritic and pei ipneic monic fymptoms frequently occur in this difeafe, and morbid appearances in the cheft have been found upon diffeftion. " It is almoft needlefs t-o remark that this fever muft of courfe. be com- ** plicated with any diforder that the patient might happen to labour under " at the time of childbirth. The chief that i have met with in this way of *' any confequence, hath been the phthifis pulmonalis* If any difeafe hath " taken its immediate origin, as it were, out of the puerperal fever, and been " combined with it, it hath been the peripneumony. I have met with fev- " eral inftances of this kind." Hulme, p. 15. " Both lobes of the lungs were inflamed, and fomewhat black, particu- <; larly in their moft dependent part." Ibid. p. 41* ('Adhcftons APPENDIX. liver,* or upon any of the vifcera, it generally proves fatal ; if upon the breafts, the limbs, pr any of the external parts, the patient always re- covers. Let us next inquire what is the fource of the matter thus abforbed. That the increafed bulk of the uterus in the latter months of pregnancy mould, by its preffure on the inteftines, obftrucl; the free difcharge of the excrements, may readily be con- ceived, and is known, by every practitioner, fre- quently to happen. Dr. Denman t has a very jufl obfervation relative to this. Speaking of the ftools in the puerperal fever, he fays, " they are " very fetid, of a green or dark brown colour, and "^working like yeft, and it is remarkable, that af- " ter the long continuance of the loofenefs, when *' the patient has taken little nourifhment, large L J ,0 ii {< Adhefions of the lungs to the pleura ; a collection of putrid fe- " lum in the thorax, and matter under the fternum,as in the cafe of Harriet " Trueman - on inquiry of the patient's friends, I could not find that (he ** had ever been in the leaft fubjeft to any complaint in the breaft." Leake, p. 93. * \ Keary, Edin. 1774, p. 8. Dr. Hulme, p. 43, fays, " The liver was of an extraordinary magnitude; irji the right lobe was found a very extcnfive abfcefs*" f Ibid, p, 13. APPENDIX. " and hard lumps of excrement will be fometimes " difcharged ; which one might fufpeft to have " been lying in the bowels a long time before de- " livery/' He is fo particular in this obfervation, that he repeats it in another place. The horizontal pofition to which women are fo frequently confined after delivery, greatly favours an abforption of the lochia. As this matter feems but imperfectly underftood, no proper diftin&ion having been made between the abforption and ob- JiruBwn of the lochia, I mall beg the reader's pa- tience while I attempt to give my ideas of it fome- what at large. Writers agree that the puerperal fever attacks indifferently perfons who have had a fmall, or a large difcharge of the lochia. This is a well founds ed fa 9; ; but from hence they have concluded that the lochia can have no mare in producing the dif- eafe a conclufion to which I cannot affent. In other cafes it is conftantly found that matter will be abforbed, whether the difcharge be fmall or great ; and, what may feem extraordinary, it is frequently feen that where the difcharge is in the largeft quantity, the abforption is moil confidera- ble. But abforption may in all cafes be increafed, and in fome entirely caufed, by fuch an unfavour- able pofition as may occafion the matter to lodge in APPENDIX. in a wound, where, growing acrid, it will produce inflammation and fever by its irritation. By the application of fponge, an incifion in the moft de- pending part, or mere alteration of pofition, thefe fymptoms frequently foon difappear ; the matter becomes more laudable, and is even diminiihed in quantity. We mall prefently fee how thefe obfer- vations apply in the puerperal fever. That accurate anatomift, Dr. Hunter, has dif- covered the falfe or fpongy chorion, called by him the caduca, or membrana decidua, to be a lamella or efflorefcence of the womb, which peels off from it like a flough at each fucceffive birth. It is an opaque membrane, thicker than the true chorion, and exceedingly tender in its texture, being hard- ly firmer than curd of milk or coagulated blood. It is however vafcular, having veflfels which carry red blood from the uterus. It is not to be inject- ed by inje&ing the placenta, being not a fetal, but an uterine part. After delivery, the greatefl part of this membrane is left behind, grows putrid, gradually diffolves, and comes away in a fluid ft ate along with the clean (ings. It frequently how- ever, is fo long in feparating, that on diffe&ion* of feveral who have died of the puerperal fever, the infide of the uterus has been found lined with it ; and it has been of fo black a colour, that the womb * See leake, p. 75, and 1 79. *7* APPENDIX. 4J 3 womb itfelf has been fuppofed to be mortified, till the miftake was difcovered by wiping off this fub- ftance. Thus we have a matter entirely fitted for abforption ; and as the communication between the mother and child is carried on not by continu- ity of veffels between the placenta and uterus, but a reciprocal abforption of blood by means of pat- ulous orifices, we may conclude that the womb is an organ of all others the moft favourably form- ed to abforb. That patients in this fever fhould generally complain of pain and forenefs at the lower part of the belly ; and that the omentum, peritoneum and inteftines mould, frequently, be firfl and princi- pally affefted, and on diffe&ion be found inflamed, fuppurated or gangrened, might naturally be ex- pected from their contiguity to the fource of the abforbed matter. Thefe are the common confe- quences of the depofition of acrid matter upon a tender part. But the inflammation excited in this manner in a relaxed habit, and happening fre- quently after a confiderable lofs of blood, is very different from one occafioned by obftra&ed per- fpiration, in a plethoric habit, where no confider- able evacuation has preceded. Dr. Leake relates the cafe of Sarah Evans, p. 224, who was of a very delicate irritable habit and lax fibres ; fhe was feized with this fever on the third day after deliv- ery, APPENDIX. eiy, when her fldh was moift and her pulfe quick and weak ; fhe died on the 12th day. On open- ing the body, evident marks of inflammation ap~ peared, particularly in the abdomen ; a great part of tlie omentum was deftroyed and converted into matter, and what remained was become gangrenous, &c. The Doftor makes the following remark. '" Where the pulfe was extremely foft and weak " and the circulation languid, it is difficult to ao " count for fo fudden and high a degree of inflam- " mation as to produce a colle&ion of matter, 6r " any inflammatory affection of the abdominal " vifcera ; but fo it was." In another place, he fays, " Confidering the " languid ftate of the patient, and the weaknefs of " the pulfe, even in the beginning of this fever, I " was furprifed to find that the inflammation had " fometimes run fo high, and made fo rapid a " progrefs, as to produce matter in the abdomert " fo early as the fourth or fifth day after the firfl " attack ; as will appear in the cafe of Harriet " Trueman."* He alfo obferves,t " that in the winter months, " when the childbed fever began, the weather was 93 ed that me could not recover. Small dofes of emetic tartar, which gently puked her, were ad- miniflered feveral times today. Buttermilk poffets and buttermilk were ordered for hef common drink, and in the evening fhe got out of bed. On the loth, her pulfe beat only 128 .times in a minute, her belly was rather fofter, me had fever- al flools, and feemed no worfe in any refpe6L On the nth, the lower part of the belly about the ute- rus was fofter, but the whole abdomen began t<5 fwell. Her pulfe beat 160 times in a minute. She had many flools ; and fait of wormwood, with the juice of lemons, was frequently given in the aft of fermentation. Upon the 12th, the whole abdomen was much diftended, and the pain, which now ex- tended itfelf to her fides, was fo violent, that her cries alarmed the neighbours. That we might procure her a little eafe, we were obliged to apply an anodyne fomentation to her belly, and to give her opiates mixed with ipecacuanha. She had a great many ftools, and her tongue had a- white fur upon it. Her loofenefs flopped, and fhe had not much pain upon the 13th, but her belly was greatly diftended. Her pulfe was fo quick as hardly to be counted. Her extremities were cold. She re* tained her fenfes to the very lafl moment ; and ex- pired about nine o'clock in the evening. T 3 DISSECTION. 294 A P P ETtf D I X. DISSECTION. The furgeon who attended her, opened her body the next day, in the prefence of another furgeon, and two young gentlemen of the profeffion. My being called to a diftance prevented my attendance ; but he told me that the appearances were exactly correfpondent to thofe which he had obferved in London, in fubje&s who had died of the true ma- lignant puerperal fever.* The omentum was al- mofl * The great variety of the appearance on diffeftion, and the little certainty as yet obtained from it with regard to the principal feat of the difeafe, are fully (hewn in the following paffage : " In about forty women whom I have had opportunity of infpefting, all or fome of the following appearances have been obferved. The uterus or its appendages were in a flate of inflammation, and fometimes mortified. The os uteri, and that part of the uterus to which the placenta had adhered, had generally a morbid appearance. Small abfceffes were formed in the fubftance of the uterus, or in the cellular membrane which connects it to the adjacent parts. The bladder was inflamed. The omentum was very thin, irregularly fpread, and in a ftate of inflammation. The inteftines were in- flamed, chiefly in the peritonseal coat, adhered in many places, and were much inflated. Inflammatory exfudations, and ferum extravafated in the cavity of the abdomen, have been found in various quantities ; but thefe were in a lefs degree when the patient had laboured under a long continued purg- ing. Large flakes of coagulable lymph were found in the cavity of the abdo- men, which have been often miftaken for diflblved portions of omentum. It muft indeed be acknowledged, that the information, acquired in this. iearch, has not been equal to the care or to the afiiduity with which it has been made*' 1 Denman on the Puerperal Fever. Second Edit, p, 29 and 30. APPENDIX. 295 tnoft wholly diiTolved : detached pieces floated in the abdomen, which contained almoft three pints of thick purulent matter, and of ferous fluid. The ilomach and inteftines were much inflated, and the interlines were glued to each other, and to the peritonaeum ; but in fuch a manner that they might be pulled afunder without tearing their coats. They appeared to be pafted together by a kind of gluten ; and inflammation feemed not to have been in the leail the caufe of their adhefion. Some of the fmaller veffels feemed to be a little turgid with blood. He did not any where obferve the appearances of inflamma-tion or mortification. The left ovary was rather larger than the other, but perfectly found. The womb, which was not contracted to its ufual fize, was capable of receiv- ing an hen's egg ; and upon cutting it open its fides were found to be three quarters of an inch in thicknefs. The inward coat appeared to be en- tirely black, as if in a flate of mortification ; but upon wiping it clean, the blacknefs was found to be nothing more than the putrid lochia and de- ciduous membrane, which had covered the whole infide of the uterus. There was not the leafl ap- pearance of laceration, or of any other external injury. T 4 REMARKS. 2 9 <5 A P P E N D~I X. REMARKS. ' The fituation of the patient's apartment, which was in the clofeft part of the town ; the remarka- ble lownefs of the room ; the vitiated ftate of the air from the breath of fo many perfons ; the hori- zontal pofition of the patient for many days to- gether ; her complaint, at firft, confined to the lower part of the abdomen, and afterwards gradu- ally rifmg higher ; the quicknefs of her pulfe in the beginning of the difeafe, and" its beating four days before death 160 times in a minute ; are cir- cnmftances which merit the utmoft attention. So quick a pulfe is feldom produced by inflammation, when unattended with depofitions or abforptions of matter, though accompanied with the moft vio- lent pain. The moft inflammatory gout, when productive of the moft excruciating torture ; the inoft violent paroxifms of the ftone either in the kidneys or the bladder, or in the paffage from one of them to the other ; the exceffive and almoft in- tolerable torture arifing from a gall ftone paffing through the duels ; the pain and inflammation in the pleurify, the iliac paflion, or the cholera mor- bus ;* nay even thofe arifing from the ftrangula- tion * The firft attack of this fever is fometimes fo violent, that in many re- fpe&s it vefembles the cholera morbus ; for the pain, ficknefs, and burning heat in the floraach and bowels, are ajmoft the fame j and the bile, in great profufion, APPENDIX. tion of the inteftines, or omentum, or from any of the principal operations in furgery, as lithotomy, amputation, Sec. 'except where a mortification is come on and the patient is in the agonies of death, do not occafionfo rapid a pulfation. A pulfe fo exceffively quick is feldom produced by pain, though accompanied by 'inflammation. A quick pulfe is however the pathognomonic fymptom of all abforptions, whether they be produced by ul- cers in the lungs, in the joints, or in any other part of the body ; though unattended by pain or in- flammation. I have known an exceffive accelera- tion of the pulfe proceed from a fmall wound in the joint of the knee, attended with abforption, where the patient was perfectly well immediately fcefore the accident. ,, Iace by pufhing at its fundus ; but as this was attended with great pain, brought on a violent forcing down, and was accompanied with much lofs of blood, I for a while defifted, from an apprehenfion that fhe might die under my hands. I now prefcribed her an opiate, with a few drops of vitriolic elixir. Upon farther confideration of her cafe, I was of opinion that the body of the uterus was too large to APPENDIX. 301 to pafs through its neck, which was a little con- tracted ; therefore in a few minutes after fhe had taken the opiate and vitriolic drops, without waiting for their effects, I haftened to reduce it by the following mode of practice, which I be- lieve to be entirely new, and which had never be- fore occurred to me. I grafped the body of it in my hand, and held it there for fome time, in order to leffen its bulk by compreflion. As I very foon perceived that it began to diminiih, I perfevered, ; and foon after made another attempt to reduce it, by thrufling at its fundus. It began to give way. I continued the force till I had perfectly returned it, and had infmuated my hand into its body. I now withdrew my hand a little and endeavoured to clofe the os uteri by aflifiing it in its contrac- tion with my fingers. It was no fooner reduced, than the pulfe in her wrift began to beat. She re- covered as faft as we could wifli, and without a (ingle alarming circumftance. REMARKS. Had not the idea occurred to me of its being practicable to dimimfh the uterus by compreflion, I am fatisfied I fhould not have been able to have replaced it ; and though my firfl attempt to re- duce it without compreflion -diftrefled my patient greatly, 3 02 APPENDIX. greatly, yet the method I afterwards purfued, feem- ed to be attended with little pain. Several circumflances might probably contribute to this accident ; the prolapfus vagina;, with which the patient had been fometime troubled the pofi- tion fhe was in at the time of delivery the fud- den delivery of the child the adhefion of the pla- centa exactly to the bottom of the uterus the in- fertion of the funis in the very center of the pla- centa, and the pulling at the navel firing too foon after the birth, before the uterus had fufficiently contracted itfelf, and whilft the woman was nearly in an upright fituation. Cafes of inverted uteri are not very frequent ; and the recoveries of patients who had met with fuch accidents have been extremely uncommon. The reafon they fo feldom occur, may probably with juftice be attributed- to the neceffity of fo ma- ny concurring circumflances. The proper means of returning the inverted uterus not being before difcovered, and the want of fpeedy affiflance may be the reafons why fo few have recovered. I know but of two written inflances of recovery af- ter a total inverfion ; one is mentioned by Ruyfch, Obf. 10, where the wife of a certain Jew was the patient, the other by Dr. Harvie in his Praftical Di- reSi0ws,p. 21. Le Motte, indeed, 1. 5. c. 10. Obf, APPENDIX. 303 384. mentions another cafe in which the patient recovered, but in this he does not feem to think that there was a total inverfion. My father informed me that he was many years ago fent for to a woman in this fituation, about ten miles from hence ; but fhe died before his arrival. She had been delivered as fhe fat upon the knee of an afliftant, and the midwife had by pulling at the navel firing too foon after the delivery, totally in- verted the uterus. About eight years ago I was fent for myfelf, and in a cafe exactly fimilar. Th$ woman lived about a mile from hence, and as I was then from home, Dr. Aikin, at that time my pupil, went in my flead. The patient died as he en- tered the chamber. He found the inverted uterus beyond the labia, and the placenta Hill adhering. Thofe who would wifh to fee more hiftories of thefe truly alarming cafes, may confult Ruyfch, Obf. 10 and 26 ; Mauriceau, Obf. 355 and 685 ; Giffard's Cafes in Midwifery, cafe 176, p. 421 ; Chapman, cafe 29, p. 197 ; La Motte, Lib. 5, chap. 10, Obf. 384 ; Smellie's Works, vol. 3, Collection 44, cafes 3 and 4, p. 494 and 495 ; and Dr. Hunter's MSS. Ledure* on the Gravid Uterus. This cafe likewife helps to prove that prolapfufes of the vagina, or bearings down ; as they are com-^ monly go4 A P P E N D I X. rnorzly called, are not occafioned by too early get* ting out of bed after delivery ; as this woma n in her firft lying in never got out of bed till the fifth day, and fcarcsly ever fat up in it during that time,; nay fhe was totally confined to her bed fourteen days, except on the fifth and fixth days - that (he was raifed, whilft her bed was made ; and yet when (he -returned to her ufual exercifes, fhe perceived the ^r0/<7jfr/k$ vagina?. It muft therefore have been owing to Tome other caufe, probably to the upright pofition during labour, and the too hafty delivery .of the fhoulders. ^ C A S E XX. HANNAH NORBURY of Biakeiy, a fmall village, about three miles from Manchefter, aged 27, was delivered of her firft child, by a mid- wife in the neighbourhood, on the 4th of March, !773> as fhe fat ,upon the knee of an affiftant. She had an eafy natural labour, and the placenta came away without difficulty. She was of a corpulent habit, but fhe had . enjoyed pretty good health except a trifling cough which fhe had been troub- led with for about eighteen months, and at the latter end of her pregnancy fhe had been for the moil part coftive. During her labour fhe com- plained of the headach, which continued after- wards. She was kept in a continual fweat, and never APPENDIX. never once fat up in bed till the third day in the afternoon, when fhe got out of it for a little while ; the child was applied to her breads this day for the firft time, the lochia were almoft flop- ped, and fhe had a fhivering fit in the evening fuc- ceeded by a burning and a fweating fit. On the fourth 'day her breafls were a little troublefome, but by rubbing with a little oil they grew eafy. On the 5th, had another fhivering fit. On the 6th, had a ftool which was the firft fhe had had fince the day before her delivery. On the 8th fhe was feized with a bilious vomiting, and a loofenefs ; her urine was high coloured and muddy, and fhe coughed much in the night. She had a delirium, but her hufband obferved that it was only at fuch times when fhe lay upon her back, but that when fhe lay upon her fide fhe was quite free from it. i , On the gth fhe remained much in the fame ftate. In the evening I was applied to, and order- ed her tartar emetic and calx of antimony, which puked her, and eafed her ftomach and bowels. On the loth I faw her for the firft time. Her pulfe were fmall, and beat 176 ftrokes in a min- ute ; her voice faultered ; fhe was fometimes delir- ious, her eyes were red and looked wild, and fhe faid her head ached. She did not make any com- plaint of her belly ; but when I kid my hand up*' U w 306 APPENDIX. on it below the navel, in any part of the hypogaf- tric region, it was fo exceedingly tender that me could fcarce bear me to touch it, but about the navel, and above it, fhe made not the leaft com- plaint though I preffed ever fo hard. Her bed was placed within half a yard of the fire ; and her friends informed me that fhe had fweated 'much fince her delivery, that her only food had been meal or groat gruel, given warm with a little wine in it, and once it was mixed with a fmall quan- tity of malt liquor. I ordered her the fait of wormwood and juice of lemons in the a6l of effer- vefcence, and gave her leave to drink butter milk poffet, which fhe had before afked for, but it had been denied. The lochia were flopped except a little brown water. She had not much milk, but the child continued to fuck her. On the nth I faw her again : Her pulfe was fo fmall and quick as not to be counted ; me had convulflve fpafms, and was not able to fpeak or take any medicines. She had one flool this day, and no vomiting. On the i2th, ftools and urine came from her involuntarily, and fhe died in the evening, REMARKS. I muft obferve that the room in which this worn- an lay had no door to it, nor were there any cur- tains APPENDIX. 307 tains to the bed ; therefore I believed there could not be much putrid air except what was confined under the bed clothes. The mifmanagement chief- ly confifted in keeping her in an horizontal pofi- tion, for three days fucceflively, without once fit- ting up in bed in permitting her to be feven days without a flool in her being too much heated by the fire, too many bed clothes, and drinking warm liquids with wine in them ; in fweating too much, and not being allowed any cool acefcent liquors. DISSECTION. Upon opening the abdomen about fourteen hours after death, there was not the lead difagree- able fmell ; the omentum was large, perfectly found, fpread regularly over the inteftines, and of a natural colour, except a little of the lower edge which was not fo bright a yellow. The inteflines fhewed not the leaft fign of inflammation, and were perfectly found : They were not glued to one another, nor was there any matter or watery fluid floating in the cavity of the abdomen. The uterus was fomething larger than my fift, of a natural colour, but flaccid ; upon cutting it open, the in- fide appeared black ; but I eafily wiped off the blacknefs, which feemed to be nothing more than fome remains of the fpongy chorion and fome par* -.rir 1 U & deles 308 APPENDIX. tides of blood. Her friends being very averfe to any farther examination, I was obliged to defift. CASE XXI. ANN WORTHINGTON,aged twenty fix, was delivered of her firft child, by a gentleman of pretty confiderable pra&ice, on Fri- day the i6th of June 1775, about noon. He in- formed me that in attempting to bring away the placenta, the navel firing broke : He afterwards tried to extract it by the manual operation, but found the uterus fo contracted in the middle, like an hour glafs, that he thought it moft prudent to defift for the prefent, and gave her an opiate. He defired I might be called in, and I faw her about five hours after her delivery. I found Ihe had flooded much ; her pulfe was fmall, and me was very pale with the lofs of blood ; but the flood- ing had now much abated, and fhe feemed tolera- bly eafy. I therefore did not examine her, nor order her any thing, but to continue to take an acid julep, which had been prefcribed her ; to drink cooling fubacid liquors ; to keep the doors and windows open, as the weather was excefiively hot; and to fit up in bed as often as poflible, if (he did not flood. The next morning me got out of bed, which was made, and her linen qhanged, and a was injeled, la APPENDIX. 309 In about 30 hours after delivery, as there was no fign of the placenta coming away, and the weather was remarkably hot, I was afraid of its growing putrid, and producing a putrid fever ; I therefore examined her for the firft time, in order to affift in bringing it away ; but found that the contrac- tion flill remained, and the placenta was quite out of my reach without ufing violence. The lochia were in proper quantities, and not ofFenfive. On the fecond night fhc had a fevere fhiveiing fit, fucceeded by a hot one, and terminated by a fweat. In the morning fhe took a vomit of ipecac- uanha in powder, and got up out of bed. On the third day had another rigour, got out of bed again in the evening, and ftaid up an hour. Being coftive, and complaining much of her head, and her belly being fwelled and tender, with her pulfe 120, an aperient mixture was prefcribed, but that not operating, fhe took two grains of calomel, and a quarter of a grain of tart. emet. which gave her feveral ftools, and fhe omitted the mixture. The next day being the fourth, when the lochia grew very offenfive, warm water* was injected per vaginam ; * In the puerperal fever whenever the lochia are ofFenfive, warm water fhould be frequently inje&ed into the uterus by means of a fyringe whic^.- has a thick fyphon and a little curved ; and I am inclined to think that fuch injections would be very ferviceable in all puerperal fevers, if properly per* formed, U 3 310 APPENDIX. vaginam ; me took antimonial powders, got out of bed twice a day, ftaid up at leaft an hour every time, and often fat up in bed. On the fifth day had another rigour : Took fait of wormwood and juice of lemons in the acl; of ef- fervefcence every three hours ; took every day great quantities of buttermilk, oranges and lemons, and the doors and windows were kept conftantly open. On the fixth day fhe got out of bed three times, flaying up an hour and half each time ; continued the neutral mixture, and the antimonial powders, which kept the inteflinal canal fufficiently open, having feveral loofe ftools every day. On the feventh night a few parny came on, and fhe parted with the placenta, which was very pu- trid, except one part, which feemed not to have been long feparated from the uterus. On the eighth day fhe was much better. On the tenth a diarrhea came on, which on the elev- enth was very fevere ; fhe therefore took a grain of ipecacuanha ; and a few grains of rhubarb, which puked her, and her loofenefs abated, On APPEND IX. 311 On the twelfth a flight preparation of the bark was ordered ; and on the thirteenth* (he faid {he had no complaints, except too much milk in her breads ; fhe kept out of bed moft of the day. From that time fhe perfectly recovered. CASE XXII. ' JYlRS. , aged 25, remarkable for good health arid fpirits, and an amiable difpofition, being arrived at the fulleft period of geftation of her fourth child, was feized with labour pains on Satur- day morning the 6th of November, 1 784, and in two hours after was delivered by a careful and experienc- ed midwife of a fine lufiy boy. During her labour, fhe (laid up till a fhort time before her delivery, when fhe was put to bed. The midwife was only an hour and a half in the room with her, andnoth- ing happened during that time worth relating, ex- cept the patient faying to the midwife, / am not as, lam ufed to be ; to which the midwife anfwer- ed^ Indeed, madam, you are, and are. doing extremely well ; fhe replied, / am 'too. old a prattitivner to be deceived ,- and I tell you, I am not doing as I ufed to do. On * In all the cafes which I have mentioned, the number of days from de- livery, it muft be underftood that the day of delivery is included. I thought it neceflary to take notice of this circumftance, as I find fome Authors ob- jferve a contrary method. 312 APPENDIX. On the third day after delivery, me got up whilft the bed was made, and that day ate a little chicken* On the fourth day {he fat up half an hour. This day her milk was a little troublefome, ^attended with a flight degree of feverifhnefs, and her breafls were gently rubbed with brandy and pommade. Her milk gradually left her. Her belly was regu- larly kept open with caflor oil, and the lochial dif- charge was proper both in quantity and quality. She had a conftant fire in her room, but I could not learn that it was kept hot, the door being frequent- ly open. On Friday evening the feventh from delivery, betwixt nine and ten o'clock, as fhe was undrefT- ing, fhe remarked to her woman that fhe never was itronger or better for the time, than fhe was at that inftant. But about ten o'clock, as fine was getting into bed, fhe complained of giddinefs in her head, and in a few minutes after, was feized with unufu- al tightnefs in the cheft, an extreme difficulty of breathing, with pains in the breaft, flomach. belly, and fmall of the back, and with a coldnefs of the extremities, attended with great reflleffnefs. The fmall of the back was fo painful that it was oblig- ed to be held by a fervant, .At APPENDIX. 313 At firft her attendants were not much alarmed, and regarding it as a common faintingfit, gave her wine and water, and fpirit of hartfhorn, and lav- ender drops ; but finding her grow rather worfc than better, they fent to a neighbouring town for a furgeon, and afterwards for a phyfician, two very ingenious men. When they arrived her pulfe was extremely quick and languid, but regular ; and ihe had an evident finking of features. Every thing in the power of art was adminiftered by them, but all in vain, as Ihe might be faid to be in articulo mortis when they arrived, and indeed from her firft feizure. She expired about four o'clock on Saturday morning, continuing fenfible to the laft. I was likewife fent for, but being at a confidera- ble diftance did not reach the houfe, being flopped by a melfenger within a few miles of it, to inform me of the melancholy event. I never faw her dur- ing her confinement, but from fome particulars of her cafe, which I received from the furgeon, who attended her during her laft moments, I thought there might pofiibly have been a rupture of fome large blood veffel in the thorax ; but as the caufe of her death was by no means clear, and the cafe appeared a very uncommon one, I fent over to re- queft leave to open the body, which was obtained. When 314 APPENDIX. When I arrived there on Monday morning, two days after her death, I was convinced, on the firft appearance of the body, that this could not be ow- ing to any blood veflel having burfl in the thorax, as the abdomen was diftended almoft as much as the {kin would bear without buriling ; the body in the moft putrid flate I ever knew one at that fea- fon of the year, fo foon after death ; and a general lividnefs had infufed itfelf from the lower part of the belly, to the whole of the body. THE DISSECTION Was performed in the prefence of the phyfician and furgeon who attended the lady. As foon as I cut through the peritoneum, a large quantity of putrid air rufhed out of the abdomen, which confid- erably leffened its Bulk ; but it Itin remained very large, owing to a quantity of air being generated within the ftomarh and inteflines. When the whole cavity of the abdomen was laid open, we oh- ferved, on examining its contents, that thofe parts of the inteflines which lay in contact with the ute- rus, were in a gangrenous (late, and of a very livid colour. The uterus was of the fize of two fifts, flabby, loofe, and the whole in a Hate of gangrene. But the neck and the right fide of the body were in APPENDIX. in the tnoft advanced ftage, all its coats in thofe places being completely mortified. The infide of the uterus was covered with the lochia, and feemed at lead not in a worfe ftate than the external parts of it. The ovaria Jimbrice, and fallopian tubes were in the lafl ftage of a fpha- celous, being perfectly black, and exceedingly pu- trid. There was nothing remarkable in the omen- turn, bladder, or any other of the vifcera, except a general lividity, and a tendency to putrefaction. There were no abfcej/es ; the inteftines had formed no adhefions ; nor were there any inflammatory exudations, extravafated ferum, or flakes of coag- ulable lymph, as defcribed by all Englifh writers on the puerperel fever ; or as the French exprefs it, any of that extravafated fluid of the nature of milk, refembling unclarified whey, containing flakes of curd like matter, many of which adhere to the furface of the inteftines. Upon opening the thorax, there was no putrid air, nor any extravafated blood ; the pericardium contained a fufficient quantity of water ; the auri- cles and ventricles of the heart, and the feptum be- tween the two ventricles, were perfectly found ; #s were alfo the lungs, ~ REMARKS. APPENDIX- REMARKS- There are feveral circumftances attending this cafe, that feem furprizing and require fome invefti- gation. I do not lay much ftrefs upon what the lady faid to the midwife, during her labour ; fuch expreffions are common, and no more is thought of them if the patient does well. Her death was evidently occafioned by a mortification of the ute- rus, and it feems extraordinary that me made no complaints till within fix hours before her deceafe, Perhaps it may be faid that if any medical per- fon had attended her, he might poffibly have dif- covered fomething either in her pulfe or tongue, or in fome other fyrnptom, from which to have prog- nofticated her danger ; but I think this is not prob- able, as me ate, drank, and flept well, and her evac- uations and difcharges were natural. ^ May we not account for the fymptoms in the following manner ? There are many different fpe- cies of mortifications ; fome are preceded by in- flammation and irritation, and are accompanied with pain and fever* from the firfl attack ; others are * '* I fnall conclude with one remark, which, thougk it has been made * { before, yet has not been fo generally received as to render any farther tef- f * timony unnereQferv, %be :7?w is, for th?, -moft part, attended with a fen- fible APPENDIX, are not ; fome are dry, fome moid ; fome are of- fenfive from the firft, others not ; fome are very quick in their progrefs, others very flow. It is evident that the mortification in this lady was not preceded or attended with any inflammation or ir- ritation, fmce flie never complained of any pain till within fix hours of her death. The uterus is an organ which is not abfolutely neceffary to life, fmce many animals * have been known c< fible degree of fever, and with all the other fymptoms recited above; " buc befides that, there are cafes in which there is no vomiting, as Ihewa " from the ancients ; there are others in which the fever is fcarcely percep- " tible, when the patient feels little pain, and is not altogether coftive. I " fay, there are fuch cafes of inflammation ; becaufe when with fymptoms fb " little akrming, the patient has died, the bowels have been found not lefs '* mortified than after the moft diftinguiihing marks of the difeafe. I " This, fo far as I know, was firft taken notice of by Dr. Simfon ||, whofe obfervation is quoted and confirmed by the Baron Van Swieten t, and late* " ly by Morgagni J, who obfcrves- that in fuch circumftances, the only pre- " fages of danger are to be taken from the tenfion of the belly, and a dull * pain upon prefling it, from the lowlefs and inequality of the pulfe, and " from a change of the countenance. What he fays upon this fubjecl: well dcfervcs attention." Pringle's Obfervations on Difeafes of the Army, 410. p, 154* j| Simfon on the Syftem of the Womb, p. 106, 107. i Comment, on Boerh. Aphor. 371. $ De Sed. et Couf. Morb. Ep. 35. 22. * jfcdus and Paulus^Egineta, fay, that they have known even women re- cover, when the uterus had been extirpated on accrtunt of an inverfion, and the fariae is mentioned by Parc 3 i8 APPENDIX. known to live after it has been taken out : Hence the fyftem was no ways afFe&ed by it, till the mor- tification communicated itfelf to the inteflines, when it was as rapid as poflible, denroying the pa- tient in fix hours. It may feem remarkable that the lochia were nev- er affe&ed in this diforder ; but let us confider whence they proceed. The lochia are nothing more than a difcharge of blood from the veflels which formerly opened into the womb, mixed with the putrid remains of the membrana decidua, cadu- ca, or fpongy chorion, and as there might be nei- ther difcharge nor putrid flench from the parts actually mortified, the lochia were not affe&ed. The uterus* had not contracted itfelf fo much as might have been expected in a week ; it is therefore moft probable that it was affefted either at the time or foon after delivery ; nor indeed are we able to trace the origin of this difeafe to any thing but * Dr. Hulme, in his T>e?tife on the Puerperal Fever, has given an ac- count of the diffeftion of fix women who died of that difeafe, and has men- tioned more particularly than any other author, the degree of contraction of the uterus in them. In the-firft five, who died on the yth, nth, 6th, i8th, and 7th days after delivery, *' the uterus was contracted to a fmall compafs, " and lay concealed within the cavity of the pelvis." In the fixth cafe, in which the patient died on the 6th day after delivery, " the uterus was lefs ' contracted, and lay flabby and loofe in the cavity of the pelvis." De Graaf fays, that the uterus is contracted to its natural Hze in days after delivery, Ch, viii. p. 128. APPENDIX. 3*9 but her labour, which was a fpeedy one, of a full grown child. How far the uterus might be injured by the child, in its paffage, it may be difficult to fay ; but thus far I think we may venture to conclude, that in all fudden labours, we mail be acting on the fafeft fide, if we do every thing in our power to retard, and nothing to accelerate fuch kind of parturitions* INDEX, N D E X. >/ i, *g* JjLBSORPTION'ot the Lochia, occafioned by a horizontal pofturc 20, 27$ . , the caufe of the Puerperal Fever . - 30, 249, 268 . . occafioned by a ftagnation, not obftru&ion of the lochia, often occurs when the difcharge is great - .105 and obftruclion of the Lochia, their diftinftion - 270 Advantages of fitting up foon after delivery great 92, 102, I53> 246, 274 Air t foul, and confined, very improper for lying in women 19, 81 f 90, 102, 146 . - worfe among poor people - 2 1 pure flaould be frequently admitted into the chamber - 102, 16* putrid, how ftudioufly to be avoided, - - 124, 128, 151 Aikin, Dr. his Thoughts on Hofpitals recommended - 1 3$ . Dr. his Teftimony of the fuccefs of the Author's Mode of Praaice - - - 286 AfterpainS) remarkable proof of their prevention - 285 mm occafioned by premature and improper delivery of the fhoulders - 77 8 5> 2 5* Alexander, Dr. his Experiments and Corollaries. Note. - 140 Appearances on difleftion of women who have died of the Puerperal Fever 3> 2 94> 37 Applications, greafy, their indifcriminate ufe condemned ~ 83 4/cs? Milk fervkeable, when - -. 60, 62 Bark INDEX. V B. Page Bark may be gitfen daring any period of the Puerperal State - 105 .. when ufeful - - 151, 160 Bathing, cold, very beneficial in preventing mifcarriages, and to nurfes giving fuck - 60, 253, & feq. - . warm and vapour, improper in the Puerperal Fever - 158 . unfuccefsfully ufed in the Puerperal Fever - 277 temperate, propofed for Puerperal Women in lying in Hof- pitals by way of prevention, when the fever appears in a malignant endemic form - - 2?3 . i . ufed in ancient and modern times, before and after delivery " - * - - * ibid* Bed, a plate of one with references * 129, & feq. Bleeding^ its ufe too prevalent - - 58, 62 not fuccefsful in the Puerperal Fever - 245 Bliflers, very improper when 1581 & feq. 167, ufeful in the laft ftage of the Puerperal Fever, 160 < their ufe in the Miliary Fever < *7 a Breajls, their (late in the Puerperal Fever - .26 their ftrufture defcribed 53 -' require great attention - - - 1 1 o, & feq method of drawing them defcribed - Hi, &feq. Broths, their impropriety - * **> vj 94 *3 Butter Milk much drank in Manchefter *'-$*** 117 C. Calculations of the number of women who have died in childbed in London and other towns - - 239, & feq, . , in different hofpitals - - 235 Camphor, its ufe improper - .. 167 Chair, a very convenient one defcribed - - - a 08 a Plate of, with references * * - no Chamber, lying in, directions for rendering it healthy - - jox Chorion or Caduca, Dr. Hunter's account of it - - 271, & feq Chord, umbilical, when to be divided - - -85 Ckghorn, Dr. his account of the appearances on diffeftion of perfons dead of Putrid Fevers - * ' 1 225 Clyjlers of great utility in preventing Puerperal Fevers - - 105- of broth improper ibid, when proper - * , . 14$ I N D E X. Columbo root, its advantages . ' - 63 -- Dr. Percival's experiments upon. Note - - ibid. * "" - - when to be given - " J 49 Cope, Mr. Extract of a Letter from - - 285, & feq. - his fuccefe in following the Author's Mode of Treatment - 284 Conclufions drawn in regard to the Secundines - - 218 Cordials, their ufe when neceflary . . 1?a Cojlivencfs how prejudicial - *. 153 Crifis of the Miliary Fever very uncertain - - j^a Cul/cn, Dr. his opinion of the Miliary Fever 49 Cure of the Miliary Fever - - - 161, & feq - i of the Puerperal Fever - - - 136, & feq. Davenport, Mary, her Cafe - - - 213, & feq. DC Haen, Dr. his teftimony on the Miliary Fever 46 Delivery, j.cmperzte bathing ufed before and after - - 278 ..... of the moulders, how performed - 71 Depofitions of matter in the Puerperal Fever - - 269, & feq. Diet proper for Puerperal Women - - - 93 Directions, not very ferviceable in difcovering the caufe of the Puerpe- ral Fever - - - IPt! - a62 Doulcct, Mr. his opinion of the Puerperal Fever - 33 his Mode of treating it . 142 Draughts of Salt of Wormwood when proper 145 .1 given by Reverius and Sydehham when ' ' \ * - 147 up their aftion d*efcribed by Lind and others . ibid. 2)refr t its management of great confequence - 53 ~- what proper for Pregnant Women - - 66 Jfyfentcrtes-almott. unknown in Manchefter - . 118 E. t ggs, raw, their good effels in the jaundice - - 64. Llajlic Vegetable Bottles, their ufe. Note - - 111,160 Emetics, when advifeable 142, & feq. EmmenagogueS) their ufe hurtful - > 160, 167 Eruptions, miliary, known to attend moil difofders - 39 i in the Puerperal Fever not critical - 27 Exercife, when improper for pregnant Women - - 6at * .iwi when proper . . - -60 Fermenting I I N D E X. 323 F. fermenting antifeptic mixtures very ufeful when - ; jg^ Tlaoding, Gfiten caufed? by too hafty delivery 83 i its proper treatment - - 1 05 & feq, fomentations , warm, improper in the Puerperal Fever - - 158 fetus, the manner in which its moulders pafs through the Pelvis, firft discovered by the Author - 7^. fumes, dry or moift, the Author's doubts of their utility during the Patient's ftay in the room - - 131 JFunis, when to be divided - - - .85 G. "Getting out of bed, the moft effectual method of promoting the Lochia 104 Gunpowder, explofions of, very ferviceable in expelling foul Air - 130 H. Heat of the body mould be as near as poflible to the ftandard of health - 96, 139, 163 -may be fo great as to prevent fweating - - 146 Horizontal Pojlure, in puerperal Women prevents ftools and lochiafrom having free exit - - 20 > - ' ' " recommended in natural labour - - 83 " . i. i occafions abforption of the Lochia - 27*, 476 Horfeback, fhort rides on, ferviceable in preventing mifcarriages - 60 Hofpitah, Puerperal Fever not eafily prevented in -121 - defcription of a Plan of, with fome improvements - 123 - the Author's good opinion of, in general - - - 244 ' for lying in Women, their different fuccefs - *35i & ^ e< 3 Hotel Dieu, Mode of curing the Puerperal Fever in it - 1 42 Hulme, Dr. his Treatife when feen by the Author 222, & feq. i. - remarks upon the opinion of 224, & feg, Hunter t Dr. his MS. Leclures 249 I. Infirmary at Manchefter, a defcription of - 124 InjeElion into the uterus recommended where the lochia are become pu- trid ... . 160 Injlruments, their ufe fometimes needful - . - 79 Johnfon, Dr, his Observations on the Delivery of the head - 7 fyecacuanha, ufed with great fuccefs in the Puerperal Fever at the Hotel Dieu , . ,. ^ . 13 D E X; Ipecacuanha, Authors claim to the firft ufe of it . 44 its good effects in the Miliary Fever Jumps, their ufe advifeable during pregnancy , ~ 66 L. Labour, the moft natural cafe of fuppofed - 86, & feq, Laceration of the Perineum frequent in confequence of hafty delivery 83 Liquors, ftrong, their impropriety . "93 * ' " acid, their advantages uo the Miliary Fever . 169 Lochia, ftagnating in the womb, become acrid and abforbed .. 21 - emollient or antifeptic injections into the uterus very beneficial in removing - igo their evacuation alone does not prevent the Puerperal or Mili- ary Fever - i Lochia fometimes much leffened and fetid z fhould not be promoted by forcing medicines - beft promoted by getting out of bed - - ibid. larger or fmaller difcharge not always a difeafe - 105 -' their abforption occafioned by ftagnation, not obftruftion, but often occurs when the difcharge is large - - ibid. when immoderate the proper treatment - ibid* - their abforption and obftru&ion not properly diftinguifhed 270 Lord, Mary, her Cafe - - - - 201, & feq, M - Management, proper, of the navel firing, firft. difcovcred by the Author I ,* ':: - ^ . 85, &. feq. 256 Matter, depofitions of, upon the internal parts fatal - 269, &. feq. _ __ - upon the external parts a fign of recovery - ibid. ffleaicines, forcing, when improper * 10^ Membrana decidua, what, difcovered by Dr. Hunter. Note - 87 pi" in entirely fitted for abforption 272 & feq, Menftruation common to thofe Quadrupeds only who ufe an upright pofture - ... 277 Metkod, common, of tying the Funis very erroneous - 85 Miajtnata, putrid, contribute greatly-to the fpreading .of the diforder 21 Midwifery, the art of, greatly improved of late - 70 Miliary fever, doubtful whether known to the Ancients - 34 "*-- - known by Riverius - - - : " " ~ 3^ ' difcovered in England bySydenham in 1685 37 ..!. .. L., Authors various in thciy opinions about the < ibid* , &L INDEX. 325 Page MiKary Fever, fully defcribed by Allomus 40 its fymptoms - ibid* once very fatal in Manchefter - - 43 . ..-.- once fuppofed to be endemic at Chefter 45 Eruptions never come out without a fweat - 44, 16* ...... i are fabricated, not critical - 46 ii Fever y Dr. Cullen's account of 49 . .... . .. .. its cure - - 161, & feq t- , its laft ftage hazardous ... 1 73 Milk Fever, its caufes - 51 _ . why more common to Women of rank - 55 Affes, ferviceable when - 60, 6a Mortification of the Womb - - 314 Uufk y when ufeful - - - 172 N. Nature to be obferved in her operations - 76 when to be affifted in her operations - 85 Navel String, bad confequences attending the tying and cutting it im- mediately after birth 86, 256 & feq/ the proper management firft difcovered and recommend- ed by the Author - 256, & feq. Nitre, proper in floodings - 108 " ' ' improper in the Puerperal Fever - - 15$ in the Miliary Fever - - - ^67 Northampton. Puerperal Fever very fatal there - 12O, 234 Number of attendants hurtful to Women in Labour - 19 Nurfes have great (hare in the management of Lying in Women 33 too much left to their management in London - 119 O. Qbjlruttion and absorption of the Lochia, their difference - 270 Omentum and inteftines, their inflammation and mortification not the true caufe of the Puerperal Fever - - 229 Opiates, when neceffary 82 y when improper ,. - - 169 P. Parturition, natural, what method to be obferved in - 80 Pains, falfe, or fpurious, their difference - 231 Perfpiration and fweat, the difference not generally known - 97 hie observations on the effefts of Putrid Effluvia, Note a at Perfumes - 326 INDEX. Perfumes of b*d confequence - . ^ fhlebfitomy, when improper . . 156, & feq. ^d^ enta 9 how to k e extra &* - 87, & feq. --- fatal caufes of - - 214, & feq. ---- irs retention, an objeft of controverfy . 6g i\'j'i .", ks confequence when j t^ - -- during delivery ~ " " 83 . ... horizontal, the caufe of the Lochia being abforbcd - 270 276? Pofture, fudden alteration of it dangerous _ jgg -.L upright of the greateft confequence after delivery $$ y & f C n. i *% 2*6, 274 Puerperal Fever, its fymptoms - - 17, & feq. . ..... - -well known to Hippocrates - 27 - ..... - i not to be afcribed to Inflammation alone - gj " -- frequently malignant - - ibid, - --- aggravated by heat of Air 32 ' - .. .-. ' more fatal in Hofpitals than in private practice 22, & feq. - -- occafioned by abforption - 31,102,105 , -- 1 . .,-, .,., . never produced without foul Air, accumulation of fe- ces, or horizontal pofture ... joa --- - the Author never loft a Patient whom he had deliver- ed in it - - - - 115 -- more common and fatal in London than in the country 1 1 9 -. - fatal by wrong treatment - 121 _ - - . may a i wa y s be prevented except in Hofpitals - ibid. if managed according to the Author's directions gener- ally curable 154 why fo common and fatal at Northampton - 233 . not fo general as from the afligned caufes it might be 37 obferved by iome to be very fatal in 1770, but not in- variably fo 2 35 ^. the difcovery of its caufes not much afiifted by dif- feaions 262 _ u - - - . tranflation of the difeafe to the external parts a fign of recovery 266, & feq. ItftffeM adtrifed to ufe the temperate Bath when in hofpitals 278 P*lfc 9 its quicknefs a moft diftinguiming fymptotai in the Puerperal Fe- ver 263, & feq. - quick in all abforptioafi of matter * - ^64 INDEX. 327 ' R, Page Ravtnfcroft, llen t her Cafe . 1 86 Regijlers of different difeafes, how long kept in Manchefter 239 Repofe upon a couch when advifeable 67 Rigg, Betty, her Cafe and Direction 174, & feq. - Remarks upon the Cafe of J75> & f e q^ Rings of Bees' Wax, their ufe - 113 S. Sago, its fenfible qualities - g^ Secundines, their retention an object of controverfy ga Shoulders, of the Child, the manner in which they naturally pafs through the Pelvis firft difcovered by the Author - . ^ .- > common directions for delivering them improper - 75 their improper delivery productive of great inconveniences 75> 2 54. 85 Sitting up in Bed foon after delivery of the utmoft confequence 92, & feq. J5 2 2 46, 274 Spungy Chorion entirely fitted for abforption 272 & feq. Stagnation of the Lochia the caufe of their abforption - 104. Stays, tight, their bad confequence - 66 Sweat and perfpiration not diftinguiflied by the ignorant . 97 Sweating in Bed, hurtful to a perfon in health - - go . I.. - particularly hurtful to Puerperal Women, and in all low nerv- ous nnrl PiitrM Fevprs - - - JOO . . to what extremes carried - 1 Q* Sweat will terminate a paroxifm of an Ague, but not prevent a frefli acceflion - . JO |, . critical, an act of Nature, and beft promoted by what - ibid. when improper - - - 141 perfons may be too hot for that evacuation . . ^(J T. Temperature of the Lying in Chamber, its confequence ^ ' - 96 Tcnefmus, frequent in the acceflion of the Puerperal Fever - 25 Tightnefs of the Stays, hurtful to Pregnant Women - - 18 Treatment , what proper for preventing Puerperal diforders - 90, & feq. of Floodings . jo 5j & f eq% U, Upright Pofture, of th utmoft coafequence after delivery 92, & feq, 1 52, 246 Urine *f IN D E X. Urine voided often, and very turbid - 2s Uterus, gravid prefling upon the omentum and inteftines, fuppofed to p be the true caufe of the Puerperal Fever by Dr. Hulme 229, & feq. controverted by the Author - - 231, & feq. ~ mortification of . Vt . , - 31 ^ V. Vegetables^ their ufe mucfc recommended - 95 Ventilators t their ufe - - .- 128 Vinepar fumigating Wards with, not fo antifeptic as was fuppofed 131 Volatile*, improper when - - 107,168 Vomits i gentle, ftrviceable 63, 144, & feq 170, & feq. W. Warm Bathings , unfuccefsful in the Puerperal Fever - 277 7F 'ater t pump, much ufed in Manchefter - - 118 Obfervations on that of London, by Dr. Heberden. Note - ibid. Whitehead, Dr, his tranflation of Doulcet's Memoir - 33, 143 Wine t its ufe, when neceflary - - - 170 Women, puerperal, fubjeft to putrefccnt diforders - 17 " too much confined to a horizontal pofture after delivery 20 ' mould get out of bed the day of delivery - icz, 275 ~- fhould fit up in bed in an hour or two after delivery 274 delivered by the Author, never troubled with Prolapfus Vaginae 246 Wriley, Mary, her Cafe . . . 205, & feq. X Young t Dr. recommends the cool regimen - . 234 , his defcription of the Lying in Ward at Edinburgh - 251 * ' ""' bis account of the Puerperal Fever, as it appeared ia that place 281 IJ