erv ftl-i Iftf.'iUl.' SW'1 ;jVi' >.,vH ra:? an Sips NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health SerTice /? j£d-i.f&c£ ■ i: A TREATISE ON THE MANAGEMENT of PREGNANT AND LYING IN WOMEN, AND THE MEANS Of CURING, BUT MORE ESPECIALLY OB PREVENTING the principal DISORDERS TO WHICH THEY ARE LIABLE, TOGETHER WITH SOME NEW DIRECTI O >fs CONCERNING THE DELIVERY of the CHILD and*PLACENTA IN NATURAL BIRTHS. I ILLUSTRATED WITH CASES. ^L&Hi***—- By CHARLES WHITE, Esq. F. R. S. Man Midwife to the Lying in Hofpital, in Mancheiter, in England, &c. &c ..o.sft '-•<'^e T^iAxiJ.-..}' Firft .SBorcefter Editio^^y rr; printed at WORCESTER, Massachusetts, by ISAIAH THOMAS. Sold at his Bookftorc in Worcester. Sold aifo by faid Thomas, and Andrews, Fault's Statue, Newbury Street, Boston ; and by faid Thomas, and Carlisle, sn Walpole, Newhampfhire. MJDCCXCIII. 1 HE 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; 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 neglect or infuffi- ciency in her moft important work. I have no curious Angularities 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 c in «ii PREFACE. in aim oft every other fcience, and has with par- ticular advantage been applied to many branch- es of medicine, no apology feems necelTary for trying the fame method of reasoning, on this important fubject, which has hitherto been too much governed by arbitrary cuftom, and igno- rant prejudice. On reflecting upon the caufe why lefs prog- refs his 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 fact. For while a more rational general doc- trine of fevers, and the ufe of cool air and regi- men in their cure (ever fince the time of Syden- 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 mult therefore take its rife from the eftablifhment of more juft ideas con- cerning * Friend, Glafs, Huxham, Pringle, Lee, Perkins, Huck, Dimfdale, lleberden, Brockldby, Rullcn, Watfon, Baker, Kirkland, and many- others. PREFACE. i cerning the ftate itfelf, and the caufes of the diforders accompanying it; and by a proper attention to thefe, I am experimentally con- vinced that not only the method of cure may be much advanced, but what is ftill more impor- tant, that thefe mifchiefs, fo diftrefling and dan- gerous, may be entirely prevented.' This then will be my chief aim in the fol- lowing Treatife j and if in purfuing it, I may feem* to pay more attention to fome minute cir- cumstances, than they really deferve, let it be remembered that the flightelt remark drawn from real obfervation, is of more utility, and gives greater fatisfaction to a judicious inquir- er, than the moft extenfive theory of caules drawn from hypothefis alone. We are too apt to neglect 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 fact, 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 acuteit fpeculation of philofo- phers had failed in the difcovery. Were t PREFACE. WereI,inJeed,difpofedto reafon in favour of the doctrines I have attempted to lay down, up- on any other ground than mere obfervation, vari- ous arguments, both a priori and from analogy would not be wanting. I might fay it is incon- ceivable that Nature ftiould fufFer her moft impor- tant procefs to be the leaft complete, and that flie ftiould need the help of art in an operation al- most prior to art itfelf. In her inferior produc- tions we find, that, in fact, ftie does not require it. The 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* fpontaneoufly without the hand of art to feparate it. In the whole animal race this procefs is equally dif- tant from difeafe.* i Why then fhould the human fpecies alone, her nobleft production, undergo her unkindnefs or neglect in fo ma- terial an object ? Though pain in bringing forth their offspring might be an unavoidable circumftance in the formation of mankind, it is however overbalanced by many advantages j but that this moft neceflary operation fhould of itfelf be a difeafe, and ftiould 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 infinuate, that either the brute or the human fpecies are at all times exempt from prcternatura' births. PREFACE. *k ture in the fupport and prefemtion of her crea- tures.* But however this ftrain of reafoning may pleafe a philofophic mind, or may have turned my thoughts to a peculiar way of con- fidering the fubject, I fhould never have ven- tured to build practical rules upon 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 may feem in inculcating fome unufual practical directions, 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 justifica- 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 fubjects; 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 iingle and married women between 15 and 25, more of the former died than of the latter in the proportion of two to one. Thpreafon of this may be, as Mr. Muret acknowledges, that the wom- en who marry are a felected body, confifting 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 expeded, that in this, as well as in all other inftances, the confequences of following Nature muft be favourable, Supplement to Price's Obferv. on Reverfionary Payments, p. 357* xli PREFACE. here offered to the judgment of the candid reader. I cannot conclude without gratefully acknowl- edging the many obligations I am under to thofe of my learned friends, who have aflifted me in revifing and correcting thefe fheets, and to my medical correfpondents who have favour- ed me with fo many ufeful articles of informa- tion. The reader will at once fee of what im- portance thefe have been in enabling me to de- duce the practical inferences which I have at- tempted to eftablifh. P. S. lam happy in the opportunity this fourth edition offers me, of expreffing my fatisfat!ion for the reception this work has already met with, and my hopes that its extenfive circulation may have been a means of accomplijhing, in a considerable degree the purpofes it was intended to anfwer. Befides three very large imprefjions which have been called for at home, a tranjlation into French has been publijhed at Paris, and an Englijh edi- tion was in the prefs at Philadelphia when the late troubles began in that country. THE xiU THE CONTENTS. v-v [Pa£« Chap. I. v^iV /£ Cafe VII. A Puerperal Fever - 201 Cafe VIII. Retention of the Placenta with Flooding, fucceeded by a Puerperal Fever 202 Cafe IX. A Puerperal Fever - 205 Cafe X. Retention of the Placenta with Flooding - - - 212 Cafe The CONTENTS. xv Page Cafe XI. Retention of the Placenta occa- Jioning a fatal Miliary Fever - 213 Cafe XII. Retention of the Placenta oc- cafioning fatal Floodings - - 215 Cafe XIII. do. - - 216 Cafe XIV. do. - - ibid. Cafe XV. do. - - 217 Conclusion - - 218 Postscript - - 222 Appendix to the fecond Edition - 252 Sect. I. On the ufe of the cold or temperate Bath - 253 II. On the delivery of the Shoulders of the Child - - 254 III. An Obfervation on the Manage- ment of Children at the time of Birth - 257 IV. On the Puerperal Fever aud Po- fition after delivery - 261 ADDITIONAL CASES. Cafe XVI. A Wound of the Omentum at the fullperiodofGefiation, which brought en Labour « * 2^7 Cafe xvi The CONTENTS. PagU Cafe X V11. A fatal Puerperal Fever with a DiffeBion - - 228 Cafe XVIII. A fatal Puerperal Fever oc- cafioned by the Effluvia arifing from foul Urine - - 297 Cafe XIX. A total Inverfion of the Uterus, returned by a new mode of operation - 299 Cafe XX. A fatal Puerperal Fever with a DiffeBion - - - 304 Cafe XXI. A remarkable Retention of the Placenta - - 308' Cafe XXII. Afatal Mortification of the U- terus, with DiffeBion - - 311 hmtft' CHAPTER CHAPTER I. Of the Causes and Symptoms of'the PUERPE- RAL or CHILD BED FEVER.f OMEN, during the time of ly- ing in, are fubje£r. 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 + This diforder in the northern part of this I Hand rs called the weed ; and in the fouthern parts by fome, the lochial fever. Puerperae ex male affefti corporis vitio tanquam aune peftilentiaiis contagio tafte/ein putridz, feu potius «w/*£s; mulieres autem di- tiores, tenellae, & pulchrse, pleraeque vitam fedentiaram degentes, quafi ma- ledifti divini graviori modo participes in dolort pariunt, indeque mox a par- tu difRciles & periculofos fubeunt cafus." Willis de Febribus Puerperarum, Febres putridae Caput xvi. Willis's account would not have been liable to any material objection, if he had not excepted the poor in general, for it is now well known that they are very liable to this fever, both in the hofpitals, and in their own houfes, efpecially if they are fituated in the middle of large manufacturing towns and Cities; but there is this to be faid in favour of the Doctor, that it is above a century fince he wrote this Treatife on the Puerperal fever, at a time when there was no hofpital for lying in women in the Britiih dominions, our man- ufactories were then in their infancy, and the diet and mode of living amongifc the poor people, were totally different from what they are at this time, PUERPERAL FEVER. 19 tious matter being abforbed into the circulation, undoubtedly occasions a great inclination to putrid- ity ; lofs of appetite foon follows, and the ftomach and duodenum being no longer distended with ali- ments, large quantities of bile are collected in the . gall bladder, the cyftic and hepatic ducts, and, by lodging there, foon acquire a putrid or putrefcent acrimony. When the woman is in labour, fhe 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£ 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 aifo more fatal in the hotter months." Compend. of Midwifery, p. 220. Lond. 1766. * It has been found by Dr. Stephen Hales (Statical ElTays, Vol. 2, p. 324) that a perfon 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 correfpondent of his, (a gentleman diftin- guifhed for his knowledge of Natural and Experimental Philofophy) has lately difcovered " That air which animals have breathed is in all refpects the fame with air in which animals have putrified. The original quantity is equally di- minilhed in both cafes ; which is found to be owing, in part at leaft,.to the precipitation of the fixed air it contained ; and they are ieftored by the fame process. 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 deadone.*' B a 20 PUERPERAL FEVER. families where putrid fevers are apt to be generat- ed, and proportionally the more fo where there is tbe greatest want of free air. . If the woman's pains be not strong enough, her friends are generally pouring into her large quan- tities of ltrong liquors, mixed with warm water, and if her pains be very strong, the fame kind of reme- dy is made ufe of to fupport her. As foon as fhe is delivered, if fhe be a perfon in affluent circum- itances, fhe 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- dows and door is flopped clofe, not excepting even the key hole, the windows are guarded not only with fhutters, and curtains, but even with blankets, the more effectually to exclude the frefh 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 constantly 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- fiits 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 polture of the pa- tient, but aifo from the great relaxation brought on by warm liquors and the heat of the bed and room, which prevent the over distended abdominal muf- cle* PUERPERAL FEV^IC. *« cles from fpeedily recovering their tone, whereby they are rendered unable to expel the contents of the abdomen, which lodging in the intestines many days, become acrid and quite putrid. The lochia stagnating in the womb, and in the folds of the vagina, foon grow acrid, for it is well known that themildeft humours in the human body, if fuffered to stagnate, 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 generally of a lax, feldom of a rigid fibre, owing in fomemeafure to their periodical evac- uations, to their fedentary, inactive, and domestic way of life, and likewife to their mufcles being fur- rounded with a much larger quantity of cellular membrane, than thofe of men; hence aifo they ar- rive at their acme fooner than men. Amonglt 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 aifo in no better a fituation, for the putrid miafmata of feverai B 3 family 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 fingle 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 itill in a worfe fituation in hofpitals*, where a number are * " II a regne pendant l'hiver dc 1746 une maladie epidemique parmi les femmes encouche: M. de Juflieu a le premierobferve cettemaladie ;elle com- mencoit par le devoiement, ou par une difpofition au devoiement, qui continuoit pendant la couche : les eaux qui accompagnent ordinairement la naifTance de l'enfant, fortoient pendant le travail de 1'accouchement; maisapres ce temps, la matrice devenoit feche, dure & doloreufe, elle ctoit enflee, & lcj vuidanges n'avoient pas leur cours ordinaire. Enfuite, ces femmes etoient prifes de douleurs dans les entrailles, fur-tout dans les parties qu'occupent lesligamenslarges de la matrice; le ventre etoit * tendu, & tous ces accidens etoient accompagnes d'une douleur dc tete, & quelquefois de la toux. Le troifieme & le quatrieme jour apres l'acouchcment, les mammelles fe fletriffoient, au lieu qu'elles durciflent & fe gonflent naturellement dans ce temps par le lait qui s'y nitre alors en plus grande quantite : enfin ces femmes moisroient entre le cinquieme & le feptieme jour de 1'acouchement. Cette maladie n'a attaque que les pauvres femmes, & elle n'a pas ete aufls violente, ni aufls 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'Hotel Dieu, a peine en echappoit-il une : cette maladie n'a pas ete fi meurtriere dans le rcfte de l'hiver. Meffrs. Col de Villars & Fontaine, Medecins de cet Hopital, nous ont rapporte qu'a l'ouverture des cadavres de ces femmes, ils avoient vu du lait caille & attache a la furface externe des inteftins, Si qu'il y avoit une ferofite laiteufe epanchee dans le bas ventre; ils ont mesne trouve aufls de cette ferofite dans la poitrine de quelquis unes; St loxfqu'oo en coupoit les poumons, ils degorgeoient une lymphe laiteufe & pourric. t'eftornac, PUERPERAL FEVER. 23 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 neceffary houfes, which are either contiguous to, or fo near the hofpital as to occafion a moft dif- agreeable fmell, and mult 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 fhare which nurfes have in directing the man- agement of lying in women, to whofe interference practitioners I/eftomac, les inteftins & la matrice bien examinees, paroiflbient avoir ete enflammes, & il eft forti, fuivant le rapport de ces deux Medecins, des gru* meaux de fang a l'ouverture des caneaux de la matrice. Dans pleufieurs de ces femnaes, les ovaires paroiflbient avoir ete en fup- puration. " Hift. de l'Acad. Royale des Sciences I'an 1746, 4to. p. 160. *' I am well informed that this fever and obftruction 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-« ticnts, the air muft always be more or lefs tainted." Johnfon'i Mid\vifery, p. S£|< B4 *4 PUERPERAL FEVER. practitioners mult in fome meafure fubmit, though contrary to their better judgment. Women have frequently many, and fometimes all of thefe difficulties to struggle with, even after the moft eafy deliveries ; but if there have been fuch violence ufed, either by instruments or by the hand, in the extraction of the child or the placenta, as to bring on an inflammation of the womb, thefe difficulties will ftill 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 unfuccefcfui attempts ^d 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 fhoulders time to accommodate thcmielves 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 fhe 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 moft 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 efr fect7 by increasing and prolonging the burning fit, which PUERPERAL FEVER. fe5 whj*?ft at lait terminates in a molt 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 lait ends in a continued fever; At other times no cold fit precedes the difeafe : It creeps on gradually, and first fhews 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 offensive all over the houfe, and to convey infection 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 flufh- ed; the urine is voided often, with pain, and in fmall quantities, and is remarkably turbid. The tongue at firft 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 s6 PUERPERAL FEVER. fequence of putrid exhalations, adheres to theeiiges 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 veiy 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 ofgreat anxiety, and oppreflion about the praecordia, attended with figh- ings, lownefsof fpirits, laflitude 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 fuppreffed. The breafts 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. If the hot regimen be continued, with vinous fpi- cy caudles, hot alexipharmic medicines, volatile al- caleousfaltsand fpirits, opiates, and a clofe room fo as to keep the patient in a perpetual fweat, vibices* or petechias appear, or eruptions either of the white or • Cooper fpeaking of this fever about the fourth day, fays, " Now if net before, fome violent pains come on, in the arms, and thighs, fucceeded by a difcolouration of the flun, occafioned by the blood corroding and ftagnasing in the veisels." Compend. of Midwifery, p. 218. PUERPERAL FEVER. 37 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 itool, and they feem to give relief. The ftools at lait are difcharged together with the urine, involuntarily; colliquative fweats, hiccupings, convulsions, Ac- come on; and death, which happens fometimes foon- er, fometimes later, 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 lived 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 ftiled either epidemic J, malignant, * Hipp, de Morb. Mulierum, lib. s. feft. 5. —on Epidemical Difeafe s, 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 obferva- 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- ham, and by Tho, Bartholine, and muft undoubtedly have happened invana. *3 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 feafont 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 f, and many to a fupprelfion of the lochia ; bly in all ages of the world, though it is now better underllood 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 connefted." Millar on the prevailing diforders o£ Great Britain, pt. 3, fe& 1. p, 334 «{ the puerperal fever. " Nonnunquam port lochiorum fuppreflionem in febrem incidunt puer- peras, qua: vel in earum qua turn graffantur epidemicarum caftra tranfit, vel ab ea foia pendit origin*." Differt. Epift. ad. Gul. Cole, M. D. Sydn. op. p. 533. t Tiflbt in hh Avis au Peuple, Eng. edit, by Kirkpatrkk, p. 371, feems 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. Sec*. 370, he fays,« The inflammation of the womb is difcoverable by pains in all the lower parts of the belly; by tendon or tight- nefs of the whole belly ; by a fenflble increafe of pain on touching it-a kind •f 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 aftonifhing change of countenance ; a light delirium or raving; a continual fever, with a weak and hard pulfc; fometimes iaceflasu vomitings; a frequent hiccup; a mod- crate PUERPERAL FEVER. £Cj lochia; tome 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 erate difcharge of a reddifh (linking fliarp water ; frequent urgings to go to ftool ; a burning kind of heat in the urine; and fometimes an entire fup- pfeffion of it." * " Femina xxx. annorum temperamenti fanguineo-melancholici, hyftencis paflionibus in puerperio, & extra illud, faspius obnoxia, tertium gravida, gef- tatitfnis tempore nee vena: fectionem admiflt, nee exquifrte fervavit prxcepta diabetica. Primis poft partum diebus non bene purgata eft utero : Sed de dolore lumborum, torminibus ventris, alvo adftrifta, & fomno per aliquot noOes inquieto conquerebatur. A praftico, quern in confllium vocavit, val- idiores effentiae ad pcllenda lochia fuerunt data: ; & ad alvum aperiendam uncia dimidia falis amari Sedlicenfis in aqua fimplici foluta eft oblata. Inde auais torminibus, nee fafta per alvum, nee per uterum excretione, converfo fonguinis verfus fuperiora motu deliravit, & accedentibns convulfionibus ex- tinAa eft." Hoffman, Tom. 3. feS. »• «•?• 5» ' obf. so de malo Hyfterico. § « As the difeafe which is the fubjeft of this Effay occafions the death of much the greater part of women who die in child bed, &c," Denman on the Puerperal Fever, p. s. U Pouteau in his Melanges deChirurgie, p. i8«, upon opening two women who died of this fever in their lying in at the Hofpital at Lyons, fays, «'En 30 PUERPERAL FEVER. eafe has been of long continuance, it has extended to the lungs, and all the neighbouring parts. In the cavity of the abdomen is generally found an extravafated ferum, mixed with purulent mat- ter, and an exfudation appears upon the furface of the inteftines, gluing them to one another, and to the peritonaeum. There is no wonder that thefe appearances fhould be obferved, more particularly in the abdomen, as the very acrid putrid ftools void- ed in this diforder mult naturally tend to inflame, and to give a putrefcent difpofition to the inteftines by tranfuding their coats, or being abforbed into their fmall veffels ; and we may conclude, that the fame caufes which produce putrefaction in the ab- domen of a dead body *, fooner than in any other ' part, " En ouvrantces matrices il ce prefenta dans l'une & dans l'autre une circon- ftance qui merite attention ; la tunique interne de ce vifcere etoit noire & molle : la matrice dans fon epaiffeur avoit une rougeur livide & vraiment gangreneufe." * Sir John Pringle gives us the following note, which he informs us he had from Doftor Hunter. " That the abdominal vifcera and mufcles cor- rupt the fooneft of all parts in the body after death, wherefore it is a rule with anatomifts to begin their diffefiions and demonstrations with thofe parts which firft become offenfive. That the quick putrefaction here may reafon- ably beafcribed to the putnd fleams of the faces with which all thofe part* are more or lefs impregnated, hence too the caufe of the fpeedy corruption of the pfoas and iliacus internus in comparifon, of the mufcles in the extrem- ities. That next to the abdominal viicera and adjacent parts, the lungs are commonly fooneft tainted, whether from the air ftagnating in the veficulas bronchiales, or fome remains of the perfpirable matter that may aft as a fer- ment, and haften the putreia&ion. For whoever tries the experiment of eoniprefcng the thorax in a body that has been dead fome time, will be fen- fibk PUERPERAL FEVER. 3i part will aifo operate in the fame manner in the liv- ing body, wherefoever there is a general putrefactive' tendency ; nor need we be furprifed that the womb itfelf fhould be found in a gangrenous ftate when we confider the great diftenfion it has undergone, and that it has afterwards fuddenly collapfed, and has been kept fome time imbued with the stagnat- 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 ten lion, forenefs and tendernefs of the lower part of the belly, and are not constant- ly affected with thofe excruciating pains which gen- erally attend common inflammations of the bow- els ; but it frequently manifests itfelf to be of a ma- lignant kind, occasioned 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 offenuvenefs of the air that is forced out of them." On the Difeafes of the Army, Appendix, p, 84, 4to. edit, 82 PUERPERAL FEVER. of management, and to a difference in the constitu- tions 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 position, pro- ducing an abforption of putrid or acrid matter, and is not occasioned 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 instance, if a woman of a ftrong constitution, and of a pleth- oric habit of body, be feized with this fever, and fpirituous liquors and hot fpices be given her, fhe will have a ftrong hard pulfe, and the fypmtoms of inflammation will run fo high as to indicate the neceflity of copious bleeding; and when the fever is farther advanced, a delirium, fubfultis tendinum, Sec. 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 fubject to> hysterical complaints be feized with this fever, and have any large evacuations either naturally, or procured by art, a train of hysterical fymptoms will fucceed. And laftly, it mult be obferved that though all the fymptoms here enumerated have been feen in different patients, yet it muft not be imagined PUERPERAL FEVER. 33 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. i782, as given in the report of a memoir of Mr. Doulcet on 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 1 have endeavour- ed to advance-tin this fubject. " But without entering into long difcuflions '« on this fubject, which would require deeper refearches than the time and •• limits of this repprt will permit, we will content ouvfelves with obferving, " that all the defcriptions we have of this difeafe, which are numerous, pre- •' fent it under tivo principal characters, that is, as a.*, highly inflammatory, •' and as a putrid difeafe. The inflammation is announced by the tenfion " and pain of the belly; and the putridity is evidently marked by the " weaknefs and fmallnefs of the pulfe, the proftration of ftrength, and the " exceflive fcetid evacuations. The more the putrid charafter 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 more w of an inflammatory nature, and at the fame time not fo alarming ; thofe '• of White, Leake, and Slaughter, as the moft putrid and moft fatal difeafe. " Of four women who were attacked with this difeafe in the Hofpice de " Vaugirard, three had aweakpulfe, remarkable proftration of ftrength, «' and extremely foetid evacuations ; and all three died. The fourth was " more robuft, and the fymptoms were fo violent as to require feveral bleed- " ings, and fhe was the only one who happily recovered. This proftration " of ftrength, therefore, which charafteiifes the putridity? is one of the '• worft figns of this difeafe. It is chiefly in hofpitals that it affurnes this " charafter, and it has no where been either fo rapid, or fo generally fatal, " as in the Hotel Dieu,»for fome years part. Does it in thefe cafes partake " of the nature of the hofpital fever ? This is the fentiment of Mr. White.'' Vid. Whitehead's TranC p. 31, c GH A P. 34 "r> 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 greateft probability that it was, from feveral paffages in Hippocrates*, Cel- fus, * " Octavo fudor frigidus per omnia membra diffufus eft, cum puftulis rubentibus, rotundis parvis, varis non abhmilibus, qux permanebant neque abfceflum faciebant. Hipp, de Morb. vulg, lib. 1. feet. 3. eeg. 2. Per magnos aeftus affatim & continenter compluit, idq; ab auftro magis* Sanies quidem plurima cuti fubnafcebatur, qua; intro conclufa dum incalef- aeret, pruriginem excitabat. Deinde vero in puftulas erumpebat iis amncs, quae in ambuftis fieri folent. Hip. de morb. vulg. lib. 2. feft, s. In febribus autem xftivis circa feptimum, octavum, & nonum diem, af- predines quasdam miliaceae, culicum morfibus fere Gmiles, quae tamen non admodum pruriebant, in fumma cute fubnafcebantur & ad judicationem uf- que perdurabant, Ibid. lib. 2. fea. 3. Euphranoris MILIARY FEVER. 35 fust, iCtiusJ, Haly Abbas§, Fernelius|jjFrancifcus Valefius*, Petrus Forreftus t, Ballonius J, and Sen- nertus. Euphianoris filio, puftulas culicum morfibus non abfimiles eruperunt,ve- rum pauco tempore duraverunt, poftridie febris irtvafit." Ibidi lib. 5. + De puftularum generibus. At puftulas maxitne vernis temporibas oriuntur. Earum plura genera funt. Nam modo circa totum corpus partemve afpredo quaedam fit, fimilis his puftulis, qux ex urtica, vel ex fudore nafcuntur; exanthemata Gr«eci vo- sant, eaique modo rubent, modo colorem cutis non excedunt. Nonnunquam plures, fimiles varis oriuntur, nonnunquam majores. Puftulas, lividcs funt,aut pallida;, aut nigrae, aut aliter naturali colore mutato : Subeftque ilhs humor. Ubi ha: ruptas funt, infra quafi exulcerata caro apparet. Phly&asna; helcodes Grasci nominantur. Fiunt vel ex frigore, vel ex igni, vel ex medicamentls. Celfus, lib. 5. cap. 28. J Fiunt etiam aliquandb puftulas rotunda; inequales, fubalbidas aut fubrn- brai, cum elevatione caronis. jEtii Serm. 5. cap. S29 De Puft. in feb. cur. ex Herod. $ Haly Abb. Reg. Difpof. Theoric. lib., viij. chap. xiv. II Exiguae & aquofas puftulas funt hidroa, id eft fudationes. Emergunt re- pente fparfim toto corpore, fed frequentius in manibus pedibufque, milii magnitudine, aqua plenas, fine rubore, fine ulio dolore. Fiunt enim ex fu- doribus fubepidermide coercitis, per cujus fpiracula hi digeri minime pof- funt : Unde a quibufdam fudorum papulae nuncupantur. Fernelii univerfa med. lib. 7. cap. 5. p. 242, . • Francifcus Valefius in Hipp, de morb. vulg. com. lib. 2. fe£t. 3. + Petrus Forreftus obf. 59. p. 205. lib. 6. vol. t. De Purpura intus rei percufTa. Obf. 60 De Purpura papulas rubentes habente. Obf. 6s De Muliere fudamina habente, & a medicaftris male traftata unde tandem mors fubfecuta eft.---- % Antequam calidis iflo invafiffet viris & majoribus apparebant maculae, echthymata, Miliares puftulas et caetera, id genus idque arftate maximi, fed. nullum id adferebat periculum. G. Ballon, Epid. & Eph. lib. 2. p. 80J. Conftitutio autumnalis. A. D.s577. C 2 36 MILIARY FEVER. nertus§. It is evident that it was known to Riveri- us ||, who does not fpeak of it as a new difeafe. But we have no accurate defcription of it till the middle of the laft century *, when it was firft obferved in the § Verum cum Exanthematum genus duplex fit, unum, quod colorem cutis faltem mutat, ut fit in febribus petechialibus, alterum in quo tuhercula quse- dam in cute erumpunt, puftularum & papularum nomen non utriquer fed pofteriori faltem generi congruere videtux, et papulae ac puftulas faltem tuber- eula fignificant, in quibus humor aliquis continetur. Senert. Tom. 3, lib. 5. p. s. cap. 22. p. 771. || Exanthemata a maculis purpureis differunt ; ex eo quod maculas ad qualitates mutatas ipfiis cutis, cum nullomodo emincant; exanthemata vcro- ad tumorum genera referuntur. Sunt enim varorum inftar aliquando alias ve-rb 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 mortifkatione. Quon- dam fymptomatice, quasdam critice, quasdam medio modo erumpunt. Alia exficcantur fimplicitcr, alia fuppurantur, alia ulcerantur. Laz. River, Prax. Med- lib. 17. feCl, 3. cap. 1. de febre peftilenti. * Gottofredus Wclfchius Lipfienfis, Chirurgiae & Anatomicae Prof. pub. Hift. Med. Puerpcrarum morb. continens, qui ipfis der Fritrjil'dicitur & (Fe- bris eft maligna Miliaris) Lipf. 1655 Chiift. Johannis Langii Prax. Med. eap. S3, de febribus feci. 9 de Purpura, & torn. 3. p. 351. Georg. Hieronym. Velfch. carat. Med. Decad. i curat ij Febris Coccinea in Pucrpera. Carol. Rayger. inMif. rutui. cur. ann. tertii.xU febre ssalign. dim, Exanth, Miliar, obf. 281. p. 496. ' Mich. Etmullcri oper. Med, Theoret, Pracr.. torn. 2. cap, S7. art. 3, p. 1047— De Furpura, feu febre Miliari Puerpcrarum, Jof. Nichol. Pechlin, obfj I'ii; !• Med, lib. 2. p. 2^9, v.b[, 19 Exanthema- ta euro, & fine febre, MILIARY FEVER. 37 the city and neighbourhood of Leipfic in Germany. It began amongft puerperal women without distinc- tion of age. It foon fpread itfelf all over Germa- ny, and proceeded to other countries. The faga- cious Sydenham*, obferved it firft in England in Feb. 1685. According to his account it began in a thaw, after the breaking up of a froft, which, though fevere, had not continued fo long, nor had been fo intenfe as that of the preceding year. A variety of Authors || who have written on this difeafe have differed greatly, not only with regard to * Sydenham. Sched. Monk de nova; febris ingreffu, p. 643. H Sir David Hamilton de febre miliari, Boettigeri differt. de purpura rubra epidemic. J. White, M. D. de rerta fanguinis miflione, or new and exaft obfervations of fevers. Sir Richard Blackmore on the plague. Juncker. confpea. Medicin, tab. 74. p. 596. Allen. Synops. art. S497, &c. Ful- ler on eruptive fevers, purple fever, p. S30, Miliary fever, p. 157. Hoff- man de febre purpurata rubra & alba miliari, torn. 2. feft. s. cap. 9. p. 68, James's dift. art. purpurea. Huxham's Effay on fevers—On the Ulcerous Sore Throat—Obf. de aere. Mead Monita Med. Levret L'art des accouch. VanSwieten'sComment, or Boerhaave's Aph. fe£l. 723, 982. Ant. de Haea traa. de febrium divifionibus. Dr. Storck's Bienn. Med. Heifter's Obferv. obs. s83,356, 475. 583— Compend of Phyfick, p. 125, 4a4. Home's Medical Farts. Pringle on the Difeafes of the Army. 4to edit. Edinburgh Effays, phyf. and lit. vol. 2. Sir Richard Manningham on the Febricula. p. is6. Allionius Traft. de Miliarum progreffu. Lieutaud. Synops. Univer, Pr. Med. Febris Mitiaris Puerpcrarum, p. 476. J. Fordyce Hift. Feb. Milia- rs. The Cure of the Miliary Fever by a fubject of Mithridates, king of Pontus. Baker's Obf. on the prcfent epidemical Fever. Glafs's Commen- taries on Fevers, p. s 70. Denman on the puerperal Fever, p. 48. Johnlon's Midwifery, p. 366. Smellie's Midwifery, vol. s. p. 4*°- Hafenorhl Hift, Med. Morb Fpidemic. p. 5. Haller PhyfioL vol. 2. p. 399' EnSlifll ediu bv C3 38 MILIARY FEVER. to its nature and caufe, but in reffp '61 to its fymp- toms and method of cure. Some have afferted that it is a fever fui generis, and that the eruption is crit- ical ; others that it is a creature of our own mak- ing, and that the eruption is produced entirely by the ufe of too hot medicines ; others again are of opinion, that the miliary eruption is critical, but allow that an eruption fimilar to this may be pro- duced by fweating, yet do not give us any criterion how they are to be diftinguifhed ; others likewife fay that this difeafe is not always terminated by any one fort of crifis. Some fay that the eruption is red, others that it is white or pearl coloured, cryfta- line or veficular, and that the red eruption is only a fimple rafh. Some mention two forts, red and white, and when both appear together, call the dif- eafe compound ; an appellation which others ap- ply when it attacks pregnant or puerperal women, or is complicated with other diforders. Some al- lege that it chiefly attacks weak and exhaufted perfons, fome that it attacks thofe of a bilious con- stitution, others that it feizes all indifcriminately. Authors by Mihles. Med. Obf. &. Inq. vol. 4. p. 29, in a paper on the Seltzer wa- ter, by Dr. Brocklefby. Commercium literarum for the year s 735. Bu- chan's Domeftic Medicine, p, 244. 574, Lobb's Practice of Phyfick, vol. 2. p. S41. Brooke's Practice of Phyfic, vol. 1. p. 181. Mem- del'Acad. des Sciences, Pan. 1747. Macbride's Experimental Effays, p. 192. Lind's pa- pers on Fevers, p. 86. 106. Etherington's general Cautions in Fevers, chap, 5. p. 50. Dr. Piniard's Account of the Epidemic Difeafe which raged at Rouen in 17 53. Dr. Wall's Account of the Ulcerated Sore Tbipat, Med. Mufeum,vol. t.p. ssg, MILIARY FEVER. 39 Authors have varied much as to the time when the eruption appears, fome have perceived it as early 4s the fifth day, fome on the feventh, or eighth, others on the tenth or eleventh, and others again as late as the fourteenth, fifteenth, and sixteenth, and even on the twenty eighth, as I have been in- formed ; whilst fome have declared that no precife time can be afcertained for its appearance. How- ever, they feem to agree in fome particulars ; as, That puerperal women are peculiarly liable to it. That it is a difeafe of a malignant or putrid ten- dency. That the eruption is promoted by fweating in bed, and is the moft plentiful on thofe parts of the body which have fweated the moft. That the pultules at laft come out with a gentle and continued, or a copious and profufe fweating ; but that thefe profufe fweats are not critical, what- ever the eruption may be. That patients are fubject to more crops than one. That miliary eruptions have however been known at different times to accompany inflammatory fevers, and molt of the diforders incident to the human body. That a happy event does not depend either upon the largenefs of the quantity, or the earlinefs of the C 4 eruption 3 <40 MILIARY FEVER. eruption ; but that, on the contrary, the fuller and the 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- cumstances 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. " 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. e; Moft things that are ufeful and noxious in pu- trid fevers, are the fame in this." If we next confider the fymptoms of the miliary fever, we fhall ftill find a great similarity with thofe 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 oj>preffion, fighingand dejeaion of MI LI ARY FEVER. 41 ofvipirit$, fo much infilled on by all authors, are the pathognomonic 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 thrufh, loofenefs, ^ale urine, and the quick and weak pulfe. Some have faid that the tenfion and tendernefs of the abdomen are pathognomonic fymptoms of the 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 hectic heats, lofs of appetite and of fpir- its, and fwellings of the legs, feet, and thighs; but thefe are nothing more than what follow other pu- trid fevers. Thofe who have had this fever, are particularly liable to returns of it during their whole lives; owing moft probably to the fkin being over relaxed, and its tone destroyed, by a too hot and forcing treatment. To * " The tenfion and teadernefs of the abdomen have been laid down as pathognomonic fymptoms of this difeafe. I mutt confefs my doubts in this point, 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 ajofe only from an accumulation of indigefted aliments in the prim* via:; since by giving a purgative, which brought away a large quantity of very putrid feces, they were entirely removed. Befides.they are to be found in a miliary, fever, as will be flsewn in the next chapter." Johafon's Midwifery, P; 35* 42 MILIARY FEVER. To what has been already faid I mult beg leave to add my testimony that I have frequently feen in puerperal women, miliary eruptions both of the red and the white kind, without any fever fuper- vening, and 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 doctrine might have been treated as chimerical, but now I do not doubt I fhall ealily 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 §, I have not the leaft doubt; and the relation of the follow- ing incident may help to prove the affertion. When ^ Doctor Shebbeare, though no friend to the cool regimen, fays," The moft effectual way is to fupport the vital heat by the gentleft means, and in an equable manner, otherwife the miliary eruption maybe rather a fymptom of the Phyfician than of the diforder, as it is to be feared that fome, through mistaken 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 as tends." Practice of Phytic, vol. 2, p. S44., MILIARY FEVER. 43 When I began to prattife midwifery, a midwife (fince dead) had for a long time been in poffeflion of great praftice amongst all ranks of women, and in other refpects was tolerably fuccefsful; but a re- markable number of women under her care were affected with the miliary fever, which proved fatal to many, particularly the wives of feveral of our principal tradefmen, 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 Manchester 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 fhe could difcover an eruption, which at laft 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 foon recovered—-How far fear might operate in this cafe I leavethe 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 bed 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 the fome occasions have, by obferving the dire&ions 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 perfect ftate of health, (excepting the local complaint, for which they underwent the operation) and no other reafon could be affigned for this eruption, but the patient's being, of a relaxed habit of body, and fweating in bed. I have often feen miliary eruptions at different peri- ods, and under different circumstances, but I can- not, upon the strictest inquiry, find that a miliary eruption was ever produced without a fweat; either in MILIARY FEVER. 45 f* in a greater or lefs degree; and yet we know that moft other eruptions will frequently come out with- out a fweat, as the fmall pox, meafles, fcarletfever, 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 greatest quantity of them in thofe parts which are the clofeft covered, efpecial- ly if covered with flannel. * Avery ingenious Phyfician at Chester 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 had known the miliary eruption often to accompany the rheuma- tifm, and many other fevers, but from obferving a * The fame gentleman has Tavoured me with the following note. " 1 have frequently feen miliary eruptions unattended with either fever or danger, and have had patients attacked with fevers of the low nervous kind, fighing, opprcf- fion about the praecordia, 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 fymptomatic than critical; the patients recovered without any miliary eruption,-'1 46 MILIARY FEVER. a different method of treating fevers in general, he was fully perfuaded that this was a fabricated fymp- tom, and never had feen it evidently critical. The testimony of Dr. De Haen, of Vienna, is fo important, fo striking, and coincides fo intimately with the doctrine I mean to eftablifh, that it is with great pleafure I quote the following paffages from his works. * During the fix years in which he had been Phyfician 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 fact be compared with in- numerable cafes of miliary and petechial eruptions intheBienniumMedicum 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 miliary erup- tions, but thefe not often. He gives feventeen cafes of petechial and miliary eruptions, moft of the latter : They are all brought to prove that thefe eruptions are not critical, that they arife fometimes from infection, that the blood is often' fizey in thefe cafes, that in fome cafes they are produced by clofe. bad air, and fweating, and that •Vol. I. Chap. 29. MILIARY FEVER. 47 that the bark is an excellent remedy in thefe erup- tive fevers J. Forty.pages are employed in confuting his adver- faries concerning the caufe, &c. of miliary and petechial eruptions. He afferts that hot medicines, regimen, and clofe warm rooms, are the caufes that thefe complaints are fo frequent at Vienna— that they arife fometimes aifo 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 JjEgri ergo numero S7 fpatio 6£ annorum Petechias, aut Miliaria, aut utrumque, in nofocomio praftico habuerunt, adeoque quinque circiter omni biennio. Pars media horum, exanthemata, antequam ad me adferrentur, jam habuerant; pars altera iifdem in nolocomio praftico correpti funt; ergoinibi fpatio trium annorum, exanthemata haec quatuor duntaxat aegris eruperunU Omnium vero duo tantum fuere, quibus id fponte contigerit ; reliquis 15 aut contagium, aut pravum regimen, medendive methodus, aut combitiatc has caufe, exanthemata produxere. In nemine vero illorum ea critica fuiffe, ipfa cujufque morbi hiftoria abunde evicit.—Concludo, fi plerifque xgris meis, citra exanthemata, integrs contingant, felicefque crifes; tunc exanthemata ilia, aliis medicis adeo frequentiffima, critica utique appellari non poffe. _ rr r Vol. 2. Cap, s. p. 13. w * Spatio decern fere annorum 14 homines exanthematici in nofocomio noftro fuere : Oao fcilicet exanthemate petcchiali, quos inter cum variolis una ; xs folo miliari: V utroque; eofque inter una cum pcffimis variolis, affecti: Horum nemo critica; eruptionis notam fuftinuit." Vol. a, Cap. s. p. 395. ^ " Cramer, pluries mihi narravit, dum plura millia Borufforum captivorum atmo 1757 & 1758 fuse cur* demandati effent, inter 300 eodem tempore, acute 4& MILIARY FEVER. From the foregoing obfervations the following inferences may, I think, be deduced: l. The miliary eruption of child bed women is frequently a fymptom attendant on fevers, caufed by 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 more, and even fometimes to appear without any fever attending, or fucceeding; and, as by removing the difeafe in its early ftage the eruption may be to- tally prevented, it cannot be called critical. 3, The cooling and extinguifhing method of cure (as it is called) cannot prove prejudicial in the early ft ages acute ut plurimum, laborantes, vix quatuor aut quinque exanthemata paflfos eff.r ; ilics vero quatuor vel quinque, aut nimium teftos, aut arete conclufos fe repevifie, antequamfibi demandarentur : Leuca autcm a fe diftanti pago, ubi ab initio morbi calida methodus in ufuerat, vix a-grotaffequofquam, qui exan- thesnate non macularentur : A militibus in incolas contagium tranfiifie ; pluref- que,una cum medicofuo,exanthematumgcnitore,mortemoccubuiire." p. 42s.. Miliaria hoc anno in nofocomio nulla. An quod extincta Vicnnx ? Min- ime, fed quod eadem non fabricemus. Tom. 3. p. 43. Cap. iij. de Miliaribus 1765. Tranfit,cum bono Deo iterum, pro more, annus Academicus fine miliaribus, ant petechiis; cum in nofocomio, turn in urbe, & fuburbiis apud aegros qui mihi ad confilia voeato, obtemperarunt in toto regimrne in alftinentia a spedtcina, & pfsferfrm in quotidiana kfti refectione. Cap. xi, p, 233. Impr. A. D. 1768. MILIARY FEVER, ^ ftages by checking the eruption, if at the fame time it removes the caufe of the difeafe itfelf. 4 Puerperal women are not fubject to this dif- eafe from any other caufe, but that of their being in a ftate much inclined to putridity, attended with a relaxation of the fkin, 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 strictly critical, may we not conclude that the eruption is oceafioned 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 mult foon acquire a putrid ftate, even if the patient had no figns of putrefcency before ? In my laft edition, I here added fome annotations from a manufcript copy of Dr. Cullen's lecture on the miliary fever, as taken down by Mr. Bew, a very ingenious apothecary in Manchefter. At that time it gave me no fmall fatisfaction 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 fi0 MILIARY FEVER. happy to find them fmce confirmed by the doctor's late publications on the fubject, in the Firft Lines of the Practice of Phyfic, vol. 2. p. 100; and in the fecond volume of his Methodical Nofology*. I mv ft aifo here return him my belt 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 idiopathkus (it, praeter opinionem medicorum, a medio feculi decimi ad hunc fere diem, omnium, et contra fententiam medicorum hujus svi, quorundam fpectabil- ium, affirmare non aufim ; fed cum experientiam in hsec re faspe fallacem, et medicos plerofque imitatorum fervum pecus fuiffe noverim, dubitare cogor ; et, utcunque fit, morbum miliarem plerumque fymptomaticum fuifie, ex ob- fervantia propria, per multos annos frequenti, certo novi. Nunquam con- tagiofam, nee manifefto epidemicam, quibufdam licet temporibus folito fre- quentiorem, vidi. Morbis febrilibus quibufcunque, turn inflammatoriis turn putridis, aliquando adjungitur; in nullis tamen, nifi regimine calido et fudo- ribus praeeuntibus, ortum, & in pluribus regimine temperato, et fudoribus vitatis, morbum, alias expectandum, prorfus vitatum obfervavi, &c." Vid. Synops. Nofol. Method, vol. 2, p. 140. CHAP. CHAP. III. of the MILK FEVER. 5* HE proximate cause of the milk fever is an accumulation of milk in the breafts, fo as to occafion confiderable tenfion, tumefaction, pain, and heat ; and if a degree of force be ufed to extract 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 fhiverings, thirft, inappetency, heat, and quick pulfe ; the matter will either find its way externally, or will be abforbed, and produce hectic fymptoms. I never knew it terminate in gan- grene, andfeldom in fchirrus, except from mifman- agement. D 2 The 52 MILK FEVER. The remote causes may be many and various; as cold, which conftringes the diameter of the vef- fels, and renders them impervious : platters; fpir- ituous, or hot applications to drive back the milk; a hot room ; too many clo.hes ; 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 ftate as to render this difficult ; and too fudden, or too early a stoppage of the blood from the uterine veffels, which, by the anaftomofing of the epigastric 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 obstruct the flow of milk into the breafts, whence aifo it is always moft violent in the firft lying in. The fmall flat nipple which Jies buried in the breaft is generally occafioned by the tight drefs, which has for fome centuries been fo conftantly worn in this ifland by the female fex of all ages, and of almoft all ranks, the molt laborious and neceffi- tous alone being excepted. This drefs, by con- ftantly preffingupon the breaft'and nipple, reduces it to a flat form, inftead of that conical one, with the MILK FEVER. 5$ the nipple in its apex, which it ought to preferve 5 and the nipple is buried in the breast. By being conftantly kept in this position, 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 greatest confequence to their daughters whenever they are in a puerperal ftate. The tightnefs of the flays is alone fufficient to do much harm, but they are aifo, often made hard and unpliable by packthread and whalebone, which muft greatly increafe the mifchief. I will here fubjoin a 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 consider- 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 _yekas, detach minute branches for the feparation of the milk, which uniting as they proceed to the nipple, form fmall canals, called the lactiferous tubes: thefe are about feven or eight in number, commu- nicating with the bafis of the nipple, and general- D3 ly 54 MILK FEVER. ly opening at its apex by the fame number of ducts, though fometimes two of them open by a common orifice. The ducts adhere to a tough ligamentary elaftic fubftance, which is continued from the gland, and terminates with the ducts in the nipple. This ligamentary fubftance and thefe ducts which it contains, are capable of extenfion and contraction to a great degree, artdm their natural ftate 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 fubject 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 fkin of the areola, are diffeminated little glands, known to anatomists by the name of feba- ceous glands. Thefe fupply an oily mucus, to defeYd the areola and nipple from that abrafion w"feich would otherwife be the confequence of fuc- tion, and likewife to glue up the mouths of the la6tiferous 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 MILK FEVER. 55 From this structure of the breaft we are enabled to explain the reafons of the feveral phaenomena of fuction. Why the milk does not flow fpontane- oufly from the breafts in all fubjects. It is pre- vented by the convoluted position 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 futtion. The tubes are elongated and unfolded, the febaceous gluten feparated from their orifices, the stream of milk keeps the tubes straight, and their channels free from impediment. By fuction 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 preffed into the tubes at a time when they are straight and open. The operation of fu&ion itfelf depends upon the principles of the air pump. The air being ex- haufted from the laftiferous tubes by the action of the child's mouth, the preffure 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 aifo exhauft- ed of air. Hence it will appear evident why women of rank, and thofe in the middle stations of life, meet with difficulty in giving fuck to children, and have gen- D 4 erally fi6 MILK FEVER. erally more or lefs of a milk fever, in their firft lyings in, but if they fuckle their children, and meet with proper treatment, have never any afterwards. Hence it will appear why hard working, labouring women, who are obliged to go very loofe about their breafts, generally make good nurfes, and that too with very little trouble. CHAP. 57 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 study of the utmoft confequence to every one who practifes furgery or midwifery. Wuhout a perfect knowledge of this branch of phyfick, the practitioner cannot hope, at leaft he ought not to expect, fuccefs, either after feveral of the principal furgical operations, or af- ter the deliveries of women, whether they be natur- al, praeternatural, or laborious. As foon as a woman has conceived, and a* flop is put to the ufual return of her menfes, it has gener- ally been imagined, that moft of her diforders, and the •t* 58 DIRECTIONS for the the danger of mifcarriage, arife principally from a plethora, and bleeding has almoft conftantly been prefcribed. This mode of practice may be good in fome cafes, but it ought by no means to be adopted as a general rule, when we confider the cufloms of the prefent times. In the days of Queen Eliza- beth, when our anceftors breakfasted upon more fubftantial food, and lived a more active life than we do at prefent, inflammations, and all thofe dif- eafes which are incident to plethoric habits, were extremely common in this ifland. With a change of diet, and mode of living, it is well known we have experienced a change too of thofe difeafes for fuch as are the conftant attendants of relaxed and weak fibres. There are few diforders of either fex which now require fuch copious bleedings as they did half a century ago; for in lefs than that time a confidera- ble alteration has taken place amongft us. It is not probable that the catameniaare caufed by a general plethora ; but even if this were allowed, it would not from thence follow that it is the cer- tain attendant of the pregnant ftate. For if we cqpfider the large quantity of blood which mult necessarily go towards the fupport of the child, and the natiea, vomiting, and almoft total lofs of appe- tite, which are the frequent concomitants of preg- « nancy PREGNANT STATE. 59 nancy in its early ftate, it will appear that if a pleth- ora did at the very firft exifl, it mult in many constitutions have a very fhort duration. I have known feveral ladies of delicate, tender, weak con- stitutions, with bad appetites, who never went to their full times when they were.bled during pregnan- cy, and as conftantly became the mothers of heal- thy children when that operation was omitted ; fo that the maxim of * Hippocrates, that venasfection in a pregnant woman will produce a mifcarriage, efpe- cially if fhe be far gone, although by much too gen- eral, appears to be not fo ill founded as has been lately fuppofed ; efpecially if we confider the re- laxed constitutions in the warm climate where he lived t. I * " Mulieri uterum gcrenti vena fecta abortionem facit, idque potiffimum fi fetus grandior fuerit." Hipp. Aph. 31. feet. 5. + Dr. Lobb, in treating of the danger of abortion, has fome ufeful and in- genious obfervations on this fubject. He computes the monthly difcharge of women at five, fix, or feven ounces at a medium. Suppofing it feven, the total quantity in ten lunar months amounts to feventy ounces, or four pounds,fix ounces. But the weight of a child with its placenta and membranes, is great- ly fuperior to this ; for in an inftance which he adduces, that of the child was fixteen pounds feven ounces, and that of the placenta, one pound four ounces. As all this quantity of matter muft firft have exifted in the mother's arterial fyftem, he concludes, that during pregnancy there muft be a continual dimi- nution of the quantity of blood, and inftead of danger from a pletb^pm, thafc^ a women will never be in fo much want of blood in any period* of herhfe. This appears aifo from the thinnefs of the face and body during that pe*d. Hence he infers the danger from bleeding of caufing an abortion, by dTniiniih- jng the vital ftrength of the mother, and depriving the childjBf its due nour- ishment. He obferves from fact, that young women who have their full Go DIRECTIONS for the I have experienced the happy effects of giving affes milk, Pyrmont, and Seltzer waters, bark, and not only the dulcified, but the acid vitriolic elixir. I have known fhort rides on horfeback, repeated daily, procure fuccefs when total confinement would not ; and have for a great number of years been fenfible of the good effe&s of cold bathing*, not only in preventing mifcarriages, when every other method has been likely to fail, but other diforders which are incident to pregnant women, and gener- ally quantity of blood, their fkfh firm, their bodies ftrong and agile, and inured to exercife, fcarcely ever fuffer abortion, except from fome violent occafion ; whereas they are moft fubject to mifcarry who are of a tender constitution, have lax mufcles, a feeble pulfe, and too little blood. Compend. of the Practice of Phyfick, p. 89, & feq, • 1 have not only obferved the good effefts of cold bathing in pregnant women, but have for fome few years paft recommended it to nurfes giving fuck, who have reaped great advantages from it. What firft put me upon this praaice was the information I had gained that feveral of the women at' Scarborough, who made it their bufinefs to attend upon ladies during their being in the fea, found that whan they were nurfes they had better health, were much ftronger, and had greater plenty of milk than they had at other times before they began this practice. There is a contrivance for bathing in the patient's clofet, which I am in- armed has been practifed many years in Scotland, and which is really very commodious* The machine that contains the water is made of tin, and is fufpend'.'d over the patient's head, who ftands in an empty tub, furrounded by blaiskets, which are fixed to the machine ; every thing being thus prepar- ed, the patient pulls at a cord, and the water falls upon her through a cul- lender'.^ , Dr. Liud fays, " The ufe of the cold bath, cither in a tub, or to dip in the fea early in the morning, has been round extremely beneficial in warm .. Zjx weather, PREGNANT STATE. 61 ally attendant upon a weak lax fibre. By cold bathing I do not mean the making ufe of a bath, cold to the greatest extreme, but the ufe of fuch as that at Buxton, or at Matlock, of fea bathing, or bathing in a tub in the patient's own houfe, with the water a little warmed. I have frequently ad- vifed my patients to bathe every other day at a time when the flomach is not overloaded, and not to flay at all in the water ; to begin this procefs as early as poffible, even before they have conceived, as there will then be no danger from the furprife, and to continue it during the whole term of preg- nancy ; and feveral have bathed till within a few days of their delivery. From the fuccefs I have feen attend this practice in preventing mifcarriages, and many of the diforders peculiar to the pregnant ft.ate, particularly naufea and vomiting, I am fatif- • fied they are much feldomer to be attributed to a plethora than to weak lax fibres, and a fympathet- ic weather, and in hot countries ; and that he can affirm, from his own experi- ence in hot climates, that many diarrhoeas and other complaints, the pure and fole effect of an unufualand great heat (relaxing the fyftem of the folids, and oc- cafioning a colliquation of the animal juices) have not only been cured, by cold bathing, but their return and the attack of fuch difeafes effectually pre- vented by it." On the Health of Seamen, p. 44* Dr. Whytt, fpcaking of cold bathing, fays, " I (hall only obferve, that I have known it of great fervice to feveral women, who chiefly from a weak- nefs of their nervous fyftem were liable to abortions." See likewife Sir John Floyer and Dr. Baynard on Cold Bathing. 62 DIRECTIONS for the ic affection of the nerves from a distention of the uterus : And in thefe cafes I have generally found that exercife, bark, elixir of vitriol, and Pyrmont water, joined with cold bathing, have had the beft effect. I am convinced that bleeding is too indifcrimin- ately ufcd, and too often repeated; and that though it may on fome occasions give immediate relief, yet upon the whole it muft aggravate the complaints, weaken the patients, and render them more liable to putrid difeafes. But I would not be understood to mean that bleeding is never neceffary: in fome habits and in inflammatory diforders, it certainly is fo, par- ticularly if the patient complain of a fenfe of fulnefs, pain of the head and back, with a ftrong full pulfe, &c. and has had a better appetite and ufed lefs exer- cife than before her pregnancy; but even in plethoric cafes unattended with inflammatory fymptoms, aff- es milk, Seltzer water, elixir of vitriol, and an ac- tive life, anfwer the fame purpofe as bleeding ; with this advantage, that they will obviate the pref- ent plethora without favouring its return, which is a ftrong objection to frequent bleeding ; at the fame time that they strengthen and brace thefolids. Riding on horfeback, and indeed all kind of ex- ercife, muft be avoided, when any fymptoms of abortion appear ; on that occafion, total reft and a recumbent pofture are^undoubtedly of the greatest confequence. PREGNANT STATE. 63 confequence. Nor is much exercife proper at the latter end of pregnancy. THe keeping the inteftinal canal open is an ar- ticle of great importance ; for this purpofe vegeta- bles and ripe fruit in large quantities may be al- lowed, bitter antifeptic purges in fmall dofes fhould be given every, or every other night, and even aloet- ics (if the patient be not fubjeft to the piles) mixed with other antifeptic refinous gums. The ufe of thefe will prevent the inteftines from being plug- ged up by accumulations of hardenerj^ceces, where- by putrid flatulencies are generated. Gentle vom- its may be administered with fafety and advantage, in order to cleanfe the ftomach when neceffary, and teas made of bitter antifeptic herbs may be drank daily : vegetable acids, columbo*, and like- wife * Though the columbo root has not yet made its way into any of the difpen- fatories, nor been mentioned by any author we are acquainted with, yet it has been given in England thefe thirty years or more, in obftinate vomitings, and in many other complaints of the ftomach and bowels. It was firft brought to Manchefter by a worthy Apothecary, about five and twenty years ago, and has been conftantly given ever fince in bilious diforders of both fexes : he had it from Mr. Robinfon of Richmond, a gentleman with whom he lived, who had given it for feveral years for fuch like complaints. Mr. Robinfon brought it from the Eaft Indies, and faid the natives there frequently took about as much of the powder as would lie upon a fixpence in a glafs of ar- rack, for the difeafes I have mentioned, and it was generally attended with fuccefs. Dr. Percival, whofe merit as an author is fufficrently known to the medi- cal world, has been fo obliging as to favour me with fome ufeful experiments he has lately made upon this valuable drug, and which he intends in a Ihort time 64 ' DIRECTIONS for the wife neutral mixtures, taken during the act of ef- fervefcence, which are all antiputrefcents, operate to the fame end, and are generally of great fervice in vomitings occafioned by a redundancy of acrid putrid bile. Raw eggst taken at any time during pregnancy, time to publifh. The refult of thefe experiments are, that columbo root is inferior as an antifeptic to the Peruvian Bark, in preserving animal flefh, hut fuperior both to the bark, and to camomile flowers, in preferving bile from putrefaction, and in reftoring it when putrificd. That an infufion of the,bark, when mixed with putrid gall and faliva, inftantly produced a coagu- lation of the gall, and considerably increafed the factor of it ; whereas an in- fufion of columbo united perfectly with it, and very powerfully corrected its offenfive fmell. Tlmfe experiments, I think, explain to us the mode of its aCuon, and the reafon of its fuccefs in bilious vomitings, and many other af- fections in the ftomach and bowels, and point out to us what diforders it is likely to relieve and cure. Hence the Doctor very justly infers that the util- ity of the columbo root .muft be evident in difeafes ota putrid tendency, or in an impaired digeftion from vitiated bile or corrupted faliva. . \ ■f- It is not improbable that the temporary jaundice, to which women with child, new born infants, and even adults of both fexts, are frequently fubject, ewes its origin to the ftoppage of the mouth of the ductus communis chole- dochus, by fome tenaceous gluten obftructing, either totally or in part, she paflTageof the bile into the duodenum, and thereby occafioning its return in- to the blood. The attention I have paid to jaundiced patients of both fexes, and of every age, who have been cured by frequently taking raw eggs in cold fpring water, has inclined me much to this opinion. My fuppofition is, that eggs act as a diflblvent of the gluten which obftructs the mouth of the duct, thereby opening a free paCage for the bile into the duodenum. We know that yolks of eggs wijl deftroy the tenacity of the gums and refins, and ren- der not only them, but aifo oils and natural balfams, mifcible with water* The firft trial I had of this remedy was upon rnvfilf, a!>out fourteen years a^i, when I had been afflicted with the jaundice many weeks, and was much reduced, no bile having for a long time paft into the inteftines, when my fkin was almoft b'.ack, and after ! had in vain taken large quantities of foap ■sadder, fteel, rhubarb, ani-aloetic medicines. An officer of marines told me PREGNANT STATE. 65 pregnancy, but efpecially at the latter end of it, are very ferviceable, (provided the ftomach will bear them.) in preventing and curing that temporary jaundice to which fome women are liable. If the patient me that if he might be allowed to prefcribe, he would immediately cure me. 1 laughed at his propofal; when he informed me, that fome years before, in the Mediterranean, he w;:«. troubled with the kme diforder to as great a degree as myfelf, and that after he had ineffectually tried all the remedies the Surgeon of the (hip could think of, a Spanifh Phyfician at Minorca bad afTur- ed him he could cure him in a few days, by this fimple prefcription only- two raw eggs, the whites as well as yolks, to be taken every morning in a glafs of water falling, with the addition of an egg every four hours during the day. That in three days after following this advice he began to perceive the bile in his ftools, though none had appeared in them for many weeks be- fore ; that he immediately began to recover, and was very foon effectually cured. Upon confidering the diflblvent property of yolks of eggs, and that eggs muft at kail, afford a nourifhment totally void of acrimony, I began to entertain a more favourable opinion of the recipe, I tried it and found it hid exactly the fame effect which he promifed me. Though I was certain no bile had pafTed through me for fix weeks before, upon taking the eggs only three days it began to flow, and in only one day more in as great plenty as I could wifh, I continued, however, to take them feveral months, and have never fince.had any return of the diforder. I have recommended the ufe of them to many perfons under the fame com- plaint, and have always had the fatisfaftion of rinding their fuccefs, except in cafes where the diforder was occafioned by a difcafed liver, or by ftoues in the gall bladder. Is not the following cafe and difTectiou trom Sir John Pringle fome proof of what I have advanced ? u A gentleman of thirty fix years of age, who die ed of a diopfy following an obftinate jaundice, was opened about twenty four hours after his death. The liver, by its tendernefs, feemed to be in a cor- rupted ftate. The gall bladder was full of bile, and three times larger than i« common. The duftis communis was fo cloizlyjlopped at its entry into the 4uod:num that no bile could be fqueezed out of the bladder into that gut." Appendix to the Dif. of the Army, sr&. E 66 DIRECTIONS for the patient cannot take raw eggs, or the diforder ftiould prove very obstinate, a fmall dofe of calomel may be given with fafety and advantage. Lacing the flays tight has been practifed not merelv in conformity to the rules of fafhion, but from a mistaken notion that by prefling the chil- dren lower down, the mothers would have better times. This I will venture to fay is one of thofe vulgar errors which have not the leaft foundation in either fact or reafon.. I never yet knew chil- dren lie too high. In their natural fituations they are much lefs inconvenient to their mothers, and are carried with greater eafe ; to which I muft add, that- the mothers have at leaft as good or better times than when they are preffed down too low, by which means the belly of the mother becomes pendulous, and the child is troublefome to carry ; the inconvenience increafes too with every child, and where the mother has had a great number, the weight at laft becomes intolerable. The conftant preffure of the uterus upon the bladder in this cafe occafions frequent motions to make water ; an in- continence or involuntary difcharge of it fometimes comes on, and it is attended with many other in-, Conveniences. I would advife every pregnant woman to wear jumps buckled on very flack, having broad eafy jhoulder PREGNANT STATE. 67 flioulder ftraps, with tapes fewed to the bottom of the jumps, to which the petticoats and pockets may be f«iflened ; fo that there may be neither tightnefs round, nor weight upon the belly, »but when the woman is in an upright pofition, as much of the weight of what fhe externally carries as poffible, may hang from her fhoulders. This will preferve the womb from being preffed too strongly againft the lower inteftines, and will help to prevent that coftivenefs, and that inconti- nence of urine which are too often attendant upon the pregnant ftate. But when the belly is r«mark- ably pendulous, preffing too much upon the pubes, fo as to occafion thefe troublefome fymptoms, in order to counterbalance this preffure, a bandage may be worn under the fhift, its lower edge com- ing to the pubes before, and fupported on the fides by the hips, or fpine of the ilia. The upper edge fhould furround the abdomen above the point of its greatest diameter, to prevent its flipping down, unlefs the hips fhould prove a fufficient fupport. This bandage, or kind of under waiftcoat, fhould be drawn tight, with a lace behind, according as circumstances require, and fhould likewife be fup- ported by ftraps palling over the fhoulders. In the latter months of pregnancy, the frequent lying down upon a couch or bed in the day time will give great relief to the mufcles, by taking off E 2 the 68 DIRECTIONS, &c. the. incumbent weight, and thereby preventing thofe pains qf the belly, back, hips, and thighs, and thofe fwellings of the legs which are fo ufual at that pe- riod. The directions I have attempted to lay down in this chapter will admit of many variations accord- ing to particular circumftances ; but, in general, I can fpeak with confidence of the advantages refult- ing from them ; and fo far from containing any thing that can weaken or injure the constitution, I have no doubt that the obfervance of them will greatly tend to eftablifh the general health of the patients, ' V CHAP, op Of NATURAL BIRTHS, particularly of the Secundines, and the PREVENTION of AF* TERPAINS. HE retention cjf the fecundines has^ in almoft all ages, engaged the atten- tion of the profeffors of the obftetric art. Controverfies and difputes have arifen, and different modes of prac- tice have been purfued, yet the proper treatment has not hitherto been precifely determined. There are fome who contend for the manual extraction, immediately after the birth of the child, in all cafes indifcriminately. There are others who leave the bufinefs entirely to nature, in every cafe whatfoev- er ; and there is yet a third clafs, who purfuing a middle courfe, try gentle methods for a while, and, upon the failure of thefe, proceed to manual ex* £ g traction* fo Of NATURAL BIRTHS. tra&ion. Advantages and di("advantages are faid to attend thefe various modes of practice. The firft of thefe has now the feweft advocates, for certain pain and danger muft attend the opera- tion, and in almoft every cafe, the odds are great that it is totally unneceffary. The feoond is fup- ported by profeffors of great abilities and experi- ence ; but the fecundines fometimes acquiring a great degree of putridity, by retenfion for many days in the uterus, or not coming away at all, but occafioning putrid fevers, and fometimes flooding* fo violent as to bring on the patient's death, thefe reafons, added to the general difcontent arifing from the retention, not only to the patient, but her friends, have very juftly prevented this mode from being generally adopted. The difadvantage faid to attend the laft method is this ; by waiting an hour or two, you lofe the opportunity of extracting the fecundines, the womb contracting, either at its mouth, or acrofs its mid- dle, like an hour glafs, by which contraction, lac- eration is endangered, if the hand be forced into the uterus. The bringing the art of midwifery to perfection, upon fcientific and mechanical principles, feems to have been referved for the prefent generation. We have Of NATURAL £lRTliS. *jt have been but lately able to explore the fecret ope- rations-of nature. The ancients, and even the moderns, till within a few years paft, were not on- ly entirely ignorant of the pofition of the child in natural labours, but even during the whole time of pregnancy : they had not properly confidered the exact form and dimenfions of the pelvis*, and the effect thefe muft neceffarily have upon the infant'? head, during the time of its delivery. Sir '* * On the whole, it is of the utmoft confequcnce to know, that the brim sf the pelvis is wider from fide to fide, than from the back to the forepart; but that at the under part of the bafon, the dimenfions are the reverfe of t!*i* proportion, and that the back part in point of depth, is to the forepart ad three to one, and to the fides as three to two." Sincllie's Midwifery, vol. s- p. 8tJ ^ In this Table, befides the general ftrufture and figure of the feveral bonesi khe dimenfions of the brim of the pelvis, and the diftance between the under parts of the offa ifchium, are particularly to be attended to, from which it will appear, that the cavity at the brim is commonly wider from fide to fide than from the back to the forepart, but that the fides below are in the contra- ry proportion. The reader, however, ought not from this to conclude that every pelvis is fimilar in figure and dimenfions, fince even well formed bnes differ in fome degree from each other. In general, the brim of the pelvis meafures about five inches and a quarter from fide to fide^ and four inches and a quarter from the back to the forepart, there being likewife the fame diftance between the inferior part of the ofia ifchium. All thefe meaf- ures, however, muft be underftood as taken from the (keleton ; for in the fubject, the cavity of the pelvis is cohfiderably diminifhed by its tegument* and contents. Correfpondent aifo to this diminution, the ufual dimenfions of the head of the full grown foetus are but three inches and a half from eae to ear, and four inches and a quarter from the forehead to the hind head." Smcllie's Explanat. of his firft Anatomical Tables E 4 72 Of NATURAL BIRTHS. Sir Fielding Ould*. in a Treatife upon Midwife- ry, publifhed at Dublin in 1742, was the firft who feems to have difcovered that the fituation of the child in the beginning of labour is not with its fore- head towards the mother's back, but turned to one fide. But though he was the firft that gave the hint, he had not then fo thoroughly confidered it as fome others have done fince the publication of his Treatife. Doctor Smellie publifhed his firft volume of Mid- wifery in 1752, and his Anatomicalt Tables in 1754, wherein he. has more fully explained this matter. "*" •v^^ We are obliged to Dr. Johnfon, whofe General Syftem of Midwifery was publifhed in 1769, for the confirmation, and farther illuftration of the manner in which the child's head paffes through the pelvis. I muft here take notice of an error in practice, which has not, that I know, been remarked by any writer * Treatife of Midwifery, p. 2?. + Notwithftanding it has been handed down as an invariable trilth, from the earlieft accounts of the art, to the prefent times, that when the head of the foetus prefented, the face was turned to the pofterior part of the pelvis yet from Mr. Ould's obfervation, as well as from fome late diffectionsof the gravid uterus, and what I myfelf have obferved in practice, I aai led to be- lieve that the head prefents, for the moft part, as is here delineated, with one ear to the pubes, and the other to the os facrum ; though fometimes this may vary, according to the form of the head, as well as that of the pelvis." Smellie's Explanat. of his 9th Anat. Table. Of NATURAL BIRTHS. 73 writer on this fubject : It depends upon the fol- lowing principles : Thefe great improvers of the aft, confidering la- bour as a mechanical operation, have perceived that the head in its paflage through the pelvis muft al- ter its direction, according to the width of it in dif- ferent places : but here they flop fhort. Thev have not applied this rule to the fhoulders, which, though not forming fo great an obftacle as the head, are yet certainly capable, by their bulk*, of forming; " * A middle fized woman brought forth by the natural efforts a large fized child, whofe weight and dimenfions were as follow : The weight ten pounds and eight dunces tToy, The diameter of the head from temple to temple was three inches and an half, from the os frontis to the occiput four inches and an half, and the circumference at thofe parts was thirteen inches, " The breadth of the body at the fhoulders was five inches, the length of the head from vertex to chin fix inches, and that of the whole child full twenty one inches. " A young woman who was mufcular, fmall fized, and in her pregnancy had fuftained a very tedious and violent labour, at laft, by force of pains brought forth a child, whofe weight was only eight pounds five ounces troy ; its head however was of the following dimenfions : From temple to temple four inches, from os frontis to occiput five inches and an half, the circumfer- ence at thofe parts fourteen inches ; and the length, from vertex to chin, was eight inches and an half. " This child's head was greatly fqueezed out in length, by the violent comprcfTure which it had fuffered in its courfe through the pelvis. " A large woman who had borne feveral children, in 1759 brought forth a child of the following weight and dimenfions : The weight fourteen pounds and one ounce troy, the length of the whole bvdy twenty two inches and an 74 Of NATURAL BfRTHS. forming a refinance when offered in a wrong pofi- tion. Now the greatest breadth of the head being in a line which forms a right angle with one which paffes through the fhoulders, it neceffarily follows, that all the turns made by the fhoulders muft be oppofite to thofe of the head. When the head paffes with the face towards the facrum, and the hind part of the pubes, the fhoulders muft pafs fideways ; and vice verfa. Accordingly we find that this is the way in which nature herfelf pro- ceeds, though art has neglected to pay attention to it. We are directed by all writers in midwifery to bring out the fhoulders as foon as the head is pro- duced, by taking hold of the head and pulling it forward in the fame direction ; whereas when the natural pains are allowed to accomplifh the work, they always come out with a turn, which throws the broad part of the fhoulders into the fame direc- tion in which the largeft diameter of the head had lately been, that is, one fhoulder to the facrum and the other to the pubes, or nearly fo. By this im- proper " The diameter of the head from temple to temple four inches ; from os frontis to occiput five inches and one eighth; its circumference at thofe parts, fifteen inchds ; and its length from vertex to chin five inches and one fourth. " The circumference of the body at the fhoulders, arms included, eighteen inches and an half ; and at the ilia fifteen and an half. The breadth of the body at the fhoulders, feven inches, and at the ilia fix inches." Johnfon's Midwifery, p. 12^ Of NATURAL BIRTHS. 75 proper interference of the artift, violence is offered to the vagina. The womb and its ligaments fuffer by an undue diftenfion, and thus, I have reafon to be- lieve, inflammations, prolapfufes, retentions of u- rine, and a train of difagreeable fymptoms are often caufed. This improper and too hafty delivery of the fhoulders, in natural labours often occafions the retention of the fecundines, and is in fome meafure the caufe of afterpains ; for the womb be- ing improperly flretched out, and the body of the child prematurely delivered without a natural pain, the womb, inftead of contracting regularly from its fundus, is thrown into fpafmodic strictures, ei- ther at its mouth, or acrofs its middle. By this means the fecundines are retained till thefe unnatur- al contractions are overcome ; and the mouths of the finufes or uterine veins are clofed before they could have an opportunity of gradually contract- ing and of difcharging themfelves of the blood which they contain, the ferous part of which drains away and leaves the craffamentum behind in the finufes, which grows the more fibrous the longer it remains ; and the parts being irritated by this extraneous body, endeavour to difburden them- felves, by what are called afterpains*. Before * Dr. Burton advifes a method of preventing afterpains being very troub- iefome, which I doubt not would be effectual, but at the fame time fo pain- ful and fo unnatural, that I apprehend it cannot bepractifed with any degree of propriety. The plan I have laid down will be as effectual without being liable to thefe objections, He fays, " Where I have been employed for perfons 76 Of NATURAL BIRTHS. Before we attempt to give aid to nature, it is our* du.y to watch her operations, and to trace her through all her paths; taking care at the fame time riot to mi (lake her efforts for thofe of art, and to Temember that few of the human race in this part of the globe arc in a ftate of nature, for which prop- er allowances muft be made. We fhall then be better able to afiTift her when fhe flands in need, and to fet her right if by any accident fhe has been diverted from her courfe. Let us confider the moft natural cafe of labour that can poffible happen. Shcjuld a flraight healthy young woman, who had never fuffered from improper drefs, inactivity, or unwholefome diet, be feized with labour pains, upon an open common, totally unattended, and wi'uh no afliftance near, fhe would for fome time —* walk about, then fit down to reft, then rife and walk again, till for her own eafe, and the fafety of the child, fhe would find it neceffary to lie down*. During pcrfons who always in former tedious labours were afflicted with violent af- teipains for fome confiderabletime, I have relieved them; for by keeping my fift at the fundus uteri, and gently moving it in a rotatory motion, an incredible number of thefe clots have come out of the finufes in a very little time, and hav- ing brought all out of the womb, the afLerpains have been trifling afterwards." Eflay on Midwifery, p. 346. * Dr. Denman is of opinion, and 1 think with great probability of truth, that resting on the hands and knees, is the pofition inftinctively fought for, and perhaps moft natural in time of labour. Yid. Introduction to tlw Practice of Midwife:y, Part s. p. $8. London. 1782, OfNATURAL BIRTHS. 77 During this time the mouth of the womb would be gradually opening, and the dilatation would occa- fion a feparation of the fpongy chorion from the womb. The communicating veffels breaking, they would difcharge a lymph moiftening the vagina and the external parts with a mucilaginous liquor. She would have intervals of eafe, and perhaps dur- ing thefe intervals fome fleep. The membranes with their contained water would advance, and at laft bursting, the remainder of the water would gradually drain away, and further help to moiflen the parts. The womb would be contracting by degrees during every pain; the head would ad- vance and make the proper turns ; the perinaeum would gradually ftretch and lengthen, fill a pain had forced the head into the world. She would then have a little refpite. The pain returning would drive the fhoulders forwards, making their proper turns, and accommodating themfelves to the different dimenfions of the pelvis, till they were quite excluded. She would then have another ref- pit£. The returning pain would expel the hips, but with lefs difficulty, the womb continuing to contract itfelf regularly as the child advances, when in confequence of the pain the whole child would be delivered. If the navel firing fhould break, it would not bleed. After a little while, when fhe had fomewhat recovered herfelf from the fatigue (he had undergone, and the womb had ftill further contracted 78 O* NATURAL BIRTHS. contracted itfelf, another pain would expel the fe- cundines. If the funis fhould not break, after the child has cried a few minutes, or a quarter of an hour, the circulation in it would ceafe. Whether it broke or not, there would be no danger of an hae- morrhage from it, provided it was not cut. If tha fecundines be wholly excluded before the puliation in the navel firing is flopped, no bad confequences will enfue, the circulation will flill be carried on betwixt the child and the placenta as perfectly as if it were in the womb, till the child's lungs are fully expanded, and the neceffary alterations have taken place. Thefe circumftances fhew the great care of nature in the preservation of her produc- tions. The poor woman would now be rejoiced at her relief from pain, and her delivery from her burden, but being over fatigued, (as well by the agitation of her mind as that of her body,) fhe would naturally fall into a gentle number. When fhe awoke, her next care would be for her tender offspring. She would fit up, take it in her arms, and apply it-to her breafts, where it would find food of a proper quality, and in quantity fufficient to fupply its trif- ling wants. She would not long remain in this fitu- ation. She would foon get up and walk to procure needful fuflenance for herfelf. This defcription is not merely ideal, it is what happens every day, with a trifling change of circum- ftances. Of NATURAL BIRTHS. 7g fiances. The female favage, the foldier's wife up- on her march, and many women privately deliver- ed of their illegitimate offspring, experience the truth of it; but I do not hence infer that the cafe would be the fame with every woman. I know it would not. Tender constitutions, hereditary difor- ders derived from the intemperance of our ancef- tors, and made worfe by improprieties of drefs, by indolence and improper diet, render this impoflible. But we fhould always have nature in our view. By clofely studying her, we learn in what manner to give her affiltance when fhe Hands in need of it. Neither would I from hence infer, that art is nev- er neceffary. I know it fometimes is in every ftage; in pregnancy, in labour, and after delivery; but it frequently happens that thofe who are the bufieft when there is no neceflity, are the moft incapable of giving relief in cafes of real danger. The prac- titioner fhould be well verfed in the knowledge of anatomy, phyfiology, and the mechanical laws ; he fhould not only understand the theory and prac- tice of midwifery, but of phyfic too; he fhould have patience, experience, and humanity; courage and dexterity in operating, together with prefence of mind, and fhould be in conftant practice. I do not fay that ftrength is neceffary, dexterity will more than fupply its place. The ufe of instruments is fometimes needful, notwithstanding any arguments to the contrary, but the 86 Of NATURAL BIRTHS. the too free ufe of them ought by no means to be encouraged. They are fometimes unneceffarily applied, and are frequently productive of great mifchief ; but many lives, not only of mothers, but of children, have been faved by them, of which every One muft be fenfible, who has been much verfed in general practice. In all natural parturitions I would purfue the fol- lowing method : In the beginning of the labour I would be fo far from confining my patient to any one pofition, that I would not even confine her to a fingle room, but would let her walkabout from one apartment to another. Whenever a pain fhould oblige her to lie down, I would take that oppor- tunity of examination, that I might know whether the child was in a right pofition, and how fait the labour was advancing, and this is beft done when the pain is going off. As foon as I was fatisfied of its right pofition, I would acquaint my patient with it, that I might afford her every comfort in my power ; but I would not encourage her, by telling her that the child would foon be born, with- out there was the greateft certainty of it, left fhe fhould be difappointed, and think the time long; and left, by fuch encouragement, fhe fhould at- tempt to affift herfelf, and thereby exhauft her strength and fpirits. During the whole time of her travail fhe ought to enjoy the freeft air; fhe ftiould Of NATURAL BIRTHS. gi fhould not be crowded with more friends or attend- ants than neceflity required, and the door, and even the window of her room, in fummer time, fhould be kept open. Too much care cannot be taken to prevent the air in the room from being rendered foul, or the patient being overheated at this time ; for if her labour fhould prove tedious, and fhe fhould for many hours be kept in a burn- ing heat, or in a fweat, the velocity of the blood would be much accelerated, the perfpiratory ducts would be obstructed by the fweat, and the patient would be much weakened; the air of the room ai- fo would be fo contaminated by fweat, and the per- fpiration from the fkin and the lungs of the patient and her affiftants, as not to be foon purified again. But the danger does not flop here. Should this treatment be continued, a fever is the inevitable confequence; fhould fhe be fuffered fuddenly to cool, the perfpiration is flill more obstructed and a fever is in this manner brought on. The keep- ing the patient continually cool, and the air free from putrid effluvia are matters of the utmoft con- fequence. The neglect of thefe cautions often lays the foundation of puerperal and miliary fevers. When the patient is coftive, a clyfter* fhould be administered to empty the lower inteftines. This will •Theelaftic vegetable bottles are greatly preferable to common clyfter bags for adminiltering clyfters. F S* Of NATURAL BIRTHS. will likewife help ,to remove thofe fpafms which are fo common in the beginning of labour. If the infant do not advance, and the mother fhould fuf- fer many fhort, but tormenting pains, without man- ifest advantage, there will be reafon to fufpect that thefe pains are fpafmodic, or what are generally call- ed falfeor fpurious, being only contractions of the abdominal mufcles, not of the uterus ; but this may be eafily known by examining whether the os ute- ri begins to dilate ; if it do not, an opiate will re- lieve her, and regular pains will probably follow. Should the labour begin with a diarrhea, the fymptom is far from being bad, but is frequently attended with the happieft effects by unloading the inteftines. If the patient become too cool and low, warmth and cordials may be allowed her, but thefe fhould be no longer continued than abfolute neceffity requires. As the labour advances fhe ■will feldom complain of cold, except fhe have been kept too hot, and have fweated profufely. The patient generally requires more air, and can bear Tnore cold than her attendants. Where the accoucheur is fatisfied that the labour is natural, and that every thing is proceeding well, the patient fhould not be teazed by attempting to haften her delivery, nor even by too frequent ex- aminations. When Of NATURAL BIRTHS. B3 When the bufinefs is fo far advanced that there is reafon to believe the child will foon be born, it is in my opinion ofgreat confequence that the wom- an fhould be in an horizontal pofition, and it will be moft convenient if fhe lie upon her fide with her back towards the practitioner. Placing the pa- tient upon her hands and knees is not an unfa- vourable pofition in natural labours; and it pre- vents the child from prefling too much on the pe- rineum. In fome preternatural cafes too, it is of- ten of great fervice. Other positions indeed, fuch as standing, fitting, hanging by the arms between two perfons, half fitting and half lying, either up- on the bed or on the knee of an affiflant may be, and I believe are often, ferviceable in expediting de- livery, and are therefore extremely proper in flow tedious labours, except at their conclufion • but I would by no means advife that the child fhould, in any cafe whatever, be born, or the placenta ex- tracted in any of thefe pofitions. Very hafty de- liveries, efpecially in fuch pofitions, are often of dangerous confequence, frequently occasioning lac- eration of the perineum and fphincter ani, prolap- fufes of the vagina and anus, inversions of the ute- rus, retention of the fecundines, floodings, after- pains, fyncopes, faintings, and death itfelf. I cannot here help condemning the freerand in- difcrimiuatcj ufe of the greafy applications, They. are Fa U Of NATURAL BIRTHS. are not only frequently unneceffary, but if they be ufed in fuch quantities as to prevent or deftroy the action of that mucus which nature has prepar- ed for the purpofe of lubricating and moiftening the parts, they may be prejudicial. Though, on the other hand, if there be not a proper quantity of this mucus fecerned, or if it be exhaufted by a te- dious labour, thefe applications may be proper and even neceffary fubftitutes. When the perineum begins to protrude, the preffure of a hand againft that part will give great eafe to the patient ; the degree of preffure muft be left to the judgment of the perfon employed; but if the pains be very forcing, it ought to be fuch as will prevent a too hafty delivery. If this caution be obferved, and the patient be kept in an horizon- tal pofition, there will be no danger of a laceration of the perineum. ^ As foon as part of the head is produced, it is the cuftom of many practitioners to feize hold of it immediately, and to drag it forth with the great- eft expedition, as if the fafety both of the mother and the child entirely depended upon it. This practice is founded upon a grofs mi flake, and the patients often fufter from this piece of rafh- liefp, from many obferyations which I have made v/ithin Of NATURAL BIRTHS. 85 within thefe few years, I am convinced that upon the management of this part of the delivery de- pends the eafy or difficult exclusion of the fecun- dines, and the prevention of afterpains. Leave things to nature, and in general fhe performs her work the beft without affiftance. After the pa- tient has recovered herfelf a little, the pain will Teturn, the fhoulders will make their proper turns, and be properly expelled. Should the navel firing be wrapt round the infant's neck and fhoulders, nay, fhould it even be drawn tight, the child would not for a confiderable time, fuffer as the circulation in it does not ftop before it has undergone a very great diftenfion. After the child is expelled in this gradr ual manner by the force of the woman's pains, the womb by degrees contracts itfelf from its fundus; its neck, and even its middle, being kept from con- traction by the part of the infant which remains within. Where nature is very flow in relieving herfelf, affiftance ought to be given, but not till it is feen how far fhe is able to do without it. The common method of tying and cutting the navel firing in the inftant the child is born, is like- wife one of thofe errors in practice that has flphing to plead in its favour but cuftom. Can it poflibly be fuppofed that this important event, this great F 3 change 86* Of NATURAL BIRTHS. change which takes place in the lungs, the heart, and the liver, from the ftate of a fetus, kept alive by the umbilical chord, to that ftate when life can- not be carried on without refpiration, whereby the lungs muft he fully expanded with air, and the whole mafs of blood, inftead of one fourth part, be circulated through them, the ductus venofus, fora- men ovale, ductus arteriofus, and the umbilical arteries and vein muft all be clofed, and the mode of circulation in the principal veffels entirely alter- ed—Is it poflible that this wonderful alteration in the human machine fhould be properly brought about in one inftant of time, and at the will of a byftander ? Let us but leave the affair to nature, and watch her operations, and it will foon appear that fhe itands not in need of our feeble affiftance, but will do the work herfelf, at a proper time, and in a better manner. In a few minutes the lungs will be gradually expanded, and the great altera- tions in the heart and blood veffels will take place. As foon as this is perfectly done, the circulation of the navel firing will ceafe of itfelf, and then if it be cut, no hemorrhage will enfue from either end: notwithftanding this, it will be always advifeable to tie it, as an hemorrhage might come on if the circulation fhould be quickened by the warmth of the ctojies arid the bed. If the funis be cut imme- diately after the birth of the child, or before the pulfation in it ceafes, that end next to the placenta. will 0 Of NATURAL BIRTHS. 87 will bleed about three or four ounces, and if that end next to the child were not tied, it would in all probability bleed to death. Whatever method be purfued it is better not to tie that end next to the placenta, for the more it is leffened by the blood being drained from it, the greater liberty is given to the uterus to contract. By this rafh, inconfiderate method of tying the navel firing before the circulation in it is flopt, I doubt not but many children have been loft, many of their' principal organs have been injured, an{J foundations laid for various diforders. When the infant is removed, the fecundines are fometimes found wholly expelled : fometimes the placenta is extruded from the womb into the vagi- na, in which cafe it is to be handled gently, and with great care gradually brought away, left any parts of the caduca*, chorion, or amnios, fhould be left behind, for this would occafion a very pu- trid difcharge, together with pain and a fever. Thefe membranes are fo extremely tender, that they will bear very little force, and it frequently will be many minutes before they can be brought away after * The third external membrane, which is very fpongy, was firfidifcover- ed by that great anatomift, Dr. Hunter, and is by him very propeily called dccidua, or caduca, as it appears to be a lamella call off from :he internal fur. face of the womb. F4 88 Of NATURAL BIRTHS. after the expulfion of the placenta, the fpongy cho- rion adhering fo clofely to the womb. Sometimes an interval of eight or ten minutes fucceeds the birth of the child, when a pain coming on, the fecundines will be eafily extra&ed by gently pulling the na- vel firing, and here an eafy preffure upon the ab- domen, by aflifting the uterus to contract, will be of fervice. If the placenta be very large, a finger may be in- troduced to bring down one edge of it as foon as it is within reach. But whatever method be made ufe of to bring it away, the patient fhould continue in an horizontal pofition. In this manner I have proceeded for feveral years, and during that period I can with fatisfaction de- clare, that in natural labours I have never had oc- casion for the manual extraction of the placenta; I have never left my patient till it came away, nor have I ever been detained a fingle hour by it; nor fmce I practifed this method have I often had oc- casion for the ufe of opiates, or any other medi- cines, to relieve the afterpains, which have general- ly been fo trifling, both with regard to violence and duration, as not to deferve notice. As to laborious or preternatural parturitions, they do not fall under my prefent consideration, and Of NATURAL BIRTHS. 89 and I fhall only obferve, that prefentations of the feet, knees, or buttocks, muft be treated in the fame manner as natural prefentations, and the ac- coucheur fhould wait with patience till the breech is born, when it will frequently be neceffary to give fome affiftance, left the child's life fliould be loft, by its head preffing the navel firing againft the pelvis, folong as to ftop the circulation in it. CHAP. ' 90 PREVENTION of CHAP. IV. Of the PREVENTION of the PUERPERAL, MILIARY, and MILK FEVERS. S foon after the woman is deliv- ered as it can be conveniently done, clean linen fhould be put about her, fhe fhould be left to the moft perfect quiet of body and mind, that fhe may, if poffi- ble, get fome fleep. The child fhould be removed into another room, and no vifitors, or other per- fons, except fuch as are abfolutely neceffary, fhould be allowed to enter the patient's chamber. A num- ber of people, befides preventing repofe, foul the air, and render a frequent fupply neceffary. From hence appears the difadvantage of a fmall apart- ment. Where the patient has it in her option, I would always recommend a large lofty room upon the firft chamber floor, and could wifh it (if in fum- mer) to have a northern afpect, but if that cannot be PUERPERAL FEVERS, &c. 9i be had, there fhould be window blinds placed on the outfide of the windows, for when they are on the infide, they do not anfwer the purpofe of keeping out the heat of the fun. In this room there ought to be no fire in fummer, and little or none in winter whilst the patient is in bed, unlefs fhe has been -uf- ed to fleep conftantly with one in her chamber ; for though fires are undoubtedly of the greateft fervice in keeping up a circulation of air, yet at the fame time a conftant fire in a fmall room, when a perfon has not been accustomed to one, may overheat the patient. This I know will be objected toby the nurfes, upon their own account, efpecially if they be to wake, but waking is what I do not approve, except on the firft night, and then only if the deliv- ery be late in the evening. It will disturb the pa- tient much lefs if the nurfe have a fmall bed in the room, but I would by no means fuffer the child to remain there, if. accommodations can poflibly be had for it in any other part of the houfe. The pa- tient fhould not be disturbed in the night, either up- on pretence of giving her liquid or folid nourifh- ment. If either be neceffary, fhe will naturally of herfelf demand it. Much mifchief is often done by binding the bel- ly too tight *. If there be any occafion for sup- port, * '• Ties difeafe (the puerperal fever) it muft be acknowledged, may fol- low * la'our under the beft circumftances, but endeavours to dilate the os. internum, $i PREVENTION of port, a thin napkin pinned very flightly round the traift,is all that is abfolutely neceffary, and the foon- er this is difufed the better. But if there really were occasion for ftrong compreffion, the common methods would be extremely inadequate. The compreffion muft neceffarily be unequal, the large hipbones of women effectually preventing fuch means as thefe from making an equal preffure up- on every part of the uterus. „ The thick fuftian waiftcoats and petticoats ufual- ly worn during the lying in, are much too warm. In the whole article of drefs and bed clothes, noth- ing fhould be added to what the patient has been accuftomed to in perfect health. In a few hours after delivery, as foon as the pa- tient has had a little reft, fhe fhould fit up in bed, with a bed gown thrown over her fhoulders. If fhe propofe to fuckle the child, it fhould now be laid to her breaft, whether there are figns of milk or no. This fhould be repeated four or five times a day, but in the night it is not neceffary either that the breaft fhould be adminiftered, or that any kind of v food fhould be given to the infant. The-patient fhould lie very high with her head and fhoulders, and fhould fit up in bed many times in internum, and too hafty a feparation of the placenta will produce it, and binding the abdomen tight after delivery." Denman on the Puerperal Fever, p. s&. PUERPERAL FEVERS, 8cc. $3 in a day, efpecially when fhe takes her food, and as often as fhe fuckles her child, and fhould kneel whenever fhe has occafion to make water, which fliould be often done. This frequent upright pofture is of the utmoit confequence, and cannot be to much enforced. It prevents the lochia from stagnating, the ftools and urine from being too long retained, and promotes the contraction of the uterus^ together with that of the abdominal mufcles. Large quantities of caudle, and thick gruel mix- ed with ale, wine, or brandy, are often very per- nicious. They clog the ftomach, and pall the ap- petite. Strong liquors, as they are apt to heat, fhould not be given to the patient, unlefs fhe has been accuftomed to them. Thin water gruel, well boiled and ftrained, panada, fago, wort, falep, bar- ley water, to which a fmall quantity of lemon juice has been added ; teas of all kinds, but particular- ly thofe of bitter antifeptic herbs, fuch as camo- mile, or buckbean ; coffee, cocoa, and chocolate, buttermilk alone, or mixed with fpring water, im- perial, orange, or lemonade, or plain toaft and wa- ter may be allowed, provided none of them have been found by experience to difagree with the patient. None of thefe liquors fhould be given hot; the cooler they are drank the better, and they may 34 PREVENTION of may even be given perfectly cold. Toafted bread, feabifcuit, or fomething folid fhould be taken to pre- vent faintnefs ; and as foontas the patient has an appetite, her food fhould confift"of boiled bread pudding, boiled fowls, lamb, or veal, vegetables, and ripe fruit. Too much animal food fhould not be allowed, and it fliould never be eat oftener than once a day, and then not without bread and greens, roots, or fome kind of vegetables. The North A- merican fago powder, diffolved in boiling water, forms a moft agreeable, tranfparent, mucilaginous, vegetable jelly, which is demulcent, restorative, and nutritious ; obtunding the acrimony of the fluids, and correcting putrefaction ; of a .more pleafant tafte, in my opinion, than/alep, and much cheaper than the foreign falep, though not fo cheap as that produced in our own country, and prepar- ed in the manner directed by Mr. Moult in the Phil. Tranf. vol. 59. p. 1. Whatever water the patient drinks, either alone or in gruel, teas, &c. fhould not be fuch as is taint- ed with any putrid animal or vegetable fubftances, which is generally the cafe in all refervoirs of flag- rant water and in rivers adjoining to large towns. Broths *, or foups made of flefh meat, efpecially if given warm, are improper, as they are apt to throw " * .The French, ar3 many other nations, give their patients meat foups, in c< acute difeafes, and after capital op.;sUors5,and they allow them but little _________________________________________________________________" bread, PUERPERAL FEVERS, &c. 95 throw the patient into a fweat, and promote putre- faction. If the patient cannot, or do not choofe to jiuckle her child, fhe fhould be very abftemious in her diet ; but if fhe fuckle it, a much greater lati- tude may be allowed. Fruits, vegetables, and all kinds of acid or acef- cent food have generally been denied to nurfes, upon a fuppofition that they created acidities in the childrens' bowels. This in fome constitutions they certainly do, but the rule is by no means gen- - eral. I have known nurfes abounding in acrid pu- trid bile indulge freely in thefe kinds of food with great advantage to themfelves, and with no difad- vantage to their infants, as plainly appeared by the r " bread or other preparations of vegetable fubftances ; but thefe foups, with- «« out bread, do not nourifh the patient fufficiently, and tend too much to " the putrefcent; and this is one reafon why more fick die in the French, " than in the Britifh hofpitals." Monro on the difeafes of the Britifh military hofpitals, Note to p. 373, Dr. Lind, fpeaking of a marine hofpital erected at Jamaica, upon a moft unhealthy fpot of ground, fays, " The recovery of patients in that hofpital " was obferved to be very tedious, and uncertain ; the leaft indifcretion or «' irregularity brought on a relapfe. After a flux had been flopped fome " days, the eating of any fort of food, which had a putrid tendency, fuch as " even a mefs of troth, would fometimes in a few hours bring on a return of " the difeafe, accompanied with all its violent fymptoms." Effay on the difeafes of the Europeans, p. 174. 96 PREVENTION of the childrens* never parting with green ftools dur- ing the time of their being fuckledt. The heat of the room ought to be fo tempered, that the patient may neither be chilled with cold, nor yet fuffer from fweat or burnings. She fhould be kept in that degree of heat that approaches near- eft to the ftandardof health. Some have kept themfelves in a conftant gentle fweat, or diaphore- sis, as it is called, in order to prevent a rigour, or cold fhivering fit; but it is well known that no de- gree of heat, let it be ever fo great, will prevent the rigour, either in a puerperal woman, or even in a common ague. There have been instances of per- fons having rigours in the hot fweating room of a bagnio, and I have been informed that thefe have been the moft dreadful ; rigours and even com- mon agues are frequent in the hotteft climates. The patient's fkin fhould be foft, but not fo much as moift ; her linen being damp with fweat will render her liable to catch cold; fhe will be fenfible of every breath of air, and cannot rife or even turn herfelf in bed without danger. The apart- ment cannot be ventilated, nor even a curtain be undrawn ; confequently fhe becomes weak, the fibres are relaxed, the lochia becomes accu- mulated and acrid, are reabforbed into the cir- culation, + Are not the four green ftools of children oftener owing to weaknefsand relaxation in their digeftive organs, and the inert quality of their bile, than to the acefcency of the milk ? and, Do we not often fee them change for the worfe, even though the nurfe has made no alteration in her diet, nor has tatted any kind of accfccnt food ? PUERPERAL FEVERS. 97 cutetion, and occafion a fever. Cuftom in this I know is much againft me, as well as in many oth- er particulars ; but'l have hundreds of evidences to prove that fweating is not neceffary even in the fmalleft degree. Much mifchief appears to have been done a- mongfl ignorant people by confounding the ideas of perfpiration *, and fweat. The difference be- tween them has been remarked by fo great a num- ber of authors, that quotations would be endlefs ; it is fufficient for common ufe to obferve, that per- fpiration is that infenfible difcharge of vapour from the whole furface of the body and the lungs which is conftantly going on in a healthy ftate ; that it is always natural and always falutary; that fweat on the contrary, is an evacuation, which nev- er appears without fome uncommon effort, or fome difeafe in the fyftem ; that it weakens and relaxes, and is fo far from coinciding with perfpiration, that it obstructs and checks it. With * Dr. Home has proved by feveral experiments, that a free pcrfpiratiop does not depend fo much upon the heat, as the drynefs of the air ; he fays, 41 Moifture flops perfpiration in a great degree. Dr. Hales has obferved that moifture has the fame effect on the perfpiration of plants." Med. Facts and Experiments, p. 2|jj. A little farther he obferves, that " by thefe two experiments it appear* that the perfpiration is greater in froft than in open weather." Ibid. p. 246. G 98 PREVENTION of With regard to fweating in febrile diforders, ma* fly contrary opinions have prevailed. It was in- troduced with the notion of carrying off by its means the morbid matter which 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 fhall 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- tninated 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. s. patient 6, 7. lib. 2. patient 7. 11, 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 perceiye, 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 prognosticated. 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 are falfe'.y afcribed to Hippocrates, there is only once mention made of a fweat procured or forced by medicines ; for the author of his fee 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 laffitude, or fome other simil- 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 fubject. If there- fore fweats are of any advantage in fevers of this kind, they fcem to derive the efficacy from nature alone. During thofe fweats, perhaps, the peccant matter might be eafily diffipatcd, and carried through the fkin, either on ac- count of the temperance of the climate, or by the good constitutions of the patients, PUERPERAL FEVERS, Sec. 99 From the whole We may conclude, 1. 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 floth and luxury : but in the pref- ent condition of mankind, we in vain expect the folution of a difeafe by fweat, whether fpontaneous and natural, or procured by art : and I believe I may juftly 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 prognosticate 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 pcrfons generally efca-pe, and moft 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 fhould have a vifible moifture on their fkin, but in very warm countries, in hot days this feems 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 fcafon 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 pleafant cure, and is agreeable to the opinion of the vulgar. Cuftom has made it familiar, and the patient finds himfetf relieved when the fweats begin to flow, and if they ftop he is abundantly hoUer, more thirfty, and reftlefs." « But G2 *oo PREVENTION or 2. That fweats are particularly detrimental to women 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- eafe, will frequently quite difappear as it advances towards the height, fo as not to be recalled by the warmeft 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 ftudious of nature, never admitted this method of practice1, and the moderns, more intimately inflructed in the facred myftery of phyfic, always rejected it, yet it is never to be expected that the old women, who have a licence o£ flaying mankind with impunity, fhould ever fuffer themfelves to be taken 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 I he matter with that carefulnefs it deferves, and banifhthis pernicious meth- od from that art which promifes health to mankind." Glafs on Fevers, Comment, so. i ,c Plerumque in piincipio morborum acutorum nocet (fudor) ; rectius tunc fuccedit, quando facta coctione materies morbi per cutem expelli para- la eft. Ipfe tamen per feipfum neque petechias, neque miliarem morbum fa- nat, neque variolas, et periculofe percalida mcdicamenta quseritur, ut ne cali- dus quidem potus nimis tutus fit, quern vidi, de mitiflimis herbis decoctum, bis intra triduum in delirium atrox homincm miliari febre laborantem con- 3«iffc ; qui idem refrigeratione undique qusefita levatus, denique convaluit." Haller. Elem, Phyfiol. torn. v. p. 51. PUERPERAL FEVERS, &c. *oi in the beginning, are alWays in their termination of one of thofe clafles, if they continue any length of time. 4. That the rigour in the paroxifm of an ague is terminated by a fweat, but the continuance of that fweat will not prevent a frefh acceffion. 5. That when the morbific matter is thrown off by the fkin, it muft be an a& of nature, and the moft probable means of promoting that end is to keep the patient in that kind of heat which neareft approaches the ftandard of health, at the fame time promoting a free circulation of air, that thofe mor- bific particles and the human effluvia may not stag- nate about the patient, but be carried off, and their abforption prevented by an effectual ventilation. The chamber door, and even the windows, if the weather be warm, fhould be opened every day. There ftiould be no board or other contrivance to ftop the chimney, on the contrary, it fhould be quite open, that it may act as a ventilator. The curtains fhould not be clofe drawn, that the efflu- via may have the liberty of efcapfng. Carpets are very ufeful, as they render wafhing the room un- neceffary, for moifture ought as carefully to be a- voided as heat or cold, therefore it ought not to be wafhed upon any account as long as ihi p 'tient G 3 flays ioz PREVENTION of flays in it. The room fhould be brufhed, and the carpets taken out every day, to be cleaned and aired. The lying in chamber fhould in every refpect be as fweet, as clean, and as free from any difagreea- ble fmell, as any other part of the houfe. The pa- tient fhould often be fupplied with clean linen, for cleanlinefs, and free, pure, and in fome cafes cool air, are the greateft neceffaries in this fituation; and, upon the strictest examination, it appears evidentto me that there never was a miliary eruption produc- ed without a fweat, nor a puerperal fever without either foul air, an accumulation of excrements in the inteftines, or confinement of the patient to an horizontal pofition, thereby occafioning a ftagna- tion ahd an abforption of acrid matter, except in cafes where violence had been ufed, either in dilat- ing the os internum, or in the delivery of the child or the placenta, or from fome very great imprudence. The fooner fhe gets out of bed after her delivery, the better ; even on the fame day if poffible; fhe fhould not defer it beyond the fecond or third at the farthereft, and then if it be winter time, it will be neceffary to have a fire. Clean, well aired fheets, fhould now be laid upon the bed, but by no means fuch as have been lain in fince their wafhing. If PUERPERAL FEVERS, <5x. 103 If the patient have not every day a flool, one ought daily to be procured. Clyfters are very proper; they will not only procure ftools, but by patting along the arch of the colon, act as fomenta- tions to the whole abdomen, without any griping or other difagreeable commotions. For this purpofe warm water is generally fufEcient; but if the feces be too much hardened, milk, oil, and brown fugar, or the decoct, commun. pro clyjl. with a very fmall quantity of the fyrup of buckthorn, may be admin- iftered : nothing of a more ftimulating nature fhould beufed; it is better to repeat thefe clyfters, in which cafe their end will certainly be anfwered. Should the patient have an aversion to thefe applications, or if a clyfter cannot be adminiftered, either upon account of lacerations in the fpbincter anrii, or from any other caufe, it will then be neceffary to give a little manna, lenitive electuary, rhubarb, caf- tor oil, Rochelle falts or magnefia. Broth clyfters are very improper, as they too much encourage putre- faction, and ftrong purging medicines, either by the mouth or clyiterwife, fhould not be given in the early days of childbed, as they may promote the abforption of the lochia ; but when an abforp- tion has once taken place, then purgatives may be given with the greateft advantage, to prevent the matter from being depofited upon the omentum, per- itoneum, or any of the vifceia. The ftools, urine, and foul linen, ftiould not be permitted to remain in the apartment. G4 If 104 pr£v;ention of If the lochia do not flow fo plentifully as may be expected, or if they entirely ftop, no irritating, forcing medicines fhould be ufed. They nev- er do any good, and are often productive of much mifchief.* If the patient be otherwife as well as can be wifhed, no regard needs to be paid to this circumstance. We not only find this evacua- tion very different in different women, but even in the fame woman in different lyings in, from which fhe recovers equally well. I have frequently known this difcharge to ftop the very firft day, without the leaft bad confequence. If fhe have other complaints, me caufes of thofe complaints muft be inquired into, and the diforder remedied; if this be done, the stoppage of the lochia will be of little or no confequence, and when the caufe is taken away they will fometimes flow again. It is not a prima- ry difeafe: the effect is mistaken for the caufe. Get- ting out of bed is the moft effectual and fafeft method of promoting the lochia. The patient's recovery does not depend upon the quantity of the difcharge, for the evacuation itfelf will * " We have aifo been taught to endeavour ftrenuoufly to remove every obftacle to the regular procedure of the lochia. But it unfortunately happens that almoft all the medicines recommended as emmenagogues are improper in every inflammatory ftate of the blood, and experience proves, that in this cafe all the fymptoms are aggravated by their ufe. " It may not be amifs to obferve, that either a great or a little quantity of the lochia, unattended with other fymptoms, is not to be looked upon as a, difcafc, or meddled with." Denraan on the Puerperal Fever, p, t\. PUERPERAL FEVERS, Sec. id£ will not prevent either the puerperal or miliary fever. It is well known that the laborious hard workinrf women (who, ufing much exereife, feeni to live in a ftate nearly approaching to that of nature) have not fo large a quantity either of the rftenfes ot lochia as the more delicate part of their fex, yet they com- monly enjoy a good ftate of health, and recover from their lyings in much fooner than others. They are the very reverfe of thofe whofe fibres are relaxed by a fedentary inactive life; and I have frequently ob- ferved, that fuch as have the lochia in greateft abund- ance are moft liable to puerperal fevers. It muft however be owned, that after thefe fevers are com- menced, stoppages are not uncommon. All I would here inculcate is, that the danger does not arife from the fmallnefs of the quantity of the difcharge, but from its ftagnation, whereby it becomes acrid, and in this ftate is again abforbed into the circulation. When the difcharge is great, but does not weaken the patient, no remedy is neceffary ; when it does, an infufion of the external rind of oranges, with the bark*, and the acid elixir of vitriol, may, during any period of the puerperal ftate, be given with fafety and advantage. To thefe may be added a ftrength- > ening incraffating diet, blomange, flummery, fago, falep, * The Peruvian Bark has been given to a woman fuccefsfully in the quanti- ty of a drachm every three hours, two days after her delivery, for twenty four iiours, without leftening the lochia: and it has frequently been given to other* during their catamenia without the leaft interruption of them. Med. Tranfact. vol. I. article 21. by D-. V. Heberdcn. 106 PREVENTION of falep, jellies of calves' feet, hartfhorn or ifinglafs. When this diforder arifes from irritations and fpafms, occafioned, as is very often the cafe, by too great an acrimony of the fluids, opiates, and the tincture of rofes well acidulated are generally fuc- cefsful. If the evacuation fhould be exceflive, pro- vided the patient be kept cool, fhe may be indulged with reft in an horizontal pofition, and more power- ful astringents mult be ufed, fuch as alum poffet, and the lixivium martis, given to the quantity of fifteen or twenty drops three or four times a day. Linen cloths or fponge, dipt in cold vinegar J, or water, fhould be frequently applied to the lower part of the abdomen, and to the loins, or what is ftill more effe&ual, an ox's bladder half filled with cold water may be applied to the forepart of the abdomen, the patient at the time lying on her back, which by its coldnefs, and likewife by its weight, making an equal preffure upon the uterus, helps it to contract. If $ Injecting cold water into the uterus is recommended by that celebrated profeffor of midwifery at Edinburgh, Dr. Young, but it is a remedy I have never tried. " Verum arteriolas rubras conftringendo ad hzmorrhagias fiftendas optime accommodatum eft frigus. Ad hoc efficiendum, applicatio topica, in partis effectae vicinia, maxime convenit. In epiflaxe, remediura apudomnes notiffimum eft. aqua frigida, quae ope lintei fronti vel nuchas im- ponitur : nee ullum quidem efficacius invenitur. Nee rarius, neque minore fucceflu, in menorrhagia adhibetur : interdum enim, multis aliis incaflum tentatis, aqua gelida dorfo, modo fupra dicto, applicata fperatum auxilium praebet. In lochiorum profluvio immodico & periculofo eandem multum laudat CI. profeffor nofter Young ; quam in uterum, per horae quadrantem, continenscr injicere jubet." Tucker DifTert. Med. Inaug. p. n. PUERPERAL FEVERS, Sec. 107 If the patient faint away t fhe muft not be routed by volatiles, or any thing elfe applied to her nofe, nor by wine or other cordials given internally. I have frequently known fainting fits put an immediate ftop to violent floodings, by giving the blood time to coagulate in the uterine veins; and large dofes of nitre * have often afforded inftant relief; which I + «' And upon this occafion I recollected a remark of Dr. Hunter's, which is, that the faintnefs which comes on after hemorrhages, inftead of alarming the byftanders, and making them fupport the patient by ftimulating medi- cines, as fpirits of hartfhorn and cordials, fhould be looked upon as falutary, as it feems to be the method nature takes to give the blood time to coagulate." Hewfon's Experimental Inquiry into the Properties of the blood, p. 68. " From this circumftance, that the difpofition of the blood to coagulate is increafed as the animal becomes weaker, we may draw an inference of fome ufe, with regard to the flopping of haemorrhages, viz. not to roufethe patient by ftimulating medicines, nor by motion, but to let that langour or faintnefs continue, fince it is fo favourable forthat purpofe ; and aifo that the medicines likely to be of fervice in thofe cafes, are fuch as cool the body, leffen the force of the circulation, and increafe that languor or faintnefs. For in propor- tion as thefe effects are produced, the divided arteries become more capable of 6ontracting, and the blood more readily coagulates; two circumftances that feem to concur in clofing the bleeding orifices. " Befides giving ftimulants and cordials to counteract the fainting, it is a common practice in many parts of England, to give women who are flood- ing, confiderable quantities of port wine, on a fuppofition that it will do them fervice by its aftringency. But furely, from its inereafing the force of the circulation, it muft be prejudicial in thofe cafes. Perhaps many of the reme- dies called ftyptics might be objected to for the fame reafon." Ibid. 71. * " It therefore (hews how much languor and faintnefs fhould be en- couraged in hemorrhages, and how carefully we fhould avoid giving any thing that can stimulate, or roufe the patient; that the medicines that are likely io& PREVENTION of t fuppofe is Owing to the power which Dr. Alexan- der jufty afcribes to it, of almoft mftantly retard- ing the velocity of the circulation, and of furprifing- ly diminifhing the number of pulfations ; but it fhould be given immediately after being diffolved, as the fame Gentleman has obferved, that it then poffefTes that power in a greater degree. In con- stitutions that are fubject to acrid putrid bile, nitre is improper, as it generally difagrees with the ftom- ach. If the difcharge of the lochia be moderate, the patient fhould not only fit up often, but fhould ev- ery day get out of bed, flaying up as long as fhe can without fatigue, and continuing it a little longer every day than fhe had done the day before. A very convenient eafy chair has been invented, to which a foot board is adapted, not only preferving the legs and feet from cold, but by the means of two ftraps, likely to be of fervice are nitre and the acids, or fuch as cool the body or have the property of diminifhing the force of the circulation, or of increaf- ing that Ian5'ior, or fain'nefs; that all anxiety and agitation of mind fhould as much as poffible, be prevented, left they increafe the circulation, that all mufcular motion fhould be avoided for the fame reafon." Hewfon's Experimental Inquiry, p. ibo. Dr. Dickfon in the Med. Obf. and Inq. vol. 4. art. 16. p. 320, fpeaking of nitre given in the form of an electuary with conferve of rofes, fays, " I have found nitre too adminiftered in this manner of lingular fervice in ute- rine hemorrhages, but only fo far, if my obfervation is correct, when there was a feverifhnefs and hardnefs of pulfe; for in other cafes the elix. vitripl. acid, given in fmall quantities, and very frequent?;, -.-epcr.trd, wa: attended "ith much greater benefit." PUERPERAL FEVERS, &c. 109 ftraps, fo contrived that the back of the chair may be depreffed, and the foot board raifed at pleafure. By means of this contrivance, if the patient be faint or fatigued with fitting up, fhe may be greatly relieved, and her pofture made as eafy as poffible. As the chair runs upon caftors, it maybe readily mov- ed, and by its affiftance the patient may be enabled to continue a long time out of bed without incon- venience. As the invention is not generally known, a draw- ing of it may perhaps not be unacceptable to my readers. [Vid. Plate I.] PLATE no PREVENTION of PLATE I. A perfpective view of an Eafy Chair, the back part let down and the foot board raifed, which has been found very ufeful for lying in women and fick perfons. a. The back of the Chair. b. The feat. c. The foot board. d. A fupport for the back of the Chair, which is only ufeful when the back is let down, and which is fixed to the chair by hinges. i N. B. Straps of garth web on each fide of the Chair pafs through the arms, and are fixed to the back and foot board. The breafts generally require great attention, ef- pecially during the patient's firft lying in. If fhe . propofes to fuckle her child, it ought to be laid to them early, before the milk can have stagnated in them, or they can have acquired any great degree of hardnefs'. It will be beneficial both to the mother and child, if this be done in a few hours after delivery ; and this is moft confiftent with the operations of unaffifted nature. If the patient have not fuckled any former child, the infant will probably meet with difficulties in faftening PUERPERAL FEVERS, Sec. llx faftening on the nipples. In this cafe the breafts mult be gently drawn by a fkilful perfon, and if her art fhould fail, cupping glaffes* of a proper form and fize fhould be applied, but no violence fhould be ufed. Where the patient will fubmit to this, and it is done with judgment, except the breafts have met with accidents, the fuccefs is al- moft certain. To prevent the ftagnation of the milk, the breafts fhould be emptied four or five times a day. If the patient's own child cannot do this, fome other infant fhould be applied, or we fhould have recourfe to an able perfon well accuftomed to draw breafts J. I am well acquainted with a family fo dexterous in this art, that an indurated gland or gathered breaft was fcarce ever known under their manage- ment. * " Papillae, ex media convexitate mammarum eminentes, multum va- riant craffitudine, & longitudine in diverfis mulieribus. Ssepius contingit, ut a loricis, quas peffimo more geltare coguntur puellae fie deprimantur papillae ut vix emineant; imo aliquoties vidi, fubfediffe penitus, ita ut loco eminentis papillae appareret foveola in mamma in qua delitefceret. Impoflib- ilis tunc eft lectatio, nifi educi poffet papilla; quodfaepe feliciter obtinetur, ft graviditatis tempore faepius applicetur parva cucurbitula, ex qua antlia? pneumatics ope educitur aer, tunc enim depreffa papilla exfurgit, & dum faplus hoc tcntatur incipit imminerc magis magifque." Van Swict. Comment. Sect. 1338. J The elaftic vegetable bottles arc not in general fufficient for thispurpoJe. 112 PREVENTION of ment. Their mode of operation is fo very eafy as to afford rather a pleafing than a painful fenfation; and I have been informed by thofe who have ex- perienced it, that they could eafily fall afleep under the opera'ion. The method of thefe practitioners has been kept a fecret, and as yet has only been tranfmitted from the mother to the daughter. Havr ing confidered this matter fully from comparing what I have feen of their practice with that of others, and from the converfation I have had with thofe who have not only been under their care, but under that too of lefs fkilful perfons, I am very certain the whole art confifts in nothing more than this: the whole breaft and nipple being ftretched out, fo that the breaft may affume a conical form, the tubes become perfectly straight and open; in this fituation a hand being applied to each fide of the breaft, the milk is forced out at the fame time that the perfon's mouth is applied to the nipple. By this method a very moderate fuction only is re- quired; and that violent degree of it upon which the generality of operators place their dependance, by which the nipple is frequently excoriated, and great pain given to the patient without her breaft being completely emptied, Jjecomestotally unnecef- fary. If the breafts grow hard and knotty they fhould he well rubbed with a fofk hand moiltened with oil, and PUERPERAL FEVERS, 3ec.~~ 113 and this operation fhould be repeated two or there times a day. In thefe cafes I have aifo applied Goulard's vegeto mineral water with advantage *. Thick rings, made of bees' wax, and fitted very exactly to the nipples, are often preventive of fif- fures,by keeping the nipples elongated, and denying them a liberty of fhrivelling up into corrugations. If there be too much milk, thefe rings are ufeful in caufing it to run out; but they fhould be made like real rings, and not like caps, as is frequently done by perfons ignorant of the reafons for which they are ufed, and who imagine there is fome fpecific virtue in the wax itfelf, whereas they only act mechanically. They fhould be applied immediate- ly after the child has finifhed its fuction, andbeput on fo that the ends of the nipples may protrude themfelves through them. Thefe rings, however, ought not to be ufed when the milk runs out in too great quantities. If fiffuresbe formed, and be attended with a fharp acrimonious humour, the acrimony may' be greatly blunted, and the parts healed by the application of a mucilage compofed of gum arabic and a decoc- tion of cooling feeds. If *Vid. Aikin's Obfervations on the external ufe of Preparations of Lead* Part II, H 114 PREVENTION of If the patient do not fuckle her child, no method fhould be ufed either to repel the milk or invite it into the breafts, but it fhould be left entirely to nature*; fhe fhould live very abftemioufly, little or no animal food, no ftrong liquors fhould be al- lowed her, and the inteftinal canal fhould be kept thoroughly open. Let *tie directions I have given be ftrictly obferv- ed, and I will venture to affert that there will be neither puerperal nor miliary fever, nor will the milk fever be worth notice, except it be her firft ly- ing in. This may be faid to be a bold affertion. I am well aware of the uncertainty of the medical art, and of the difficulty of afcertaining facts, efpe- cially by thofe who, neglecting nature as their guide, feem rather to take pleafure in obftructing her in her operations. I know likewife the diffi- culty there is in bringing patients to conform to proper directions, and the ftill greater one in in- ducing nurfes, and other attendants, to follow the rules which are prefcribed them. I am not now amufing the public with idle theo- ries, and fpeculative reafonings ; I am treating on an affair of confequence, not only to the female fex, but to mankind in general. I fpeak from facts, from * Thofe who wifh to fee this matter more fully difcuffed, I muft beg leave to refer to my examination into xhe propriety of drawing the breafts of thofe who do, and aifo of tbofe who do not give fuck; publifhed along with an inquiry into the nature and caufe of that fwelling in one or both of tlic- lWer extremities, which fometimes happens to lying in women. PUERPERAL FEVERS, Sec. 115 from facts which cannot deceive me, founded upon my Father's experience of more than fixty years, and upon my own of above two thirds of that peri- od. I appeal to the inhabitants of this town and neighbourhood, where, if I be guilty of mifrep- refentation, I muft meet with the imputation I defer ve. It would be eafy to produce a long lift of fuc- cefsful cafes; fuccefsful cafes avail nothing, where the unfuccefsful are concealed. It is evident that by much the greater part of the fex will do well, e- ven under the worft of treatment. The practitioner therefore can only judge from the refult of general practice ; and here, for the fake of the moft im- portant argument I can ufe, I am obliged to refer to a fact, which otherwife could fcarcebe mention- ed wilhout a fhew of ostentation, which I defpife. Out of the whole number of lying in patients whom I have delivered (and I may fafely call it a great one) I have never loft one, nor to the beft of my recollection, has one been greatly endangered, by the puerperal, miliary, low nervous, putrid malig- nant, or milk fever ; nor have any of thefe fevers ended in madnefs*, or any other difagreeable com- plaint. * " It is not only ih lying in cafes that madnefs is fometimes in confe- quence of the neglect, or ill treatment of this fever, for, in other perfons it too often terminates in this manner. It is therefore well worth obferving, fince experience confirms the fact, that this fort of madnefs, which follows this low fever, will by no means yield to the common methods for the cure H a nt5 PREVENTION of plaint. Some few indeed have had the puerperal fever, but this has evidently arifen from nonobferv- ance of the rules above laid down. Some few too have had miliaiy eruptions, proceeding from the fame caufe, though not one, unlefs my memory greatly fails me, ever had what properly might be called a miliary fever. Where feverifh fymptoms have appeared before delivery, they have been hap- pily extinguifhed. The reader may perhaps im- agine, that by a different treatment diforders may take different forms, and appear under different denominations. That I may not feem to fhelter myfelf under fo poor a fubterfuge, I am neceffifat- ed to make a farther declaration. I never loft a patient either during her month, or at any other time, where there was the leaft reafon to imagine her death was the confequence of her lying in. It muft however be remembered, that in this laft dec- laration I fpeak only of natural parturitions. -I would by no means be underftood to include in this account preternatural cafes, or fuch labouri- ous ones as have required the ufe of instruments ; thofe of floodings, or convulfions, or thofe in which confumptions have taken rife before the patient's time of delivery. I only mean likewife thofe pa- tients whom I have myfelf attended during the time ef madnefs, becaufe great evacuations, as purging, vomiting, and efpecially bleeding, always heighten the difeafe, and foon cither deftroy the patient, or bring oo an incurable fooliftmefs," EthciiDgton on Fevers, p. 4s, PUERPERAL FEVERS, Sec. 117 time of delivery. After fevers have been created I bave been unfuccefsfully called in to thofe deliv- ered by others. I have however the pleafure to ob- ferve, that thofe fevers, in this neighbourhood at leaft, have of late years greatly decreafed. This muft chiefly be attributed to a fyftem of manage- ment lately introduced, much to the honour of our prefent practitioners, and of thofe nurfes who feem fenfible of the advantages arifing from it ; and I muft here do my brethren the justice to atf- fert, that I do not know a place where midwifery is more fuccefsfully practifed. Perhaps fome gen- eral caufe may contribute to this fuccefs amongst the poor in this town, viz. their eating very little animal food, and living chiefly upon vegetables. Potatoes are a principal part of their diet, on ac- count of their goodnefs and cheapnefs in this country. We have butter milk likewife in the greateft perfection, and it is drank by the common people both in ficknefs and in health. This liquor when properly managed has a pleafant acidity, and very happily contributes to prevent and cure any diforders arifing from putridity. In many parts of this kingdom it is fo ill prepared, that the poor people will not drink it, and it is either thrown a- way or given to the fwine. We are likewife well fupplied with coals, which is an article of confe- quence, as fires prevent moifture,. and keep up a circulation of air, and there is little danger of the H 3 poor 118 PREVENTION of poor people keeping fuch large fires as to be over heated by them. Does not the pump water* of this place, by being impregnated with felenitical and aluminous falts, contribute in fome degree to pre- vent putridity, whatever bad effects it may have in promoting diforders arifing from glandular ob- structions ? *It may be worthy of obfervation, that dyfenteries are almoft unknown in this towm Is it not one caufe of the frequency and fatality of the puerperal, jail, hofpital, and other putrid fe- vers, in London, that fo many of the inhabitants drink, and ufe for moft culinary purpofes, the New River water, which is frequently replete with putrid vegetable and animal fubflances, or the Thames water f, which is full of all kinds ,of pu- trid matter ? It * Vid. Dr. Percival on the Pump water of Manchefter, Effays Med. and Exp. p. 288. f " Moft pump water is as incapable of changing and of being fpoiled by keeping as diftilled water ; for though it be loaded with various foreign particles, yet it fcldom has any, or at moft but a fmall proportion of a veg- etable, or animal nature, and therefore it will always remain the fame. This property of water is not fo much attended to as it ought to be by fail- ors, who ufually fupply their fhips with river water taken up near great cities, and then keep it in wooden calks; the necefTary confequence is, that it foon putrifies, and moft probably contributes very much to the occafioning of thofe putrid diftempers with which failors are fo apt to be afflicted. Pump or fpring water would be greatly preferable, and if they could keep this in glafs or ftone bottles, or earthen jars, they would find it, after being e:-riled round the world, juft the fame as when they fet out." Med. Tranf. vol. s. p. 19. by Dr. W. Hcberden. PUERPERAL FEVERS, &c. 119 It may feem ftrange, but it is neverthelefs true, that the puerperal and miliary fevers are more com- mon and more fatal in London than in the country; and yet it muft be acknowledged than in general the ableft men in every branch of the profeffion refort to the metropolis : But our wonder will ceafe when we reflect that not only the general caufes in large populous towns will operate, but likewife that the articles of air, diet, drefs, &c. are left to the management of the nurfes in that city, who claim it as a kind of prerogative, and it is next to facrilege to encroach upon their privi- leges. Whether this circumstance has been con- fidered in the important light it deferves, or wheth- er the fuccefs of a reformation has been defpaired of, I will not pretend to determine. The nurfes in London are a numerous and powerful body, and an attempt to reform their ancient cufloms might be « The great tendency in the Thames water firft to ferment, and then to become pure, in long voyages is well known, and it is probable that this quality is owing to the extraordinary quantity of putrid matter with which it is impregnated at the place where it is taken up, viz.. a little below Lon- don bridge," Pringle's Appendix, p. 67. Sir John Pringle in his Obfervations on the Dyfentery fays, « Having obferved in my private pra&ce that fome were better for drinking Briftol water, not only at the fpring, but at a diftance, I defired one of my patients (who had come from the Havannah) to obferve whether he found any differ- ence between drinking the river water and the pump water in this city; and after fome trials he affured me that he was lefs liable to a return of his flux when he ufed the latter," , , . , . „«,n„ Obf. on the Difeafes of th: Army, p. 285, H 4 i«e> PREVENTION of be looked upon as an open attack upon them, a vi- olation of their rights, and an actual declaration of war. A young man juft coming into bufinefs might juftly think it too daring rn attempt to en- counter them ; he would in all probability be une- qual to the talk, and his future progrefs would be ftopt, by making fuch powerful enemies.' The man in full and eflablifhed bufinefs could not per- haps fpare fo much time as would be neceffary, for it would require a very f fequent and conftant attend- ance upon his patients to fee that the nurfes did their duty ; and by fuch an attempt he might lofe much, and gain little, except trouble and oppofi* tion. But the fatality of thefe fevers is riot confined to the metropolis. There are feveral country towns where puerperal fevers are very fatal, particularly the town of Northampton, a place otherwife re- markable for its healthfulnefs, and fituated in an open, champaign country ; and I am acquainted with two gentlemen in another town, where the whole bufinefs of midwifery is divided betwixt them, and it is very remarkable that one of them lofes feveral patients every year of the puerperal fe- ver, and the other never fo much as meets with the diforder : but their methods of treating their pa- tients, as I am informed, are very different. From PUERPERAL FEVERS, Sec. 121 From what has been above remarked, I imagine it will appear that where a due obfervance is paid to nature, not only during labour, but for fome time afterwards, there is not the leaft danger to be apprehended from natural parturitions; thatmoft,- if not all of thofe diforders which are ufually fup- pofed to be peculiarly incident to the puerperal ftate, are either the effects of mifmanagemeht in the accoucheur or nurfes, or elfe arife from the pa- tient's own imprudence ; that they may in general be truly faid to be fabricated, and may always, ex- cept in lying in hofpitals, be avoided. In hofpitals indeed, where numbers are crowd- ed together, not only in the fame houfe, but in the fame ward, the puerperal fever* cannot fo ea- fily be prevented, though the miliary fever un- doubtedly may. > A * Van Swieten, in his Commentaries upon Boerhaave's Aphorifms, Sect. I33I1 gives the following quotation from Peu. " Obfervaufideliaconfirm- averunt, putrida haec miafmata nocuiffe puerperis, dum in nofocomiis de- cumbebant : Magnus enim illarum numerus peiibat; & fufpicari ceperant nofocomii prafecti, ignoiantiam aut negligentiam obftetricantium in caufa effe. Plura fecabantur cadavera defun£larum, & corporis interiora abfccGi- bus plena fuerunt inventa. Sapiens medicus, omnia attente examir.ans, hane caufam invenit, quod fub conclavi puerpcrarum dccumberent vulncraj.. Confirmabatur ejus fentenlia inde imprimis, quod aucto vulneratorum de- cumbentium numero crefceret puerpcrarum ftrages, minuto pariter dccrefce- ret. Aer humidus, tarn calidus, quam frigidus nocebat; ficcus autem prode- rat : Notum enim eft, humidum aerem putredini favere, praecipue fi fimul calidus fucrit. Dum autem puerpera; locabantur in conchvi infeiiori, nov. obfcrvabatur amplius hacc ftrages : Aer enim, putridis exhalation.bus imbu^ tus, levior eft, unde fuperiora petit." Peu le pratiq. a\a accouch. p. -' " tea 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 recollection they loft about twenty patients in the month of June ; that during this month he himfelf delivered fix women in a fhort time in the hofpital of natural births, and they all died : He was fo fhocked with the lofs, that he deiired the gentleman who had the care of the hofpital to deliver fome of thofe who fhould 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 fatisfactory 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 " upon which the Royal Medical Society has been confulted by 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 fince the year S774. " The late Mr. Doulcet found a method of curing this difeafe, extremely " fimple, and which has never yet failed of fuccefs fince it has been employ- " ci ; although before this method was made ufe of, the difeafe had always " been fatal to every woman who was attacked with it :n that hofpitar." PUERPERAL FEVERS, &c. 123 the air might be kept in conftant r.;rc illation lr» fuch a manner that there would be ■-'. dagger either of the creation or communicatee of this "In- order. The expenfe of fuch edifices would },e rather greater than ufual. The 1-■•« is» rpaft be lofty, open galleries withunglazed window Ihoied run through the whole building? The uds ftiould be all upon the centre flooi., and eey fhould have no doors except into the galleries, >nd thofe doors fhould be oppofite to the window j. 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 fhould be feveral holes to let out the foul air. The ground plans fhould ferve for offices, and the upper flories be converted into lodging rooms for nurfes and fervants. An entire apartment ftiould be allotted to every patient, or elfe if large wards were constructed the windows fhould be placed very high, with the uppermoft fafhes made to let down. Large apertures fhould be made as high as poffible in the partition wall which divides the walls from the gallery, after the manner of the Leicester infirmary ; and in the upper part of fome of the windows the farthest from the fire fhould 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 fuppofc that 124 PREVENTION of that the fuperior advantages of thefe ventilators over a leaden lattice confifts in admitting more frefh, or extracting more foul air ; but by their circulatory motion they prevent the air from rufh- ing directly->upon the perfons in the room, and thereby giving them cold. Thefe fhould 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 fake 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 Manchefter 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 situated 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, &c. 125 thirteen beds. A large gallery runs through the whole length of the houfe, and that is interfected by the chapel and the great flair 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 firft institution of this charity, 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 18-j. In the prefent infirmary between the 24th of ^une, 1755, and the 24th of June, 1771, 6459 m patients were admitted ; out of that num- ber 263 died in the houfe, which is nearly one in 24^-. This difference of fuccefs muft, I think, be principally owing to the plenty of room and free ventilation, for the perfons concerned when this charity 126 PREVENTION of charity was in its infancy, were more careful both in regard to the admiffion and difcharge of patients than they have fince been, left a long lift of deaths fhould have brought the infant charity into difre- pute. PoiTibly 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 practifed in St. George's hofpital.* Moifture * V In wards which are clofe it has been found that one or two fouare holes of about fix or eight inches diameter, cut in the ceiling, and a tube made 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 tor 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 have fuch tubes now fixed at St. George's hofpital. A hole cut above the door 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^n 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 fhips 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 constitutions 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 fleams, we perhaps form no imper- fect idea of the efficient caufe of that ficknefs, which generally prevails in large new built fhips : And however fimple the inveftigation may be, the analogy it bears (the aggravating circumflance of difeafed perfpiration ex- cepted) to all experienced fickly climates, feems abundantly to confirm the folution. Thofe who have feen the effects 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. 128 PREVENTION of I am not ignorant of the ufe of Hales's and Pringle's ventilators, which are exceedingly prop- er, and fliould, together with every other affiftance 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, notwithftanding 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 fkull, 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 fhould be of iron. [Vid. •Plate II.] PLATE 1'iate.. y 1 l;amm......uniiiiBimin »!■ •niLJiami.Ti- PUERPERAL FEVERS, &c. 1*9 v P L A t e II. Fig, 1. A perfpective view of an Iron Bedftead made at Birmingham, the invention of Doctor Vaughan, an ingenious Phyfician at Leicester. 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 and 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 aifo 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 twelv« teeth each entering between the teeth of the rack wheels which are connected by an arbor from g. to g, Mr. Alexander Brodie, Whitefmith, near Tem- ple Bar, has obtained a patient for a contrivance I fomething *3cr PREVENTION of fomething fimilar to thisi, which he calls his new invented Bedfcrew Lever, calculated for the eafc of lick and gouty people, or childbed women ; which raifes them from a lying to a fitting pofture, 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 fhould be wafhed, the floor and wood work fhould be cleanfed with vinegar, and it would ftill add to the falubrity of the apart- ment, if it were ftoved with brimftone, or what is much more effectual, if explofions of fmall quan- tities of gunpowder were made in it after the man- ner defcribed by Doctor Lind, which driving out the foul air, a frefh current immediately rufhes in to fill up the void fpace occafioned by the explosion. The Do&or feems to think that the good effesSls of it in purifying fhips, or other infected places, is owing to the antifeptic vapour arifing from it; but, I Is it not mere probably owing to the explofion ? He fays he has found this method effe&ual in purifying the air, and that it is inoffenfive to the lungs. The fleams of warm vinegar applied to the patient's noitrils are very refrefhing; but fumi- gating the wards with it, as has been advifed by many authors, has not, I believe, proved fo anti- feptic PUERPERAL FEVERS, Sec. 131 feptic as was at firft imagined; which may be ow- ing probably to the following caufe : In distilling 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 quanti- 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 raifed 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 designed to remedy ; for it is univer- fally allowed that heat and moifture when joined are the parents of putrefaction. I have my doubts in regard to the utility of dry or moift fumes*, or fprinklings in general, fuch •Doffie, fpeakingofthe Murrain, fays, "But thefe fumigations, fre. quently repeated as they were for this purpofe, in clofe places where the beafts 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 terebinthiflate fubflances, they injured the refpiration of the beafts, and thence diminifhing the animal ftrength, rendered them more difpofed to be affected by the contagion. A multiplicity of facts confirm the truth of this remark, as it appears from nearly all the accounts given, that the greater number of beafts have been loft where means of this kind have been moft employed. The medicating the cattle externally, by rubbiug them with fulphur, gunpowder, tobacco water, and other fubflances, do lefs harm than the fumigations, but not moje good, at experience has largely evinced, "A I 2 13* PREVENTION of fuch ai camphorated vinegar, tobacco, nitre, pitch, tar, refinous ga 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 fuflicienL quantity of free air be admitted they will feldom be neceffary. And if by their means the air is either heated or moiftened, they will certainly be prejudicial : But all thefe methods may be ufed with advantage if there be no patient in the room. If the lungs be inflarned, or the patient have any difficulty in breathing, the receiving fuch acrid fteams or fumes' into the lungs would certainly be of bad. confequence. In " A free refpiration of undepraved air is effentially neceffary to the ftrength of the beafts, in order to their refilling the effects of the contagion. It has appeared from a number of obfervations which are recorded by the writers ors this fubject, 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 fubject to take this infection, and recovered in greater numbers when feized with it, than thofe which were houfed. In Denmark during the ter- l>ble visitation mentioned above of this difeafe in. the year S759, manY of the boors attempted to preferve their cattle from the infectioa by the fume* of tobacco, which they contisiually fmoked in .the cow houfe, even fitting Dp the whole night in turns for that purpofe in the midft of thesn-. But it was remarked that scarcely any of the cattle to treated avoided the contegioa and death in c&nfaiucstis of it." Memoirs of Agriculture, p. $9g; PUERPERAL FEVERS, Sec. 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, stagnated air, and human efflu- via, fuch as fweat and the perfpiratory matter from the lungs and the fkin, &c. are the grand promot- ers of putrefaction; without thefe obstacles can be removed, every attempt to correct the vitiated air will not, I am afraid, avail. A probable method is propofed by Dr. Alexander t of placing large quantities * " Fragrances odores, quibus multi adeo abut folent, ut etiam mutatis veftibus tota cutis illis imbuta maneat, turbant fxpe adeo puerperas ut mox fequancur cnormes capitis dolores, deliria lochiorum fuppreffio." Van Swieten. Comment. Sect, 133s. + Alexander fpeaking of putrid diftempers, fays, " As the breathing of cool frefh air feems above all -other things 3 fine qua nen, directions to fupply the patient plentifully with it can never be too frequently, or too strongly inculcated : Where this is impoflible to be done, as in jails, the holds of fhips, &c. every method we are capable of mentioning fhould be tried fia correct and deftroy the -virulence of thefe putrid particles, which cannot poffibly 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, wafhing the room with vinegar, with fpirits, &c It does hot appear however upon the ftricteft inquiry, that thefe method* have been attended with any remarkable, nor indeed with any vifible suc- cess. Their intention indeed is certainly a very rational one, via. to im- pregnate the whole air of a room with antiseptic matter, in such a mannet that the patient may draw a good deal of it into his lungs, at every infpira- tion. But as their haviag hitherto done fo tittle good, give* ground for « t fufpicion I 3 134 " 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 manifest 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 fubject 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 fufHcient quantity, I think other methods ought to have a fair trial a}fo, efpecially as there feem to be others better calculated for rendering 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 fweetened feveral pieces of putrid meat by fufpending them in the fleams arifing from fermenting antifeptics ; and this methinks fur- nifhes us with a hint how to endeavour to correct the air of a confined place, and render it antifeptic, where patients with putrid difeafes are ; which ii by placing large quantities of fermenting antifeptic mixtures in different parts of it. If this expedient should not be found to anfwer, a ftill farther trial may be made. Let a large quantity of a decoction of bark, camomile flowers, &c. when in the act of fermentation, into which it may be eafily brought, be put by the patient's bed fide, and his head fupported over it, so as to breathe the fteam as often, and as long at a time as can be done. Should this method produce any good effect, it might very eafily be impror, ed by means of a machine contrived to convey the greateft part of the fteam arifing from fuch a mixture, into the patient's lungs." Experimental Effays, p. 66, PUERPERAL FEVERS, Sec. 135 during the act 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. Notwithftanding what I have advanced for the neceffity 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 obstructions and fevers ; and although great ad- vantages have accrued from the ufe of acids, acef- ent liquors, and fruits, yet it 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 primes 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 hofpitals fur- ther difcufled, to a very fenfible pamphlet lately publifhed by my worthy Iriend Dr. Aikin, entitled, Thoughts on Hofpitals. 14 CHAP. $$6 CURE of the CHAP. VII. of the CURE of 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 a fweat, we fhould 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 flage, 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 perfon 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 fymptoms, I am clearly of opinion that it is the hot fit, or fever, which PUERPERAL FEVER. 337 as fufih, have not, I believe, fpoken from facts falling under their own infpection. 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 existing 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 fhivering fit of an in- termittent, it appeared that the heat of the patient by Fahrenheit's thermometer was 104 degrees, whereas that of a perfon in health feldom exceeds 98 +. In fome agues the thermometer applied to the patient's body finks below the ftandard, as was found in the Edinburgh infirmary, but this hap- pens in very violent cafes only. In which not only often endangers the patient's life, but aifo in the moft com- mon cafes of intermitting fevers, by its continuance, weakens and impairs his whole habit of body." Lind's Advice to Europeans, Appendix, p. 313- * Med. Facts, p. 221. + 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 left than the natural heat." But his experiments, perhaps, were made at the firft approaches of the cold fit, when the obftructions in the capillaries are confiderable, and the increafe of circulation inconfiderable. Ibid. p. ?2j. I38 CURE OF THE In 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 \ ry refrefhing. But as this is not always the cafe at the very beginning of a fever, they ought to have fi me perlon to feel their bodies many times in a day, in order to regulate the heat of the room, and tl e quantify ef clothes they are to have 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, during the continuance of the cold fit. At the beginning of the fit, if fhe be really colder than in health, warm flannels, bags filled with toafted grains, bottles with hot water, or hot bricks, may be applied to the patient's feet; but what is of more confequence, her limbs fhould be gently rubbed with a warm hand, or with flannel, to prevent the blood from stagnating in the capilla- ries, and fome additional clothes fhould be laid upon the bed, particularly upon the legs and feet. It muft however be remembered, that thefe clothes fhould be taken away as foon as ever the hot fit comes on, at which time an emolient clyfter fhould be in- jected, 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. 139 whey, barley water, or decoct, pectoral very Utth warmed, or even entirely cold*. The room fhould now be fupplied 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 nec- effary is impoffible. 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- tile to her, but wine by no means." On Epidemics, Book 5, Cafe ss. Doctor 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 fhe 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, fhe had but little more than a fhect 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- dered to be made rather warm. Reply to Maxwell, p. 86, 140 C'U R E OF THE fooner will the fweating fit* come on ; which if |t 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 Effays, 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 pofUbility of fweating. But, although there is a ftandard degree of heat, at which, and perhaps at no other, a fweat can be produced, yet we may reafonably con- clude that this degree is not the fame in all perfons, nor i* the fame perfon at all times, but that it rather differs, according to the difference of confti- rutional heat, and other circumftances." Experimental Effays, p. 166. " That profufe fweating is more destructive to the natural heat and ftrength, 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 thing to fee a perfon thrown into a large and continued fweat, without assy apprehension 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 strength 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 circumftances, 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 confequences of large fweating in low putrid distempers, and accordingly exclaims againft it in the keeneft and moft nervous manner, as having a very direct tendency toward the deftruction of the patient. But I carry the matter ftill farther, and affirm, that in all diftempers whatever, profufe fweating too long con- tinued, may have the fame effect, and that it feldom or never can be ufeful, » all the purpofes of it may be fully anfwered by a gentle mador on the (kin, PUERPERAL' FEVER. j41 hot burning fit, yet they muft not be given during the fweating fit. The heat of new milk will be the moft proper temperature. If nature be not in- terrupted, fhe ufually difcharges the morbific mat- ter fkin, which may be much longer continued with lefs hurt to the ftrength oi the patient." Experimental Effays, 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 pulfe 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. S77» , " The following Corollaries, drawn from experiments and obfervation* may perhaps throw fome light upon this fubject. " Coroll. 1. When the velocity of the blood is too great, and its mo- mentum too little in proportion, fweating will generally increafe the vetoes* ty, and diminifh the momentum. " Coroll. 2. When the velocity of the blood is too little, and its mo- mentum too great in proportion, fweating will generally diminifh 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 exhaufl 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 fweat- 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 increafing the velocity, and diminifhing its momentum, we are furethat it is weakening the patient, and therefore muft endeavour to ftop it. Again when we find a fweat increafing the 14* CURE of THi ter of this paroxifm by fweat; and this fweatiftg, which commonly ends in a few hours, may in fome 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, leffens the milk and lochia, occasions 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 thefe fymp- toms, it is neceffary 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 fure that it is then emptying the overloaded veffels, or opening fome obftructionS, and in one of thefe ways adding to the natural ftrength. Farther, when we find a fweat diminifhing the velocity and momentum of the blood, when they are both too great, we have reafon to believe it is then carrying off fome morbific matter, which 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 allur- ed, that while they do this, nature is never weak ; as very few, if any in- stances ever happen, where great weaknefs is not attended with a very quick pulfe." Alexander's Experimental Effays, p, 207, 8, 9, * " The method of cure, therefore, eftablifhed at prefent in the Hotel " Dieu, and which has never yet failed of fuceefs fince it was applied, con. " fifts PUERPERAL FEVER. ,43 of fome antimonial preparation, emetic tartar for instance, effence of* antimony, antimonial wine, or James's powder. The dofe fhould 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 " fills 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 " 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 fame, 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, compofed 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 althsa ; 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- *' gcncy of the cafe, " It is evident, therefore, that the efficacy of this method of cure confifts " wholly in its early application, namely, in the very moment when the «* difeafe firft commences : And though experience has fince taught us that ■' the lofs 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 Memoes, p. 10. The invention of the above method of curing this diforder, by giving vomits at the very firft attack of it, and frequently repeating them, cannot be afcribed to Mr. Doulcet, fince Dr. Denman, in his Effay on the puerpe- ral fever, publifhed in S768, advifed the ufe of them with this difference only, that he recommended tartar emetic, whereas Mr. Doulcet gives ipecac uanha • Scorzonera Utifolit, Cafp, Bauhiss, Angl. Viper's Grafs. *44 CURE of the ever of thefe medicines is made ufe of, it fhould be giyen at firft in a fmall quantity, and if no vifible effect enfue, if it neither affect the patient by ftool or vomit, the fucceeding dofes fhould 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 fwal- lowed into the ftomach, 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 action of vomiting might increafe thofe pains. If cuanhathe preference. But in this Treatife of mine, which was publifhed in S773, I recommended ipecacuanha in fubftance, and as it was tranflated into French, and publi.lied at Paris in S774, it is moft probable Mr. Doulcet muft have feen it, fince he appears by bis memoir, never to have ufed this mode of 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. Vicq. D'Azyr, and the gentlemen of the Royal Medical Society of Paiis, for the report which they publifhed. * " The abforbent quality of the faliva moreover fhews, how apt it muft be to lay hold of infeaious miafmata which oftentimes are in reality putiid vapours, or fixed air, detached from bodies during putrefaction ; and con- firms what hath been frequently recommended, namely, to fhake off infec- tion, and prevent the miafmata from getting into the mafs of fluids by imme- diate vomiting ; and we may likewife fee, that the cautions given by authors concerning the fwallowing of the faliva while in the places abounding with iofectiou* vapours, are founded in reafon." Macbridc's Exper. E&ys, p. 268. By PUERPERAL FEVER. i45 If the patient be coftive, or have a tenefmus, emollient clyfters, which not only help to carry off the morbific matter, but are extremely ufeful as fomentations to the whole abdomen, fhould be frequently injected; but efpecial care fliould 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, Glaubers, Ro- chelle, or Epfom falts, rhubarb or caftor oil ; if thefe fhould fail, ftill stronger 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 demons may be given in draughts. This laft medicine fhould be taken during the act 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 effervefce in the ftom- ach. Thefe dofes fhould be repeated every two 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 fcverally and fome of them conftantly employed, during eighteen months, in various offices about the fick in Hafiar hofpital, where there conftantly was a great number of people ill of fevers that were highly infectious. See his Difccvrfc en Fevers and Infcilion, paper 2, p. 74' K 14& CURE OF THE hours or oftener ; they will correct and fweeltett the acrid putrid bile, and will allay the feverifh fymptony. Doctor Lind, who has prefcribed them frequently upon the acceflion of cold fits, tells us that they generally fhorten the fits, and occafion profufe fweatings. It may be neceffary perhaps to remind the reader, that though fweating$ 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 refpect 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, whilst the morbific matter is carrying off, which, Was the caufe of the augmentation, Rrvcrius PUERPERAL FEVER. u Riverius* gave fait of wormwood and juice ci lemons in obstinate vomitings attendant upon :-v.~ trid malignant fevers. Sydenham a^eni-r^ree. * fcruple of fait of wormwood in a fpooisfui e i lem- on juice, during the illiac pafiion which fiice.tded the depuratory fever, and in an intermittent fever- attended with almoft continual vomitings, iio gave the fame quantity fix or eight 168. % " Ek aceti partibus quatuor, Sc bilis recentis partibus quinque, miftura beta, neutrius faporem pracbebat} fed medium quendam,manifeftedulcem.M RobertusRamfay Differt. Med. Inaug. de Bile, exper. xvii. " Miftura accti & bilis, ut in exp. xvii. facta, lafcti recenti affufa, coagulum hujus non induxit, etfi eadem aceti copia, per fe affufa plus quam f.ifficiens ad coagulum inducendum fuiffet." . Ibid, exper. xix. * " Frigus, quatenus corporis calorcm & cerebri vel nervorum energura roiinuif, fedans eft. Si calor nimius fit, frigus ad s 53. Baglivy relates the hiftory of a puerperal fever unfuccefsfully treated, where blifters were attended with a manifeft difadvantage to the patient. " Mulier c-cto menJium gravida, juvenis, & gracilis, integro octiduo doloribus ventris moleitata, PUERPERAL FEVER. 15$ 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 molcflata, demum infantem peperit. Poft partum adhuc continuabant dolorcs, cum infigni ventris tenfione. Quoniam vero omne genus remedio- ] rum fpreverat, vel potius neglexerat, demum a quodam medico quatuor vefi- cantia Gbi apponi permifit. Lochia qu* primum fluebant exinde fupprefla sunt. Faucis poft diebus denuo apparentibus lochiis, abdomen gravitercon- velli caepit cum infigni dolore, adeo ut ne digito quidem premi poffet; ex- inde fudorcs frigidi, cum rcfrigeratione extremorum apparuerunt; pulfus & refpiratio erant diminuta, 8c fere ad extremum vit* redacta fuit patient. Elapfis paucis diebus in melius aliquantulum procedebat; derepente tamen fupervenientibus graviffima fpirandi difficultate ex genere convulfivarum, & interdum in delirium fe commutante, nee non alvi fluxu flavo, & fcetido, qui per octo dies continuavit, demum decima feptima die morbi, obiit pa- tiens," Sec. Baglivi oper. p. 59s. Etherington, fpeaking of the low, nervous, and hyfteric fever, fays, "For although blifters 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 cauflic falts of the cantharides. Many fatal inftanccs attending the application of blifters at this time have been obferv- ed." General Cautions in the Cure of Fevers, p. 41. " I 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 the early part of the bilious conftitution, they promote the propenfity to fymptomatic 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 puttid kind diiTolvc the blood, and turn into a dark corrupted fames." Glafs's Cos*. 375. t$Q .. CURE of, &c. The whole clafs of ftimulating medicines, called emmenagogues, which are-faid to promote a dif- charge of the lochia, are equally to be avoided. They irritate the womb, increafe the fever, and do not anfwer the end for which they are adminiftered. In the laft ftage of this diforder, when the pa- tient feems to fink under it, we muft endeavour to fupport her by ftrong infufions and tinctures of the Peruvian bark, by wine and other cordials, and to stimulate and roufe her by volatile falts and blif- ters ; and in this ftate of the difeafe they may even be applied to the abdomen. I muft not omit to mention, in this place, the ^ood effe&'s I have experienced from emollient or antifeptic injections into the uterus, by means of a , large ivory fyringe, or an elaftic vegetable bottle. In thofe cafes where the lochia have become acrid or putrid, and by being abforbed into the circula- tion, haveferved as a conftant fomes to the difeafe, I have by this means known the fever much affuag- ed, and in many cafes wholly extinguifhed; for though, as I have before obferved, the quantity of the lochia is not to be much regarded, the quality of this difcharge is a matter of infinite importance. CHAP, 6i CHAP. VIII. of the CURE of the MILIARY FEVER. N the sixth chapter I have laid down the prophylactic treatment of this diforder. If I can pro- nounce with certainty of any medical fact, it is, that the milia- ry fevers of puerperal women may be prevented ; and I am equally confident that they may, in their firft flages, be totally extinguifh- ed, without any of thofe bad confequences which too frequently attend them when they are fuffered to take their ufual courfe. As foon as any fymptoms of the diforder appear, whether they come on with or without a rigour, a gentle emetic will be neceffary. This remedy may be adminiftered at anytime, except during thepar- oxifm, If there be a coldfhivering fit, fucceeded by; L burning J$j CURE of the burning and fweating, thefe fymptoms are to be treated in the manner 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 act as an emetic, neither cream of tartar nor any other acids fhould be given along with it*. If thefe dofes do not oc- cafion gentle vomitings, as the ftomach in this dif- order is generally relaxed, and abounds with heavy phlegm and mucus, a few grains of ipecacuanha fhould be adminiftered every, or every other day, and neutral draughts in the act of effervefcence fhould be given every other hour. If the patient be coftive. emollient clyfters fhould be every day injected. They allay the febrile heat and prevent loofenefs, which is often occafioned by the feces lodging and thereby growing putrid and acrimonious in the inteftines. An upright pofture, with cold liquors and free, pure, and even cold air, accompanied with the greateft cleanlinefs, are abfolutely ueceffary. If thefe and the direc- tions given in the preceding chapter be properly purfued, I have no doubt but they will prove ef- fectual in totally extinguifhing the fever. Bleed- ing * " Cream of tartar and acids check the operation of vomits, but more cfocciaily of antimonial vomits." Robinfon on the Operation of Medicines, p« s6a; MILIARY FEVER. 16*3 ing and other evacuations, except gentle emetics and emollient clyfters, will be uniieceitary. There can be indeed no objection made to a mild purga- tive at the beginning of the diforder, provided it be not given immediately after delivery. Great care and circumfpection is required in conducting the patient through the fecond ftage of this difor- der, when there is a large crop of miliary puftules, 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 fhould be frequently changed, that the bed curtains fhould be undrawn, and the room ventilated, and though it may fometimes be expedient that a current of frefli air fliould pafs over the patient, yet thefe things ought not to be done fuddenly or rafhly ; cautioufly, and by de- grees they may be performed with fafety. The de- gree of cold admitted fhould be fuch as will reduce the heat of the body as near as poffible 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 worft of confequences. A few loofe ftools (in fome L 2 cafes 164 CURE OF THF 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 ftage 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 r^eef'ery. She did not feem to be in immediate danger, I took eight or ten ounces of blood f;om her arm, but was inftantly convinced of my error. Before I flopped the blood fhe began to dioop, 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 fhe 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 fometimes drank a gallon of wine, in a MILIARY FEVER. 165 a fingle day, exclufive of brandy, and of the cordials from the Apothecary sfhop, and all this too without intoxication. Many have fallen viftims to this practice, and thofe who have recovered under it, have in general been fo much enfeebled, and have had their constitutions 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, " The ufe of fudorifics has bc»n 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 neceffary. Neither is promoting at laft 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 difeafes is attended with bad confequences. Probably from carrying off the thinner fluids, which fhould fupport and keep up the eruption." General Cautions in the Cure of Fevers, p. 52. " 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 fucceffive crops of miliary eruptions, as they are called, they all the while melting away, and weltering in their own fweat, and tne bed rotting under them." Huxham on Fevers, p. 87. " How exceedingly pernicious hot alexipharmic mcdic'nrs are in the mil- iary fever, eNpcvicnce luth too frequently taught us ; by which it -.pears '.xJt' L3 166 CURE oft he 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 pofture, and from the feeblenefs of the mufcular libres of the hear.t, which profufe fweats had great- ly debilitated. I have known feveral perfons who, under thefe circumftances, notwithftanding the greateft care to prevent the effects 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 ei permitted even to fit up in it. In the laft flage " of this difeafe, as well as in that of the fea fcur- t: vy, it fhould feem that the force of the heart is " too fmall to convey the blood to the brain, ex- " cept when the body is in an horizontal pofture*." But as an horizontal pofition is very bad in all fe- vers to which puerperal women are fubject, I al- ways that by means of fuch medicines, and keeping the patient too warm, almoft 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 m a continual fweat, of which fcarce a third part recovered." Glafs's Comment, on Fevers, Eng. edit. p. 135, * Difeafes vi the Army, p. 314. 410. rdir, MILIARY FEVtfR. lrty ways advife the patient, if fhe cannot fit up in bed', to have feveral pillows, or bolsters fo applied to Her head and fhoulders, as to raife them as high as fhe can bear without inconvenience. Blistering is fo far from doing good in the firft or fecond ftages 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 puftules, attenuates the blood, increafes the urine, promotes putrefaction, caufes thirft, drynefs of the tongue, watchings, deliriums, tenefmus, fub- fultus tendinum, hiccoughs, and convulsions. Nitre, efpecially if given alone, though an antifeptic, hath no place in this diforder. In weak and delicate ftomachs it caufes too great a chillnefs, it aug- ments the patient's anxiety, adds to the vaft op- preffion of the precOrdia, 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 muft be avoided. They heat and irritate the patient, and are never productive of good. Camphor has been held in great estimation in inflammations of the uterus, in acute and malig- L 4 nanc *68 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 constitutions, when adminiftered in large dofes, it has been known to produce ftrangury, coftivenefs, heat, thirft, fpafms, and even convulsions. * The ingenious Dr. Alexander, after making fev- eral experiments with this drug, fome of which were near costing 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 afcertain the ex- act 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 phyfician who * Dc Haen (in Hift. Morb. Vratifl.) fays, thePhyficians of Breflaw found that camphor in the malignant fever did more harm than good. Ratio Medcndi. p. s$o. •« 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 fhe had taken a camphor bolus, which fhe herfelf imputed to the camphor, and no other probable caufe of it could be affigned. Camphor in its nature is nearly allied to fpirit of turpentine, one drachm of which taken internally brings on a ftrangury as certainly as cantharides." Med. Tranf. vol. s. p. 470. Art, 2t. by Dr, Hebetden, t Eflay on the Puerperal Fever, p, 2, MILIARY FEVER. ,£9 who converfed with him upon this fulyect, that he afterwards altered his opinion. Whenever it is thought neceffary to give it, I would advife it to be adminiftered in fome acid vehicle, in lemon juice as directed by Hoffman, or in the julep, e camphor of the College, prepared with vinegar in- ftead 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, butterr 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. Lyfons, 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 nstwithfianding this, 1 am of opinion that thefe 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 direftcd by Mr. Rowley, with very sood effett to perf-jxa afUifted with ul- cers of the legs. !70 CURE OF THE in current jelly has been diffolved, lemon and orangeade, imperial, or Clutton's febrifuge julep may be drank, provided they do not occafion grip- ings ; infusions 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, butter milk, and wort, are aifo proper. If the bowels be in too lax a ftate, rofe leaves, baluftines, or Pomegranate bark, may be added to the wort. Salep, barley water, or cold water with- out any thing added to it, fhould 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 which render wine im- proper, brandy or rum maybe fubitituted in its room. Ipecacuanha given in fmall dofes, fo as only to occafion a gentle puking, is of great fervice. It not only cleanfes the ftomach of that glaffy phlegm with which it fo much abounds in this fever, but is preventive of diarrheas by discharging 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 muft be fuppreffed or modcraied by astringents, fuch MILIARY FEVER. ,7i fuch as gum, rubr. aftring. lign. campech. fang. dracon. terr. japon. jelly of Englifh 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 vice, which may be known by four eructations, vomit- ings, or by green ftools, the chalk julep with tinc- ture of bark may be given with advantage, and the white decoction may be drank for common drink. Neutral draughts may be continued through this ftage of the diforder, giving along with them oc- casionally fuch cordials as the rad. ferpent. contray- erv. and confect. 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 fiever, 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 flender ones, fuch as cold infufions of it, bark tea, and Huxharn's tincture, are of great fervice in bracing and strengthening the fibres, preventing fweat. and refilling putrefaction. If the patient's fiomach will not bear the bark{ it. may be adminiftered in clyfters.* The * Dr. Tath'-cl'i relates the cafe of a woman who had a fever in her lying in where the " . ■ - was of great fervice given in clyfters. Elf. Flryf. & Lit. vol. 2. p. <:8. 172 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 linctus. The third or laft ftage of this diforder is very hazardous. I have frequently known mufk of great fervice in watchings, deliriums, the fubfultus tendinum, hiccoughings, and convulfions ; but it is often given in too fmall dofes ; and hiccoughings have often been relieve^ by a few drops of oil of cinnamon. If the patient's pulfe fink, and fhe become le- thargic, blifters and finapifms mult be applied to ftimuiate and roufe her, and the higheft cordials, particularly wine in confiderable quantities, and even the fal c. c. are neceffary for her fupport. During the whole treatment of the miliary fever in puerperal cafes, the greateft circUmfpection and delicacy are required. The patient can frequently neither bear to be raifed nor depreffed. She can endure but few evacuations. Bleeding, purging, and even bHftering, except as a stimulus in the laft ftage of this diforder, are hurtful. Ntither fudorifics nor diuretics fhould be adminiftered. No animal food, nothing that is feptic, nothing weakening, nothing heating, irritating ordiHulving the MIMARY FEVER. t7g 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 primce 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 are beneficial, and too much ftrefs cannot be laid upon acid and aftringent antifeptics. i All irregular difcharges muft be restrained, and the patient properly fupported. We muft remem- ber there is no particular, and indeed feldom any crifis in this diforder; wherever there is it is the at5l of nature, not of art; and I muft add, that critical eruptions, or difcharges are fo far from be- ing prevented by cold air 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 labouriug 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 that it began to fade as foon as they were hot in bed. i Is it owing to experience or hypothefis that eruptions are believed to be thrown out more vigoroufly by warmth and lying in bed?" Queries by Dr. Heberden, Med. Tranf, vol. i. p. 470, 1*4 C A S £ Si >/W h-sm^m^dJ^ %\^H »iii CASES. CASE I. ANUARY 14th, 1761. Betty Rig*, « aged 21, died in the Manchefter in- firmary of a peripneumony after three >jjjt or four days illnefs, being about fix months gone with child, and I had an opportunity of infpecting 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 epigastric region, being fupported by the distended 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 facrum, the left to the os pubis, fhe breech and feet to the fundus ute- ri, CASES. i7h ji, the knees drawn up to the belly, and the chin 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 ftate. Her friends coming prevented any further examination. Remark. 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 a sitting pofture in the womb, with the face to the mother's belly, and the head to the fundus uteri ; that at the 8th month or later the head growing heavier than the reft of the body, and fpecifically heavier than the fluid in which it fwam, turned itfelf down to the os uteri, with the face to the mother's back, and remained there till the labour came on, and was then forced forward in the fame direction. By the frequent diffections of pregnant women, children have been found in various pofitions, which has occafioned variety of opinions. But the greater number of cafes, efpecially thofe that have been taken notice of within thefe few years, feem to favour the following opinion; that the chjld in all natural cafes from the time of concep- tion riyG CASES. tion to the time of labour lies with the head down- wards, the breech and feet to the fundus uteri, one "fide to the mother's back, and the other to the mother's belly, and after labour is come on, the child moves downwards in the fame direction, with one ear to the os facrum, and the other to the os pubis, till the child is pretty far advanced, when its face turns into the hollow of the os facrum, and the occiput comes from under the os pubis ; and I believe this is always the cafe, except when na- ture is by fome accident or other put out of her natural courfe. The form of the pelvis, the touch- ing frequently in the laft months of pregnancy, and at different times of labour, all feem to con- firm this. % Though this is now the general doctrine of the teachers of midwifery, yet as few real diffections to confirm it have been made public, I thought it might not-be ufelefs to add one to the number. CASE II. IVlRS.----was delivered upon the 2 lit of April, 1770, of her third child. Her habit of body was delicate. She was very fubject to nervous diforders, had been accuftomed to warmth, and had all her life been treated with the greateft ten- deraefs. She bad a good natural labour, and the placenta CASES. 177 placenta came away without difficulty. Several days clapfed before fhe made any complaints, but I obferved when I vilited her that fhe was always in a fweat. There was a large fire in the room which made it very hot, and there was a difagreea- ble fmell in it. Her lochia were in proper quan- tity, but very offensive. I repeatedly defired that fhe might be kept cpol, that a little frefh air might be frequently admitted, and ordered her to be got up every day ; but none of thefe directions were complied with. On the 5th day fhe had feveral loofe ftools with flight pains in the abdomen, her tongue was whit- ifh, her pulfe rather too quick, fhe was troubled with the heartburn and had four eructations, and continued fweating. As her complaints were trif* ling, I only prefcaibed four large fpoonfuls of the chalk julep to be taken every four hours, and or- dered her the white decoction for common drink. In the evening the diarrhea and pains in her bel* ly increafed, fhe feemed eafier however after everj ftool, and was direaed to take three fpoonfuls of Fracaftorius's deco&ion every three hours. Day the 6th. Her loofenefs was abated and fhe feemed better. M Oa if* CASES. On the 7th. Her fweats continued, the diar- rhea increafed, and her pains returned. Her ftools were fo very frequent, that I thought it neceffary to check them by a clyfter of the chalk julep in which two grains of opium had been diffolved. In the evening her pains and loofenefs were much worfe, and fhe complained of a cough. She was or- dered an oily draught, with twenty drops of liquid laudanum, and a mixture made with the jelly of ftarch, of which fhe was direaed to take three large fpoonfuls after every loofe ftool. On the 8th. Her pulfe beat 120 times in a min- ute : her tongue had a white fur upon it, her milk decreafed, her lochia flopped, and fhe had eighteen or twenty ftools. Her fweat arid ftools were fo extremely putrid as to be offensive not only to thofe in the room, but to the whole houfe. No argu- ments could prevail upon her attendants to admit frefh air. A clyfter was adminiftered compofed of the jelly of ftarch, and half an ounce of diafcordi- um. Draughts consisting of jelly of ftarch, a fcru- ple of the cordial confeaion, and a drachm of the iyrup of poppies were given her every four hours. In the evening fhe took a draught with ten grains of rhubarb in it. On the 9th. Continued much the fame. On the 10th her tongue had contraaed a thick fur; her pulfe beat 120 times in a minute, her milk was much CASES. 179 tnuch deereafed, her fweats and loofenefs continu- ed. My worthy and learned friend Dr. Brown was joined in confultation with me. We ordered her two grains of ipecacuanha in a little mint water, which procured her one gentle puke. Draughts containing ten grains of the compound powder of bole, a fcruple of the cordial confeaion, and five grains of nitre, were given her every fix hours. In the evening the pains in her abdomen were fo great that fhe was obliged to take a grain of the Theban extraa. Day nth. She remained much the fame. The draughts were continued, Day 12th. Very little alteration. The draughts continued. On the 14th. The diarrhea, fweats, quick pulfe and white tongue, as in the four preceding days. The pains in her belly as bad as ever. The nitre was omitted, and forty drops of the Paregoric elix- ir were added to each draught. There was little alteration either in her fymptoms or her medicines till her 19th day, when fhe feemed to be worfe than ever, and complained much of a weight and op^reflion about her breaft and ftomach. Being both alarmed and furprifed at the obstina- cy of her cafe, we talked with her hufband about M2 it. 3$0 C A s e a it. He informed us that her mother, and another lady, with the nurfe and child, had conftantly lain in the fame room with her fince her delivery, that our direaions in regard to air and ventilation had never been complied with, and that if we had opened a door, it was fhut immediately after our leaving the houfe. That a large fire had been kept in the room day and night, that the curtains had been always drawn clofe round her bed, and that fhe had not been permitted to breathe any air but what had been polluted by her fweat and excre- ments, and the effluvia arifing from the breath of fp many perfons. That feveral of thofe who were moft with her had got the fame kind of putrid dia rrhe'a, but that he had himfelf efcaped it, moft probably becaufe he had avoided as much as poffible going into the room, upon account of the exceffive heat, and offensive fmell which it afforded. He faid he was now fenfible both of the danger fhe was in, and of the abfurdity of the praftice of thofe about her, and that he was therefore determined to fee our di- reaions ftriaiy complied with. The fire was tak- en out of the room, which was gradually cooled, and thoroughly ventilated by frequently opening the door and window. Eight grains of rhubarb were given her in a folution of fpermaceti. The next morning fhe was confiderably better ; her pulfe, which for many days had never beat lefs tfeaj* 120, heat now no more than too times in CASE S. 1S1 in a minute, and href' urine depofited a fediment. The ipecacuanha was repeated. On the 2 lit. The lochia returned, and her loofe- nefs was more moderate : fhe was direaed to take two fpoonfuls of Huxham's tinaure Of bark every eight hours. The room was fprjinkled with vine- gar, and the ipecacuanha repeated. The 2 2d. The ipecacuanha having puked her gently, relieved her breaft and ftomach, and was therefore repeated. She was considerably better, was removed into another room, and our direaions were punaually complied with. The 23d. Her milk was entirely gone, her loofenefs very moderate, and the ipecacuanha was repeated. The 24th and 25th. The ipecacuanha repeated. The 26th. She was very cool. On the 27 th. She took a draught containing (en grains of the powder of rhubarb, and the fame quantity of compound powder of bole; her pulfe was reduced fo as only to beat eighty times in a minute, and fhe had no complaint, but that of want of fl rength, for which fhe was ordered a decoaioa M3 of 18a CASES. of the bark with Huxham's tindure, and the com- pound powder of bole. In a little while fhe per- fectly recovered her ftrength, and has had another child fince. During her laft lying in, fhe ftriaiy obferved the direaions I gave, and had no fever, or other bad fymptoms. CASE III. MRS.----, a ftrong, lufty, healthy woman, was delivered on the fourth of May, 1770, of a fine large child. She had a natural labour, and the fecundines came away very eafily. This was her fourth lying in, Her room was clofe and fmall, a large fire, which had been kept in it conftantly, render- ed it very warm.—Every time t vifited her I found her in fweats. I frequently defired that the room might be kept cooler and more air admitted into it, but this was not complied with. The lochia were in proper quantity, but fo off fen live as to affea the whole room. She made no particular complaints till the fifth day in the morning, reckoning from the day of her delivery, when fhe was feized with violent pains, attended with a forenefs, (welling and tenfion of the CASES. 183 the abdomen, accompanied with a tenefmus, the motions of which, though frequent and very pain- fur, occafioned her to void very little, except mu- cus. Her pulfe was quick, her tongue white, and burning heats now came on, fucceeded by fweat- ings. She complained of pains in her head, back, and loins. I direaed emollient clyfters to be ad- miniftered every half hour, which procured her eafe and copious ftools. She laboured likewife un- der naufea, retchings, and vomitings. The apoth- ecary was direaed to give her a vomit of a fcruple of ipecacuanha in a draught, and to work it off with an infufion of camomile, and I defired her to fit up often in bed, and to get out of it once every day. On the fixth xlay fhe had feveral difcharges by ftool, and after every ftool feemed fomething^eajfier. In other refpeas fhe was no better. Her lochia flop- ped, and her milk abated in quantity. I ordered the fire to be taken out, the door to be thrown back, and a window in an adjoining room to be kept con- ftantly open, and I vilited her frequently, and faw that this was really done. She was taken out of bed whilft clean fheets were laid on, and five grains of the calx of antimony, and half a grain of emetic tartar were given her three times a day. On the 7th day the window and door were con- tinued open, and a free circulation of the air was brought on by opening the window of the room in which fhe lay. The calx of antimony and emetic M 4 tartar 184 CASE S. tartar were continued. She had plenty of ftooll, was much cooler, her fweatings were abated, and her pains fbmething better. On the 8th day, all her complaints were gone ; her milk and lochia returned, and fhe removed into another room. CASE IV. January 12th, 1771. At two o'clock in the morning, Mrs.------was delivered of a fine child, without any affiftance; the navel llring was torn off clofe to the placenta, and did not bleed. I faw her about half an hour af- ter the child was born, the placenta was expelled from, the womb by her natural pains only, and I hacHfthing to do but take it from her. After the child had been born about an hour, I cut the navel firing about four inches from the child's bo- dy, and it did not bleed. Her labour being much quicker this time than it had been of her former children, fhe was unprepared for it. The night was exceedingly cold, being a very fevere froft ; the fire was almoft out; fhe was jult got out of bed, with only half her clothes on, when the waters broke, and the child was born; the nurfe n London, I was defirous, if poffible, of finding out the caufe, and I have been favoured with the following account from a gentleman of diflinguifh- ed abilities in that place. He informs me, that " when the lying in women are committed folely " to nurfes, they are generally kept in a clofe warm " room, and plentifully fupplied with wine or beer «' caudle, with aromatics; fometimes even gin and " other fpirituous liquors, efpecially among the .« lower clafs of women, are prepofteroufly admin- " jftered. They generally keep lying in women «' in i34 POSTSCRI PT. " in bed four or five days after delivery. Where " the faculty are concerned, a cooler and more tern- " perate regimen is obferved, and the patient al* " lowed to fit up the third day after delivery." I have juit now been favoured with a letter from Dr. Young, Profeffor of Midwifery at Edinburgh, who is not only poffeffed of a principal fhare of private praaice in that branch, but has the fole direaion of a lying in ward in the Royal Infirma- ry in that city. Speaking of the puerperal fever, he fays, " We have no fuch, fever, and, excepting " one woman who died in the lying in ward, feem- " ingly of a mortification after a very fevere la* " bour, I have not loft one patient after delivery 'i for fome time, " I have within thefe few years made a very "great change upon the method of treating wom- " en after delivery in this place, which was before t: entirely in the hands of the women. The lying " tainly recover much falter." By Dr. Price's obfervations, and by the bills of mortality, it appears that in Edinburgh the proba^ bility of a human life is as low as in London, an4 much worfe than in Dublin, Manchefter, or North- ampton : p O H S C R I P f. £££ • ampton : and though this laft named town is the fmalleft of the five, and more healthful in other refpects, yet the puerperal fever, by the belt ac- counts I have been able to obtain, is aimbft as fa- tal there as in London, and much, more fo than in any of the other towns I have mentioned. In London the puerperal fever was obferved by ■ fome to be more fatal in the year 1770, than in (any other year ; but I do not find that the fame ob- , fervation held good invariably either there or in other places. The fatality that attends the patients In fome of the lying in hofpitals, greatly exceeds i that of any private piaaice, at leaft any that I have ' been acquainted with. In one publick lying in t hofpital, from the firft opening on the 20th of A- k pril 1767, to the 29th of November 1772, 653 ';' women have been delivered, of whom 18 died, "which is more than one in 36; in this hofpital the {beginning of the year 1770 was particularly unfa- vourable ; for out of 63 women who were deliver- ed betwixt the 30th of November 1779 and the 15th of May 1770, 14 died, which is in the pro- portion of one in 4-j. In the printed accounts of another lying in hofpital from its firft institution in November 1749 to the 31ft of December 1770, there were 9108 delivered, of whom 196 died in the hofpital after delivery, which is neareft one ysx 46 j j out of the number, 890 were delivered in. the *3« POSTSCRIPT. the year 1779, and 35 died, which is more than the proportion of one in 25 \ ; the year 176Q was likewife very unfavourable to this hofpital. In another hofpital there have been fince the begin- ning of the year 1747 to the prefent time, 47138 women delivered, and 93 have died, which is about the proportion of one in 51. The year 1771 was the moft unfavourable to the lying in women in this hofpital, for out of 282 delivered that year, 10 died, which is about the proportion of one in 28, In another lying in hofpital I am informed, tha$ the year 1770 was not unfavourable to the child- bed women, but the year 1771 was. But this gen* cral fatality does not feem to have attended every lying in hofpital in London, for in one instituted about fix years ago, 790 women have been delivf ered, and only fix have died, viz. two of the puer* peral fever, one in the year 1770, the other in 1771 ; three of floodings ; and one of a confump- tion, which is no more than one in 1312-3. In the lying in hofpital in George's lane. Pub* lin, from March 1745 to the firft of Oaober j 754, there were delivered 3206 women, and 2g died, which is about the proportion of one in 110^. In the new lying in hofpital in Great Britain ftreet, Dublin, from the opening on the 8th of December 1757, to the 31ft of Oaober 1775, there have been delivered POSTSCRIPT. z%7 delivered in the hofpital 10726 women, of whom 152 have died, Which is nearly one in 70. In this hofpital, in the year 1768, 633 women were delivered, and feventeen died, which is nearly one in 37. In the year 1770, 616 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 ntuated at nearly equal diftances from the centre of the fame city, viz. London, both instituted a- k Jbout the fame period of time, and both under the ■ direaion of men of confiderable eminence in the feflion, and nearly the fame number of women having been delivered in both houfes ; that in one of them, they fhould 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 diftinguifhed himfelf for his knowledge in this branch of praaice. He in- forms *S8 POSTSCRIPT. forms me, that " This hofpital is fituated near, " and open to the fields ; no particular care is " taken of their diet or regimen in any refpefct, " but there are fcarcely ever more than four in the " 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- ,c ceive eight." Perhaps there are fome other particulars relative to this hofpital which may contribute very materi- ally to its fuccefs. It was instituted for the pur- pofe of inftruaing young gentlemen, and not only unmarried women, but even thofe of the moft a- bandoned charaaers 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- mit 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 different1* towns, ^ n ' P O S T S C R I P T. «39 towns, via- London, Northampton, Manchester, Holy Crofs in Salop, Chefter, Warrington, Liver- pool, Ackworth near Ferrybridge, Yorkfhire, and feveral places in Germany ; it is not in my power to do this with precision, as we cannot exaaiy.deter- mine the number of women who have been delivered every year in each town : However, from compar- ing the number of christenings 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 conjeaure. Yet if we make proper allowances Tor the stillborn and chrifoms, we fhall find that the number of women delivered each year will greatly exceed the christenings, therefore the fuc- cefs of general praaice will be much greater than is here reprefented. In Manchefter, registers 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 fhew that though the town has increafed 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 regiiters have not been longer kept, a« the fatal period I «luve alluded to in the former part of this treatife when *|o POSTSCRIPT. when the ftkalkj" was occafioned by mifmanage* ment, was prior to that time, during which period from my own recolleaion, 1 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 christenings, and 3552 women died in childbed, which is the proportion of one in 71^. In the laft eighteen years there were 281304 christ- enings, 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 christ- 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 christenings, which is in the proportion of one in 99. In Northampton, in the parifh of Allfaints, from the beginning of the year 1737 to the end of the year 1753, there were 1535 christenings, dif- fenters included, and 20 women died in childbed, which is in the proportion of one in j6%. In the laft eighteen years there were 1602 christenings, and POSTSCRIPT. 241 and 20 women died in childbed, which is in the proportion of one in 80. In the parifh of Holycrofs, in Salop*, from Michaelmas 1750 to Michaelmas 1760, there were 331 chriftenings, and 4 women died in childbed, which is about the proportion of one in 82. From that time to Michaelmas 17701, there were 382 chriftenings, and 4 women died in childbed, j which is about the proportion of one in 95. In Manchefter, at the collegiate church, from the beginning of the year 1754 to the end of the year 1759, there were 4117 chriftenings, 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 chriftenings, and 40 women died in childbed, which is about the proportion of one in 11 of. In the laft fix years there were 5251 chriftenings, and 47 women died in childbed, which is nearest one in 11 i-J. In the- year 1770 there were 897 chriftenings, and eight women died in childbed, which is in* the propor- tion of one in 112. In the year 1771 there were 1001 chriftenings, and 6 women only died in child- bed, which is one in 167 ; this and the year 1759 were the moft favourable to lying in women, and the * See Phil, Tranf. vol. LI I. p. s. Art. 2$, + Ibid, vol, LXI. p. 1. Art. 6, Q 242 POSTSCRIPT, 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 christened 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 Manchefter 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 9if. 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 g^. 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 11 women died in childbed, which is nearly in the proportion of one in 100. At Ackworth, a fmall village near Ferrybridge in Yorkfhire, from the 8th of December 1744 to the 31ft of December 1773, being 29 years and a few days, POSTSCRIPT. 243 days, there were 559 chriftenings, and 6 women died in childbed, which is nearly in the proportion of one in 93. In Leipfic,* from the beginning of the year 1720 to the end of the year 1725, there were 5237 chriftenings, 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 christened, and 2 died in childbed. At Coburg, in 1725, 206 were christened, and 2 died in childbed. Total 6181 chriftenings, and 132 women died in childbed, which is about the proportion of one in 463. 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, fome of them much worfe than none at all ; and that very few of them can be attended by regular, or even by a- ny nurfes, but are obliged to take care of them- felves, deftitute of proper affiftance, and of even the neceffaries of life, and perhaps affliaed with dan- gerous diforders ; if under all thefe difadvantages it Q 2 fhould * Martin's Abridgment of the Phil. Trans', vol. 7. fart +> S44 POSTSCRIP T. fhould be found that the fuccefs attending ^hem fhould be greater than that of fome private praiice among the affluent, or even the praaice in fome lying in hofpitals, where all proper affiftance is fuppofed to be at hand, we have great reafon to apprehend mifmanagement in fome department or, oj&er. %t may perhaps be thought neceffary to make fome apology for thefe calculations and compari- sons, 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 higheft opinion of hofpitals and infirma- ries, efpecially thofe which are maintained, by vol- untary fubfcriptions. They are the nobleft of all charities, the leaft 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. i The buffy or fizy 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 on being expofed to the air, as in the cafe which Mr. IJewfon * .mentions of a patient in the Britifh ly- ing in hofpital. The blood was drawn three days before • Ex^iojjotel Inquiry, p, 1 u, POSTSCRIPT. S|£ 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 diffeaion : and pof- fibly the blood might oftener have the fame ap- pearance if patients were bled late in this diforder. Moft pregnant women have fizy blood where there are no fymptoms of inflammation. Sir John Pririgle, 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, fhowing an inflam- matory cruft, and very foon changing to a fanious and diffolved ftate, fo that no certain indications can be drawn from it. With refpea to bleeding in the puerperal fever, I cannot upon the ftriaeft 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 fliould only be " looked upon as a fecondary help, though it u fhould always be firft 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 indifcriminately. Emetics, cathartics* and clyfters are certainly proper to cleanfe the jrrimd vice, and likewife fuch medicines and diet as Q 3 will 246 POSTSCRIPT* will correft 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- inae, or any other complaint which I have the leaft reafon to fufpea could poffibly arife from fuch treatment. Several difficulties which arife concerning the puerperal fever may, I imagine, be more consistent- ly and fatisfaaorily anfwered from the ideas I have attempted to give of it than from any others. , enormis, et poftquam pcrfciffum eft, abceffum ccntinerc repertum." Dijf. Med. Inaug. de Febre Puerptr. Patr. Keary, Edin. i?u, p. 8. Dr. Hulme, p. 43, fays, " The liver was of an extraordinary magnitude; to the right lobe was found a very extenfwe abfceiV f Ibid. p. S3. *7° APPENDIX. " and hard lumps of excrement will be fometimes et difcharged; which one might fufpea 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 imperfeaiy underftood, no proper diftinaion having been made between the abforption and ob- JlruBion of the lochia, I fhall 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 found- ed faa ; but from hence they have concluded that the lochia can have no fhare in producing the dif- eafe—a conclusion 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 moft 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 A P P E N D I X. 271 m 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 diminiftied in quantity. We fhall prefently fee how thefe obfer- vations apply in the puerperal fever. That accurate anatomist, 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 veffels which carry red blood from the uterus. It is not to be injea- ed by injeaing the placenta, being not a fetal, but an uterine part. After delivery, the greateft part of this membrane is left behind, grows putrid, gradually diffolves, and comes away in a fluid ftate along with the cleanfings. It frequently how- ever, is fo long in feparating, that on diffeaion* of feveral who have died of the puerperal fever, 1 the infide of the uterus has been found lined with it; apd it has been of fo black a colour, that the womb * See Leake, p. 75, and 179. 2/2 APPENDI X. womb itfelf has been fuppofed to be mortified, till the miftake was discovered by wiping off this fab* fiance. 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 fhould, frequently, be firft and princi- pally affeaed, and on diffeaion be found inflamed, fuppurated or gangrened, might naturally be ex- peaed 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 obftruaed 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- crv. APPENDIX, *7fc ery, when her fkin 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 the omentum was deftroyed and converted into matter, and what remained was become gangrenous, Sec.—The Doaor makes the following remark. " Where the pulfe was extremely foft and weak " and the circulation languid, it is difficult to ac- " count for fo fudden and high a degree of inflam- " mation as to produce a collection of matter, or " any inflammatory affeaion of the abdominal <{ vifcera ; but fo it was." In another place, he fays, " Considering 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 abdomen " fo early as the fourth or fifth day after the firft " attack ; as will appear in the cafe of Harriet " Trueman."* He aifo obferves, t " that in the winter months, " when the childbed fever began, the weather was " obferved to be remarkably mild and moift, *l with a warmer temperature of the air than was *l natural * Leake, p. so6. t Ibid, p. 37, S 474 APPENDIX. " natural to the feafon." But it is well known that true inflammatory diforders prevail moft in cold dry easterly winds. In regard to the prevention and cure of this fe- ver, there is not, I believe, a man of eminence in the profeffion who is not thoroughly convinced of the neceffity of pure, free, and even cool air ; though perhaps their direaions on this head are feldom fo ltriaiy put in execution as might be wifhed. But there is another point of praaice which is by no means hitherto fettled ; this is the pofition of the patient for fome time after deliv- ery. Several of the firft accoucheurs and princi- pal nurfes in London keep their patients in bed for five or fix days, or more, without ever permit- ing them to get out of it, and what perhaps is worfe, without fuffering them to fit up in bed, or even raife their heads from the pillow. And one gentleman, defervedly of high charaaer in the profeffion, in a late publication. has declared, (( that in his own praaice he has feen more frequent inftances of the puerperal fever from early fitting up than from all other accidental caufes united." Were this, however, the real caufe of puerperal fevers, it would be aftonifhing that any of my patients fhould ef- cape them, as I conftantly direa them to fit up in an hour or two after delivery, and to repeat it as frequently as poffible, and even to get out of bed APPENDIX. 275 in lefs than twenty four hours ; and it is feldom that they exceed this period. One lady, indeed, whom I attended in two lyings in, lay in bed five days each time, and in one of them was for the moft part confined to a horizontal 'pofture ; and in that fhe had a puerperal fever ; whereas this dif- eafe has very rarely occurred among others whom I have delivered, and has never once proved fatal. Perhaps in London it may be thought early to fit up in one day after delivery,' or to get out of bed in two or three. Now if a horizontal pofition has been conftantly maintained for that time, and the feeds of the puerperal fever have been thereby fown, the fudden change of pofture and of cloth- ing may perhaps make it fhew itfelf fomewhat fooner than it would otherwife have done; and this I think I have feen. I have taken fome pains to inquire both of the gentlemen of the faculty, and the moft intelligent nurfes, whether they had other reafons befides that already mentioned for keeping their patients fo long in a horizontal pofture ; and as far as I can learn, early fitting up occafioned, as they imagin- ed, a prolapfus of the vagina, or bearing down, as it is commonly termed. But I have already de- clared my opinion that this complaint is generally owing to a quite different caufe, the forcible ex- traaion of the fhoulders of the child ; and I can S 2 affirm *7* APPENDIX. affirm in the molt pofitive manner, that early fit? ting up has never produced it in the flightelt de- gree, in thofe whom I have delivered. That a horizontal pofition fhould promote that abforption of matter which I confider as in great meafure the caufe of puerperal fevers, will appear probable from various considerations. The weight of tlie uterus in this pofture carries it clofe to the vertebrae, and caufes its fides to approach each oth- er, fo as to render its figure flatter ; by which means its contraaion mult be impeded, and confequently the expulfion of its contents retarded. The difc* charge of the lochia, too, is not, in this cafe, affift- ed by gravitation ;r hence they will be apt to lodge and stagnate in the tranfverfe rugae of the vagina. Whereas an upright position produces effeas the contrary to thefe. The uterus preffing forwards upon the foft parietes of the abdomen, will meet with no obftacle to its contraaion ; and the lochial difcharges, finding a ready exit by a depending ori- fice, will drain off as foon as they have acquired Sufficient fluidity. An obfervation from natural history may be ad- duced in confirmation of this idea of the different effeas of an upright and a horizontal pofture. No quadrupeds are found to menftruate, except fome of the monkey tribe ; and of thefe, according to that APPENDIX. 2?7 that eminent naturalist Mr. Buffon, * only fuch as either habitually or occafionally ufe an erea pof- ture in fitting or walking, are fubjea to this peri- odical difchafge. By the mode of praaice which it has been the purpofe of the foregoing treatife to inculcate, I have hitherto been able either to prevent, or if call- ed in time, to cure the puerperal fever ; but when it exifts in that malignant endemic form in which it fometimes appears in a lying in hofpital, I fear no method, as yet propofed, will be fufficient to ftop its ravages. Under thefe deplorable circum- ftances, one remedy, which has not, I believe, been mentionedb^-'any writer on the fubjea, might be tri- ed without the imputation of rafhnefs. This is a bath of fuch a degree of temperature as only to give a gen- tle fhock. Warm bathing has been ufed without fuc- cefs. Dr. Leaket fays, " One would have imagined " that the warm bath bid fairer to anfwer this inten- " tion than any thing elfe, as it aas like an uni- " verfal fomentation applied to the furface of the " body ; * ,c Le Gibbon, Le Magot, &c. Les femclles font, comme les Femmes, fujettes a une ecoulement periodique de fang." Tom. 14. «• Le Coaita, L'exquime, &c. Les femclks ne font pas fujettes a l'ecoule- ment periodique." Tom. s 5. *' Simia —— Femina menftruat." Linncei Srf% Wat, Vol. I. p.V$. S3 t lb, p. 117. 278 APPENDIX. " body ; and the rather, fince it has been found to " procure almoft inftant eafe in other diforders of " the bowels ; but to the confufion of all theory, " in thofe cafes where it was tried, it by no means " anfwered my expeaation ; and from what I "could learn, fucceeded no better with others ; " for the greateft part of thofe died for whom it " was direaed." That a temperate bath might prove efficacious in preventing the difeafes to which lying in women, from too delicate treat- ment, are liable, we have fome reafon to conclude, from the praaice which, both in ancient and mod- ern times, has prevailed in many parts of the world, of bathing immediately after, and in fome before delivery, in water of the common tempera- ture. Some examples, which might eafily have been multiplied, of the prevalence of this cuftom, are inferted in the notes. * Whether, while the puerperal ». With refpect to ancient teftimonies of this practice, we have the fal« lowing paffagc in the Andrian of Terence, Act. III. Sc. 2, L E S B I A. Adhuc Archillis qua: adfolent, qua?que oportet Signa ad falutem effe, omnia huic effe video. Nunc primum fac, ifthaec ut lavet; poft deinde, Quod juffi ei ante bibera, & quantum imperavi, Date : Mox ego hue revertor, Madame Dacier's remark upon thefe lines is much to our purpofe. 3. Nunc primum fac, ifihtec ut lavet. La premier chofe que vous devezfaire e'eflde labaig- ner. Cetoit la coutume en Greet, des qu'une femme etoit accouchee on la mettoit au bain. II y a fur cela un paffagc remarquablc dans CaJlimagnc, Sc pn autre dans Lucien^ A P,'P E N D I X; 279 puerperal fever is aaually prefent, this praaice might with fafety or probability of fuccefs be em- ployed, I fhall not venture to determine. In an obstinate The paffage in Callimachus here-referred to proves that women bathed in a running flrcam immediately after delivery. Avrtxa Sityiro foot vSccto*;, u xe roxoto Avparx yyfouaouro, tilv $ in X?UT* hoio-rau. Hie te poftquam mater magno depofuit ex utero, Statim quaerebat rivum aquae, quo partus_/ui I Sordes ablueret, tuumque corpus purgaret. Some of the moft particular and beft attefted modern accounts of this cuf. torn, are the following: " The Americans that inhabit the Ifthmus of Darien, make no difficulty of plunging into cold wa'.er when they are in a fweat, to cool themfelves ; likewife the mothers with their children bathe in cold water immediately after they are brought to bed. This is certain, that they never receive any damage from this cuftom ; whereas, on the contrary, many women fuffer greatly in thefe parts from too delicate a regimen." Brookes's Nat. Hift. Vol. I. p. 175. The following quotation is taken from Wafer's new Voyage and Defcrip- tion of the Ifthmus of America, price 2s. printed in 1704, now added to Pampier's Voyage, Vol. III. p. 360. « When a woman is delivered of a child, another Woman takes it in her arms within half an hour or lefs after it is born, and takes the lying in worn- an upon her back, and goes with both of them into the river and wafhes them there." Wafer, p. 360. " The $ 4 a8o APPENDIX. obftinate coriftipation of the bowels, attended with extreme pain, confiderable fever, and immediate danger, Dr. Stevenfon informs us that a cure was obtained " The Brazilian women are extremely fruitful, have very eafy labours, and rarely mifcarry, for no fooner is a women delivered, but up fhe gets to the next river, and without any further help wafhes herfelf there." Newhoff's Voyages, p. igt. " The Tapoyar woman cut the navel ftring with a fhell, and wafh them- felves and their children every morning and evening after delivery." lb. p. 154. The Brazilian women are very fruitful, have eafy labours, retire to the woods, where they bring forth alone, and return after wafhing themfelves and their child ; the hufbands lying in bed the firft twenty four hours, and being treated at if they had endured the passu. Confirmed by Woods Rog- ers, p. 57. " The California!?* had adopted that abfurdity, which i« (b much laughed at in the accounts of Brazil, that the women after delivery, ufed imme- diately to go to some water and wafh themfelves and the child; and in other particulars to obferve no manner of caution, going to the foreft for wood and food, and performing every other fervice the hufband wanted." Nat. and civil Hift. of California, tranflated from the original Spanifik of Miguel Venegas, a Mexican jfefuit; publifhed in S758, tranflated 1759. p. 8s and 82. N. B. The northern point of California is in lat. 46. . Long, Efq; one of the judges of the admiralty, in his Hiftory of Jamaica, publifhed in 1774, Vol. II. Book III, Chap. s. p. 380, fpeaking of the negroes on that part of the African continent called Guinea, or Ne- gro Land, fays,' *' Their women are delivered with little or no labour ; they have therefore no more occafion for mid wives than the female Oranoutang, or any other wild animal. A woman brings forth her child in a quarter of an hour, and goes the fame day to the fea and wafh.es herfelf. Some have been known to bring forth twins without a shriek or a fcream, and it is fcldom they are confined above two, or at moft three days. Immediately before A P P E N D I X. a$* obtained chiefly by dafhing cold water upon the lowt^r extremities up as high as the pubes, arid plunging the feet into cold water, after the warm bath had failed. Edin. Med. Eff. vol. VI. 393.' What analogy this cafe may have to the puerperal fever, I leave my readers to judge. Since the publication of the former edition of my treatife, I have received a letter from that ex- cellent profeffor of midwifery, Dr. Young of Ed- inburgh, containing an account, well worthy the attention of the, faculty, of the appearance of the puerperal fever in the lying in ward of the infirmary of that city. The letter is dated November 21, 1774, and the following is an ex- traa from it: « We had the puerperal fever in the infirmary *< laft winter. It began about the end of Febru- '* ary, when almoft every woman, as foon as fhe *' was delivered, or perhaps about twenty four «« hours after, was feized with it; and all of them " died, though every method was tried to cure the " diforder. before her labour (he is conducted to the fea fide, or a river, followed by a »umber of little children, who throw all manner of ordure or excrement at her in the way, after which fre is wafhed with great care. Without tins Cleanly ceremony, the negroes are perfuadcd that either the mother, the child, or one of the parents, will die during the period of lying in." «8* APPENDIX, " diforder. What was lingular, the women were " in good health before they were brought to bed, " though fome of them had been long in the hof- " pital before delivery. One woman had been dif- " miffed the ward before fhe was brought to bed ; "came into it fome days after with her labour "upon her; was eafily delivered, and remained " perfeaiy well for twenty four hours, when fhe " was feized with a fhivering and the other fymp- " toms of the fever. I caufed her to be removed to " another ward ; yet, notwithftanding all the care " that was taken of her, fhe died in the fame man- " ner as the others. I muft'inform you at the " fame time, that the difeafe did. not exift in the " town. To account for this diftemper in the ly- " ing in ward, I muft acquaint you that it has " been a general obfervation, that the patients in " the infirmary who had undergone any confider- " able operations, were more fubjea to eryfipelat- " ous fwellings than formerly. I found that the " women in the lying in ward laft year did not " recover fo well as formerly, but fcarcely any of " them died. It was thefe appearances which " made me think there was a local infeaion, and " determined me to fhut up the ward till it could "■ be removed. This I did, after lofing fix wom- " en. I then wafhed and painted the ward, caufed " all the bedding to be removed, and fired gunpow- " derat different times in the ward, I had a number « of AP'PENDI X. 583 " of chaffers filled with cinders, which burnt all " night ; and all the windows were opened through 16 the day. This operation lafted about a fort- " night, when I furnifhed the ward with new bed- " ding, put no curtains to the beds, and by this * put an entire ftop to the difeafe. The ward was " open to receive patients in a fortnight from the " time it was firft fhut up. The bodies of all the " women were opened, and we found exaaiy the " fame appearances as are mentioned by thofe who " have wrote upon that diforder. Though the " omentum was often found fuppurated, yet in " none of them was there any appearance of a *' gangrene." Several faas of importance in the hiftory of the puerperal fever are contained in this account ; par- ticularly—that none of the women were feized with it before delivery, though fome of them had been long in the houfe—that although the difeafe was fo fatal in the infirmary, it did not exift in the town—and that an entire ftop was put to it by thoroughly cleanfing and new furnifhing the ward, fo that in a fortnight after it was opened again with fafety for the reception of patients. Poflibly it may be urged as an argument againft abforption, that " almoft every w6man as foon as X fhe was delivered, or perhaps about twenty four «' hours 884 . APPENDIX. " hours after, was feized with this fever." But I believe this objeaion will not be found of any force, if we confider that it will not be an eafy mat- ter to determine whether the heat, fhiverings, or ac- celerated pulfe, which happen in fome hours after delivery, are the fymptoms of a puerperal fever,' or merely the effeas of the labour ; efpecially in an irritable habit of body, as thefe are fymptoms which are frequently feen foon after delivery when no fever has fupervened ; and an abforption may take place in a very few hours. Mr. Eli Cope, an ingenious furgeon of Leek in Staffordfhire, who formerly lived in my houfe a confiderable time as a pupil, and whofe veracity may be depended on, has favoured me with a remarkable confirmation, from his own pra&ice, of the fafety and advantage of the method of treat- ment which I have inculcated. From an exaa ac- count of every woman he has delivered fince he left me, amounting to 593, with the circumftances of their cafes, he affures me that he has not loft one from the puerperal fever, nor from any other caufe where he alone was concerned. Many preternat- ural, laborious, and flooding cafes had occurred a- mong this number ; yet they were all managed ac- cording to the plan above recommended; and par- ticularly not a fingle patient had lain in bed twen- APPENDIX. $85 ty four hours together after delivery. One in- flance that he relates of the good effeas of fuffer- ing their fhoulders to make their proper turns, in preventing afterpains, is fo remarkable that I fhall give it at length in his own words. " A Farmer's wife in our neighbourhood appli- " ed to me in February 1773, defiring me to at- " tend hee in her labour, which fhe expeaed in a " few weeks. She told me fhe had had fix chil- " dren, and had very eafy labours ; but that fhe " had fuffered fo much with afterpains for a fort- " night, that it rendered her unable to leave her " room at the end of fix weeks. I attended her in " a natural good labour. A? foon as the head of " the child was born, I obferved the fhoulders to " make their turn, having my left hand under the " child's chin, and the right hand on the occiput. " In this pofition I was determined to wait till a " pain came, which was feventeen minutes : This " forced the child as far as the hips. The next pain, '' which was in about two minutes, totally expell- " ed the child. " I have fince attended her, and only waited " fourteen minutes after the head was born. She " never after had a fingle afterpain, but was about " her bufinefs in three weeks," My 286 A"P P E N D I X. My worthy friend Dr. Aikin, whofe charaaer and abilities are well known to the public, and others of my pupils, as well as many other praai- tioners, have aifo favoured me with their testimo- ny to the fuccefs of the feveral points of practice recommended in the foregoing treatife. ADDITIONAL APPENDIX. 287 ADDITIONAL CASES. CASE XVI. JONATHAN KERSHAW'swifeofHav- en near Greenacre Moor, in the parifh of Oldham, about thirty years of age, being at the full period of geftation, had the misfortune on the fecond of July 1770, to fall upon a pot veffel, which broke, cut through her clothes, and made an horizontal wound in the abdomen, about a quarter of an inch above the navel, and about two inches in length. Labour pains immediately fucceeded, and fhe was delivered in about thirteen hours of a living child. I faw her in about fifty hours after the accident, and found that a piece of the omentum, as large as my fift, had protruded itfelf through the wound, and lay upon the outfide of the abdomen; it had a very *88 APPENDIX, very putrid appearance, difcharged a bloody ferum, and fenelt very offensively. The omentum was wounded, and a triangular piece of pot was found within it. I fpread it open carefully, to examine whether any portion of the inteftines was protruded along with it, and being fatisfied that there was not, I applied a ligature round it clofe to the abdomen, and then cut off all that part beyond the ligature. In about a fortnight the ligature came away, and in lefs than a month the wound was perfeaiy healed without the leaft inconvenience, and fhe has fince had another living child. REMARK. This cafe, as far as one instance will go, proves that the omentum in puerperal women is not par- ticularly liable to inflammation, fuppuration, and mortification ; but in thofe cafes where there has been that appearance upon diffeaion, it has been owing to acrid matter being abforbed and deposit- ed upon it, and not to any original difeafe in the part produced by pregnancy or parturition. CASE XVII. IN the poltfcript to my account of the puerperal fever, I think I have fufficiently refuted the APPENDIX. 289 the doarine of tfaofe. phyficians who have imagin- ed that the (diforder is equally common in all places. The following cafe will, I believe, be a fufficient anfwer to thofe who have maintained the oppofite opinion, alleging that it is only generat- ed in the metropolis, and never .exists in other parts. of the kingdom. We fhall here fee it, in a very malignant ftate, make its appearance in. the town of Manchefter. A. B. of Manchefter, a remarkably heal hy woman, who had hitherto fcarcely experienced a- .ny diforder, was in the beginning of her firft preg- nancy affliaed with pains in her ftomach, attend- ed with vomitings ; but during the laft four months fhe was perfeaiy well, at leaft as free from complaints as one can be fuppofed to be in her fit- uation. On the 27th of Oaober, 1772, fhe was deliver- ed of two children by a careful furgeon in this town, who conduaed the labour with great pro- priety. Her labour which continued about fifteen hours, was rather flow than difficult. The firft bora child prefented itfelf in a natural pofition ; the fec- ond with the buttocks foremoft ; but, as the infant was very fmall, it was eafily brought into the world in that pofture. The placenta was expelled na- turally. For a day or two, the patient imagined T "1S ago APPENDIX. fhe perceived a large lump which feemed to roll about within her belly, and which (he fometimes endeavoured to fix by holding her hand upon it. This, however, gave her no pain; and after the fec- ond day, this fymptom, which arofe from the womb's not having fufficiently contraaed itfelf, entirely vanifhed. The lochia flowed plentifully, her milk was fecerned in proper quantity, and fhe gave fuck to her children. On the third day, fhe complained of a little pain in her belly ; and as fhe had not had a ftool fince her delivery, a clyfter and fome opening medicines were adminiftered, which procured a plentiful e- vacuation ; and in the evening fhe took an opiate. On the fourth day fhe was pretty eafy. On the fifth fhe complained of pain and fore- nefs in the lower part of the abdomen, which grew fo troublefome, that it was thought neceffary to re- peat the opiate ; and fome fmall dofes of emetic tartar were adminiftered, which puked her, procur- ed a few ftools, and brought on a gentle perfpira- ration. Her lochia and milk began to diminifh, fhe got out of bed for the firft time in the evening, but was fo fick that fhe could not bear up, and was immediately put into bed again. Her pulfe was ve? ty quick, and her diforder feemed to be increafing, In APPENDIX. 291 In the morning and evening of the fixth, fhe took a little rhubarb and nitre. On the ninth day I was defired to vifit her by the gentleman who had delivered her. I was in- formed that fhe had feldom fat up in bed, and on- ly once been out of it. The houfe was fituated in the moft crowded part of the town. The room fhe lay in was about fix yards in length and five in breadth ; but it was very low, its height not ex- ceeding fix feet and a half. It was not however remarkably hot, though a fire, at which the viau- als of the family were dreffed, was kept conftantly in it : The fire Was at a confiderable diftance from the bed. The nurfe and both the children lay in the fame bed with the patient, and her hufband lay in another in the fame room. The furgeon who was employed, Very prudently ordered the door, and fometimes a window, to be opened in the daytime; but his direaions were hot complied with, and when he had himfelf opened them, they Were im- mediately fhut upon his leaving the chamber. She had every day wine, though in no great quantity, put into her gruel, and no acids were given her. She complained of frequent motions to make wa- ter ; of pain, forenefs, tenfion, and fwelling in the lower part of the abdomen. Upon examining the parts with the greateft attention, I found that her T 2 complaint* *9* A P P EWl'X. complaints were confined to the region of the ute- rus and bladder; and that the fwelling was perfeaiy circumfcribed; and that neither the pain, the fwell- ing, nor the forenefs, extended beyond the halfway from the pubis to the navel; nor was there at that time any reafon to apprehend, either from the na- ture of the fymptoms, or the touch, that there was any inflammation, or other diforder, either in the ftomach, omentum, or inteftines, if we except a gentle forenefs with which it was affeaed. The gentleman who was employed for her, in- troduced a catheter into her bladder, that he might difcover whether it was diftendei with water ; but it did not contain above three or four fpoonfuls. Upon preffing the catheter againft the fundus of the bladder, fhe complained that there was the feat of her diforder. She was thirlty, but her tongue was very little, altered from its natural ftate; it having neither a white nor a..brown fur upon it. She had very, little milk, and her lochia were re- duced to a fmall fanious difcharge. She had nei- ther rigours, vomitings, nor eruptions. The heat of her fkin, and the exceffive quicknefs of her pulfe, which beat no lefs than 160 times in a min- ute, were her only alarming fymptoms. I feveral times examined her pulfe by a ftop watch, when fhe was neither fluttered nor" in great pain, and conftantly found them the fame. From this fin- gle circumstance, upon my firft vifit I prognofticat- cd A P P END I X. 893 ed that fhe could not recover. Small dofes of emetic tartar, which gently puked her, were ad- miniftered feveral times today. Buttermilk poffets and buttermilk were ordered for her common drink, and in the evening fhe got out of bed. On the 10th, her pulfe beat only 128 times in a minute, her belly was rather fofter, fhe had fever- al ftools, and feemed no worfe in any refpea. On the 1 ith, the lower part of the belly about the ute- rus was fofter, but the whole abdomen began to fwell. Her pulfe beat 160 times in a minute. She had many ftools ; and fait of wormwood, with the juice of lemons, was frequently given in the aa 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 ftopped, 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 laft moment; and ex- pired about nine o'clock in the evening. T 3 DISSECTION. ao.4 APPENDIX- 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 exaaiy correfpondent to thofe which he had obferved in London, in fubjeas who had died of the true ma- lignant puerperal fever.* The omentum was al- moft * The great variety of the appearance on diffection, and the little certainty as yet obtained from it with regard to the principal Jieat of the difeafe, are fully fhewn in the following paffage : " In about forty women whom I have had opportunity of infpecTing, all or fome of the following appearances have been obferved. The uterus or its appendages were in a ftate 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 peritonaeal 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 diffolved portions of omentum. It muft indeed be acknowledged, that the information, acquired in this fearch, has not been equal to the care or to the affiduity with which it ha* t been made." Denman on the Puerperal Fever. Second Edit, p, 29 and 30. APPENDIX. 295 moft wholly diffolved : detached pieces floated in the abdomen, which contained almoft three pints of thick purulent matter, and of ferous fluid. The ftomach and inteftines were much inflated, and the inteftines 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 palted together by a kind of gluten ; and inflammation feemed not to have been in the leaft 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 inflammation or mortification. The left ovary was rather larger than the other, but perfeaiy found. The womb, which was not contraaed 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 ftate 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 leaft ap- pearance of laceration, or of any other external injury. T 4 REMARKS, so^ APPENDIX, R E M A R- K S. 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 riling 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- cumftances which merit the utmoft attention. So quick a pulfe is feldom produced by inflammation, when unattended with depositions or abforptions of matter, though accompanied with the moft vio- lent pain. The moft inflammatory gout, when produaive of the moft excruciating torture ; the lnoft 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 pafling through the duas ; the pain and inflammation in the pleurify, the iliac paflion, or the cholera mor- bus ; * nay even thofe arifing from the strangula- tion * The firft attack of this fever is fometimes fo violent, that in many rc- fpefts it lefembles the cholera morbus + -for the pain, ficknefs, and burning heat ia the ftomach and bowels, arc almoft the fame \ and the bile, in great proluhon, APPENDIX. 297 tion of the inteftines, or omentum, or from any of the principal operations in furgery, as lithotomy, amputation, Sic. except where a mortification is come on and the patient is in the agonies of death, do not occafion fo 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 perfeaiy well immediately before the accident. CASE XVIII. BEING called to Afhtonunderlme, a town in this neighbourhood, to fee a patient, as I was talking with Mr. Greaves, an ingenious young furgeon of that place, a corpfe with a white fheet thrown over the coffin was carrying through the ftreets to be buried. Concluding from this circum- flance. that itwas a woman who haddiedin childbed, I profufion, is difcharged upwards and downwaids i though in the flrft, the pulfe is .more pick f.J weak. u^ p< ^ 29* A P P E N D I X. I inquired into the nature of her diforder. He in- formed me fhe died of a puerperal fever. Her name was Ann Leek, a poor woman, about 35 years of age. The particulars were as follow : He was called to her in the middle of the eighth mon.h of her third pregnancy, for a flooding, which was fo violent that the blood ran through not on- ly the bed, but even the floor into the room below; but by taking plentifully of the bark, fhe recover- ed and went to her full time, when fhe was deliv- ered by a midwife on the 16th of November, 1772, and had a very eafy natural labour. He heard no more of her till the 23d, when he found her with a very quick pulfe, brown dry tongue, and delirious. She had a great number of petechie ; and her ftools, which came from her in- voluntarily, were very offenfive. Her friends in- formed him that fhe was feized a few days after her delivery with a fhivering fit, fucceeded by vom- iting and loofenefs, and complained much of her belly. She died upon the 24th, being the ninth day from her delivery. Upon inquiring into the molt probable caufes of her death, Mr. Greaves informed me that the room fhe lay in was intolerably offenfive, owing to a veffel containing about four gallons, kept there as a refervoir for all the urine of the family, which was APPENDIX. 2gg Was emptied once a week for the ufe of the dyers, but was never cleaned. CASE XIX. AjBOUT five years ago, Mrs. W—, who was then twenty one years of age, was deliv- ered of her firft child, as fhe fat upon the knee of an affiftant. She was confined to her bed till the fifth day after her delivery, and during this time fcarcely ever fat up. On the fifth and fixth days fhe was raifed, that her bed might be made, but was not able to continue up longer than was necef- fary for that purpofe ; and fhe was afterwards a- gain confined to her bed eight fucceflive days with- out getting out of it. During this time fhe was at- tacked by a violent fever, attended with miliary e- ruptions, both of the white and red kind. Of this fever fhe perfeaiy recovered ; but upon returning to her ufual exercife, fhe was feized with a prolap- fus vaginae, which, except in the latter end of her pregnancies, hath ever fince continued. On the feventh of January 1773, fhe was deliv- ered, by a gentleman of this town, of her third child, as fhe fat upon the knee of an affiftant. He informed me that, as foon as the child was born, he pulled gently at the navel firing]; and that a fmart pain too A P P £N D I #. pain came on, which totally. inverted the uterus, forcing it down, to the fize of his hand, •throtigh the labia, with the placenta ftill adhering to its fundus. The nature of her cafe immediately struck him ; but to be more perfeaiy fatisfied, af- ter making an apology for fo uncommon a requeft, he called for a candle, and found he was not mif- taken in his conjeaure. He carefully feparated the placenta from the uterus with his fingers, and attempted, but in vain, to reftore the womb to its prifline ftate. He was only able to pufh it up in- to the vagina. In this fituation fhe was put to bed, and he came to me to defire I would vi fit her along with him. In about an hour after this I faw her, and found the uterus about the fize of a large new born infant's head, totally inverted, and lying with- in the vagina. She was in great pain, had loft much blood, was very faint, and no pulfe could be felt in either arm. I attempted tp return the „ uterus to its place 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 throughTits neck, which was a little con- tra aed ; therefore in a few minutes after fhe had taken the opiate and vitriolic drops, without waiting for their effeas, I haftened to reduce it by the following mode of praaice, 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 compreffion. As I very foon perceived that it began to diminifh, I perfevered ; and foon after made another attempt to reduce it, by thrufting at its fundus. It began to give way. I continued, the force till I had perfeaiy returned it, and had infinuated my hand into its body. I now withdrew my hand a little and endeavoured to clofe the os uteri by aflifting 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 wifh, and. without a fingle alarming circumstance. REMARKS. Had not the idea occurred to me of its being praaicable to diminifh the uterus by compreffion, I am fatisfied I fhould not have been able to have replaced it ; and though my firft attempt to re- duce it without compreffion diftreffed my patient greatly, go* APPENDIX. greatly, yet the method I afterwards purfued, feem* ed to be attended with little pain. Several circumftances might probably contribute to this accident ; the prolapfus vaginae, 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 exaaiy 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 contraaed 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 justice be attributed to the neceffity of fo ma- ny concurring circumftances. The proper means of returning the inverted uterus not being before difcovered, and the want of fpeedy affiftance may be the reafons why fo few have recovered. I know but of two written inftances 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. Harviein his PraBical Di- rections,?. 21. Le Motte, indeed, 1. 5. c. 10. Obf. 384, APPENDIX. 303 3B4. 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 affiftant, 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 exaaiy 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 ftill adhering. Thofe who would wifh to fee more histories of thefe truly alarming cafes, may confult Ruyfch, Obf. 10 and 2.6 ; 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, Colleaion 44, cafes 3 and 4, p. 494 and 495 ' and Dr. Hunter's MSS. Leaures on the Gravid Uterus. This cafe likewife helps to prove that prolapfufes of the vagina, or bearings down, as they are com- monly 3»4 A\P-P E NkD IX. moaly called, are not occafioned by too early gffc ting out of bed after delivery ; as.tbisi woman in her firft lying in never got out of bed.till the fifth day, and fcarcely ever fat up in it during that time; nay fhe was totally confined to herbed fourteen days, except on the fifth and fixth -days that fhe was raifed, whilft her bed was made ; and yet: when fhe returned to her ufual exercifes, fhe perceived the prokpfus vaginae. It muft therefore have been owing to fome other caufe, probably to the upright pofition during labour, and the too hafty delivery of the fhoulders. CASE XX. HANNAH NORBURY of Blakely, 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 4 th of March, 1773, 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 molt 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. 305 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 breafts this day for the firft time, the lochia were almoft ftop- ped, and fhe had a fhivering fit in the evening fuc- ceeded by a burning and a fweating fit. On the fourth day her breafts were a little troublefo ne, 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. On the 9th fhe remained much in the fame .ftate. In the evening I was applied to, and order- ed her tartar emetic and calx of antimony, whicfc puked her, and eafed her ftomach and bowels. On the lpth I faw her for the firft time. Her pulfe were fmall, and beat 176 strokes 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 laid my hand up- U en 306 APPENDIX. on it below the navel, in any part of the hypogaf- tric region, it was fo exceedingly tender that fhe 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 aa 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 ftopped 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 ; fhe had convulfive fpafms, and was not able to fpeak or take any medicines. She had one ftool this day, and no vomiting. On the 12th, ftools and urine came from her involuntarily, and fhe died in the evening. REMARKS. I muft obferve that the rccm in which this wom- an lay had no door to it, nor were there any cur- tains APPENDIX. 307 tains to the bed ; therefore I believed there could hot be much putrid air except what was confined under the bed clothes. The mifmanagement chief- ly confifted in keeping her in an horizontal posi- tion, for three days fucceffively, without once fit- ting up in bed—in permitting her to be feven days without a ftool—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 leaft difagree- able fmell ; the omentum was large, perfeaiy 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 inteftines * fhewed not the leaft fign of inflammation, and were perfeaiy 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 lift, of a natural colour, but flaccid ; upon cutting it open, the inr 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- U 2 tides 3Q8 APPENDI X, tieles of blood. Her friends being very averfe to any farther examination, I was obliged to delist. CASE XXI. ANN WORTHING TON,aged twenty fix, was delivered of her firft child, by a gentleman of pretty confiderable praaice, on Fri- day the 16th 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 extraa it by the manual operation, but found the uterus fo contraaed 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 fiye hours after her delivery. I found fhe had flooded much ; her pulfe was fmall, and fhe 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 lulep, which had been prefcribed her; to drink cooling fubacid liquors ; to keep the doors and windows open, as the Weather was exceflively hot; and to fit up in bed as often as poflible, if fhe did not flood. The next morning fhe got out of bed, which was made, and her. linen ^hanged, and. a. clyfter was. injeaed. In APPENDIX. 3159 In about 30 hours afterdelivery, as there was no Hgn 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 ftill 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 fhe had a fevere fhivering 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 injeaed per vaginam ; * In die puerpwal fever whenever the lochia are offenfive, warm watrf fhould be frequently injeaed into the uterus by means of a fyringe which has »thick fyphon and a little curved ; and I am inclined to think that fuch injection! would be very ferviceable in all puerperal fevers, if properly.p«. formed. U a g-io APPENDIX. vaginam ; fhe 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 aa 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 inteftinal canal fufficiently open, having feveral loofe ftools every day. On the feventh night a few pains 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 I.X. 311 On the twelfth a flight preparation of the bark -was ordered ; and on the thirteenth * fhe faid fhe had no complaints, except too much milk in her breafts ; fhe kept out of bed moft of the day. From that time fhe perfeaiy recovered. CASE XXII. JeVlRS.----, aged 25, remarkable for good health and fpirits, and an amiable difpofition, heing arrived at the fulleft period of geftation of her fourth child, was feized with labour pains on Satur- day morning the 6th of November, 1784, and in two hours after was delivered by a careful and experienc- ed midwife of a fine lufly boy. During her labour, fhe flaid 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 Jam ufed to be ; to which the midwife anfwer- ed, Indeed, madam, you are, and are doing extremely well; fhe replied, / am too old a pratlitioner 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 neceffary to take notice of this circumftance, as I End fome Authors ob- serve a contrary method, 312 APPENDIX. On the third day after delivery, fhe got up whilft the bed was made, and that day ate a little chicken. On the fourth day fhe fat up half an hour. This day her milk was a little troublefome, 'attended with a flight degree of feverifhnefs, and her breafts were gently rubbed with brandy and pommade. Her milk gradually left her. Her belly was regu- larly kept open with caftor 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 undreff- ing, fhe remarked to her woman that fhe never was ftronger or better for the time, than fhe was at that inftant. But about ten o'clock, as fhe was getting into bed, fhe complained of giddinefs in her head, and in a few minutes after, was feiaed with unufu- al tightnefs in the cheft, an extreme difficulty of breathing, with pains in the breaft, ftomach, belly, and fmall of the back, and with a coldnefs of the extremities, attended with great reftleffnefs. The fmall of the back was fo painful that it was oblig- ed! to he 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 worfe 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 fhe had an evident finking of features. Every thing in the power of art was adminiftered by them, but all in vain, as fhe 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 ftopped by a meffenger 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 poflibly 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- quest leave to open the body, which was obtained. When 314 APPENDIX. When I arrived there on Monday morning, two days after herdeath, I was convinced, on the firft appearance of the body, that this could not be ow- ing to any blood veffel having burft in the thorax, as the abdomen was diftended almoft as much as the fkin would bear without burfting ; the body in the moft putrid ftate 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- erabiy leffened its bulk ; but it ftill remained very large, owing to a quantity of air being generated within the ftomach and inteftines. When the whole cavity of the abdomen was laid open, we ob- ferved, on examining its contents, that thofe parts of the inteftines which lay in contaa with the ute- rus, were in a gangrenous ftate, and of a very livid colour. The uterus was of the fize of two fills, flabby, loofe, and the whole in a ftate of gangrene. But the neck and the right fide of the body were in APPENDIX. V$ in the moft advanced ftage, all its coats in thofe places being completely mortified. The infide of the uterus was covered with the lochia, and feemed at leaft not in a worfe ftate than the external parts of it. The ovaria fimbria;, and fallopian tubes were in the laft ftage of a fpha- celous, being perfeaiy black, and exceedingly pu- trid. There was nothing rem \rkable in the omen- tum, bladder, or any other of the vifcera, except a general lividity, and a tendency to putrefaaion. There were no abfceffes; 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 fcptum be- tween the two ventricles, were perfeaiy found ; as were aifo the lungs. REMARKS. 8*6 APPENDIX. REMARKS. There are feveral circumftances attending this cafe, that feem furprizing and require fome investi- gation. I do not lay much ftrefs upon what the lady faid to the midwife, during her labour ; fuch expreflions 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 fhe 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 fymptom, from which to have prog- nosticated her danger ; but I think this is not prob- able, as fhe ate, drank, and flept well, and her evac- uations and difcharges were natural. I 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 firft attack ; others are * ** I fhall conclude with one remark, which, though it has been made " before, yet has not been fo generally received as to render any farther tef- ** timony unneceffary. The ileus is, for the moft part, attended with a fen- « fiblc APPENDIX. 317 are not; fome are tlry, fome moift ; 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, fince fhe never complained of any pain till within fix hours of her death. The uterus is an organ which is not abfolutely neceffary to life, fince many animals * have been known *' fible degree of fever, and with all the other fymptoms recited above; " but befides that, there are cafes in which there is no vomiting, as fhewn " 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. £ " fay, there are fuch cafes of inflammation ; becaufe when with fymptoms fo " little alarming, the patient has died, the bowels have been found not left " mortified than after the moft diftinguifhing marks of the difeafe. " This, fo far as I know, was firft taken notice of by Dr. Simfon ||, whofe « obfervation is quoted and confirmed by the Baron Van Stvieten-r, andlate- » ly by Morgagni %, who obferves 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 preffing it, from the lowlefs and inequality of the pulfe, and « from a change of the countenance. What he fays upon this fubjeft well " deferves attention." Pringle's Obfervations on Difeafe* of the Army, 4W. p, 154. || Simfon on the Syftem of the Womb, p. 106,107. f Comment, on Boerh. Aphor. % 37s. + Dc Sed. et Couf. Morb. Ep. 35- 22« • iEtius and Paulus iEgineta, fay, that they have known even women re- cover, when the uterus had been extirpated on account of an inv«rfion, and the f»sne i* mentioned by Pare. gi8 APPENDIX. known to live after it has been taken out: Hence the fyftem was no ways affeaed by it, till the mor- tification communicated itfelf to the inteftines, when it was as rapid as poffible, destroying the pa- tient in fix-hours. It may feem remarkable that the lochia were nev- er affeaed in this diforder ; but let us confider whence they proceed. The lochia are nothing more than a difcharge of blood from the veffels 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 aaually mortified, the lochia were not affeaed. The uterus* had not contraaed itfelf fo much as might have been expeaed in a week ; it is therefore molt probable that it was affeaed 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 Treatife on the Puerperal Fever, has given an ac- count of the difleftion 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 ;ih, nth, 6th, 18th, Bnd 7th days after delivery, " the uterus was contracted to a fmall compafs, •c 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 Icf. ** contracted, and lay flabby and loofe in the cavity of the pelvis." De Graaf fays, that the uterus is contracted to its natural fize in fifteen days after delivery, Ch. viii. p. 128. APPENDIX. 315, but her labour, which was a fpeedy one, of a full grown child, i 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 fhall be aaing on the fafeft fide, if we do every thing in our power to retard, and nothing to accelerate fuch kind of parturitions. INDEX. g£0 Tf I N D E X. ABSORPTION of the Lochia, occafioned by a horizontal pofture ao, 270 __________— the caufe of the Puerperal Fever - 30, 249, 268 _______ occafioned by a ftagnation, not obftruclion of the lochia, often occurs when the difcharge is great - 105 _ and obftrudtion of the Lochia, their diftinftion - 270 Advantages of fitting up foon after delivery great 92,102, 153, 246, 274 Air, foul, and confined, very smproper for lying in women S9, 8s, 90, S02,146 ■ worfe among poor people - - - - s ____pure fhould be frequently admitted into the chamber - so2, S62 ——putrid, how ftudioufly to be avoided, - - 124, 128, 15s Aikin, Dr. his Thoughts on Hofpitals recommended - - »3j ____Dr. his Testimony of the fuccefs of the Author's Mode of Practice , - - - - *86 Afterpains, remarkable proof of their prevention - - 285 1. . occafioned by premature and improper delivery of the fhoulders - - - 77, 85, 25S Alexander, Dr. his Experiments and Corollaries. Note. - S40 Appearances on diffection of women who have died of the Puerperal Fever - - - 3°> 294, 3°7 Applications, greafy, their indifcriminate ufe condemned - 83 AJes' Mm fervlceable, when - - - 60,6a Bark t N D E Xi 3fci B. Page Bark may be given durirrg'any period of the Puerperal State - 105 —— when ufeful - - . - 151, sola Bathing, cold, very beneficial in preventing mifcarriages, and to nurfes giving fuck - - - .60, 253, & feq. ■ warm and" vapour, improper in the Puerperal Fever - s 58 ——— unfuccefsfullV 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 - - 27* 1 ufed in ancient and modern times, before and after delivery .... - ib«. Bed, a plate of one with references ... 129, & feq. Bleedings its ufe too prevalent - • - />8> 62 , . ■. notfuccefsfulin the Puerperal Fever » - a15 Blifters, very improper when - - *58» & fe<*" l6?» . ufeful in the laft ftage of the Puerperal Fever, - 160 ' - their ufe in the Miliary Fever - - - *7* Breafts, their ftate in the Puerperal Fever • .26 ■ ■' ■ their ftructure defcribed - - S3 require great attention - sso, &feq. ——— method of drawing them defcribed - »•*, Stftq. Broths, their impropriety - - - 94> 1°£ Bulter Milk much "drank in Manchefter •' 1 **? C. Calculations of the number of women who have died in qhildbed in Londonand other towns - " 239i & 'e ibid. INDEX, 325 Miliary Fever, fuUy defcribe* by Allonius - - 40 ————— it* fymptoms ... ibid. ■ ■' ■ once very fatal in Manchefter * " 43 ■ ■----once fuppofed to be endemic at Chefter - 45 ■ —- Eruptions never come out without a fweat - 44, joe - ■ ' are fabricated, not critical - 46 Fever, Dr. Cullen's account of 49 its cure - 16s, & feq. —— its laft ftage hazardous - - - 17a Milk Fever, its caufes - • - S* ■ why more common to Women of rank » - 55 1 Ajfcs, ferviceable when • 60, 62 Mortification of the Womb - - - 3-14- Mufk, when ufeful • • - - 17* N. Nature to be obferved in hex 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. ffitre, proper in floodings - - - .108 __ improper in the Puerperal Fever - - 156 ■r—;---------in the Miliary Fever - - 167 Northampton, Puerperal Fever very fatal there - - 120,234 Number of attendants hurtful to Women in Labour - ig Nurfes have great fhare in the management of Lying in Women 23 -----— too much left to their management in London - X19 O. Obflrutlion and abforption of the Lochia, their difference - iJO Omentum and inteftines, their inflammation and mortification not the true caufe of the Puerperal Fever - - *39 Opiates, when neceffary - - - °2 ■ when improper - - **>9 P. Parturition, natural, what method to be obferved in • 80 Pains, falfe, or fpurious, their difference - - 23s Perfpiration and fweat, the difference not generally known - 97 ■eu, his observations on the effects of Putrid Effluvia, Note - 12s Perfumes 3*6* I N D E XJ Perfumes of bad confequence - - - 133 Phkbotomy, when improper - - I56, &feq. Placenta, how to be extracted - - 87, fcipq^. ■ ■ fatal caufes of ... as4, & feq. --------its retention, an object of controverfy - - .69 ■( Pofition, its confequence when - - - . 1^5 .-------during delivery - . - - 53 .-----— horizontal, the caufe of the Lochia being abforbed - 270, 276 Pofture, fudden alteration of it dangerous - - 166 .------upright of the greateft confequence after delivery 93, & feq. 15s 246, 274 Puerperal Fever, its fymptpms - - S7, & feq. —,-----well known to Hippocrates - - 27 _______ - not to be afcribed to Inflammation alone - 3s ------------■— frequently malignant - - ibid, --------------aggravated by heat of Air 32 --------------"more fatal in Hofpitals than in private practice 22, & feq. occafioned by abforption - 31, s 02", s 05 .-----——— never produced without foul Air, accumulation of fe- ces, or horizontal pofture - - - - S02 .----1---------the Author never loft a Patient whom he had deliver- ed in it - - - - ' 11,5 _-------,_____more common and fatal in London than in the country 11 q _____________fatal by wrong treatment - - 12s ___________— may always be prevented except in Hofpitals - ibid. _____________its cure ' ■- - - 136, & feq, ____________„ if managed according to the Author's directions gener- ally curable - - - - *54 _____________ why fo common and fatal at Northampton - 233 ____._________not fo general as from the affigned caufes it might be 37 ;___________ obferved by fome to be very fatal in 1770, but not in- variably fo - - ■ 235 ,_______the difcovery of its caufe* not much affifted by difr feaions . ... - " " «62 / tranflation of the difeafe to the external parts afign of recovery - - - - 2S6, & feq. _________Women advifed to ufe the temperate Bath when in hofpitals 2^8 Fu'fe, its quicknefs a moft diftinguifhing fymptom in the Puerperal Fe- ver " - - - - 263, & feq. ——— quick in all abforptions of matter - - t 264 Ravenfcrtftj r N D E X, 3«; R. Paga Ravenfcroft, Elle*, her Cafe - . - 186 Regifiers of different difeafes, how long kept in Manchefter - 239 Repofe upon a couch when advifeable - - ^67 Rigg, ^etty, her Cafe and Diffection 174, & feq. ■ — Remarks upon thfc Cafe of - - 175, & feq. Kings of Bees* Wax, their ufe * U3 s. Sago, its fenfible qualities - 94 Secundines, their retention an object of controverfy - - 69 Shoulders, of the Child, the manner in which they naturally pafs through the Pelvis firft difcovered by the Author - 74 ., common directions for delivering them improper - 75 i. their improper delivery productive of great inconveniences ' 75» 254. 85 Sitting up in Bed foon aftex delivery of the utmoft confequence 92, & feq. < : *52> 246> 2H 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 diftingnifhed by the ignorant - 97 Sweating in Bed, hurtful to a perfon in health 99 _______particularly hurtful to Puerperal Women, and in all low nerv- ous ahd Putrid Fevers - - - 100 »______- to what extremes carried - . - 164 Sweat will terminate a paroxifm of an Ague, but not prevent a frefh acceffion - - - - *oi .____critical, an act of Nature, and beft promoted by what - ibid. ----when improper - - - - ' 141 ——perfons may be too hot for that evacuation - - 146 T. Temperature of the Lying in Chamber, its confequence - 96 Tenefmus, frequent in the acceffion 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 .... 105, & feq, * U. Upright PofturCfOi the utmost confequence after delivery 92, & feq, 152,246 * Urine 328 INDEX* Urine voided often, and very turbid - "25 Uterus, gravid prelfing upon the omentum and inteftines, fuppofed to be the true caufe of the Puerperal Fever by Dr. Hulme 229, St,feq, -----controverted by the Author - - a3*» & ^l* - ■ ■ mortification of - - * 31! • H* v. Vegetables, their ufe muck- recommended - - 95 Ventilators, their ufe - - - _ . i28 Vinegar, fumigating Wards with, not fo antifeptic as was fuppofed 13s Volatiles, improper when - 107, 168 Vomits, gentle, ferviceable 63, 144, & feq 170, & feq, W. Warm Bathings, unfuccefsful in the Puerperal Fever - * 27.jp Water, 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, its ufe, when neceffary - - • 170 Women, puerperal, fubject to putrefcent diforders - - l) ■■ too much confined to a horizontal pofture after delivery 2 o 1 fhould get out of bed the day ^>f delivery - 102, 275 —-------------fhould fit up in bed in an hour or two after delivery 274 ——— delivered by the Author, never troubled with Prdlapfac Vaginae 246 Wriglcyy Mary, her Cafe - 205,-flc fcq. Y. Young, Dr. recommend? the cool regimen - , 434 ■ his defcription of the Lying in Ward at Edinburgh - 251 -- his account of the Puerperal Feyer, as it appeared in that place 281 &feq. •* e FINIS. a $ s ★ * ARMY * * MEDICAL LIBRARY Cleveland Branch Me^t. Hist