F
THE
PRINCIPLES
MIDWIFERT;
INCLUDING THE
DISEASES
WOMEN AND CHILDREN.
BY JOHN BURNS, M. D.
LECTURER OX MIDWIFERT, AND MEMBER OF THE FACULTY OF PHYSICIANS
AND SURGEONS, GLASGOW.
THE FOURTH AMERICAN, FROM THE THIRD LONDON EDITION,
GREATLY ENLARGED.
WITH IMPROVEMENTS AND NOTES,
BY THOMAS C. JAMES, M. D.
PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF PENNSYLVANIA.
VOL. II.
PHILADELPHIA:
i*«-atH.^
PUBLISHED BY EDWARD & RICHARD PARKER, BENJAMIN WARNER, MATIUW
CARET & SON, BENJAMIN & THOMAS KITE, SOLOMON W. CONRAD,
ANTHONY FINLEY, AND MOSES THOMAS.
3, R. A. Sker*«t, JMujer., . ,
18.(7. :..>' ''.'•'
Qjjj>>\
DISTRICT OF PENNSYLVANIA, TO WIT:
Be it remembered, That on the seventh day of September, in the
thirty-eighth year of the Independence of the United States of America,
A.D. 1813, Benjamin and Thomas Kite, Johnson and Warner, Edward
Parker, Kimber and Conrad, Mathew Care}', Moses Thomas, Anthony
Finlev, and Redwood Fisher, of the said District, have deposited in
this office the title of a Book, the right whereof they claim as Proprie-
tors, in the words following, to wit:
"The Principles of Midwifery,- including the diseases of Women and
" Children. By John Burns, Lecturer on Midwifery, and .Member of
" the faculty of Physicians and Surgeons, Glasgow. The third Ameri-
" can, from the second London Edition, much enlarged. With Improve-
" ments andJYotes, by Thomas C. James, M. D. Professor of Midwifery
"in the University of Pennsylvania."
In conformity to the Act of the Congress of the United States, intituled,
"An Act for the Encouragement of Learning, by securing the Copies
of Maps, Charts and Books, to the Authors and Proprietors of such
copies during the times therein mentioned."—And also to the Act, en-
titled, " An Act supplementary to an Act, entitled«An Act for the En-
couragement of Learning, by securing the Copies of Maps, Charts and
Books, to the Authors and Proprietors of such copies during the times
therein mentioned,'and extending the benefits thereof to the Arts of
designing, engraving, and etching historical and other Prints."
D. CALDWELL,
Clerk of the District of Pennsylvania
CONTENTS.
book n.
Of Parturition.
CHAPTER I.
Of the Classification of Labours, Page 1
CHAPTER II.
Of Natural Labour.
Section 1. Stages of labour - - 6
Section 2. Duration of process - - 11
Section 3. Of examination - - 13
Section 4. Causes of labour - - 21
Section 5. Management of labour - 23
CHAPTER III.
Of Premature Labour, 34
CHAPTER IV.
Of Preternatural Labour.
Order 1. Presentation of the breech - - 38
Order 2. Of the inferior extremities - 43
Order 3. Of the superior extremities - 45
Order 4. Of the trunk 53
Order 5. Of the face, &c. - - - 54
Order 6. Of the umbilical cord - - 58
Order 7. Plurality of children and monsters - 59
CHAPTER V.
Of Tedious Labour.
Order 1. From imperfection or irregularity of
muscular action ."-..'."" - - 63
-4iM$$
IV
Order 2. From some mechanical impediment Page 74
CHAPTER VI.
Of Instrumental Labours.
Order 1. Cases admitting the application of the
forceps or lever - 80
Order 2. Cases requiring the crotchet - 9S
CHAPTER VII.
Of Impracticable Labours, 102
CHAPTER VIII.
Of Complicated Labour.
Order 1. Labour complicated with uterine he-
morrhage - - - - 107
Order 2. With hemorrhage from other organs 109
Order 3. With syncope - - - 109
Order 4. With convulsions - - - 109
Order 5. With rupture of the uterus - 116
Order 6. With suppression of urine - - 120 j
I
book in.
Of the Puerperal State.
CHAPTER I.
Of the Treatment after delivery,
CHAPTER II.
Of Uterine Hemorrhage,
CHAPTER III.
Of Inversion of the Uterus,
CHAPTER IV.
Of Afler-Pains,
122
125
- 138
142
Y
CHAPTER V.
Of Hysteralgia, - Page 145
CHAPTER VI.
Of Retention of Part of the Placenta, - 146
CHAPTER VII.
Of Strangury, - - 149
CHAPTER VIII.
Of Pneumonia, - - 149
CHAPTER IX.
Of Spasmodic and Nervous Diseases, 149
CHAPTER X.
Of Ephemeral Fever, or Weed, - 152
CHAPTER XI.
Of the Milk Fever, - - 155
CHAPTER XII.
Of Miliary Fever, - 155
CHAPTER XIII.
Of Intestinal Fever, - - 157
CHAPTER XIV.
Of Inflammation of the Uterus, - 159
CHAPTER XV.
Of Peritoneal Inflammation, - 164
CHAPTER XVI.
Of Puerperal Fever, - - 167
CHAPTER XVII.
Of Swelled Leg, 172
VI
CHAPTER XVIII.
Of Paralysis, - Page 177
CHAPTER XIX.
Of Puerperal Mania and Phrenitis, 17"8
CHAPTER XX.
Of Bronchocele, - - 181
CHAPTER XXI.
Of Diarrhoea, - - 183
CHAPTER XXII.
Of Inflammation of the Mamma, and Excoriation of
the Nipples, - - 183
CHAPTER XXIII.
Of Tympanites, - - 188
CHAPTER XXIV.
Of the Signs that a Woman has been recently Delivered, 189
BOOK IV.
Of the Management and Diseases of Children.
CHAPTER I.
Of the Management of Children.
Section 1. Of the separation of the child, and the
treatment of still-born children - - 192
Section 2. Of cleanliness, dress, and temperature 196
Section 3. Of diet - - - - 198
CHAPTER II.
Of Congenite and Surgical Diseases.
Section 1. Hare-lip - 202
Vll
Section 2. Imperforated anus, urethra, &c. Page 203
Section 3. Umbilical hernia - - 204
Section 4. Spina bifida - 205
Section 5. Marks .... 206
Section 6. Swelling of the scalp - - " 208
Section 7. Distortion of the feet - - 209
Section 8. Tongue-tied - 209
Section 9. Malformed heart - - 209
Section 10. Swelling of the breasts, hydrocele,
excoriation, &c. - - - 210
Section 11. Foetid secretion from the nose - 212
Section 12. Opthalmia - - - 212
Section 13. Spongoid disease of the eye - 213
Section 14. Scrofula - - . - 213
Section 15. Rickets - - - 214
CHAPTER III.
Of Dentition, - - 215
CHAPTER IV.
Of Cutaneous Diseases.
Section 1. Strophulus intertinctus - - 220
Section 2. Strophulus albidus - - 221
Section 3. Strophulus confertus - - 222
Section 4. Strophulus candidus - - 223
Section 5. Lichen - 223
Section 6. Intertrigo - - - 224
Section 7. Crusta lactea ... 225
Section 8. Anomalous eruptions, and general
remarks on the remedies - - 226
Section 9. Pompholyx, pemphigus, and pock-
eruption __--- 227
Section 10. Miliary eruption - - 228
Section 11. Prurigo - - - - 229
Section 12. Itch 230
Section 13. Herpes - 232
Section 14. Ichthyosis - - - 236
Section 15. Psoriasis - - - 236
Vlll
Section 16. Impetigo - - r°Se 238
238
Section 17. Pityriasis -
-^ 239
Section 18. Porngo
Section 19. Scabs from vermin
241
Section 20. Boils and pustules
242
Section 21. Petechia -
Section 22. Erysipelas and erythema
Section 23. Excoriation behind the ears - 246
Section 24. Ulceration of the gums - 247"
Section 25. Erosion of the cheek
Section 26. Aphthae - - - - 249
Section 27. Aphthae on the tonsils - 254
Section 28. Excoriation of the tongue, lips, &c. 254
Section 29. Syphilis ... 255
Section 30. Skin-bound - - - 259
Section 31. Small-pox - - - 261
Section 32. Cow-pox - 267
Section 33. Chicken-pox _ - - 274
Section 34. Urticaria - - - - 276
Section 35. Scarlatina - - - 278
Section 36. Measles - - - - 285
Section 37* Roseola - 29°
CHAPTER V.
Of Hydrocephalus, - - 292
CHAPTER VI.
Of Convulsions, - - 301
CHAPTER VII.
Of Chorea and Paralysis, - 307
CHAPTER VIII.
Of Croup, - - 309
CHAPTER IX.
Of Hooping Cough, - - 318
IX
CHAPTER X.
Of Catarrh, Bronchitis, Inflammation of the Pleura,
and of the Stomach, - Page 323
CHAPTER XI.
Of Vomiting, - - 328
CHAPTER XII.
Of Diarrhoea, - - S29
CHAPTER XIII.
Of Costiveness, - - 340
CHAPTER XIV.
Of Colic, - 341
CHAPTER XV.
Of Peritonitis, 345
CHAPTER XVI.
Of Marasmus, - - 343
CHAPTER XVII.
Of Tabes Mesenterica, - 345
CHAPTER XVIII.
Of Worms, - - 348
CHAPTER XIX.
Of Jaundice, - - 351
CHAPTER XX.
Of Diseased Liver, - - 353
CHAPTER XXI.
Of Fever, - - 356
Appendix ----- 365
Tables - ' - - - - 378
Notes - - - - - 381
Index - - - - 391
^Vl
THE
PRINCIPLES
OF
MIDWIFERY.
BOOK LT.
OF PARTURITION.
CHAP. I.
Of the Classification of Labours.
Labour may be defined to be the expulsive effort made by
the uterus for the birth of the child, after it has acquired
such a degree of maturity, as to give it a chance of living
independently of its uterine appendages.
I propose to divide labours into seven classes; but I do
not consider the classification to be of great importance, nor
one mode of arrangement much better than another, for the
purposes of practice, provided proper definitions be given and
plain rules delivered, applicable to the different cases.
The classes which I propose to explain are,
Class I. Natural Labour; which I define to be labour taking
place at the end of the ninth month of pregnancy; the
child presenting the central portion of the sagittal suture,
and the forehead being directed at first toward the sacro-
iliac symphysis; a due proportion existing betwixt the
size of the head, and the capacity of the pelvis; the
VOL. n. b
s
pains being regular and effective ; the process not con-
tinuing beyond twenty-four hours, seldom above twelve,
. and very often not for six. No morbid affection superven-
ing, capable of preventing delivery, or endangering the
life of the woman.
This comprehends only one order, (a)
(a) Our author might, perhaps with propriety, have divided this class
into two orders, viz.
Order 1. The posterior fontanelle of the child presenting towards the
left acetabulum, and the anterior fontanelle, or forehead, towards the
right sacro-iliac symphysis. This is by far the most common presen-
tation.
Order 2. The posterior fontanelle presenting towards the right acetabu-
lum, and the anterior fontanelle, or forehead, towards the left sacro-
iliac symphysis. This position or presentation, according to Baude-
locque, occurs but in the proportion of 1 to 7 or 8 of the first.
In an accurate register kept by Baudelocque, it appears, that of 12,183
presentations of the head, 10,003 were of the first position, or with the pos-
terior fontanelle towards the left acetabulum, and 2,113 in the second posi-
tion, or with the posterior fontanelle towards the right acetabulum.
Classification and systematic arrangement generally, are most frequently
purely artificial and arbitrary; and that of our author's as laid down above,
is not such as we can cordially approve, but as his division of the subject in
the following sections is founded upon it, we have not deemed it proper to
propose any essential alteration. The great and deserved celebrity of Bau-
delocque as a practical writer, seems, notwithstanding, to demand that we
should here biiefly state his division of the presentations of the vertex, which
he considers as natural.
There are then, according to him, six positions in which the vertex pre-
sents at the superior strait, viz.
1. The posterior fontanelle is situated behind the left acetabulum, and the
anterior before the right sacro-iliac symphysis.
2. The posterior fontanelle is situated behind the right acetabulum, and the
anterior before the left sacro-iliac symphysis.
3. The posterior fontanelle answers to the symphysis of the pubis, the ante-
rior to the sacrum.
4. The anterior fontanelle answers to the left acetabulum, and the posterior
to the right sacro-iliac symphysis.
5. The anterior fontanelle is situated behind the right acetabulum, and the
posterior before the left sacro-iliac symphysis.
6. The anterior fontanelle is behind the symphysis of the pubis, and the pos-
terior before the sacrum.
The more frequent occurrence of the 1st and 2d than of the 4th and 5th is
calculated to be in the proportion of 80 or 100 to 1. The 3d and 6th pre-
3
Class II. Premature Labour, or labour taking place consi-
derably before the completion of the usual period of
utero-gestation, but yet not so early as necessarily to
prevent the child from surviving.
This comprehends only one order.
Class III. Preternatural Labour, or those in which the pre-
sentation, or position of the child is different from that
which occurs in natural labour; or in which the uterus
contains a plurality of children, or monsters.
This comprehends seven orders.
Order 1. Presentation of the breech.
Order 2. Presentation of the inferior extremities.
Order 3. Presentation of the superior extremities.
Order 4. Presentation of the back, belly, or sides of the
child.
Order 5. Malposition of the head.
Order 6. Presentation of the funis.
Order 7. Plurality of children, or monsters.
Class IV. Tedious Labour, or labour protracted beyond the
usual duration; the delay not caused by the malposition
of the child, and the process capable of being finished
safely, without the use of extracting instruments.
This comprehends two orders.
Order 1. Where the delay proceeds from some imper-
fection or irregularity of muscular action.
Order 2. Where it is dependent principally on some me-
chanical impediment.
Class V. Laborious or Instrumental Labour; labour which
cannot be completed without the use of extracting in-
struments ; or altering the proportion betwixt the size
of the child, and the capacity of the pelvis.
This comprehends two orders.
sentations are extremely rare, and indeed may be almost considered as pre-
ternatural, or pre-supposing some deformity of the pelvis or foetal head.
It will be observed, that in the arrangement of our author, the first and
second positions of the vertex only, are admitted into the class of natural la-
bour, whilst the third, fourth, fifth and sixth positions of Baudelocque, are
thrown into the class of preternatural labours under order 5. Malposition
of the head.
*
Order 1. The case admitting the use of such instruments
as do not necessarily destroy the child.
Order 2. The obstacle to delivery being so great, as to
require that the life of the child should be sacrificed
for the safety of the mother.
Class VI. Impracticable Labour; labour in which the child,
even when reduced in size, cannot pass through the
pelvis.
This comprehends only one order.
Class VII. Complicated Labour; labour attended with some
dangerous or troublesome accident or disease, connected
in particular instances with the process of parturition.
This comprehends six orders.
Order 1. Labour complicated with uterine hemorrhage.
Order 2. Labour complicated with hemorrhage from
other organs.
Order 3. Labour complicated with syncope.
Order 4. Labour complicated with convulsions.
Order 5. Labour complicated with rupture of the uterus.
Order 6. Labour complicated with suppression of urine,
or rupture of the bladder.
Calculations have been made, of the proportion which these
different kinds of labour bear to each other in practice. Thus
Dr. Smellie supposes, that out of a thousand women in la-
bour, eight shall be found to require instruments, or to have
the child turned, in order to avoid them : two children shall
present the superior extremities; five the breech; two or
three the face; one or two the ear; and ten shall present
with the forehead turned to the acetabulum.
Dr. Bland has, from an hospital register, stated the pro-
portion of the different kinds of labour, to be as follows: of
1897 women, 1792 had natural labour. Sixty-three, or one
out of 30, had unnatural labour; in 18 of these, the child pre-
sented the feet, in 36, the breech, in 8, the arm, and in 1,
the funis. Seventeen, or one out of 111 had laborious la-
bour ; in 8 of these, the head of the child required to be les-
sened, in 4, the forceps were employed, and in the other 5,
the face was directed toward the pubis. Nine, or one in 210,
5
had uterine hemorrhage before or during labour. It is evi-
dent, however, that this register cannot form a ground for
general calculation ,• and the reader will perceive, that the
number of crotchet cases exceeds those requiring the forceps,
which is not observed in the usual course of practice.(ft)
(6) From the register kept at PHospice de la Maternite, a lying-in hos-
pital at Paris, under the direction of Baudelocque, it appears, that of 12,751
labours, 12,573 at least were natural ,• the assistance of art being necessary
in 178 cases only, which is in the propoition of 1 to 71 f, of these,
Cases'.
The face presented in - - - - - -18
The shoulders --..... 38
The head and umbilical cord ------ 15
The thighs ....... 22
The feet ---..... 11
Other parts not specified ------ 24
Convulsions and floodings --...- 4
As 1 to 96j 132
The forceps were applied in 37 cases, which is as 1 to 3442.
The cranium was perforated, or the crotchet applied, in 9 cases only.
Gastrotomy was performed in one case only, and that to extract an extra-
uterine foetus.
It also appears from a late periodical publication, that there were admit-
ted into the lying-in hospital at Paris, called Maison d'Accouchemens, be-
tween the 9th of December, 1799, and the 31st of May, 1809, 17,308 wo
men, who gave birth to 17,499 children
presentations of the vertex to the os uteri
No.
215 were presentations of the feet
296 the breech
59 the face
52 one of the shoulders
4 the side of the thorax
4 the hip -
4 the left side of the head
4 the knees
4 the head, an arm, and the cord
3 the belly -
3 the back ...
3 the loins -
1 the occipital region -
1 the side, with the right hand
1 the right hand and left foot -
to
of which number 16,286 were
Proportions.
81|
59£
296$
336^
4374J
4374|
4374£
4374|
4374?
5833
5833
5833
17499
17499
17499
6
We cannot form an estimate of the proportion of labours,
with much accuracy, from the practice of individuals, as one
man may, from particular circumstances, meet with a greater
number of difficult cases, than is duly proportioned to the
number of his patients. Thus Dr. Hagen of Berlin says,
that out of 350 patients, he employed the forceps 93 times,
and the crotchet in 28 cases; 26 of his patients died. Dr.
Dewees again, of Philadelphia, says, that in more than 3000
cases, he has not met with one requiring the use of the
crotchet.
CHAP. II.
Of Natural Labour.
§ 1. STAGES OF LABOUR.
Previous to the accession of labour, we observe certain
precursory signs, which appear sometimes for several days,
oftener only for a few hours before pains be felt. The uterine
fibres begin slowly and gradually to contract or shorten them-
1 the head, and the feet .... 1— 17499
2 the head, the hand, and forearm - - - 1— 8749$
37 the head and umbilical cord - - - 1— 473
Of this great number of women, 230 were delivered by art, the rest were
natural births, being in the proportion of 1 to 76$; 161 were dehvered by
the hand alone, the cliildren being brought by the feet; 49 were dehvered
by the forceps, either on account of the small dimensions of the pelvis, the
falling down of the umbilical cord, or the wrong position of the head, when
the woman was exhausted, or her life was in danger by convulsions, &c.;
13 were extracted by the crotchet after perforation of the head, on account
of mal-conformation of the pelvis; in these instances tiie death of the cliild
was first ascertained.
The exsarean operation was performed in two cases, the diameter of the
pelvis being only one inch six lines from sacrum to pubis.
In one, the section of the symphysis pubis was performed, the diameter
of the pelvis from sacrum to pubis being only two inches and a quarter.
Gastrotomy was performed once, the foetus being extra-uterine; the child
weighed 81b. 2oz.
7
selves, by which the uterus becomes tenser and smaller. It
subsides in the belly, the woman feels as if she carried the
child lower than formerly, and thinks herself slacker and less
than she was before. For some days before gestation be
completed, she in many cases is indolent and inactive, but
now she often feels lighter and more alert. At the same
time that the uterus subsides, the vagina and os uteri are
found to secrete a quantity of glairy mucus, rendering the
organs of generation moister than usual; and these are some-
what tumid and relaxed, the vagina especially becoming
softer and more yielding. These changes are often attended
with a slight irritation of the neighbouring parts, producing
an inclination to go to stool, or to make water frequently,
and very often griping precedes labour, or attends its com-
mencement.
The intention of labour is, to expel the child and sccun-
dines. For this purpose, the first thing to be done, is to di-
late, to a sufficient degree, the os uteri, so that the child may
pass through it. The next point to be gained, is the expul-
sion of the child itself: and last of all, the foetal appendages
are to be thrown off. The process may therefore be divided
into three stages. The first stage is generally the most
tedious. It Is attended with frequent, but usually short pains.
which are described as being sharp, and sometimes so severe,
as to be called cutting or grinding. They commonly begin
in the back, and extend toward the pubis or top of the thighs;
but there is, in this respect, a great diversity with different
women, or the same woman at different times. Sometimes
the pain is felt chiefly or entirely in the abdomen, the back
being not at all affected during this stage; and it is generally
observed, that such pains are not so effective as those which
affect the back. Or the pain produced by the contiaction of
the womb may be felt in the uterine region ; and when it goes
off, may be succeeded by a distressing aching in the back.
In other cases, the pain is confined to the small of the back,
and upper part of the sacrum; and is either of a dull aching
kind, or sharp and acute, and, in some instances, is attend-
ed with a considerable degree of sickness, or tendency to
s
syncope. The most regular manner of attack, is for the
pains to be at first confined to the back, descending lower by
degrees, and extending round to the belly, pubis, or top and
fore part of the thighs, and gradually stretching down the
back part of the thighs, the fore' part becoming easy ; oc-
casionally one thigh alone is affected. At this time also, one
of the legs is sometimes affected with cramp. The duration
of each pain is variable ; at first it is very short, not lasting
above half a minute, perhaps not so long, but by degrees it
remains longer, and becomes more severe. The aggravation,
however, is not uniform, for sometimes in the middle of the
stage, the pains are shorter, and more trifling than in the
former part of it. During the intermission of the pains, the
woman sometimes is very drowsy, but at other times is par-
ticularly irritable and watchful. The pains are early attend-
ed with a desire to grasp or hold by the nearest object, and
at the same time, the cheeks become flushed, and the colour
increases with the severity of the pain.
The pains of labour often begin with a considerable de-
gree of dullness; or an unusual shaking or trembling of the
body, with or without a sensation of coldness. These tremors
may take place, however, at any period of labour; they may
usher in the second stage, and be altogether wanting during
the first, or they may not appear at all, even in the slightest
degree; or they may be present only for a very short time.
They do not generally precede the uterine pain, but may be
almost synchronous in their attack j in other cases, they do
not appear until the pain has lasted for a short space of time;
but whenever they do come on, it is usual for the uterine pain
to be speedily removed. Hence it might be supposed, that
they should materially retard labour, but this is far from
being always the case. In degree, they vary from a gentle
tremor to a concussion of the frame, so violent as to shake
the bed on which the patient rests, and even to bear some re-
semblance to a convulsion. The stomach also sympathizes
with the uterus during this stage, the patient complaining of
a sense of oppression; sometimes of heartburn or sickness
or even of vomiting, which is considered as a good symptom,
9
when it does not proceed from exhaustion; or of a feeling of
sinking or faintness, but the pulse is generally good. When
there is in a natural labour, a sudden attack of sickness,
faintishness, and feeble pulse, the patient is generally soon
relieved by vomiting bile.' These symptoms, however, are
often wanting, or attack at different periods of labour; like
the rigours, they may be absent during the greatest part of
the first stage, or until its end, ushering in the second ; but
in general, they are confined to the first stage, going off
when the os uteri is fully dilated. In consequence, partly of
those feelings, partly of the anxiety and solicitude connected
with a state of suffering and danger, and partly from the
pains being free from any sensation of bearing-down, the
woman, during this stage, is apt to become desponding, and
sometimes fretful. She supposes that the pains are doing no
good; that she has been, or is to be, long in labour; that
something might be done to assist her, or has been done,
which had better have been avoided; and that there is a
wrong position of the child, or deficiency of her own
powers.
When the pains of labour begin, there is an increased dis-
charge of mucus from the vagina, which proceeds from the
vaginal lacunse, and from the os uteri. It is glairy, whitish,
and possesses a peculiar odour. When the os uteri is con-
siderably dilated, though sometimes at an earlier period,
there is, in consequence of the separation of the decidua, a
small portion of blood discharged, which gives a red tinge to
the mucus.
The distension of the os uteri is often attended with irrita-
tion of the neighbouring parts, the woman complaining of a
degree of strangury; or having one or two stools with or
without griping, especially in the earlier part of the stage.
The pulse generally is somewhat accelerated.
The os uteri being considerably dilated, the second stage
begins. The pains become different, they are felt lower down,
they are more protracted, and attended with a sense of bear-
ing-down, or an involuntary desire to expel or strain with the
muscles; and this desire is very often accompanied with a
vol. ii. c
10
strong inclination to go to stool. A perspiration breaks out,
and the pulse, which during the first stage beat rather more
frequently than usual, becomes still quicker; the woman com-
plains of being hot, and generally the mouth is parched.
Soon after the commencement of this stage, it is usual for the
liquor amnii to be discharged. This is often followed by a
short respite from pain, but presently the efforts are re-
doubled. Sometimes there is no cessation, but the pains im-
mediately become more severe, and sensibly effective. The
perinseum now begins to be pressed outward, and the labia
are put upon the stretch. The protrusion of the perinseum
gradually increases, but it is not constant; for when the pain
goes off, the head generally recedes a little, and the perinseum
is relaxed. Presently the head descends so low, that the
parts are kept permanently on the stretch, and the anus is
carried forward. Then the vertex pressing forward, the
labia are elongated, and the orifice of the vagina dilated.
The perinseum is very thin, much stretched, and spread
over the head of the child. As the head passes out, the peri-
nseum goes back over the forehead, becoming narrower,
but still more distended laterally. If the perinseum did not
move backward as the head moved forward, it would run
a greater risk of being torn ; and indeed, even in the most
regularly conducted labour, a part of it is often rent.
Delivery of the head is accomplished with very severe suf-
fering ; but immediately afterwards, the woman feels easy,
and free from pain. In a very little time, however, the
uterus again acts, and the rest of the child is expelled, which
completes the second stage of labour. The expulsion of the
body is generally accomplished very easily, and quickly ;
but sometimes the woman suffers several strong and forcing
pains, before the shoulders are expelled. The birth of the
child is succeeded, after a short calm, by a very slight degree
of pain, which is consequent to that contraction which is ne-
cessary for the expulsion of the placenta. This expulsion is
accompanied and preceded by a slight discharge of blood,
which is continued, but in decreasing quantity, for a few
days, under the name of the red lochia.
11
§ 2. DURATION OF THE PROCESS.
The duration of this process, and of its stages, varies not
only in different women, but in the same individual in succes-
sive labours; for although- some, without any mechanical
cause, be uniformly slow or expeditious, others are tedious in
one labour, and perhaps extremely quick in the next, and this
variation cannot be foreseen from any previous state of the
system. A natural labour ought to be finished within 24
hours after the first attack of pain, provided the pains be
truly uterine, and are continued regularly; for occasion-
ally, after being repeated two or three times, they become
suspended, and the person keeps well for many hours, after
which the process begins properly. In such cases, the labour
cannot be dated from the first sensation of pain, nor deemed
tedious. The greatest number of women do not complain
for more than 12 hours, many for a much shorter period,
and some for not more than one hour. Few women call the
accoucheur, until, from the regularity and frequency of the
pains, they are sure that they are in labour, and feel them-
selves becoming worse. As the celerity of the process can-
not be previously determined, many women thus bear their
children alone, becoming rapidly and unexpectedly worse.
On an average, it will be found, that in natural labour, the
accoucheur is not called above four hours previous to delivery.
The regularity and comparative length of the different
stages is also various; but it will be generally observed, that
when a woman has a natural labour protracted to its utmost
extent, the delay takes place in the first stage; and in those
cases where the second stage is protracted, the delay occurs
in the latter end of that stage. In most cases, the first stage
is triple the length of the second. The first stage may be
tedious, from the pains not acting freely on the os uteri, or
being weak and inadequate to the effect intended, or becom-
ing prematurely blended with the second stage; that is to
say, bearing-down efforts being made, before the os uteri be
much dilated. Various circumstances may conspire to pro-
duce this delay, such as debility of the uterus, rigidity of its
12
mouth, premature evacuation of the water, improper irritation,
injudicious voluntary efforts, &c. The second stage may be
tedious, from irregularity of the uterine contraction, or from
a suspension of the bearing-down efforts, or from the head
not turning into the most favourable direction, or from the
rigidity of the external organs.
These, and other causes, which will hereafter be considered,
may not only protract the labour, but may even render it so
tedious, as to remove it from the class of natural labours al-
together. It is a general opinion, that a first labour is always
more lingering than those which succeed. We should be
led, however, to suppose, that parturition, being a natural
function, ought to be as well and as easily performed the first
time, as the fifth; the process not depending upon either habit
or instruction. But we do find, that here, as in many other
cases, popular opinion is founded on fact; for although in se-
veral instances, a first labour is as quick as a second, yet in
general, it is longer in both its stages. This, perhaps, depends
chiefly on the facility with which the different soft parts dilate
after they have been once fully distended. Some have attri-
buted the pain of parturition to mechanical causes, ascribing
it to the shape of the pelvis, and the size of the child's head.
But this is not the case, for in a great majority of cases, the
pelvis is so proportioned, as to permit the head to pass with
great facility. The pain and difficulty attending the expul-
sion of the child in natural labour, are to be attributed to the
forcible contraction of the sensible fibres of the uterus, and
to the dilatation of the os uteri and vulva, in consequence
thereof. Women will therefore, cozteris paribus, suffer in pro-
portion to the sensibility of the organs concerned, and the
difficulty with which the parts dilate. In proportion as we
remove women from a state of simplicity to luxury and refine-
ment, we find that the powers of the system become impaired,
and the process of parturition is rendered more painful. In
a state of natural simplicity, women in all climates bear their
children easily, and recover speedily1; but this is more espe-
cially the case in those countries where heat conspires to re-
lax the fibres. The quality or quantity of the food has much
13
less influence than the general habit of life, upon the process
of parturition. In a savage state, women, though living ab-
stemiously, and often compelled to work more than men, bear
children with facility; whilst in this country, women who live
on plain diet are not easier than those who indulge in rich
viands.
§ 3. OP EXAMINATION.
The existence and progress of labour, and the manner in
which the child is placed, are ascertained by examination per
vaginam. For .this purpose the woman ought to be placed in
bed, on her left side,* with a counterpane thrown over her,
if she be not undressed. The hand is to be passed along the
back part of the thighs to the perinseum, and thence imme-
diately to the vagina, into which the fore finger is to be in-
troduced. It never ought to be carried to the fore part of the
vulva, and from that back to the vagina. The introduction
is to be accomplished as speedily and gently as possible, and
the greatest delicacy must be observed. The information
which we wish to procure is then to be obtained by a very
perfect, but very cautious examination of the os uteri, and
presenting part of the child, which gives no pain, and conse-
quently removes the dread which many women, either from
some misconception, or from previous harsh treatment, en-
tertain of this operation.
When a woman is in labour, we should, if the pains be re-
gular, propose an examination very soon after our arrival.
It is of importance that the situation of the child be early
ascertained, and most women are anxious to know what pro-
gress they have made, and if their condition be safe. As it
is usual to examine during a pain, many have called this
* A standing or half-sitting position has been proposed by some, and may
doubtless in certain diseases of the uterus, be proper, that it may, by its
weight, come within reach. Sometimes in the early months of pregnancy,
it is allowable from the same motives; but, during labour, it is not often that
the uterus is so high that the examination cannot be performed in a recum-
bent posture.
14
operation "taking a pain;" but there is no necessity forgiv-
ing directions respecting the proper language to be used, as
every man of sense and delicacy will know howT to behave,
and can easily, through the medium of the nurse, or by turn-
ing the conversation to the state of the patient, propose ascer-
taining the progress of the labour. Some women, from
motives of false delicacy, and from not understanding the
importance of procuring early information of their condition,
are averse from examination until the pains become severe.
But this delay is very improper; for, should the presentation
require any alteration, this is easier effected before the mem-
branes burst, than afterwards. When the presentation is
ascertained to be natural, there is no occasion for repeated
examinations in the first stage, as this may prove a source
of irritation, and should the stage be tedious, may be a mean
of exciting impatience. In the second stage, the frequency
of examination must be proportioned to the rapidity of the
process.
In order to avoid pain and irritation, it is customary to
anoint the finger with oil or pomatum ; but unless this prac-
tice be used as a precaution to prevent the action of the mor-
bid matter on the skin, it is not very requisite, the parts
being, in labour, generally supplied with a copious secretion
of mucus. It is usual for the room to be darkened, and the
bed curtains drawn close, during an examination; and the
hand should be wiped with a towel, under the bed-clothes,
before it be withdrawn. The proper time for examining is
during a pain; and we should begin whenever the pain
comes on. We thus ascertain the effect produced on the
os uteri, and, by retaining the finger until the pain goes off,
we determine the degree to which the os uteri collapses, and
the precise situation of the presenting part, which we cannot
do during a pain, if the membranes be still entire, lest the
pressure of the finger should, were they thin, prematurely
rupture them.
An examination should never, if possible, be proposed or
made whilst an unmarried lady is in the room, but it is
always proper that the nurse or some other matron be present.
15
The existence of labour is ascertained by the effects of the
pains on the os uteri; and its progress, by the degree to
which it is dilated, and the position of the head with regard
to different parts of the pelvis.
Before labour begins, the os uteri is generally closed, and
directed backwards toward the sacrum. When we examine
in the commencement of labour, the os uteri is to be sought
for near the sacrum, at the back part of the pelvis, whilst
between that spot and the pubis, we can pass the finger along
the fore part of the cervix uteri. On this the presenting
part of the child rests, so that, in natural labour, it assumes
somewhat the shape of the head ; and, for the sake of dis-
tinction, I shall call it the uterine tumour. In some, it is so
firmly applied to the head, and so tense, that a superficial
observer would take it for the head itself. In this case the
labour often is lingering. This tumour, or portion of the
uterus, is broad in the beginning of labour, but becomes
narrower as the os uteri dilates, until at last it is completely
effaced, the head either naked or covered with the mem-
branes, occupying the vagina. The breadth of this portion
of the uterus, therefore, as well as the examination of the os
uteri, will serve to ascertain the state of the labour.
The os uteri gradually dilates by the pains of labour, but
this dilatation is easier effected in some cases than in others.
In some, though the pains have lasted for many hours, and
have been frequent, the os uteri will be found still very little
opened. In others, a very great effect is produced in a
short time; nay, we even find, that the os uteri may be
partly dilated without any pain at all. We cannot exactly
foretell the effect which the pains may have by any general
rule.
We find, in different women, the os uteri in very opposite
states. In some it is thick, soft, and protuberant; in others,
thin and tubulated; sometimes it is not prominent, but the
edges of the mouth are on the same plane, like the mouth of
a purse; these edges may be thin or thick, and both these
states may exist with hardness or softness of the fibre. In
some cases, they seem to be swelled, as if they were tedema-
16
tous, and this state is often combined with cedema of the vulva,
or it may proceed from ecchymosis. Now, of these condi-
tions, some are more favourable than others; a rigid os uteri,
with the lips either flat or prominent, is generally a mark of
slow labour, for as long as this state continues, dilatation is
tardy; a thick cedematous feel of the os uteri is also unfa-
vourable ; and usually a projecting or tubulated mouth, espe-
cially if the margin be thick and hard,* is connected with a
more tedious labour than where the os uteri is flat. In some
cases of slow labour, the os uteri for many hours is scarcely
discernible, resembling a dimple or small hard ring, perfectly
level with the rest of the uterus. But although these obser-
vations may assist the prognosis, yet we never can form an
opinion perfectly correct; for it is wonderful how soon a
state of the os uteri, apparently unfavourable, may be ex-
changed for one very much the reverse, and the labour may
be accomplished with unexpected celerity. Our prognosis
therefore, should be very guarded. When the pains produce
little apparent effect on the os uteri, when they are slight
and few, and when the orifice of the uterus is hard and rigid,
or thick and puckered during a pain, there is much ground
to expect that the labour may be lingering; on the other
hand, when the pains are brisk, the os uteri thin and soft,
we may expect a more speedy delivery : but as in the first
casej the unfavourable state of the os uteri may be unexpect-
edly removed, so in the second, the pains may become sus-
pended or irregular, and disappoint our hopes. The os uteri
seldom dilates equally in given times, but is more slow at
first in opening than afterwards. It has been supposed,
that if it require three hours to dilate the os uteri one inch,
it will require two to dilate it another inch, and other three
to dilate it completely. This calculation, however, is subject
to great variation, for in many cases, though it require four
hours to dilate the os uteri one inch, a single hour more may
be sufficient to finish the whole process.
* If the margin be thin and soft, the os uteri sometimes, in the course of
an hour, loses its projecting form, and becomes considerably dilated.
17
The os uteri is, in the beginning of labour, generally pretty
high up; but as the process advances, the uterus descends
in tiie pelvis, along with the head ; and, in proportion as it
descends, the os uteri dilates, whilst the uterine tumour
diminishes in breadth. Should the os uteri remain long high,
even although it be considerably dilated, but more especially
if it be not, there is reason to suppose that the labour shall
be continued still for some time. On the other hand, should
the uterus descend too rapidly, there may be a species of
prolapsus induced, the os uteri appearing at the orifice of
the vagina. This state is generally attended with premature
bearing-down pains, and indicates a painful, and rather te-
dious labour.
The protrusion of the membranes, and discharge of the
liquor amnii, ought to bear a certain relation to the advance-
ment of labour. Whilst the os uteri is beginning to dilate,
the membranes have little tension ; they scarcely protrude
through the os uteri, until it be considerably opened. But
in proportion as the dilatation advances, and the pains be-
come of the pressing kind, the membranes are rendered
more tense, protruding during a pain, and becoming slack,
and receding when it goes off. In some cases, by examina-
tion, we find the membranes forced out very low into the
vagina, like a segment of a bladder, tense and firm, during
a pain, but disappearing in its absence. Sometimes, although
the head be so high as not to touch the perinseum, the mem-
branes protrude the perinseum, and the fseces are evacuated
or pressed out, as if the head were about to be expelled.
When the membranes burst, the head is in such cases often
delivered in a few seconds; but the pains may remit for a
short time, and the woman be easier than formerly. The
protrusion of the membranes, which has been described by
some as constituting a part of a natural labour, is by no
means an universal occurrence; for in numerous instances
the membranes protrude very little, and scarcely form a per-
ceptible bag in the vagina. When the pains have acted
some time on the membranes, pushing the liquor amnii
against them, and especially when they become pressing, the
VOL. II. t>
18
membranes burst, and the water escapes, sometimes in a con-
siderable quantity; but in other cases, very little comes
away, the head occupying the pelvis so completely, that most
of the water is retained above it, and is not discharged until
the child be born. If there be great irregularity in the de-
gree to which the membranes protrude, there is no less in
the period at which they break. In some cases, from natu-
ral feebleness or thinness, they break very early, and the
liquor amnii comes away slowly. Sometimes they break in
the middle or latter end of the first stage, in the commence-
ment of the second, or not until the very end, when the head
is about to be born. The opening is sometimes very large,
and the head enlarging it, passes through it; at other times
it is small, and the membranes are not perforated by the
head, but they come along with it like a cap or cover. By
examination, we ascertain the state of the membranes, and
may be assisted in our judgment of the progress of the labour.
When the membranes feel tense, and are protruded during a
pain, we may be sure that the action of the uterus is brisk
and good. When much water is collected beneath the head,
forming a pretty large bag in the vagina f or when, during
the pain, there is a tense protrusion of the membranes, though
they be flat, forming a small segment of a large circle, we
may expect, that if the pains continue as they promise to do,
the membranes will soon burst, and the pains become more
pressing. If during each pain, after the rupture, a quantity
of water come away, it is probable, that whenever the uterus
is pretty well emptied of the fluid, it will contract more
powerfully. Should the membranes break when the os uteri
is not fully opened, perhaps only half-dilated, we may, if
there be a large discharge, expect a brisker action, and that
the full dilatation of the os uteri will be soon accomplished •
but if the water only ooze away, and the pains become less
frequent, and not more severe, the labour may probably be
protracted for some time.
In the first stage of labour, the head will be found placed
obliquely along the upper part of the pelvis, with the vertex
directed toward one of the acetabula. The finger can easily
19
ascertain the sagittal, and afterwards the lambdoidal suture;
the central portion of the sagittal suture is the point from
which we set out, and, if the finger is readily led to the angle
formed by the posterior edges of the parietal bones, we may
be sure that the presentation is favourable. If, on the other
hand, we can feel the anterior fontanelle, the vertex is ge-
nerally directed to the sacro-iliac articulation. When the
pelvis is well formed, and the cranium of due size, the head
may commonly be felt in every stage of labour; but there are
cases, in which, even although the pelvis be ample, it is not
easily touched for some time. Such instances, however, are
rare; and whenever we are long of feeling the presentation,
and do not discover a round uterine tumour, we may suspect
that some other part of the child than the head presents.
Even in the end of pregnancy, and long before labour begins,
the head can usually be discovered resting on the distended
cervix uteri; but different circumstances may for a time pre-
vent it from being felt, the head perhaps in some cases, as
from a fall for instance, being for a short time displaced to-
wards one side.
In proportion as the head descends in the pelvis, the vertex
is turned forward; so that, when the whole head has entered
the pelvis, the face is thrown into the hollow of the sacrum,
and the sagittal suture rests on the perinseum, whilst the oc-
ciput is placed under the symphysis pubis, or on its inside.
This takes place earlier in one case than in another.
When the head comes to present at the orifice of the va-
gina, or passes a line drawn from the under edge of the sym-
physis pubis back to the sacrum, the perinseum and skin near
the tuberosities of the ischia become full, as if swelled, but
not tense. This at first proceeds from relaxation of the mus-
cles, and some degree of descent of the vagina and rectum.
Whenever this is felt, we may be sure that the head is de-
scending ; but although a few pains may distend the perinseum,
it may yet be some hours before this takes place, the pains
for all that time appearing to produce very little effect, al-
though the pelvis be well formed. Should the perinseum be-
come stretched, and the anus be carried forward a little dur-
20
ing the pain, we may expect that delivery is at hand. If the
woman has already borne children, the child is sometimes
delivered within a few minutes after the perinseum is first felt
to become full.
When the pelvis is well formed, the head generally de-
scends without much change of the scalp; but when it is con-
tracted, or the head rests long on the perinseum, the scalp is
either wrinkled or protruded like a tumour filled with blood.
By examination, we ascertain the presentation, and the
progress which the labour has made; but in forming an opi-
nion respecting the probable duration of the process, we must
be greatly influenced by the state of the pains, and in part
also by our knowledge of former labours, if the woman have
borne many children. The different stages of labour are ge-
nerally marked by a different mode of expressing pain. In
the first stage, the pains are sharp, and the woman either
moans or frets, or sometimes bears in silence. The second
stage is marked by a sound, indicating a straining exertion,
a kind of protracted groan, so that, by the change of the cry,
a practitioner may often determine the stage of the labour.
Sometimes in this stage, the woman clinches her teeth, or
holds in her breath, so that she is scarcely heard to complain.
In the moment of expelling the head, some women are quite
silent, or utter a low groan, others scream aloud. When the
pains in the first stage are increasing in frequency, in
severity, and in duration, and when they are accompanied
with a corresponding dilatation of the os uteri, and especially
when it, together with the head, gradually descends, the prog-
nosis is very favourable. When the pains, after the os uteri
is considerably dilated, become forcing, with an inclination
to void the urine or fseces, and when these pains are ac-
companied with a full dilatation of the os uteri, the head at
the same time descending lower, and the vertex beginning to
turn round, we may look for a speedy delivery. But if the
pains in the first stage be weak and few, and occur at long
intervals, or, though not unfrequent, if they last only for a
few seconds, and especially, if at the same time the os uteri
be high up, or hard, or thick, we may conclude that the pro-
21
cess is not likely to be rapid. If, when the os uteri is little di-
lated, there be an inclination to bear down, the labour is ge-
nerally slow, and hence all attempts to press with the abdomi-
nal muscles are improper; for whether these be made volun-
tarily or involuntarily, they, during this stage, add to the
suffering, fatigue the woman, produce a tendency to prolap-
sus uteri, so that, in some instances, the os uteri is forced to
the orifice of the vagina, and render the labour always slow
and severe.
When the head is brought so low as to protrude the peri-
nseum, the pains generally become more frequent and severe,
and very soon effect the expulsion. But if they be forcing,
and propel the head considerably each time, but it recedes
completely thereafter, it is likely that the delivery of the
head will be difficult and painful; for in some cases, the ex-
ternal parts are long of yielding, and require repeated efforts
to distend them before the head can safely be expelled.
Sometimes the pains, after beginning regularly and brisk-
ly, become suspended, or less effective, and this alteration
cannot be foreseen. It is a popular opinion, that if a woman
be not delivered within twelve hours after she is taken ill, the
labour will become brisker at the same hour at which it be-
gan, that is to say, twelve hours after its commencement;
and this opinion is, in many instances, countenanced by fact.
In other cases, the labour becomes decidedly brisker six hours
after its commencement. Most women begin to complain
during the night, or early in the morning, and a great ma-
jority are delivered betwixt twelve at night and twelve
o'clock noon.
§ 4. CAUSES OF LABOUR.
Different attempts have been made to explain why labour
commenced at the end of the ninth month of pregnancy. The
mysterious power of numbers, the influence of the planets, the
distension of the uterine fibres, the pressure of the child upon
the developed cervix and os uteri, have all in succession been
enumerated, as affording a solution of the question. It can
22
serve no good purpose to enter into the investigation. We
know, that whenever the process of utero-gestation is com-
pleted, the womb begins to contract. If, by any means, this
process could be protracted, then labour would be kept off;
and, on the other hand, if this process be stopped prematurely,
either from some peculiarity connected with it, by which it is
completed earlier than usual, or, from being interrupted by
extraneous causes, acting either on the uterus, or by killing the
child, then contraction does very soon commence. The imme-
diate cause of the delivery of the child has been attributed to
efforts made by the foetus itself, the expulsive force of the ab-
dominal muscles, or the contraction of the uterus. The first
is fully set aside, by our finding, that the fcetus, when dead is
born cceteris paribus, as easily as when it is alive and active.
That the muscles alone cause the expulsion of the child, is
disproved, by observing, that in the early part of labour they
are perfectly quiescent, and no voluntary effort made with
them is attended with any good effect. That the delivery is
in a great measure owing to the action of the uterus, is
proved by observing, that the uterus contracts in proportion
as the delivery advances, and when the child is born, it is
found to be very greatly diminished in size. But we have a
still more positive proof of this, in attempting to turn the
child, for then we feel very powerfully the action of the ute-
rus, and the efforts which it makes to expel its contents. It
is not just, however, to consider the action of the womb it-
self, as the sole agent in parturition; for in the second stage,
the abdominal muscles do assist in the expulsion, not only
by supporting the uterus, and thus enabling it to contract
better, but also directly, by endeavouring to force the uterus,
and consequently its contents, down through the pelvis. Two
purposes are intended by the uterine action ; the first is to
open the os uteri, the second to propel the foetus through it.
Whilst, then, the fibres of the uterus itself contract, those of
the os uteri must dilate, and, in proportion as the foetus ad-
vances through the pelvis, the uterine fibres must shorten
themselves. Thus the uterine cavity is gradually diminished,
so that the placenta can very easily, by a continuation of the
23
same process, be thrown off; and the uterine vessels having
their diameter greatly lessened, hemorrhage is prevented
after the separation of the placenta.
Parturition, then, is a muscular action, and we might in
one view conceive that it should be most speedy and easy in
those who possessed a powerful muscular system, and great
vigour. But this is far from being the case, for the process
is tedious or speedy, easy or difficult, according to the rela-
tion which the power bears to the obstacle to be overcome.
Now in many weak and debilitated women, the parts very
easily relax and dilate, and a very small power is required
to complete the expulsion; whilst we often find, that those
who possess a tense fibre, and great strength of the muscu-
lar system, accomplish the dilatation of the os uteri, not with-
out much pain, and repeated efforts.
§ 5. MANAGEMENT OF LABOUR.
Women in a state of nature make little preparation for
their delivery, and conduct the process of parturition without
much ceremony. They retire to the woods, or seclude them-
selves in a hut or bower, until they bear the child; after
which, if the religious custom of their country do not require
their separation for a time, they return to their usual mode
of living.
In Europe, [and in a state of civilization generally] we
find that the process of parturition is conducted with more
care, and is supposed to require greater preparation. Differ-
ent countries have different customs in this respect. In
some, women are delivered upon a chair of a particular con-
struction ; in others, seated on the lap of a female friend.
Some women use a little bed, on which they rest, until the
process is completed; and others are delivered on the bed,
on which they usually sleep. This last, for many reasons,
is the best and most proper practice; but in order to prevent
the bed from being spoiled, or wet with the liquor amnii or
blood, and also from other motives of comfort, it is usual to
make it up in a particular manner. The mattress ought to
24
be placed uppermost, and a dressed skin, or folded blanket,
placed on that part of it on which the breech of the woman
is to rest. The bed is then to be made up as usual; after
which, a sheet folded into a breadth of about three feet is put
across the under fold of the bed-sheet. This is intended to
absorb the moisture; and after delivery, if not during labour,
that part which is wet is to be drawn completely away, so that
a dry portion may be brought under the woman. This ar-
rangement is generally attended to by the nurse, whenever
labour begins. When the pains begin, the woman generally
dresses in dishabille; but when the process is considerably ad-
vanced, it is necessary to undress, and lie in bed. Some at
this time put on a half-shift, that is to say, one that does not
reach below the waist, so that it is not liable to be wet.
Others are satisfied with having the shift pushed up over
the pelvis, so as to be kept dry; its place, in either case, is
supplied with a petticoat. These, and other circumstances
relating to dress, and to the quantity of bed-clothes, must be
determined by the woman herself, and the season of the year.
It is of consequence that the room be not overheated by
fire, or the woman kept too warm with clothes. Heat makes
her restless and feverish, adds to the feeling of fatigue, and
often, by rendering the pains irregular or ineffective, pro-
tracts the labour. No more people should be in the room
than are absolutely necessary. The nurse and one female
friend are perfectly sufficient for every good purpose; and a
greater number, by their conversation, disturb the patient,
or by their imprudence, may diminish her confidence in her
own powers, and also in her necessary attendants. The mind,
in a state of distress, is easily alarmed; and therefore whis-
pering, and all appearance of concealment, ought to be pro-
hibited in the room.
If the woman be disposed to sleep betwixt the pains, she
ought not to be disturbed, but allowed to indulge in repose. If
she have not this inclination, and be not fatigued, cheerful
conversation, upon subjects totally unconnected with her situ-
ation, will be very proper.
Women have seldom an inclination for food whilst they are
25
in labour; and, if the process be not long protracted, there
is no occasion for it. If, however, the patient have a desire
to eat, she may have a little tea or coffee, with dry toast, or
a little soup, or some panado; but every thing which is
heavy or difficult of digestion must be avoided, lest she be
made sick and restless, or have her recovery afterwards in-
terrupted. Even very light food is apt at this time to sour,
and cause heartburn.
Stimulants and cordials, such as spiced gruel, cinnamon
water, wines, and possets, were at one time very much em-
ployed, but now are deservedly abandoned by those who fol-
low the dictates of nature. Given in liberal doses, they arc
productive of great danger, disposing to fever or inflamma-
tion after delivery; and in smaller doses, they disorder the
stomach, and often, instead of forwarding, retard the labour.
If however, the woman be weak, or the process tedious, then
a small quantity of wine, given prudently, may be of con-
siderable advantage.
Some women wish to keep out of bed as much as possible,
in order that labour may be forwarded by walking about;
others have the same desire, from feeling easier when they
are sitting. In this respect, they may be allowed to please
themselves, but they ought to be as much as possible out of
bed, provided they do not feel tired.
The urine ought to be regularly and frequently evacuated;
and for that purpose, the practitioner should occasionally
leave the room. If the woman be costive, or the rectum con-
tain fseces, a clyster ought always to be given early, which
facilitates the labour. On the other hand, if the bowels be
very loose, a few drops of tincture of opium may be given
with much advantage.
It is immaterial in what posture the woman place herself
during the first stage of labour; but in the second stage,
when delivery is approaching, it is proper that she be placed
on her side, and it is usual for her to lie on the left side, as
this enables the practitioner to use his right hand. The knees
are a little drawn up, and generally at this time kept sepa-
rate by means of a small pillow placed between them. Many
VOL. II. E
26
women wish to have their feet supported, or pressed against
by an assistant, and it is customary to give her a towel to
grasp in her hand. This is either held by the nurse, or fas-
tened to the bed post. We must, however, be careful that
these contrivances do not encourage the woman to make too
strong efforts to bear down.
When the woman is in bed, it is proper to have a soft
warm cloth applied to the external parts, in order to absorb
any mucus or water that may be discharged, and this is to be
removed when it is wet.
Attempts to dilate the os uteri or the vagina, and the ap-
plication of unctuous substances, to lubricate the parts, are
now very properly abandoned by well instructed prac-
titioners.
The membranes ought generally to be allowed to burst, by
the efforts of the uterus alone, for this is the regular course
of nature; and a premature evacuation of the water either
disorders the process and retards the labour, or, if it accele-
rate the labour, it renders it more painful. I cannot, how-
ever, go the length of some, who say, that the evacuation of
the water is always hurtful; for there are circumstances in
which it may be allowable and beneficial. It is allowable
when the os uteri is fully dilated, and the membranes pro-
truded, perhaps even out of the vagina. In such a case, they
would in a few pains at farthest give way; but by rupturing
them we can take precautions to keep the person dry, and
more comfortable than she would otherwise have been. Even
if the membranes are not considerably protruded, if the os
uteri be completely dilated no injury can arise from ruptur-
ing them, for they ought, in the natural course of labour, to
give way at this time. But although the practice be not
detrimental, yet it does not thence follow that it is always
expedient; and it will be a useful ride to adhere to, that the
seldomer we interfere in this respect in a natural labour, the
more prudent shall our conduct be.
Examination ought, in the first stage of labour, to be prac-
tised seldom ; but in the second stage we must have recourse
to it more frequently; and, when the pains are becoming
37
stronger and the head advancing, we must not leave the bed-
side. At this time we should be prepared for the reception
of the child. A pair of scissars, with some short pieces of
narrow tape, must be laid upon the bed or chair, and a warm
cloth or receiver must be at hand, or spread under the clothes,
to wrap the child in. As the fseces are generally passed at
this time involuntarily, a soft cloth is to be laid on the peri-
nseum ; and when the second stage of labour is drawing to a
conclusion, the hand is to be placed on this, in order to pre-
vent the rapid delivery of the head, and the consequent lace-
ration of the perinseum. This is a point of very great im-
portance, and which requires to be carefully considered by
the practitioner. There arc several arguments against this
practice: for we should, a priori, conceive, that as parturition
is a natural process, it ought not in any part to be defective,
or to require the regulation of art. Next, we should strengthen
this doctrine, by finding, that in the savage state, a lacerated
perinseum is rarely discovered, and in all those women who
arc speedily delivered by themselves, the recto-vaginal septum
is seldom torn. But on the other hand, the fact is ascertained
beyond all dispute, that the perinseum is sometimes lacerated,
notwithstanding these presumptive proofs against the occur-
rence of the accident. This being ascertained, it becomes
our duty, however rare the case may be, to determine its
causes, and prevent its occurrence in every instance; for we
cannot exactly say who the unfortunate individuals may be,
to whom it is to happen. We may decidedly say, that the
perinseum is torn in consequence of distension; but in every
delivery, the perinseum must be distended, and in some to a
great degree. In proportion to the facility of the distension,
and the ease with which the vagina dilates, is the risk of la-
ceration diminished. It has, therefore, become a practical
rule, to resist, with the hand placed on the perinseum, the de-
livery of the head, until the parts be sufficiently relaxed ; and
this pressure ought to be exerted over the whole tumour, but
especially at the fourchette, for although the perinseum has
been perforated by the head, which did not pass through the
orifice of the vagina, yet usually, the rem begins at the four-
28
chette and proceeds backwards to a greater or less degree.
In every case, the fourchette and a small part of the poste-
rior surface of the vagina are lacerated, though the integu-
ments of the perinseum remain sound. By firmly supporting
the perinseum, and, at the same time, exhorting the woman
not to force down during a pain, and thus retarding the de-
livery of the head until we feel the vulva, as well as the peri-
nseum relaxing, we may generally prevent laceration, and
therefore this accident will seldom if ever happen in the hands
of a prudent practitioner. Still it is possible for the peri-
nseum to be torn under good management. A little bit of it
is not unfrequently lacerated, notwithstanding all our precau-
tion ; and although, in this slight degree, it is of no conse-
quence, yet we thus see that art cannot completely prevent the
accident. Sometimes the restlessness of the patient almost
inevitably prevents the necessary precautions from being
used ;* and it may happen, that the frame is so very irritable,
that the perinseum unexpectedly lacerates at the time when
it is supposed to be in a favourable state. As there must be
some point where the resistance must stop, else the labour
would be unnecessarily protracted, or perhaps even the uterus
ruptured, it is possible that such resistance may be made, as
generally is sufficient to prevent the accident, but which may
not in some particular case, owing to the irritable state of the
perniseum, be adequate to the intended purpose; or the
power of the uterus may be so strong as to expel the head,
in spite of every allowable resistance, and in some of these
cases it is possible for the perinseum to be torn.
It is not sufficient that the practitioner support the peri-
nseum, until the head is going to be expelled; he must con-
tinue to do so whilst it is passing out, for there is then a great
strain on the part, as the forehead is passing over the peri-
neum, and even the face moving along it, may produce
injury. After the head is delivered, it is still necessary to
place the hand under the chin, and on the perinseum, for the
* Dr. Denman, a most worthy and experienced practitioner, with a candour
which does him honour, acknowledges, that from tliis cause the accident oc-
curred in his own practice.
29
arm of the child comes next to press against this part, and
may either tear it by pressure, or by coming out with a jerk.
Farther, to prevent injury and avoid pain, the body of the
child should be allowed to pass out in a direction correspond-
ing to the outlet of the pelvis, that is to say, moving a little
forwards. But there is no occasion that the child should be
carried forward betwixt the thighs, for, in a natural labour,
the back of the child is directed to the thighs; he can easily
bend, and will naturally so incline himself in the delivery,
as to take the proper direction. The last advice to be given
respecting this stage of* labour is, that as we retard rather
than encourage the expulsion of the head, so we are not to ac-
celerate the delivery of the body. Women in a state of pain
call for relief, and expect that the midwife is to assist the de-
livery of the child; but no entreaties ought to make us hasten
the expulsion of the head, and after that event, there is little
inducement to accelerate the labour. Sometimes, in a few
seconds, the child is expelled, but there may be a cessation of
pain for some minutes. In the first case, we take care that
the body is not propelled rapidly, and with a jerk: in the
second, we attend to the head, examining that the membranes
do not cover the mouth, but that the child be enabled to
breathe, should the circulation in the cord be obstructed.
There is no danger in delay, and rashly pulling away the
child is apt to produce flooding and other dangerous acci-
dents. Should there, however, be a considerable interval
betwixt the expulsion of the head, and the accession of new
pains, we may press gently on the belly, or pull the child
slightly, so as to excite the uterus to contract. Or, should
the woman have several pains without expelling the body of
the child, it may be allowable gently to insinuate the finger,
and bring down the shoulder; but even this assistance is rare-
ly required, and on no account ought we to attempt the deli-
very by pulling the head. Sometimes a delay is produced
by the cord being twisted round the neck; and in this case,
all we have to do, is to slip it off over the head.
The child being born, a ligature is to be applied on the cord
very near the navel, and another about two inches nearer the
30
placenta.(e) It is then to be divided betwixt them, and the
child removed. The hand is next to be placed on the belly,
to ascertain that there be not a second child ;(rf) and the finger
may, for the same purpose, be slid gently along the cord to
the os uteri. The hand of an assistant should be applied on
the abdomen, and gently pressed on the uterus, which may
excite it to action, and prevent torpor. If the placenta be
not expelled soon, the uterine region may be rubbed with the
hand to excite the contraction of the womb. Immediately
after the expulsion of the child, there is often a copious eva-
cuation of water, which is sometimes mistaken by the woman
for a discharge of blood. But hemorrhage never takes place
so instantaneously, in such quantity. It is generally a minute
or two, sometimes much longer, before flooding come on;
against the occurrence of this, we are to be on our guard.
The woman, after the delivery of the child, feels quite well,
(c) The ligature should not be applied, until the pulsation of the funis has
ceased, or at least until the child has cried, that the new circulation now to
commence may be thus properly estabhshed. Until this has taken place,
the life of the child, according to Mr. White, is to be considered as merely
foetal, or as if it were yet in utero. Whilst there remains a pulsation of the
arteries of the funis, it proves the existence of the foetal life, and the exist-
ence of the foetal life proves the imperfection of the animal life. Whilst the
animal life, therefore, is imperfect, Mr. White lays it down as a rule, that
the foetal life ought not to be destroyed. The funis umbilicalis, therefore,
should never be divided or tied, whilst there is any pulsation in its arteries.
" By this rash inconsiderate method of tying the navel string, before the cir-
culation in it is stopt, I doubt not (continues Mr. White) but many children
have been lost, many of their principal organs have been injured, and foun-
dations laid for various disorders." White on the Management of Pregnant
and Lying-in Women, page 87.
Whilst on the subject of tying the funis, we may mention an observation
of Sabatier, which is worthy of notice. He says that he has often known, in
cases of congenital umbilical hernia, that the displaced intestines have pro-
truded along the umbilical cord without much increasing its size, and have
been tied by the ligature made on it, occasioning the death of the infant.
Medicine Operatoire, Tom. I. p. 152.
(d) If a second child remain, we very distinctly feel the enlarged uterus
between the pubis and umbilicus, and even above the latter, and not so much
diminished in size as we should have previously supposed, but if there is no
second child, we feel the uterus contracted into a small round ball, extend-
ing not far above the symphysis pub's
31
and expresses, in the strongest language, the transition from
suffering to tranquillity. But in a short time, generally with-
in half an hour, one or two trifling pains are felt, and the
placenta is expelled, which completes the last stage of partu-
rition ; and when the process goes on regularly, nothing is
required in this stage, except watchfulness, lest hemorrhage
supervene.
But it sometimes happens, that the placenta does not come
away so early or so readily as we expect. It may be re-
tained for many hours, or even for some days. This reten-
tion can be caused by preternatural adhesion of the placenta,
or by the uterus contracting spasmodically round the pla-
centa, forming a kind of cyst, in which it is contained; or
the uterus may not contract on the placenta so strongly as to
expel it. Some, from a confidence in the powers of nature,
have inculcated as a rule of conduct, that unless flooding take
place, the placenta ought not to be extracted. Others have,
with equal zeal, advised it to be brought away immediately
after the birth of the child. The safest practice seems to lie be-
twixt the two extremes. To leave the expulsion of the pla-
centa altogether to nature, is a step attended with great dan-
ger ; for as long as it is retained, we may be sure that the
uterus has not contracted strongly and regularly. If then, in
these circumstances, the placenta should be partially or com-
pletely detached, hemorrhage is very likely to occur. If it
still adhere to the uterus, the risk of hemorrhage certainly is
diminished, for those vessels alone, which opened on the de-
cidua, can be exposed; but we have no security that this ad-
hesion shall remain universal for any given time. As long,
then, as the placenta is retained, the woman is never free
from the risk of flooding. In many cases, she has died from
this cause before the placenta was expelled; or if, after a long
delay, the placenta has come away, its exclusion has some-
times been followed by fatal hemorrhage.* But this, although
* Mr. White, has, in his Treatise on the Management of Pregnant and
lying-in women, p. 507, related several cases where the practice of leaving
the placenta to be expelled by nature alone, was productive of fatal hemorr-
hage ; and in one instance, this event took place, although the placenta
was at last expelled.
32
a dreadful accident, is not the only one arising from reten-
tion of the whole or part of the placenta. For great debility,
constant retching, and fever, are often produced by this
cause, and may ultimately carry off the patient.(e) It is
therefore not without great reason, that women are anxious
for the expulsion of the placenta; and this prejudice may
have a good effect in operating against the conceits of specu-
lative men, who suppose that nature is, in every instance,
adequate to the accomplishment of her own purposes.
On the other hand, daily experience must convince every
one, that there is no occasion for extracting the placenta im-
mediately after the birth of the child, for it is usually expelled,
with perfect safety within forty minutes after the child is de-
livered. Nay, we find that the speedy extraction of the pla-
centa is directly hurtful; both as it is painful, and also as it
is sometimes followed by uterine hemorrhage, or, if rashly
performed, by inversion of the womb. The practice then, I
think, may be comprised in two directions: First, that we
ought never to leave the bed-room, until the placenta be ex-
pelled ; and secondly, that if it be not excluded in an hour
after delivery, we ought to extract it. This point being ad-
justed, it is next to be enquired, how the retention is to be
prevented, and, if not prevented, how the placenta is to be
extracted. With regard to the first question, it may be an-
swered, that the placenta will be less apt to be retained, if
the expulsion of the child be conducted slowly, and the uterus
made to contract fully upon it. As to the mode of extracting
the placenta, we can be at no loss, if we recollect that the
expulsion is accomplished by the contraction of the uterus.
Our object, then, is to excite this when the placenta is re-
(e) The celebrated Ruysch, we are told, was the first to abandon the ab-
surd practice of hasty extraction of the placenta, enlightened, no doubt, by
his superior anatomical knowledge. Dr. Hunter in Great Britain, fully
pointed out its impropriety. He however erred on the other extreme;
" Tncidit in Scyllam cupiens vitare Charybdim."
Teaching that nature unassisted was adequate to the expulsion of the pla-
centa in every case, he never interfered; but experience, says Dr. Hamilton,
soon taught him the error of this practice : for by suffering the placenta tn
rpmain too long, he lost five patients of rank in one year.
33
tained, in consequence of the womb not acting strongly. The
hand is to be slid slowly and cautiously into the uterus,
which is often sufficient to make it contract; but if it do not,
the hand is to be moved a little, or pressed gently on the pla-
centa, at the same time that we pull very slightly by the
cord, or lay hold of the detached placenta with our hand, and
with caution extract it slowly. This requires no exertion,
for the uterus is pressing it down, and, if any force be used,
we do harm. Attempts to bring away the placenta, by pull-
ing strongly at the cord, whether the hand be introduced into
the uterus or not, are always improper. If persisted in,
they generally end, either in the laceration of the cord, or
the inversion of the uterus.
There are two circumstances, however, under which the
placenta may be retained, which require some modification
of the practice. The first is, when the placenta is retained
by spasm. In this case, when the hand is conducted along
the cord through the os uteri, the placenta is not perceived,
but it is led by the cord to a stricture, like a second, but con-
tracted os uteri, beyond which the placenta is lodged. This
contraction must be overcome before the placenta can be
brought away, which may be accomplished by gradual and
continued attempts to introduce one, two, or more fingers
through it; and these, if cautiously made, are perfectly safe.
It will, however, be observed, that the uterus at short inter-
vals contracts, which is accompanied with pain; but this con-
traction is confined to the stricture alone, the cavity of the
womb not being lessened by it, and during this state all at-
tempts to dilate the aperture are hurtful. We must be satisfied
with keeping the fingers in their place, to preserve the ground
we have gained. Opiates have been proposed to remove this
spasm, and render the introduction of the hand unnecessary;
they seldom, however, succeed alone, but given in a full dose
may make the manual attempt more easy. Sometimes the
sudden application of a croth, dipped in cold water, to the
belly, has the same effect. Tlie second circumstance to which
I alluded is, adhesion of the placenta, which usually is only
partial. This may occur with or without a change of struc*
vol. n. r
34
ture, but in general the structure is more or less altered, the
adhering part being denser than usual, and sometimes almost
like cartilage. The separation of the adhering portion should
not be attempted hastily, nor by insinuating the finger be-
tween it and the uterine surface. It is better to press on the
surface of the placenta, so as thus to excite the uterine fibres
to contract more briskly at the spot; or by gently rubbing,
or, as it were, pinching up the placenta between the fingers
and thumb, it may be separated. If, however, the adhesion
of the part of the placenta be very intimate, we must not, in
order to destroy it, scrape and irritate the surface of the
uterus, but ought rather to remove all that does not adhere
intimately, leaving the rest to be separated by nature1. But
in taking this step, we are not to proceed with impatience,
nor to attempt to bring away the non-adhering portion, un-
til a considerable time has elapsed, and cautious efforts have
been made to remove the entire placenta; thus satisfying our-
selves of the existence of an obstinate and intimate union.
Cases, where this conduct is necessary, are very rare, and
when they do occur, there is usually an induration of the ad-
hering part. It is generally thrown off in a putrid state in
forty-eight hours, Sometimes the placenta adheres when it
is unusually tender and soft, and then we must, with peculiar
care, avoid hasty efforts, by which the placenta would be
lacerated, and part left behind, which would be hurtful after-
wards ; whereas by a little more patience, and gentle pres-
sure on the surface of the placenta, the uterus might have
been excited to throw the whole off.
CHAP. III.
Of Premature Labour.
When a woman bears a child in the seventh or eighth
months of pregnancy, she is said to have a premature labour •
and this process forms a medium between abortion and natu-
ral labour.
35
In some cases, the uterus is fully developed before the
usual term of gestation, and then contraction commences; but,
in a great majority of instances, premature labour proceeds
from accidental causes, exciting the expulsive action of the
uterus, before the cervix and os uteri have gone through their
regular changes. The cervix must, therefore, be expanded by
muscular action, before the os uteri can be properly dilated ;
and this preparatory stage is generally marked by irregular
pains, and not unfrequently by a feverish state, preceded by
shivering. A feeling of slackness about the belly, with differ-
ent anomalous sensations, often accompany this stage of pre-
mature labour. When the cervix is expanded, then the os
uteri begins to dilate, and this part of the process is often
more tedious than the same period of natural labour, and
generally as painful. It is also frequently attended with a
bearing-down sensation. The second stage of labour is usually
expeditious, owing to the small size of the child. The deci-
dua being thicker than at the full time, the protrusion of the
membranes is attended with more sanguineous discharge;
and if the woman move much, or exert herself, considerable
hemorrhage may take place. The third stage is likewise
slow, for the placenta is not soon thrown off. In the last
place, spasmodic contraction of the uterus is more apt to take
place in all the stages of premature than of natural labour.
A variety of causes may excite the action of the uterus pre-
maturely, such as distension from too much water; or the
death of the child, which is indicated by shivering, subsidence
of the breasts, cessation of motion, and of the symptoms of
pregnancy; or the artificial evacuation of the liquor amnii;
or violent muscular exertion; or drugs acting strongly on
the stomach and bowels ; or passions of the mind; or acute
diseases ; or rigidity of the uterine fibres. Certain general
conditions of the system render the operation of these causes
more easy, such as plethora, debility, and great irritability.
Premature labour is often preceded by severe shivering, dur-
ing which, or immediately before it, the child dies, and in
some time thereafter pains come on. It is worthy of notice,
36
that a much larger proportion of premature labours are pre-
ternatural, than of labours at the full time.
A tendency to premature labour is to be prevented by the
means pointed out when treating of abortion. I have only
to add, that when the abdomen is tense and hard, or painful,
indicating a rigidity of the uterine fibres, or of the abdominal
muscles, tepid fomentations, gentle laxatives, and repeated
small bleedings, are useful.
When a woman is threatened with premature labour, we
ought, unless there be very decided marks of the death of the
child, to endeavour to check the process, which is done by
exhibiting an opiate, keeping the patient cool and tranquil,
and removing any irritation which may exist. If she be
plethoric, or the pulse be throbbing, blood is to be detracted.
When labour is established, it is to be conducted much in
the same way with parturition at the full time: but the fol-
lowing observations will not be improper. The patient must
avoid much motion, lest hemorrhage be excited. Frequent
examination and every irritation are hurtful, by retarding the
process, and tending to produce spasmodic contraction. If
this contraction take place, marked by paroxysms of pain re-
ferred to the belly or pubis, little or no effect being produced
on the os uteri, a full dose of tincture of opium should be
given, after the administration of a clyster. Severe pains,
with premature efforts to bear down, and a rigid state of the
os uteri, require venesection, and afterwards an opiate. The
delivery of the child is to be retarded, rather than accelerat-
ed in the last stage, that the uterus may contract on the pla-
centa. This is farther assisted, by rubbing gently the uterine
region after delivery. If the placenta be long retained, or
hemorrhage come on, the hand is to be gently introduced
into the uterus, and pressed on the placenta, to excite the
fibres to throw it off. We should not rashly attempt to re-
move it, for we are apt to tear it; neither are we to pull the
cord, for it is easily broken. In those cases where prema-
ture labour is connected with redundance of liquor amnii, I
think it useful to introduce the hand immediately on the de-
37
livery of the child, for I have observed, that the placenta is
apt to be retained by irregular contraction. We do not in-
stantly extract the placenta, but it is desirable to get the
hand in contact with it before the circular fibres contract.
Great attention is to be paid to the patient for some days
after delivery, as she is liable to a febrile affection, which
may be either of the inflammatory type, or of the nature of
weed, to be afterwards noticed.
CHAP. IV.
Of Preternatural Labour.
Various signs have been enumerated, by which it was
supposed, that malposition of the child might be discovered
antecedent to labour. An unusual shape of the abdomen;
some peculiar feeling, of which the mother is conscious, and
which she has not felt in any former pregnancy; greater
pain or numbness in one leg than in the other; a sensation
of the child rising suddenly towards the stomach ; have all
been mentioned as indicating this, but are all, even when
taken collectively, uncertain tokens. We cannot determine
the presentation, until labour has begun. In a great majority
of instances, the head, during the end of gestation, may be
felt resting on the cervix uteri, but, in repeated instances, I
have not been able to distinguish it in a pregnancy which
ended in natural labour. Sometimes, in consequence of a
fall, or other causes, the head seems to recede, but after-
wards returns to its proper position. When labour begins,
we may generally distinguish the head by its proper charac-
ter ; but, if it lie high, and especially if the pelvis be de-
formed, we may not find it always easy to ascertain the pre-
sentation at a very early period. In such cases, it is of
great consequence to preserve the membranes entire. When
the head does not present, the presentation is generally more
38
distant, and longer of being distinctly ascertained,* the lower
part of the uterus is more conical, and the tumour formed by
the cranium cannot be felt through the membranes or cervix
uteri: when the finger touches the part through the mem-
branes, it very easily recedes, or seems to rise up. If the
child lie more or less across the uterus, the os uteri is gene-
rally long of being fully dilated, the membranes protrude
like a gut, and sometimes, during the pains, the woman
complains of a remarkable pushing against the sides. The
pains are severe, but in cross presentation, she is sensible
that they are not advancing the labour.
It is a fact well ascertained, that although the head have
been felt distinctly in the commencement of labour, yet when
the membranes break, it maybe exchanged for the shoulder,f
or some other part. On this account, as well as for other
reasons, it is always proper to examine immediately after the
membranes have given way.
ORDER 1. PRESENTATION OF THE BREECH.
The breech is distinguished by its size and fleshy feel, by
the tuberosity of the ischia, the shape of the ilium, the sulcus
between the thighs, the parts of generation, and by the dis-
charge of meconium, which very often takes place in the
progress of labour.:): After the breech has descended some
way into the pelvis, the integuments may become tense or
swelled, so as to make it resemble the head. Before the
* When the presentation is long of being felt, we have been advised to
examine the woman in a kneeling posture, or even to introduce the hand
into the vagina, and rupture the membranes. The last advice is sometimes
useful, as it enables us, if the presentation require it, to turn the child at a
time when it can be easily done. But this is not to be hastily practised, nor
adopted till the os uteri be well dilated.
f I have been informed of a case, where the shoulder was exchanged for
the head, and Joerg seems to have met with the same circumstance. Hist.
partus, p. 90.
4 A discharge of liquor amnii, apparently coloured with meconium, is no
proof that the breech presents, neither is it a sign that the child is dead.
39
membranes burst, the presentation is very mobile, and bounds
up readily from the finger.
Many have advised, that when the breech presented, the
feet should be brought down first; but the established prac-
tice now is, when the pelvis is well formed, and other cir-
cumstances do not require speedy delivery, to allow the
breech to be expelled without any interference, until it has
passed the external parts.
The breech, and consequently the body of the child, may
vary in its position with regard to the mother;(/) but there
are chiefly two situations requiring our attention, because the
rest are ultimately reduced to these. First, where the thighs
of the child are directed to the sacro-iliac junction of the
pelvis; and secondly, where they are directed to the aceta-
bulum. In either of these cases, delivery goes on with equal
ease, until the head comes to pass. Then, if the thighs have
been directed to the fore part of the pelvis, the face will also
be turned toward the pubis, and cannot clear its arch so
easily as the vertex.
When the thighs are directed to the back part of the pelvis,
we find that the process of delivery is as follows: The breech
generally descends obliquely, one tuberosity being lower
(/) Baudelocque has divided the presentations of the breech into four
positions. In the
1st. The child's back is towards the mother's left side, and a little forward.
But in proportion as it descends, its greatest breadth becomes parallel to
the antero-posterior diameter of the inferior strait; the left hip placing itself
under the pubes and the right before the sacrum.
2nd. The child's back is towards the right side of the uterus, and a little
forward; the right hip placing itself under the arch of the pubes, the left
being turned towards the sacrum.
3rd, The spine of the child's back is turned directly towards the umbili-
cus of the mother. Although it is allowed seldom to descend in this posi-
tion.
4th. The spine of the child is towards the sacrum of the mother, and its
abdomen towards the anterior and middle part of the uterus of the mother.
As it descends, the breadtbyfrom one hip to the other becomes parallel to
one of the oblique diameters of the pelvis.
40
than the other. The lowest one follows the same turns as
the vertex does in natural labour, and observes the same re-
lation to the axis of the brim and outlet of the pelvis. The
breech is expelled with one side to the symphysis of the
pubis, and the other to the coccyx ; and after the presenting
tuberosity protrudes under the arch of the pubis, the other
clears the perinseum, like the face, in natural labour. Whilst
the breech is protruding, it gradually turns a little round, so
that the shoulders of the child come to pass the brim diagon-
ally, the diameter from the acetabulum to the sacro-iliac junc-
tion being the greatest. The breech being delivered, a conti-
nuance of the pains pushes it gradually away, in the direc-
tion of the axis of the outlet, until the legs come so low as to
clear the vagina. When this takes place, the head is gene-
rally passing the brim obliquely, the face being turned toward
the sacro-iliac junction ; and most frequently the arms pass
along with it, being laid over the ears. They then slip down
into the vagina, by the action of the uterus, and the head
alone enters the cavity of the pelvis. The face turns into
the hollow of the sacrum, and the chin tends toward the
breast of the child. Then it clears the perinseum, which
slips over the face, and the vertex comes last of all from
under the pubis. If, however, the chin be folded down on the
breast before the head has descended into the pelvis, then,
from the unfavourable way in which it enters the brim, there
may be some difficulty to the passage, for it in some respects
resembles a presentation of the face. The hand should be
introduced, and the face pressed up. In one case, Dr. Smellie
found so much difficulty, that he applied the crotchet on the
clavicle.
Now the management of this labour is very simple. Whilst
the breech is coming forth, the perinseum is to be supported,
and nothing more is to be done till the knees are so low as
to be on a line with the fourchctte. If they do not naturally
bend, and the feet slip out, the finger of one hand is to be
employed to bend the leg gently, ami bring down the foot;
the knee, in this process, pressing obliquely on the abdomen
41
of the child. But whether the legs be expelled naturally, or
be brought down, we must carefully protect the perinseum,
lest it should be torn by a sudden stroke of the leg in passing.
Next, the cord is to be pulled gently down a little, to make
the circulation more free. Thirdly, we attend to the arms;
if these do not descend by the natural efforts, we introduce a
finger, and gently bring down first one, and then the other,
using no force, lest the bone should break. The perinseum
is also to be guarded, to prevent a slap of the arm from*in-
juring it. Fourthly, if the head do not directly tin down,
the finger is to be carried up, and placed upon the chin or in
the mouth, in order gently to depress it toward the breast,
and this is generally sufficient. To guard the perinseum, the
hand must be applied on it, and the body of the child moved
near the thighs of the mother, that the vertex may more
readily rise behind the pubis whilst the face is passing. If
the body be, on the contrary, removed farther from the mo-
ther, and nearer the operator, the head can neither pass so
easily into the pelvis, nor out from the vagina. In a natural
labour, after the head is expelled, the whole body should be
allowed to be slowly born by the efforts of the womb alone.
But in breech cases, should the process, after the breech is
expelled, be slow, the delivery of the body and head must by
the means I have related, be accelerated, lest the umbilical
cord suffer fatal compression. The first symptom of danger
is a convulsive jerk of the body, and if the head be not speedi-
ly brought down, the child will be lost. Should delay inevi-
tably arise, we must try to bring the cord to the widest
part of the pelvis. But even although all pressure could be
removed, the child cannot live long, if it be not delivered,
as the function of the placenta is sown destroyed, that organ
being often entirely detached from the womb, following the
head whenever it is born.
When the thighs, in breech cases, are directed to the pu-
bis or acetabulum, then the face cannot turn in to the hollow
of the sacrum. It rests for some time on the pubis, and it
comes out with difficulty under the arch ; for in breech and
footling cases, the face is generally born before the vertex.
VOL. II. C
42
In order to prevent this difficulty, it will, as soon as the
breech is expelled and the feet are delivered, be proper to
grasp the breech, and slowly endeavour to turn the body
round; but, should this not succeed, or not have been attempt-
ed till the shoulders have come down, and the head is about
to pass the brim, the practice is dangerous, and the neck may
be materially injured. It is, in this case, better to introduce
a finger, and press with it on the head itself, endeavouring
thus to turn the chin from the acetabulum to the sacro-iliac
junction of the same side. If the position be not rectified,
then we assist the descent by depressing the chin, and gently
bringing it under the pubis ; and this may be facilitated by
pressing the vertex upward and backward, and making it
turn up on the curve of the sacrum, to favour the descent of
the face. We must bo careful of the perinseum.
When the pelvis is contracted or deformed, it will be pru-
dent, at an early stage of the labour, to bring down the feet.
But if this have been neglected, then, should the difficulty of
delivery, or the length of time to which the labour is pro-
tracted, require it, a blunt hook, or a soft ribband has been
insinuated over one of the groins, and the breech thus ex-
tracted ; but the forceps may be applied with much more ad-
vantage. When the resistance is slight, the insinuation of
the fingers over the groin, may sometimes enable us to use
such extracting force, as at least excites the uterus more
briskly to expel. Should the head not easily follow the body,
we must not attempt to extract it by pulling forcibly at the
shoulders, as we may thus tear the neck, and leave the head
in utero.* The cord is, first of all, to be freed as much as
possible from compression ; then we gently depress the
shoulders, in the direction of the axis of the brim, at the same
* \a Motte, Chapman, Smellie, and Perfect, give examples of the head
being left in utero without the body, and the body without the head. There
are chiefly two sources of danger, the first and most immediate is ute-
rine hemorrhage; the second is the consequence of putrefaction, which pro-
duces sickness, nausea, fever, and great debility. The head may be extract-
ed, by fixing a finger in the mouth, or by the crotchet, with or without per-
foration.
43
time that we with a finger act upon the chin. Should this
not succeed, we must apply the finger over the head, and de-
press in the proper direction. If this fail, the only resource
is to open the cranium above or behind the ear, and fix a
.hook in the aperture; but this is not to be done until we
have fully tried other means, and by that time the child will
be dead.
When the breech presents, and parturition is tedious, the
parts of generation are often swelled and livid. When the
parts are merely turgid a little, and purple from congestion
of venous blood, nothing is necessary to be done. But when
inflammation takes place, it is more troublesome, for being of
the low kind, it is apt to end in gangrene. Fomentations are
useful, but often spirituous applications succeed best.
ORDER 2. OF THE INFERIOR EXTREMITIES.
Presentation of the feet is known, by there being no round-
ed tumour formed by the lower part of the uterus.(g) The
membranes also protrude in a more elongated form than
when the head or breech present. The presenting part, when
touched during the remission of the pain, is felt to be small,
(g) Baudelocque distinguishes four principal positions of the feet, to which
he considers all the rest may be referred. Of these four positions he con-
stitutes as many species of labour. In the
1st Position, the heels answer to the left side of the pelvis, and a little
forward ; the toes to the right side, and backward, nearly opposite the sacro-
iliac symphysis. Above that symphysis are placed the breast and face;
while the back is situated under the anterior and left lateral part of the
uterus.
In the 2nd position, the heels are towards the right side of the pelvis, and
the toes to the left and a little backward. The trunk and head are so situ-
ated, that the breast and face answer to that part of the uterus which is over
the left sacro-iliac symphysis, and the back to the anterior and right lateral
part of that viscus.
In the 3rd position, the heels are turned towards the pubes, and the toes
to the sacrum. The cliild's back is under the anterior part of the uterus, and
its breast answers to the lumbar vertebrae of the mother.
The 4th position is exactly the reverse of the 3d; the child's back and
heels are towards the posterior part of the uterus, while the toes, the face
and breast, are under its anterior part.
44
and affords no resistance to the finger. When the membranes
break, we may discover the shape of the toes and heel, and
the articulation at the ankle. Sometimes both the. feet and
the breech present. Two circumstances contribute to an
easy delivery : first, that the toes be turned toward the sacro- .
iliac junction of the mother; and secondly, that both feet
come down together. The best practice is, to avoid ruptur-
ing the membranes till the os uteri be sufficiently dilated;
then we grasp both feet, and bring them into the vagina; or,
if both present together at the os uteri, we may allow them to
come down unassisted. In either case, we do not accelerate
the delivery till the cord is in a situation to suffer from pres-
sure, that is, till the knees are fully protruded, and the thick
• part of the thighs, near the breech, can be felt; then, if the
face be towards the belly of the mother, we grasp the thighs,
and gently turn the b«-.!y round. The management is the
same as in breech cases. There is Utile danger of the feet of
two different children being brought down together, as twins
are included in separate membranes. But as the case is pos-
sible, ii is proper to attend that the feet be ri.jfht and 1: it.
Sometimes a knee and foot, or the knees alone. pre>e.it;(ft)
and as they form a larger tumour than tin t'evi. they may at
first be taken for the breech or the head. Generally only one
knee presents, and it lies obli |i;I;>. with its side on the os
ut:-ri. It is known by its shape, and the flexure of the joint.
Some advise that the case should be left altogether to nature,
but it is often advantageous to bring down the feet.
(h) Baudelocque distinguishes four principal positions of tiie knees also.
In the 1st position the child's legs, which are always bent when the knees
present, are towards the mother's left side, and the thighs towards the right
side.
In the 2d, the thighs answer to the left side of the pelvis, and the legs to
the right.
In the 3rd, the anterior part of the thighs is turned towards the sacrum of
the mother, and the legs are under the pubes.
in the 4th it is the reverse, the child's thighs being behind the pubes of
tile mother, and the legs placed against the sacrum.
4,5
ORDER 3. OF THE SUPERIOR EXTREMITIES.
When the shoulder or arm presents, the case has the gene-
ral character of preternatural presentations.(i) The round
tumour, formed by the head in natural labour, is absent,
whilst we can ascertain the shape and connection of the arm
and shoulder. A shoulder presentation can only be confound-
ed with that of the breech. But in the former case, the shape
of the scapula, the ribs, the sharpness of the shoulder joint,
and the direction of the humerus, together with our often
feeling in our examination either the hand or neck, will be
distinguishing marks. In the latter, the rounder shape and
greater firmness of the ischium, the size of the thigh, its di-
rection upwards, and its lying in contact with the soft belly,
the spine of the ilium, the parts of generation, the size of the
tuberosity of the ischium, and the general shape of the back
parts of the pelvis, contribute with certainty to ascertain the
nature of the case.
The hand and arm may present under different circum-
stances. The original presentation may have been that of the
shoulder, but the arm may have, in the course of the labour
been expelled; or the hand may rest on the os uteri, before
(i) The presentations of the shoulder are divided into four species by
Baudelocque. In the
1st, The side of the neck rests on the edge of the os pubis, and the side of
the breast over the sacrum, so that the fore part of the breast is towards the
left iliac fossa, when the right shoulder presents, and towards the right iliac
fossa when it is the left shoulder.
In the second position, the side of the neck is over the superior edge of
the sacrum, and the side, properly so called, is over the pubes,- the breast
answers to the right iliac fossa, when the right shoulder presents and vice
versa.
In the third, the neck and the head rest on the left iliac fossa, while the
side and the hip are over the right; so that the back is placed transversely
under the anterior part of the uterus when it is the right shoulder, and on the
posterior part of that viscus, when it is the left.
The child is also placed transversely in the fourth position of the shoulder,
but the head lies in the right iliac fossa, and the lower part of the trunk over
the left; the breast is under the anterior part of the uterus when it is the
right shoulder, and over the sacrum when it is the left.
16
the membranes have broken; or the fore arm may, for a
length of time, lie across the os uteri, the hand not being
protruded for some hours. Sometimes both hands are felt at
the os uteri, and even both arms may be expelled into the
vagina; but in most cases this does not happen, unless an
improper conduct be pursued. In some rare instances, the
hands of twins have been found presenting together, both sets
of membranes having given way ; it is more common to find
botli the hands and feet of the same child presenting; and
this, next to the presentation of the feet alone, is the easiest
case to manage.* It is not uncommon, in this case, to find
the cord presenting at the same time, and then, by delay, the
child may be lost.
In most cases where the superior extremities present, the
feet of the child are found in the fore part of the uterus, to-
ward the navel of the mother. But their situation may be
known, by examining the presentation. If we feel the
shoulder, we know, that if the scapula be felt toward the
sacrum, the feet will be found toward the belly. If the arm
be protruded into the vagina, the palm of the hand is found
in pronation, directed toward the side where the feet lie. It
is easy to know which hand presents. If we examine with
the right hand, we shall find, that if the palm of the child's
hand be taken into ours in a state of pronation, the thumb of
the right hand, or the little finger of the left hand, will cor-
respond to our thumb.
In these preternatural presentations, the ancients were ac-
quainted with the practice of turning, and delivering the child
by the feet. But their remarks on this subject formed no
general rule of conduct; on the contrary, practitioners were
almost invariably in the habit of endeavouring to remove the
presentation, and to bring the head to the os uteri. Pare
was among the first who advised turning as a general prac-
tice; but even his pupil Guillimeau disregarded the rule,
* If the uterus be firmly contracted, the liquor amnii having been all eva-
cuated, it may sometimes be necessary to carry the hand up to the knees, to
change the situation
17
and left it to Mauriceau to enforce it, both by reasoning and
practice.*
We should be careful not to rupture the membranes pre-
maturely ; and more effectually to preserve them entire, we
must prevent exertion, or much motion on the part of the
mother. As soon as the os uteri is soft, and easily dilatable,
the hand should be introduced slowly into the vagina, the os
uteri gently dilated, and the membranes ruptured. The hand
is then to be immediately carried into the uterus, and up-
wards until the feet are found. Both(fe) feet are to be grasp-
ed betwixt our fingers, and brought down into the vagina,
taking care that the toes are turned to the back of the mother.
The remaining steps have been already described. This ope-
ration is not very painful to the mother; it is easily accom-
plished by the accoucheur, and it is not more hazardous to
the child than an original presentation of the feet. But it is
necessary in order to render this assertion correct, that the
operation be undertaken before the liquor amnii be evacuat-
ed ; and it is of importance to fix upon a proper time. We
are not to attempt the introduction of the hand whilst the os
uteri is hard and undilated; this is an axiom in practice; on
the other hand, we are not to delay until the os uteri be di-
lated so much, as to be apparently sufficient for the passage
of a bulky body. In the cases now under consideration, the
os uteri does not dilate so regularly, and to so great a de-
gree, before the membranes break, as 'when the head pre-
sents. If we wait in this expectation, the membranes
will give way before we are aware. If the os uteri be dilated
to the size of half a crown, thin and lax, the delivery ought
* Mauriceau justly observes, that although, after much fatigue, the head
can be brought to the os uteri, the woman may not have strength to finish
the delivery.—In a case mentioned by Dr. Smellie, the patient died of flood-
ing.—Joerg still admits the propriety of bringing the head, when it is nearer
than the feet, to the os uteri, or the foetus is so placed, that the feet cannot
without difficulty and danger be brought down.
(k) It is not absolutely necessary that both feet should be found and
grasped, in the first instance; it will be sufficient to find and bring down
one, if both cannot be easily reached, the second foot, with proper manage-
ment, (to be hereafter directed) will soon follow.
18
not to be delayed, for every pain endangers the rupture of
the membranes. If they do give v\ay, we are immediately
to introduce the hand, and will still find the operation easy,
for the whole of the water is not discharged at once, nor does
the uterus immediately embrace the child closely. If the
liquor amnii have been discharged in considerable quantity
previous to labour, or if the membranes have burst at the
commencement of it, when the os uteri is firm and small, we
must by a recumbent posture, try still to preserve a portion
of the waters, till the orifice will permit delixery. The in-
troduction of the hand into the vagina and os uteri may be
rendered easier, and less painful, by previously dipping it in
oil or linseed tea, or any other lubricating substance.
But if the water has been long evacuated, then the fibres
of the uterus contract strongly on the child, the presentation
is forced firmly down, and the whole body is compressed so
much, that the circulation in the cord frequently is impeded,
and, if the labour be protracted, the child may be killed. This
is a very troublesome case, and requires great caution. If
the pains be frequent, and the contraction strong, then all at-
tempts to introduce the hand, and turn the child, must not
only produce great agony, but, if obstinately persisted in,
may tear the uterus from the vagina, or lacerate its cervix or
body. After a delay of some hours, however, the uterus may
be less violent in its action, or by medical aid, the pains may
be suspended. Copious blood-letting, certainly, has a power
in many cases of rendering turning easy, but it impairs the
strength, and often retards the recovery. If the patient be
restless and feverish, it may, to a certain extent, be necessa-
ry and proper; but if not, we shall generally succeed, by
giving a powerful dose of tincture of opium, not less than
sixty or eighty drops. Previous to this, the bladder is to be
emptied, lest it should be ruptured during the operation ; and,
if necessary, a clyster is to be administered. The patient is
then to be left, if possible, to rest. Sometimes in half an hour,
but almost always within two hours after the anodyne has
been taken, the pains become so far suspended, as to render
the operation safe, and perhaps easy. Our first object is, to
19
get the hand into the uterus; and for this purpose, we must
raise up the shoulder a little, working the fingers past it, by
slow, cautious, but steady efforts. The cervix often contracts
spasmodically round the presentation, and is the chief obstacle
to the delivery, but the opiate generally allays this.* Some-
times our efforts renew the pains, which, although they may
not prevent the operation, make it more painful, and cramp
and benumb the hand. Having passed the hand beyond the
cervix, we carry it on betwixt the body of the child and the
surface of the uterus, which is felt hard and smooth, from the
tonic or permanent action of the fibres, until we reach the feet,
both of which, if possible, we seize and bring down; but if
we cannot easily find both, one is to be brought down into
the vagina, and retained therc.(J) The child will be born,
with the other folded up on the belly. In bringing down the
feet, as well as in carrying up the hand, we must not act during
a pain, but should keep the hand flat on the child; a con-
trary practice is very apt to lacerate the uterus. Before in-
troducing the hand, we must ascertain, by examining the
presentation, which way the feet lie, that we may proceed di-
rectly to the proper place. We must also consider, whether
we shall succeed best with the right or the left hand. If the
right shoulder or arm present, some have made it a rule to
deliver with the left hand, others with the right; but much
must depend on the dexterity of the operator, and the posi-
tion of the woman. The most common position is the same
as in natural labour. Sometimes we may find it useful to
make the woman lie forward on the side of the bed, with her
feet on the ground, and to place ourselves behind her.
When the hand and arm have been protruded, and the
shoulder forced down in the vagina, it has been the practice
with many, before attempting to turn, to return the arm again
within the uterus ; and when this was impracticable, it has
* The spasm may yield rather suddenly to the hand, as if rupture of the
fibres had taken place. I was informed of one case of this kind, but the
womb was entire, and no bad symptoms came on.
(/) By means of a noose applied round the ancle. ^^— c'riCAL n~^ -■
VOL. II.
H /&&
lis.
50
been torn or cut off,(m) especially if the child was supposed
to be dead. Others advise, that we should not attempt to
reduce the arm; nay, even that we should, in diflicult cases,
facilitate the operation, by bringing down the other arm, in
order to change, to a certain degree, the position of the child.
So far from it being necessary to replace the arm, we shall
sometimes find advantage from taking hold of it with one
hand, whilst we introduce the other along it; as the parts
are thus a little stretched, and it serves as a director by
which we slip into the uterus.
By the means pointed out, and by a steady, patient con-
duct, we may, in almost every instance, succeed in delivering
the child. But it must be acknowledged, that in some cases,
from neglect or mismanagement, the woman is brought into
great danger, or may even be allowed to die undelivered.
This catastrophe proceeds sometimes from mere exhaustion,
or from inflammation, but oftener, 1 apprehend, from rupture
of the uterus ; or in a neglected case, so much irritation may
be given to the system, as well as to the parts concerned
in parturition, that although the delivery be easily accom-
plished, the woman does not recover, but dies, either from
pulmonic or abdominal inflammation, or fever, or flooding.
Moreover, such tedious cases generally end unfavourably for
the child.
When turning has not been practicable, if the child was
supposed to be alive, the os uteri has been cut, or the c«sa-
rian operation has been proposed and practised.* If dead,
it has been extracted, by pulling down the breech with a
crotchet;| and sometimes, in order to assist delivery, the
(m) We would strenuously dissuade from unnecessarily mutilating the
foetus, even under the supposition of its death. We have known the cliild
born with symptoms of life, even after the head has been opened, and the
greatest portion of the brain evacuated, and born alive, after its death had
been considered as certainly ascertained. It can seldom, if ever, be neces*
sary to take off the arm to facilitate the operation of turning.
* Vide Memoir by M. Baudelocque, in BecueilPeriod. Tome V. tablet.
cases 5 and 15.
f Teu, in one case where both arms were protruded, applied a fillet over
51
body has been mutilated,* or the head opened with the per-
forator. It is in general sufficient to carry the finger between
the perinanim and the thorax to the abdomen, pierce it, and
either by means of the finger or a hook fixed on the pelvis, it
may be pulled down.
When the child has been small or premature, it has hap-
pened that the arm and shoulder have been forced out of the
vagina, and then, by pulling the arm, the delivery has been
accomplished.! In a greater number of instances, a sponta-
neous turning of the child has taken place, and the breech has
been expelled first. The action of the uterus is exerted in
the direction of its long axis, and therefore tends to push its
contents through the os uteri. The child forms an ellipse ;
and cither in natural labour, or presentation of the breech,
the long axis of the ellipse corresponds to the long axis of the
uterus. But in a shoulder presentation, the axis of the el-
lipse lies obliquely with regard to that of the uterus, or to the
direction of the force; and therefore the continued action of
the uterus may tend, by operating on the side of the ellipse,
to depress the upper end, and force it gradually into the
pelvis. Dr. J. Hamilton justly observes, that the evolution
can only take place when the action of the uterus cannot be
exerted on the presenting part, or where that part is so
shaped that it cannot be wedged in the pelvis. This occur-
rence was first of all noticed, I believe, by Schoenheider;{
but Dr. Denman§ was the first who, in this country, called^
the attention of practitioners to it. He collected no less than
the breech to bring it down. Pratique p. 412.—Smellie, in 1722 brought
down the breech with the crotchet. Col. 35. case 3.—Giffard did the same
in 1725, case 5.
* Vide Perfect, Vol.1, p. 351.—Dr. J. Hamilton's Cases, p. 104. He found
it necessary to separate three of the vertebra:.—Dr. Clarke twisted off tiie
arm, and perforated the thorax freely. At the end of 36 hours the foetus
was expelled double. Med. and Phys. Jour. Vol. VII. p. 394.
f Giffard, case 211; and Baudelocque l'Art. §. 1530, in a note.—In Mr.
Gardiner's case, the head followed the shoulders. Med. Comment. V. 307.
t Acta Havn. Tom. 11. art. xxiii.
§ Lond. Med. Jour. Vol. V. p. 64.—See also case by Mr. Outnwait,in New
Lond. Med. Jour Vol. II p. 172.—Mr. Simmons Med. Facts and Obs. Vol. I.
p. 76.—Perfect's cases, II. 367.—Med. and Phys. Journ. Vol. III. p. 5.
53
Ourty cases, but in these only one child was born alive. It
does not appear that the child being large, is an obstacle to
the delivery.*
When this process is going to take place, we find that the
shoulder is forced lower by strong pains ; the clavicle lies un-
der the arch of the pubis, the ribs press out the perinseum ;
and then appear at the orifice of the vagina. As the expul-
sion goes on, the clavicle is found on the pubis, and the acro-
mion rises to the top of the vulva. Presently the arm, shoul-
der, and one side of the chest are protruded, and the breech
has got into the hollow of the sacrum. By farther efforts the
breech and extremities are expelled, and although neither the
arm nor shoulder ever retire, yet this may be considered ul-
timately as a peculiar kind of breech case, for it is born be-
fore the head. When turning is impracticable or dangerous,
and nature appears to have begun this process, it is hurtful
to interfere, at least by attempts to push back the presentation,
because we then retard the evolution. If any aid is to be
given, the direction in which the shoulder should be made to
move may be learned from the detail of the progress of the
evolution.
A knowledge of this fact does not exonerate us from mak-
ing attempts to turn; for although a considerable number of
cases are recorded where it has taken place, yet these are
few in proportion to the number of presentations of the
shoulder. In this city, (Glasgow) which contains not less
than 110,000 inhabitants, I cannot learn that more than one
case of spontaneous evolution has taken place, though some
women have either died undelivered, or have not been de-
livered until it was too late to save them.f
* Mr. Hey's case, in Lond. Med. Jour. Vol. V. p. 305.
f Delivery by spontaneous evolution is a very rare occurrence. But that it
occasionally happens is proved beyond suspicion by the cases recorded by
Dr. Dcnman and other respectable practitioners. Considering the difficulty
and even danger often incident to turning, it is certainly important to know
how to distinguish those particular casts in which this'ourious resource of
nature will probably be successfully exerted. To warrant such an expecta-
tion, it must clearly appear that the uterine action, instead of operating on
53
Sometimes the arm presents along with the head, and
"this can only render delivery tedious or difficult, by encroach-
ing on the dimensions of the pelvis. This case does not re-
quire turning; but if we can, we should return the arm
beyond the head ; if we cannot, we may succeed in bringing
it to a place where it will not interfere much with the pas-
sage of the head. Sometimes the head is placed pretty high,
being retained by a spasmodic contraction of a band of fibres
round it, and the arm'is the only presentation which can be felt,
until the hand be introduced. Opiates, in this case, may be
of service. We must never attempt by force to destroy the
stricture, in order either to return the arm or bring down
the head.
Occasionally both a hand and the feet have been found
presenting with the head, or the feet and head present. In
such cases, we can, if necessary, bring down the feet al-
together, and this is in general proper.
Besides these presentations, we may meet with the back
part of the neck, and the upper part of the shoulder; or the
nape of the neck alone; or the throat.(n) These, which are
very rare, require turning. They are recognised by their
relation to the head and shoulders.
ORDER 4. OF THE TRUNK.
The hips, back, belly, breast, or sides, may, though very
rarely, present, the child lying more or less transversely.(o)
The hip is sometimes taken for the head,* but is to be dis-
the presenting part, fixing it more closely in the pelvis, has the contrary ef-
fect of displacing it, and gradually bringing it out of the pelvis. But, if we
are convinced after a careful examination that there is no tendency to spon-
taneous evolution, we should proceed to turn the child, as in proportion to
the delay of the operation is commonly the hazard attending it. C.
(n) Of each of these, Baudelocque has constituted four varieties of presen-
tations, for a synopsis of wliich we must refer to the table, which the reader
will find at the end of this volume.
(o) Of each of these presentations there are also, according to Baude-
locque, four varieties; for an enumeration of which, the reader is referred
to the close of this volume.
* La Motte was of opinion that no part resembled the head more than
the hrp. Vide obs. 283 and 284.
54<
tinguished by the shape and relations of the ilium. In all
the other cases, the presentation remains long high; but
when the finger can reach it, the precise part may be ascer-
tained, by one who is accustomed to feel the body of a child.
If the child lie transversely, it may remain long in the same
position, and the woman may die if it be not turned. But if,
as is more frequently the case, it be placed more or less ob-
liquely, then, if the pains continue effective and regular,
either the breech or the shoulder will be brought to the os uteri,
according as the original position favoured the descent of
one or other end of the ellipse formed by the child. In these
presentations, the hand should be introduced, to find the feet,
by which the child is to be delivered. But, this rule is not
absolute with regard to the presentation of the hip, wliich
only renders labour tedious.
ORDER 5. OF THE FACE, &c.
The child may present the head, and yet it may be impro-
perly situated, and give rise to painful and tedious labour.
1st. The forehead, instead of the vertex, may be turned to
the acetabulum.^) In this case, the presentation is felt in
the first stage high up, smooth and flatter than usual. In a
little longer, we discover the anterior fontanelle, and the si-
tuation of the sutures. By degrees, the head enters the ca-
vity of the pelvis, the vertex being turned into the hollow of
the sacrum; and by a continuance of the pains, the forehead
either turns up within the pubis, and the vertex passes out
over the perinseum ; or the face gradually descends, and the
chin clears the arch of the pubis, the vertex turning up within
the perinajum towards the sacrum, till the face is born. The
first is the usual process in this presentation ; all the steps of
the labour are tedious, and often, for a considerable period,
the pains seem to produce no effect whatever. In the last
stage, the perinseum is considerably distended, and it requires
(/») This includes the fourth and fifth presentations of the vertex, accord-
ing to the division of Baudelocque, and have already been explained in our
note on the Classification of Labours. Book II. chap. 1.
05
care and patience to prevent laceration. This presentation
is difficult to be ascertained at an early stage, before the
membranes burst; and sometimes the duration of the labour
is attributed to weakness of the uterine action, and not to
the position of the head. If it be discovered early, it is cer-
tainly proper to rupture the membranes, and turn the vertex
round ; a proceeding which is easily accomplished, and which
prevents much pain and fretfulness. If this opportunity be
lost, we may still give assistance. Dr. Clarke says, that in
thirteen out of fourteen cases, he succeeded in turning round
the vertex, by introducing either one or two fingers between
the side of the head near the coronal suture, and the sym-
physis of the pubis, and pressing steadily, during a pain,
against the parietal bone.(V e
must act and cease to act alternately, and examine, as we go
on, the progress we are making, and also ascertain that tlie
instrument is still properly adapted to the head. The head
being made to descend, the face begins to turn into the hol-
low of the sacrum, and, in the same degree, the handles
must move round on their axis ; and when the face is thrown
fully into the hollow, the handles must be turned more for-
ward and upward, being placed in the axis of the outlet
The pendulum kind of motion must now be very little, and
is to be directed from one ischium toward another. As the
head passes out, the handles turn up over the symphysis pubis.
In this stage, we must proceed circumspectly, otherwise
the perinseum may be torn.
If the fontanelle present, the blades of the forceps are to
be placed directly over the ears. If the lever be used, its
point will rest on, or near one of the mastoid processes. If
the face present, the lever will rest on the back part of the
temporal bone, or on the occipital bone; the forceps will have
their points directed toward the vertex, but in face cases, the
lever being less apt to slip, is preferable.(u')
(J) We are obliged here again, unwillingly, to dissent from the respecta-
ble authority of our author. The forceps, even in face cases, will rarely slip
if properly applied. It is generally owing to improper application, not
having first accurately ascertained tlie precise position of the head, that we
hear complaints of the forceps not keeping a firm hold.
93
If the forceps or lever be injudiciously introduced, the
bladder or uterus may be perforated; or if the head be al-
lowed to remain too long jammed in the pelvis, some of the
soft parts may slough. The under and posterior part of the
bladder is apt to slough off, leaving the woman incapable
of retaining her urine. This is best prevented, by being ex-
tremely attentive in every case, especially in those where
the soft parts have suffered much or long from pressure, to
evacuate the urine regularly twice a-day, employing, if neces-
sary, the catheter. The parts ought also to be kept very
clean, and may be frequently bathed with decoction of camo-
mile flowers, (e)
ORDER 2. OF CASES REQUIRING THE CROTCHET.
It unfortunately happens, that sometimes the pelvis is so
greatly deformed, as not to permit the head to pass until it
has been lessened by being opened.
It is universally agreed, that a living child, at the full time
cannot pass through a pelvis whose conjugate diameter is only
two inches and a half. It has been even stated, by high au-
thority, that if the dimensions were "certainly under three
inches a living child could not be born;" but although this
opinion be too frequently correct, yet, like all other general
rules, it has exceptions, depending on the original size and
peculiar constitution of the child, together with the pliability
of the cranium, on the peculiar shape of the pelvis, and the
force and activity of the uterus, as well as the general strength
of the woman. There have been instances, where, by the
efforts of nature, living children have been expelled through a
pelvis scarcely measuring three inches; and there are similar
examples of the delivery, being under the same conformation,
(e) The rectum likewise, where it passes over or near the projection of
the sacrum, may, by long continued pressure of the head, have its life
destroyed, and sloughing take place into the vagina, through which the
faeces will be discharged. These deplorable effects sometimes follow cases
of impaction, or the locked head, where instruments have not been used.
91
accomplished with the lever or forceps.* We are not war-
ranted, therefore, to open the head, merely because we esti-
mate that the pelvis does not, in its conjugate diameter, mea-
sure fully three inches; but because we have ascertained by
a sufficient trial, that the uterine action cannot force down
the head, and that the forceps or vectis cannot be ap-
plied or acted with effectively. In all cases where the
dimensions and circumstances of the case are barely such as
to warrant a belief that the head must be opened, an attempt
ought previously to be made, not in a careless or hasty man-
ner, but deliberately and attentively, to introduce and act
with the vectis or forceps.
We may, however, if the dimensions be much under three
inches, be assured, that delivery cannot be accomplished with-
out the destruction of the child. But as it is a matter of
great nicety to say whether the pelvis measures three inches,
or only two and a half, or two and a fourth, a practice found-
ed on arithmetical directions must be unsafe. In every case,
therefore, we ought to allow some time for the pains to pro-
duce an effect; and this time should be longer or shorter, ac-
cording as, in our estimation, the dimensions diminish from
three inches to two inches and a half. In such extreme de-
formity as this, we have no reason to expect that the head can
pass, unless it burst,f or be artificially opened ; and therefore
it should, for the advantage of the mother, be perforated as
soon as the os uteri is properly dilated: but until the os uteri
is fully opened, no attempt to introduce the perforator can be
sanctioned.
* M. Baudelocque relates a most interesting case, where there were de-
cided marks of the foetus being dead in utero, and yet these were delusive,
for, by the forceps, the woman was delivered of a Uving child, altliough the
pelvis measured only about three inches. L'Art des Accouch. sect. 1898.—
Cases in point may also be seen in Dr. Alexander Hamilton's Letters, pp.
94, 102, 113.—Similar instances have come within my own knowledge.
f So far as I can judge, the sutures yield sooner than the scalp, and the
brain is effused, or pushed out like a bag. When tlie integuments open
first, it is owing, 1 apprehend, to sloughing from pressure and injury. A
very distinct case of spontaneous bursting of the cranium may be found in .1
Hamilton's Cases, p. IT.
95
But although it be thus laid down as a general rule, that
the pelvis, which measures three inches in its conjugate dia-
meter, may admit a living child to pass, either by the appli-
cation of the vectis or forceps, or still more rarely by the
efforts of the womb, yet it is nevertheless true, that sometimes
the child must be destroyed, even when the space is fully three
inches. This may become necessary, owing to the great size
of the child and firmness of the cranium, or a hydrocepha-
lic state of head;* or the soft parts in the pelvis may swell
so much as to diminish, in an increasing ratio, the size of the
pelvis, and effectually to obstruct delivery.! The parts may
also be so tender, as to render even a common examination
painful, and to prevent the application of the forceps or their
effective action, in a case merely equivocal. Alarming con-
vulsions may likewise induce us to perforate the head in a case
of deformity, where it is perhaps possible that the vectis or
long forceps might succeed, after a greater delay or length of
time than is compatible with the safety of the mother; but this
combination of evils must be rare. No practitioner, I believe,
in this city, [Glasgow,] has met with such a case. At one
period, however, the crotchet was employed in cases of con-
vulsions, where the vectis or forceps would now be used.
By the rash and unwarrantable use of the crotchet, living
children have been drawn through the pelvis with the skull
opened, and have survived in this shocking state for a day or
two.|
To prevent all risk of bringing a living mutilated child to
the world, and to avoid, at the same time, killing or giving
pain to the child,§ even in those cases which clearly demand-
• 1 have seen a cranium so enlarged with water, that when it was inflated
after delivery, so as to resume its former size, it measured twenty-two inches
in circumference.
f Baudelocque l'Art. des Accouch. sect. 1705.—See also a case in point in
Dr. A. Hamilton's Letters, p. 83.—Every attentive practitioner must, from
his own experience, admit the fact.
* Vide Mauriceau, obs. 584.—La Motte, case CXC.—Hamilton's Letters,
p. 153.—Peu La Pratique, p. 346.—Crantz de Re Instrument, &c. sect. 38.
§ It has been disputed, whether the cliild in utero was capable of s-c-nsa
tion," but both facts and reasoning are in favour of its sensibility.
96
ed the use of the perforator, some have delayed operating
until the child appeared to have been destroyed by the expul-
sive efforts or other causes, and have therefore been anxious
to ascertain the signs by which the death of the child might
be known.2 It was still more desirable to know these, at a
time when the forceps were undiscovered. But the signs
are in general extremely equivocal, nor is this much to be
regretted, for we do not operate because the child is dead,
but because it is impossible for the woman to be otherwise
delivered.
The steps of the operation, are very simple. The rectum,
but especially the bladder, being properly emptied, we place
the fore finger of the one hand on the head of the child, and
with the other hand convey the perforator to the spot on
which the finger rests. The instrument, being carried cau-
tiously along the finger as a director, can neither injure the
vagina nor os uteri, and in general no difficulty is met with in
this part of the operation. Sometimes, however, in very
great deformity, the os uteri is placed so obliquely, that it
must previously be gently brought into the most favourable,
that is, the widest part of the pelv is; and afterwards, the
perforator, being placed on the head, must have its handle in
the axis of the brim, which may require the perinseum to be
stretched back. These points being attended to, the scalp is
then to be pierced, and the point of the instrument rests on
the bone, through which it directly, or after a momentary
pause, is to be carried,(/) either by a steady thrust or a
boring motion. It is to be continued in, till checked by the
stops. The blades are then to be opened, so as to tear up
the cranium ; and in order to enlarge the opening, they may
be closed and turned at right angles to their former position,
and again opened, so as to make a crucial aperture. If the
liquor amnii have been well evacuated, and a portion of the
cranium have entered the pelvis, the perforation can be made
without any assistance; but if the whole of the head be above
(/) Where one of the sutures or fontanelles can be conveniently reached,
the operation is facilitated by perforating through these, as must occur to
every one.
97
the brim, it may be necessary to have it kept steady, by pres-
sure above the pubis. It may be proper to add, that if the
face present, we must perforate the forehead, just above the
nose. If we have turned the child, and wish to open the
head, the instrument must be introduced behind the ear.
The brain is next to be broken down, by turning the per-
forator round within the head. If part of the cranium have
entered the pelvis, some of the brain will come out with a
squirt, whenever the bones are opened; and at all times we
have more or less hemorrhage from the vessels of the brain.
Sometimes the blood flows very copiously. The patient is
now, if fatigued, to have an anodyne; and at any rate, ex-
cept in very urgent cases, is to be left for some hours to re-
pose, or to the operation of natural pains. Dr. Osborn, in
his elaborate essays, advises, that the head should be opened
early, and that we should then delay to extract for thirty
hours. In cases of great deformity, decidedly requiring the
use of the crotchet, the first direction is important; but where
there is any possibility of avoiding the perforation, it ought
not to be attempted till the event has proved the necessity.
The general principle of the second direction is just, where
the first has been acted on, and the strength is good, and no
urgent symptom is present: but the delay of the specific
number of thirty hours is, in most cases, too long; and I
question if it be sufficient to produce, in any case where the
child was alive when the skull was perforated, such a degree
of putrefaction as materially to facilitate the operation. The
chief benefit of delay is, to bring as much of the cranium as
possible into the pelvis.
If the deformity have been no more than just sufficient to
require the use of the perforator, then, if the pains become
strong, it is possible for the head to be expelled without far-
ther assistance. But if the deformity be greater, or the
pains weak, then only the pliable part of the cranium will
descend, and the face and basis of the skull remain above the
brim of the pelvis. In this case, the crotchet is to be intro-
duced through the aperture of the cranium, and fixed upon
the petrous bone, or such projection of the sphenoid bone, or
VOL. II. ©
98
occiput, as seems to afford a firm fixture. We then pull
gently, to try the hold of the instrument; and this being
found secure, we proceed to extract in the direction of the
axis of the brim, by steady, cautious, and repeated efforts,
exerting, however, as much strength as may be necessary
to overcome the difficulty. In doing this, we must always
keep a hand, or some of the fingers, in the vagina and on
the cranium, to save the soft parts, should the instrument
slip. If the force be steadily and cautiously exerted, we may
always feel the instrument slipping or tearing the bone, and
have warning before it comes away. We should, in extract-
ing, co-operate as much as possible with the pains.
But it sometimes happens, that the pelvis is so small, as to
require the head to be broken down, and nothing left but the
face and base of the skull. This is an operation which will
be greatly facilitated by the putrefaction or softening of the
head, which takes place some time after death. If the child
be recently dead, the bones adhere pretty firmly, and, in a
contracted space, it will require some management to bring
them away. But if the parts have become somewhat putrid,
or the child been long dead, the parietal and squamous bones
come easily away, and the frontal bones separate from the
face, bringing their orbitary processes with them. We have
then only the face and basis of the skull left, and if the pelvis
will allow these remains to pass, then the crotchet can be
used. I have carefully measured these parts, placed in dif-
ferent ways, and entirely agree with Dr. Hull, a practitioner
of great judgment and ability, that the smallest diameter
offered, is that which extends from the root of the nose to the
chin. For, in my experiments, after the frontal bones were
completely removed, this did not in general exceed an inch
and a half. It is therefore of great advantage, to convert
the case into a face presentation, with the root of the nose,
directed to the pubis. The size of the crotchet, which ought
to be passed over the root of the nose, and fixed on the
sphenoid bone, must, however, be added to this measure-
ment. I never have yet been so unfortunate as to meet with
what may be considered as the smallest pelvis, admitting of
99
delivery per vias naturales ,•* but I would conclude, that
whenever the pelvis, with the soft parts, measures fully an
inch and three quarters,! or, if the head be unusually small,
the child not being at the full time, an inch and a half, the
crotchet may be employed, provided the lateral diameter of
the aperture in the pelvis be three inches, or within a fraction
of that, perhaps two inches and three quarters, if the head
be small or very soft; and the operation will be easy, as we
extend the diameter of the pelvis beyond what may be con-
sidered as the minimum. It is scarcely necessary to add,
that if the outlet be much contracted, it will make the case
more unfavourable; and where we have any hesitation, owing
to the shape and dimensions of the brim, will determine us
against this operation.
In this manner of operating, the face is drawn down first,
and the back part of the occipital bone is thrown flat upon
the neck like a tippet. If we reverse this procedure, and
bring the occiput first, and the face last, fixing the instru-
ment in the foramen magnum, then, as we have the chin
thrown down on the throat, we must have both the neck and
face passing at once, or a body equal to two inches and three
quarters. If on the other hand, we fix the instrument on the
petrous bone which is certainly preferable to the foramen
magnum, and, bring the head sideways, we must have both
that bone and the vertebrae passing at once, or a substance
equal to two inches and a half in diameter; and if the head
pass more obliquely, then it is evident that the size must be
a little more. Although, therefore, Dr. Osborn be correct,
in saying, that the base of the cranium, turned sideways,
does not measure more than an inch and a half; yet we must
not forget, that when the opposite side comes to pass, the
neck passes with it, which increases the size.
* I cannot learn that any case of extreme deformity in a pregnant woman,
such as to render it barely possible to deliver with the crotchet, or neces-
sary to have recourse to the cesarean operation, has occurred in this city
since the year 1775, when Mr. Whyte performed the latter operation.
f M. Baudelocque considers the crotchet as inadmissible, when the pelvis
measures only an inch and two thirds.
100
The head beiug brought down and delivered, we then fix
a cloth about it, and pull the body through; or, if this can-
not be done, we open the thorax, and fix the crotchet on it,
endeavouring to bring down first a shoulder, and then the
arm. .
In operating with the crotchet, we must always bring the
head through the widest part of the pelvis; but where the
deformity is considerable, no small .force is requisite. This
is productive of pain during the operation, and of danger of
inflammation afterwards, which may end in the destruction
of some of the soft parts; or affecting the peritoneum, it
may prove fatal to the patient. From injury done to the
bladder, retention of urine may be produced, wliich if ne-
glected, is attended with great risk. Incontinence of
urine is less to be dreaded, as it is sometimes cured by time.
Severe pain in the loins and about the hips, with lameness,
is another troublesome consequence. If the patient be not
affected with malacosteon, the warm, and at a more advanced
period, the cold bath, friction, and time, generally prove
successful.
To avoid the destruction of the child, and the severity of
the operation of extracting it, the induction of premature la-
bour has been proposed ;3 and the practice is defensible, on
the principle of utility as well as of safety. We know that
the head of a child, in the beginning of the seventh month,
does not measure more than two inches and a half in its late-
ral diameter; two and three quarters in the end of that
month; and three in the eighth month. We know farther,
that there is no reason to expect that a full grown foetus can
be expelled alive, and very seldom, even after a severe labour
dead, through a pelvis whose dimensions are not above two
inches and a half: and lastly, we have many instances,
where children born in the seventh month have lived to old
age. Whenever, then, we have by former experience ascer-
tained beyond a doubt, that the head, at the full time, must
be perforated, it is no longer a matter of choice, whether, in
succeeding pregnancies, premature labour ought to be in-
duced. It is^ certainly easier for the mother than the appli-
101
cation of the crotchet, and no man can say that it is worse
for the child.* All the principles of morality, as well as of
science, justify the operation; they do more, they demand
the operation. The period at which the liquor amnii should
be evacuated must depend upon the degree of deformity;
and where that is very great, it must be performed at a period
so early, as to afford no prospect of the child surviving: it
must be done in this case to save the mother, or sometimes
it may be requisite to use the lever, even when labour has
been prematurely brought on. There are cases, and these
cases are not singular, where the bones gradually yield, and
become so distorted, as at last to prevent even the crotchet
from being used. Now, granting a succession of pregnan-
cies to take place in this situation, it follows as a rule of con-
duct, that if the deformity be progressive, we should regularly
shorten the term of gestation, exciting abortion, even in the
third month, if necessity requires it, and treating the case as
a case of abortion, enjoining strict rest, and plugging the
vagina to save blood. Some may say, shall we thus, by ex-
citing abortion, destroy many children to save one woman ?
This objection is more specious than solid. Those who
make it would not, in all probability, scruple to employ the
crotchet frequently ; and where is the difference to the cliild,
whether it be destroyed in the third or in the ninth month ?
How far it is proper for women in these circumstances to
have children, is not a point for our consideration, nor in.
which we shall be consulted. I would say, that it is not pro-
per ; but it is no less evident, that when they are pregnant
we must relieve them.(^)
* It has been proposed, by low diet, to restrain the growth of the child,
but this is a very uncertain and precarious practice.
(g) The reader is referred to a case of premature labour artificially induced,
where the cliild lived for some time after dehvery, related by the Editor in
tlie Eclectic Repertory, Vol. I. p. 105, and seq.—See also a paper on " cases
of premature labour artificially induced, in women with distorted pelvis, to
wliich are subjoined some observations on this method of practice by S. Mer-
riman, M. D. Physician-Accoucheur to the Middlesex Hospital, &c. Stc."
Medico-chirurgical Transactions, Lond. 1812, Vol. III. p. 123, and seq.
Dr. M concludes, that "In the greater number of instances, indeed, the
103
CHAP. VII.
Of Impracticable Labour.
It may be urged against the reasoning in the conclusion of
the last chapter, that the csesarean operation ought to be per-
formed, and, doubtless, in cases of extreme deformity, if the
proper time for inducing labour be neglected, it must be per-
formed. But the danger is so very great to the mother, that
this never can be a matter of choice, but of necessity. In ba-
lancing the cesarean operation against the use of the crotchet
or the induction of abortion, we must form a comparative es-
timate of the value of the life of the mother and her child.
By most men, the life of the mother has been considered as
of the greatest importance ; and therefore, as the csesarean
operation is full of danger to her, no British practitioner will
perform it, when delivery can, by the destruction of the
child, be procured per vias naturales. As, in many instances,
the woman labours under a disease found to be hitherto in-
curable, it may be supposed, that the estimate will rather be
formed in favour of the child. But, in the first place, we can-
not always be certain that the child is alive, and that the
operation is to be successful with respect to it: and, in the
second place, it ought to be considered, how far it is allow-
able, in order to make an attempt to save the child, to per-
form an operation, which, in the circumstances we are now
talking of, must, according to our experience, doom the mo-
ther to a fate, for which, perhaps, she is very ill prepared.
There are, I think, histories of twenty-one cases, where
this operation has been performed in Britain; out of these
only one woman has been saved,* but eleven children have
been preserved. On the continent, however, where the ope-
child will cither be dead born, or will be born with so little life as to expire
in a few hours; but in many cases the cliild has been preserved. Thus out
of 17 instances of distorted pelvis, in which this operation had been practised,
at least 19 children had been born alive and capable of living."
* Vide a case by Mr. Barlow, in Med. Records and Researches, p. 154.
103
ration is performed more frequently, and often in more fa-
vourable circumstances, the number of fatal cases is much
less.* If we confine our view to the success of the operation
in this island, we must consider it as almost uniformly fatal
to the mother. This mortality is owing, not only to the in-
jury done to the cavity of the abdomen, and the consequent
risk of inflammation, even under the most favourable circum-
stances, and with the best management; but also to the mor-
bid condition of the system, at the time when the operation
was performed; many, of the women being affected with
malacosteon, which would in no very long time have of itself
proved fatal. From this unfavourable view, it may perhaps
arise as a question, whether nature, if not interfered with,
might not, as in extra-uterine pregnancy, remove by abscess
the child from the uterus ? It has been said, that this event
has taken place; but I do not recollect one satisfactory case
upon record. Whenever this has happened, the uterus has
either been ruptured, and the cliild expelled into the cavity
of the abdomen; or, in a very great majority of the instances,
the child has, evidently from the first, been extra-uterine.
We are therefore led to conclude, that the mother who cannot
be delivered by the crotchet, must submit to the csesarean
operation, or must inevitably perish, together with the fruit
of her womb.
It has been asserted by Dr. Osborn, that this operation,
can seldom if ever be necessary; never where there is the
space of an inch and a half from pubis to sacrum, or on either
side: and that he himself has, in a case where the widest
side of the pelvis was only an inch and three-quarters broad,
and not more than two inches long, delivered the woman, by
breaking down the cranium, and turning the basis of the
skull sideways. As the patient recovered, and afterwards, I
think, died in the country, where she could not be examined,
we cannot say to a certainty what the dimensions of the pel-
vis were. Dr. Osborn must only speak according to the best
* According to Dr. Hull, we had when he published, at home and abroad,
records of 231 cases of this operation, 139 of which proved successful. Vide
Translation of M. Baudelocque's Memoir, p. 233.
104
of his judgment, I have the highest respect for his character
and for his works, and nothing but irresistible arguments
could make me doubt his accuracy. But from the statement
which I have already given of the dimensions of the head,
when broken down at the full time, as well as from the ex-
periments of Dr. Hull, and the arguments of Dr. Alexander
Hamilton and Dr. Johnson, I am convinced that there must be
some mistake in Sherwood's case. Had the child been brought
by the face, there might have been room for it to pass, so far as
the short diameter of the passage is concerned; but the lateral
diameter is too small for the head, if of the usual size, to pass,
in that which I consider as the most favourable position. In
the cases related by Dr. Clarke,* who is a practitioner of the
highest authority, we are informed, that the short diameter of
the passage did not exceed an inch and a half, but we are not
informed of the lateral extent. As the women both recovered,
the precise dimensions and construction of the pelvis cannot be
determined. It is likew ise much to be regretted, that the dia-
meter of the cranium, or cranium and neck, in the state in
which they may have been supposed to come through the
passage, was not taken after delivery. AVhere, and only
where, it can be ascertained, that the head placed iu the po-
sition in which it was drawn through the pelvis, does not
form, in any part, a substance measuring more than an inch
and a half by two inches or three inches, it is allowable to
infer, that the cavity through which it passed may have been
as small as that.
Finally, this is a question on which, although we may lay
down a general rule, we must admit of some exceptions; for
a premature, or a very small child, may be brought through
a pelv is which will not permit, by any means, an ordinary
sized foitus to pass. But it behoves us, in our reasoning, to
judge every child to be at the full time, unless we know the
contrary, and to make an estimate on the average magnitude;
and until the contrary is proved, by dissection of the mother,
or careful and rigid measurement of the child after delivery,
* Vide Dr. Osborn's Essays, p. 203, and London Med. Journal.. MI. p. 40.
105
I must hold to the position formerly laid down, that the
crotchet cannot be used when the child is of the full size, un-
less we have a passage through the pelvis, measuring fully an
inch and three quarters in the short diameter, and three inches
in length, or, if the child be premature and soft, an inch and
a half broad, and two inches and three quarters long.1
The operation itself, although dangerous in its conse-
quences, and formidable in its appearance, is by no means
difficult to perform. Some advise the incision to be made per-
pendicularly in the linea alba,(/i) others, transversely in the di-
rection of the fibres of the transversalis muscle. Perhaps the
precise situation and direction of the wound must be regulat-
ed by the circumstances of the case, and the shape of the ab-
domen; but in general, I apprehend, that the transverse
wound will be most eligible. The length of the incision,
through the skin and muscles, ought to be about six inches;
and if a vessel bleed, so as to require the ligature, it will be
proper to take it up before proceeding farther. The uterus
is next to be opened, by a corresponding incision; and as the
fundus, owing to the pendulous shape of the abdomen, is the
most prominent part, the incision will in general be made
there, unless the external wound be made lower than usual.
The child is next to be extracted, and immediately afterward
the placenta. One assistant is to take the management of
the child, whilst another takes care to prevent the protrusion
of the bowels. In this part of the operation, although pretty
large vessels are divided, yet the hemorrhage is seldom great;
it has, however, proved fatal. The external wound is now to
be cleaned, its sides brought together, and kept in contact by
a sufficient number of stitches passed through the skin alone,
(h) Mauriceau, Baudelocque, Capuron, Solayres, and the generality of the
modern French Accoucheurs and Surgeons who have had the greatest sue-
cess in performing the Cesarean operation, prefer making tlie incision in the
linea alba. Cooper agrees in recommending this mode. Vide Diet, of Sur-
gery : Dorscy's Echtion, Vol. I. p. 163. Some of the reasons assigned for this
preference, are that the incision is made with greater facility and is less pain-
ful, because there are fewer parts to be divided; ^nd the hemorrhage is less
profuse. The uterus is readily brought into view, and it is cut in its mid-
dle portions, and parallel to its principal fibres.
VOL. I. P
106
or the skin and muscles, avoiding the peritoneum. Adhesiv*
plasters are to be placed carefully in the intervals; and a
bandage, with a soft compress, being applied, the patient is
to be laid to rest. An anodyne should be given, to diminish
the shock to the system; and our future practice must, upon
the general principles of surgery, be directed to the preven-
tion or removal of abdominal irritation or inflammation. The
patient may die, although there be very little inflammation of
the peritoneum. It has been proposed by Dr. Hull, to whose
work I refer for more particular information, to operate as
soon as the os uteri is dilated, and before the membranes
burst, in order that the wound of the uterus may contract into
a smaller size.
In order to supersede the csesarean operation, and even to
avoid the use of the crotchet, it was many years ago proposed
to divide the symphysis pubis, in expectation of thus increas-
ing the capacity of the pelvis. This proposal was founded on
an opinion, that the bones of the pelvis, either always or fre-
quently, did spontaneously separate, or their joinings relax,
during gestation and parturition, in order to make the de-
livery more easy. In deformity of the pelvis, the symphysis,
was first divided by a knife during labour, by M. Sigault, in
1777, assisted by the ingenious M. Alphonse Le Roy. The
operation was afterwards repeated on the continent, w ith va-
rious effects, according to the degree of deformity and extent
of the separation.(i) It has only once* been adopted in this
country, because it is not only dangerous in itself to the mother,
but also of limited benefit to the child. We have already seen,
that there is a certain degree of deformity of the pelvis,
which must prevent a child at the fulLtime, and of the average
size, from passing alive, or with the head entire. Now, in a
case, where it is barely impracticable to use the lever or for-
ceps, and where it just becomes necessary to open the head,
(»') It has of late again been recommended, by some French writers of
eminence: Vide Capuron Cours theorique et pratique, &c. p. 673, & seq.
Gardien Traite d'Accouchemens. Tom. 3. p. 20, & seq. & J. B. De Mangeon,
De Ossium pubis S>nchondrotomia, Parisiis, 1811.
* Vide case by Mr. \\ clchman, in London Med. Jour, for 1790, p. 46.
107
l he division may perhaps save the child, and with less danger
to the mother than would result from the csesarean operation,
which is the only other chance of saving the infant. If we
increase the contraction of the pelvis beyond this degree,
then the chance of saving the child is greatly diminished;
and the extent to which the bones must be separated to ac-
complish delivery, would, in all probability, be attended with
fatal effects. In such a case, the crotchet can be employed
with safety to the mother, and continues to be eligible, until
we find the space so small as to require the csesarean opera-
tion ; and in this case, the division can do no good. It can-
not even make the crotchet eligible, owing to the shape of
the pelvis in malacosteon, and the great mischief which would
be done to the parts after the division, by the necessary steps
of the instrumental delivery. There is only one degree of
disproportion, then, betwixt the head and the pelvis, which
will admit of the division, but the smallest deviation from this
destroys the advantage of the operation. Now, as this dis-
proportion is so nice, we cannot in practice ascertain it; for
although we could determine, within a hundredth part of an
inch, the capacity of the pelvis, yet we cannot determine the
precise dimensions of the head, and thus establish the relation
of the two. On this account, the division of the symphysis
pubis cannot be adopted with advantage, either to the mother
or cliild.
CHAP. VIII.
Of Complicated Labour.
ORDER 1. LABOUR COMPLICATED WITH UTERINE HEMORR-
HAGE.
During labour, there is always a slight discharge of
bloody slime, when the membranes begin to protrude; for
the small vessels of the decidua, near the cervix uteri, are
opened. In some cases, a very considerable quantity of
108
watery fluid, tinged with blood, flows from the womb, but this
is attended with no inconvenience. It may happen, however,
that pure blood is discharged, and that in no small quantity.
If this take place in the commencement of labour, it differs
in nothing from those hemorrhages which I have formerly
considered. But occasionally the flooding does not begin,
till the first stage of labour be nearly or altogether com-
pleted. If the membranes be still entire, it proceeds certain-
ly from the detachment of part of the placenta or decidua,
and often is connected with unusual distension of the uterus,
from excessive quantity of liquor amnii, or with ossification
of the placenta. If the membranes have broken, then we
must consider the possibility of its proceeding from rupture
of the uterus, and must inquire into the attending symptoms.
Sometimes it will be found to proceed from tedious and ex-
hausting labour, from improper exertion, or rude attempts
to dilate the os uteri, or alter the presentation; or it may be
caused by rupture of the umbilical cord. Now, in this order
of labours, the practice is very simple, and admits of little
difference of opinion. For every experienced practitioner
must admit, that when the hemorrhage is considerable, and
is increasing or continuing, the only safety consists in
emptying the uterus. If the pains be smart, frequent, and
effective, the labour advancing regularly, and there be reason
to suppose that it will be finished before the hemorrhage
have continued so long as to produce injurious effects, we
may safely trust to nature. We must keep the patient very
cool, and in a state of perfect rest. But if the pains be weak,
ineffective, and rather declining than increasing, whilst the
hemorrhage is rather increasing than diminishing, we must
deliver tlie woman, either by turning the child, or applying
instruments, according to the circumstances of the case, and
the situation of the head.*
* The forceps have been recommended, in preference to turning in such
cases. They can, however, hardly ever be applied with advantage where
labour is so little advanced. It has also been proposed to rupture tlie mem-
branes, in order that the uterus may contract round the body of the child,
and thus suppress the hemorrhage. This suggestion cannot be too much
109
ORDER 2. WITH HEMORRHAGE FROM OTHER ORGANS.
When hemorrhage takes place from the lungs or stomach
during parturition, we ought to have recourse, in the first
place, to blood-letting, or such other means as we would em-
ploy were the patient not in labour. If the hemorrhage con-
tinue violent, or be increased by the pains of parturition, we
must consider, whether artificial delivery, or a continuance
of the natural process, will be attended with least exertion
and irritation, and consequently with least danger j and we
must act accordingly.
ORDER 3. WITH SYNCOPE.
Syncope may proceed from various causes, such as hemorr-
hage, or rupture of the uterus; but these cases have been al-
ready, or will be considered. It may proceed from a deli-
cate nervous constitution, from long continued labour, from
particular states of the heart or stomach, and from passions
of the mind. A simple paroxysm of fainting, unless it pro-
ceed from causes which would otherwise incline us to deliver,
such as tedious labour, flooding, &c. is not to be considered
as a reason for delivering the woman. We are to employ
the usual remedies, and particularly keep the person in a re-
cumbent posture. Ammoniated tincture of valerian or tinc-
ture of opium are useful. But if the paroxysms be repeated,
whatever their cause may be, we ought to deliver the woman,
if the state of the os uteri will permit. We must be very
careful to prevent hemorrhage, after the expulsion of the
child.
ORDER 4. WITH CONVULSIONS.
Convulsions may occur, either during pregnancy or labour,
and are of different kinds, requiring opposite treatment. One
discountenanced. If adopted, it would lead to a rash experiment, which
could only succeed accidentally, and which in its failure would aggravate
the difficulty, and might prevent altogether the turning of the child. C.
110
species is the consequence of great exhaustion, from exces-
sive fatigue, tedious labour, or profuse hemorrhage. This
makes its attack without much warning, and generally al-
ternates with dcliquium, or great feeling of depression and
debility; the muscles about the face and chest are chiefly af-
fected, and the pulse is small, compressible, and frequent,
the face pale, the eye sunk, the extremities cold. The fits
succeed each other pretty quickly, and very soon terminate
in a fatal syncope. This species naturally requires that we
should, first of all, check the farther operation of the exciting
cause, by restraining hemorrhage, or preventing every kind
of exertion, and then husband the strength which remains,
or recruit it by cordials. Opiates are of great service. De-
livery is usually necessary.
Hysterical convulsions are more common during gestation,
than during labour, and have formerly been described and
considered. 1 have therefore only to say now, that if they
do not speedily yield to antispasmodics, venesection must be
resorted to, and if that fail, we must deliver the patient.
The most frequent species of puerperal convulsions, how-
ever, is of the epileptic kind, which occurs fifty times for
once that the others appear. Convulsions may affect the pa-
tient suddenly, and severely. She rises to go to stool, and
falls down convulsed; or, sitting in her chair, conversing
with her attendants, her countenance suddenly alters, and she
is seized with a fit; or, she has been lying in a sleep, and the
nurse is all at once alarmed by the shaking of the bed, and
the strong agitation of her patient. Immediately all is con-
fusion and dismay, and the screams of the females announce
that something very terrible has happened. Presently the
convulsion ends in a short stupor, from which the woman
awakes, unconscious of having been ill; and thus, for a time,
the apprehensions of the attendants are calmed. But in a
short time the same scene is generally repeated ; or, perhaps,
although the convulsion has gone off, the stupor remains. It
is, however, not unusual for the fit to be preceded by some
symptoms, which, to an attentive observer, indicate its ap-
proach. These may even exist to a degree which cannot be
Ill
neglected. They arc, head-ache, which is sometimes dread-
ful; or acute pain in the stomach, with unsupportable sick-
ness ; ringing in the ears; dazzling of the eyes, or appear-
ances of substances floating before them, either opaque, or,
more frequently, of a fiery brightness. The pulse is slow,
the patient sometimes sighs deeply, or has violent rigours,
which, in the second stage of labour, are always hazardous.
There is great drowsiness during the pains. It is neither
uncommon nor dangerous for the woman to be drowsy be-
tween the pains; but here, even during them, she falls into a
deep sleep. When the attack comes on, which very often is
soon after these preludes appear, the muscles are most vio-
lently convulsed, the whole frame shakes strongly, and the
face is dreadfully distorted,* and often swollen. The tongue
is much agitated, and is very apt to be greatly injured by
the teeth; foam issues from the mouth, and the convulsive
inspiration often draws this in with a " hissing noise;" or
she snores deeply, and cannot be roused during the fit. The
skin becomes, during the convulsion, livid or purple. This
attack may end at once in fatal apoplexy, but generally the
patient recovers, and is quite insensible of having been ill.
Soon, however, the fits are renewed; and if they do not prove
fatal, or are not averted by art, they recur with the regularity
of labour pains, becoming more and more frequent as they
continue. Tlie woman appears to have no labour pains, yet the
os uteri is affected, and sometimes the child is expelled, or if
the patient become sensible in the intervals, and feel a pain
coming on, it appears to be speedily carried off by a super-
vening convulsion. The fit may last only a few seconds, or
may continue with very little remission for half an hour.
Apoplexy may take place at the commencement of labour,
or during gestation, without convulsions. In the latter case,
the os uteri is rarely affected; but in a few instances it has
been found dilated, if death did not take place instantaneously.
Copious blood-letting is the principal remedy in this case.
* Mr. Fynney gives a case, where the lower jaw was luxated during con-
vulsions, which came on in the birth of a second chUd, or twin. Med. Com-
ment. Vol. IX. p. 380.
112
Convulsions may occur in any period of labour, or before
it has begun, or after the delivery of the child; and in this
last case, are sometimes preceded by great sickness or op-
pression at the stomach. Dr. Leak relates the case of a
patient who had ten or eleven of these fits; the abdomen was
swelled and tense, and she vomited phlegm mixed with blood,
which probably came from the tongue. She recovered by
means of blood-letting and clysters.
Puerpjeral convulsions seem to be different from common
epilepsy, for they recur at no future time, except perhaps in a
subsequent pregnancy. They take place in greater number
in a given time, than epilepsy does in general. They often
recur exactly like labour pains, or are frequently accompanied,
or preceded by them; though when the convulsion comes on,
the feeling of pain is suspended, and often, though not always,
the uterine contraction is stopt or diminished.(fc) The same
observation applies to excessive rigours, which are, indeed,
a species of convulsions, but are not attended with distortion
of the face nor insensibility. If the patient be in a state of stu-
por, she frequently has the countenance distorted at intervals,
accompanied with some uterine action. They are preceded by
different symptoms, and never by aura; and the patient usu-
ally recovers sensibility much sooner, and more completely
during the intervals, than in epilepsy. The organs of sense,
particularly the ear, are often preternaturally sensible. Some-
times the child is unexpectedly born during a fit.
Convulsions, of the kind I am considering, evidently are
connected with gestation or parturition; they occur at no
other time, and are more frequent in a first labour. They
arise particularly from uterine irritation, but also seem fre-
quently to be connected with a neglected state of the bowels,
(fr) Dr. Clarke of London, thinking it necessary, in a case of convulsions,
to turn the child and deliver it, a convulsion occurred whilst his hand was in
the uterus, when, of course, he had an opportunity of observing how it
was affected.—He remarked, that instead of a regular contraction taking
place, the uterus seemed to flutter, or, be irregularly and tremulously con-
tracted and relaxed again quickly, and he was disposed to believe, that it
was in that state during every case of puerperal convulsions.
113
a fact to which T wish to call the attention of the practitioner,
I shall not, however, enter into the theory, but state the prac-
tice, which is of more consequence. The first object is, to
prevent the patient from injuring the tongue, by inserting a
piece of wood into the mouth; this occupies no time. Next,
we bleed the patient, and, if the circumstances of the case will
permit, we should open the jugular vein.(f) We must not
spare the lancet. All our best practitioners are agreed in this,
whatever their sentiments may be with regard to the nature of
the disease, or to other circumstances. We must bleed once
and again, whether the convulsions occur during gestation or
pregnancy.* There is more danger from taking too little
blood, than from copious evacuation. Often in a short time,
several pounds of blood have been taken away with ultimate
advantage. Blood-letting also tends to relax the os uteri.
Next, we administer a smart clyster, which, if given early,
and during the precursory stage, is of itself often sufficient
to arrest the progress of the disease. A smart dose of calo-
mel, or solution of salts, may also be given with advantage,
when the person can swallow, especially if the convulsions
have occurred during pregnancy, with little tendency to
labour. We must also attend to the bladder, that it be emp-
tied, for its distension alone has sometimes brought on con-
vulsions.!
One part of the practice, then, and a most important and
essential one, too, consists in depletion, by which the risk of
fatal oppression of the brain or extravasation of blood within
(l) Where this cannot be conveniently accomplished, we should detract
blood very freely by cupping from the temples and back part of the neck.
I have more than once been witness to the best effects resulting from this
practice, and therefore must here strongly recommend it.
* La Motte mentions a case, 225, where a woman, in the last five months
of pregnancy, was bled eighty-six times. Sometimes two oz. would reheve
her.—By modern practitioners, from 40 to 80 oz. have been taken with ad-
vantage, in a case of puerperal convulsions. Puzos insists on the necessity
of copious blood-letting and speedy delivery. The practice is adopted by
the most judicious of the present day.
f La Motte, 223, 224.—Leak relates a case, where it produced subsiding
tendinum, and excessive pain at the pubis. Vol. II p. 344.
VOL. IT. 0.
114
the skull is diminished, and the convulsion mitigated. But
this is not all; for the patient is suffering froni a disease
connected with the state of the uterus, and the state is got
rid of by terminating the labour. Even when convulsions
take place very early in labour, the os uteri is generally
opened to a certain degree, and the detraction of blood,
which has been resorted to on the first attack of the disease,
renders the os uteri usually lax and dilatable. In this case,
although we have no distinct labour pains, we must introduce
the hand, and slowly dilate it, and deliver the child. I en-
tirely agree with those who are against forcibly opening the
os uteri ;x but I also agree with those who advise the woman
to be delivered as soon as we possibly can do it without
violence.2 There is, I am convinced, no rule of practice
more plain or beneficial,* when evacuation fails to check
the convulsions. Delivery does not, indeed, always save the
patient, or even prevent the recurrence of the fits, but it does
not thence follow that it ought not to be adopted.
Internal remedies have been advised, such as opium, and
musk, and camphor; but experience does not establish their
utility when trusted to alone; nay, where there is fulness of
the vessels, the first of these medicines does harm.
If the fits have been only apprehended, but have not taken
place, then we may use remedies as preventives. The mos
beneficial treatment is, to empty the vessels and the bowels.
When there are evident symptoms of disordered stomach, a
gentle emetic has been advised ; but I have never seen it ad-
ministered myself, and am, from its effects on the head, not
partial to its exhibition. When a violent pain in the stomach
takes place, we should bleed and give an opiate. I wish it to
be carefully remembered, that when we have head-ache, or
any other symptoms indicating a tendency to convulsions,
the lancet is necessary. Blood-letting can seldom do harm,
* Even evacuating the liquor amnii has, M. Baudelocque admits, been of
service, §. 1108,1111. In one case, the os uteri was hard and callous, it was
divided, tlie child speedily born, and tiie woman immediatelv became calm.
111,1.
110
it may do much good; and if this book serve only to impress
that fact on the mind of one reader, I will not regret having
written it.
When symptoms of nervous irritation exist, without any
determination to the head or fulness of vessels, then, after
bleeding, opiates may be of advantage.* Camphor has been
strongly recommended by Dr. Hamilton, as the most power-
ful internal remedy which can be • prescribed; but I cannot
from my own observation, say much respecting its virtues as
a preventive. But when convulsions have continued after de-
livery, or when the recovery was not complete, I have found
it of service, and recommend it to be always tried. In these
circumstances, it is always proper to blister and shave the
head. If convulsions take place after the delivery of the
child for the first time, then the placenta, if it have not come
away, is immediately to be extracted ; and if the pulse do
not expressly forbid it, a vein is to be opened, and afterwards,
the bowels purged. If the practice be prompt and vigor-
ous, the generality of patients recover from puerperal con-
vulsions.
* Opiates have been strongly recommended by some practitioners, par-
ticularly Dr. Bland. Journ. Vol. II. p. 328, &c.—Dr. Hamilton as strongly
prohibits them. Annals of Med. Vol. V.—Petit says, they kill both the
'■ |>ther and the child.
[Dr. Hamilton in an interesting paper on puerperal convulsions, which
he terms Ecclampsia, [In Annals of Medicine for 1800,] says, that no patient
to whose assistance he had been called, who had taken a dose of opium pre-
viously to his arrival, had ever recovered. Camphor he strongly recom-
mends, and gives it in doses of from 5 to 10 grains, frequently repeated;
he says that every patient to whom it was possible to give it, recovered.—
The Digitalis he has also used with advantage in those cases where oedema
existed.
This mode of treating the disease has proved so successful in his hands,
that, in the paper above referred to, which is well worthy of perusal, he
states, that in 15 months immediately preceding its publication, he had at-
tended twelve cases of the disease, where the fits had occurred previously
to his being sent for; and although in more than a majority of them, every
symptom deemed unfavourable concurred, yet every patient recovered^—
This is certainly a favourable result, for Mauriceau relates 21 cases of the
disease, 13 of which died. Giffard mentions 4 cases, 2 of which perjphed.]
f
tie
ORDER 5. WITH RUPTURE OF THE UTERUS.
The uterus may be lacerated during labour, under different
circumstances, and from various causes. Any part of it may
be torn, but generally the rupture takes place in the cervix,
and the wound is transverse. Sometimes the uterus is entire,
and the vagina alone is torn. This may happen during any
stage of labour, and even before the membranes burst,* but
this is uncommon. It may take place when the head has ful-
ly entered the pelvis, or in the moment when the child is de-
livered.3
The uterus may be ruptured, by attempts rashly made to
turn the child jf or after the water has been long evacuated,
some projecting part of the child may so affect a portion of
the uterus, as to make it tear. A certain set of fibres may
also be suddenly and spasmodically contracted, and laceration
may thus take place. In these cases, there is often very lit-
tle warning, and the accident may happen when we are just
in expectation of a happy termination of the labour.(m) In
a case detailed by Dr. Douglass, (p. 50.) the head of the child
was resting on the perinseum, when the lady, who had been
subject to cramp, uttered a violent cry, and the head receded.
The child was delivered, but the patient died. Mr. Goldson's
patient complained of cramp in tlie leg, in the intervals of the
labour pains; and in the instant when the rupture happened,
she exclaimed " the cramp!" Dr. Monro's patient (Works,
p. 677.) was sitting in a chair, when she suddenly screamed,
and the uterus was lacerated; she was not delivered, but lived
from Tuesday till Friday. Rigidity of the os uteri may also
be a cause of laceration4 It dilates very slowly, requires
great exertion of the uterine fibres, and the patient suffers
much pain. The uterus may at last be torn, even although
* Vide Mem. of Med. Soc. Vol. II. p. 118.
f A fatal case of this kind is related by Mr.Dease.—One more fortunate
iu ihe issue, is inserted in Mom. of Med. Soc. Vol. IV. p. 253.
) An interesting case of this nature, is related by Dr. Merriman, in
Edinburgh Med. & Phys. Journal for 1810, and in Eclectic Repertory, Vol.
I. p. 269, & seq.
VOL. II. R
book in.
OF THE PUERPERAL STATE.
CHAP. I.
Of (lie Treatment after Delivery.
Immediately after the placenta is expelled, the finger
ought to be introduced into the vagina, to ascertain that the
perineum or recto-vaginal septum be not torn, and that the
uterus be not inverted.
Then, if the woman be not much fatigued, she is to turn
slowly on her back, and a broad bandage is to be slipped un-
der her, which is to be spread evenly, and pinned so tightly
round the abdomen, as to give a feeling of agreeable support.
This bandage is made of linen or cotton cloth; and it is usual
to place a compress over the uterus, to assist contraction.
The wet sheet is also to be pulled from below her, and an
open flannel petticoat is to be put on; it has a broad top-
band, and is introduced and pinned like the bandage. A
warm napkin is then to be applied to the vulva, and the
woman laid in an easy posture, having just so many bed-
clothes as make her comfortable. If she desire it, she may
now have a little panado, after which we leave her to rest.
But before retiring, it is proper to ascertain that the band-
age be felt agreeably tight, that there be no considerable he-
morrhage, and that the after-pains are not coming on severe-
ly. It is also proper to mark the state of the pulse, and to
leave strict directions with the nurse, that every exertion,
and all stimulants be avoided.
Having thus simply stated what appears to be necessary,
I must next say what ought to be avoided. It is customary
1&3
with many nurses, to shift the patient completely, and, for
this purpose, to raise her to an erect posture. Now this
practice may not always be followed by bad consequences,
but it is very reprehensible; for the patient is thus much
fatigued, and if she sit up even for a short time, hemorrhage
or syncope may be produced* The pretext for this is gene-
rally to make the woman comfortable; and, indeed, if the
clothes be wet with perspiration or discharge, there may be
some inducement to shift her. But this ought to be done
slowly, without raising her, and if she have been fatigued,
not until she have rested for a little. Another bad practice
is, the administration of stimulants, such as brandy, wine,
or cordial waters. I do not deny, that these, in certain
cases of exhaustion, are salutary; but I certainly maintain,
that generally they are both unnecessary and hurtful, tend-
ing to prevent sleep, to promote hemorrhage, and excite fever
and inflammation. A third practice, no less injurious, is,
keeping the room warm with a fire, drawing the bed-curtains
close, increasing the bed clothes, and giving every thing
warm to promote perspiration. This is apt to produce de-
bility, and many hysterical affections, as well as a trouble-
some species of fever, which it is often difficult to remove.
It also renders the woman very susceptible of cold, and a
shivering fit is very readily excited. Lastly, gossiping and
noise of every kind, is hurtful, by preventing rest, occasion-
ing head-ache or palpitation, as well as other bad symptoms.
At our next visit, which ought to be within twelve hours
after delivery, we should inquire whether the patient have
slept, and ascertain that the pulse be not frequent, that the
after-pains have not been severe, nor the discharge copious.
We should also particularly inquire if she have made water;
and if she have not, but have a desire to do so without the
power, a cloth dipped in warm water, and wrung pretty dry,
should be applied to the pubis. If this fail, the urine will often
be voided if the uterus be gently raised a little with the fin-
ger, or the catheter may be introduced. There are two states
in which we are very solicitous that the urine be voided; the
first is, when the woman has much pain in the lower belly,
la*
with a desire to void urine; the second is, after severe or in-
strumental labour.
A stool should be procured within twenty-four or thirty-six
hours after delivery, either by means of a clyster or a gentle
laxative. If the patient usually have the milk-fever smartly,
or the breasts are disposed to be painful and tense, a mild
dose of some saline laxative is better than a clyster. But if
she be delicate, and have formerly had little milk, a clyster
is to be preferred. If she is not to suckle the child, then the
laxative should be rather brisker, and may be repeated at the
interval of two days.
After delivery, there is a discharge of sanguineous fluid
from the uterus for some days, which then becomes greenish,
and lastly pale, and decreases in quantity, disappearing al-
together within a month, and often in a shorter time. This
is called the lochial discharge. During this time, it is ne-
cessary that the vagina and external parts be daily washed
with tepid milk and water.
During the latter end of gestation, milk is generally secret-
ed in a small quantity in the breasts, and sometimes it even
runs from the nipples. After delivery the secretion increases,
and about the third day the breasts will be found considera-
bly distended. Many women, indeed, complain at this time
of much tension and uneasiness, and there is usually some
acceleration of the pulse. A pretty smart fever may even be
induced, which is called the milk-fever. The best way to
prevent these symptoms from becoming troublesome, is to
keep the bowels open, and apply the child to the breasts be-
fore they have become distended. This may generally be
done twelve hours after delivery.
The diet of women in the puerperal state ought to be light;
and if they are not to give suck, liquids should be avoided,
the food must be of the dry kind, and thirst should be quench-
ed, rather with fruit than with drink. If they are to nurse,
the diet, for the first two days, should consist of tea and cold
toasted bread for breakfast, beef or chicken soup for dinner,
and panado for supper; toast water, or barley water, may be
given for drink, but malt liquor should be avoided. Unless
125
the patient be feeble, and at the same time have no fever,
wine should not be allowed for the first two days; a little may
then be added to the panado or sago, which is taken for sup-
per ; and a small glass, diluted with water, may be taken after
dinner. A bit of chicken may be given for dinner, and in
proportion as recovery goes on, the usual diet is to be return-
ed to.
The time at which the patient should be allowed to rise a
little, to have the bed made, must be regulated by her strength,
and other circumstances. It ought never to be earlier than
the third day, and, in a day or two longer, she may be allow-
ed to be dressed, and sit a little; but even in the best reco-
very, and during summer, the woman ought not to leave her
room within a week. She ought not to go out for an airing,
in general, till the third week. In cold weather, and when
the patient is delicate, she must be longer confined. By ris-
ing too soon, and making exertion, a prolapsus uteri may be
occasioned, and still more frequently the lochia are rendered
profuse, and the strength impaired. If there is, or has for-
merly been, the smallest tendency to prolapsus, it is absolute-
ly necessary to keep the patient very much for some time in a
recumbent posture, on a sofa, avoiding, however, that degree
of heat which relaxes the system. It is also necessary to
stimulate the uterine lymphatics to absorption by a smart pur-
gative once in the three or four days, to bathe the external
parts with rose water, having a third part of spirits added to
it, and at the end of a fortnight begin with a tonic, mixed
with a mild diuretic.
CHAP. II.
Of Uterine Hemorrhage.
In natural labour, after the expulsion of the child, the
uterus contracts so much as to loosen the attachment of the
placenta and membranes to its surface, and afterwards to ex-
pel them. This process is always accompanied by the dis-
126
charge of blood, but the quantity in general is small. If,
however, the uterine fibres should not duly contract after the
delivery of the child, so as to diminish the diameter of the
vessels, and at the same time accommodate the size of the
womb to the substance which still remains within it; then,
provided the placenta and membranes be wholly or in part
separated, the vessels which passed from the uterus to the
ovum, shall be open and unsupported, and will pour out blood
with an impetuosity proportioned to their size and the force
of the circulation. This flow will continue until syncope
check the motion, or coagula stop the mouths of the vessels.
It is evident that the cause of flooding is the torpor of the
Hterus.* The fibres may become inactive, or have their tonic
contraction impaired immediately after the pain which ex-
pels the child. This will more especially happen if the wo-
man be weakly, if the labour have been tedious, and the
child at last expelled suddenly by a strong, but perhaps only
momentary contraction.
The hemorrhage, therefore, appears very soon after de-
livery, and before the placenta has come away. It is pro-
fuse, and produces the usual effects of hemorrhage on the sys-
tem, and these effects are greater and more speedy than
those which follow from hemorrhage before delivery, for the
loss is instant and extensive. The first gush indeed does not
produce great debility, because it consists chiefly of blood,
which formerly circulated in the uterus, and is not taken
directly from the general system; and the separation of the
placenta not being wholly effected at once, the loss at first is
more slow. But immediately after this, the effect appears in
all its danger; and it is not unusual for the woman, if not
assisted, to die within ten minutes after the birth of the
child.f
* When the uterus contracts properly after tlie dehvery of the child, it
will be felt, if the hand be applied on the abdomen, hke a hard and solid
mass; but when torpid, it is not so distinctly felt, for it is softer, being des-
titute of tonic contraction.
f The patient may die speedily after the birth of the cliild, in consequence
of other causes, some of which it may not be improper to notice. Sudden
127
If flooding occur after delivery, the woman says there is
surely an unusual discharge; and, on examining, it is found
to be really so; but at first the pulse is pretty good, and the
countenance is not much altered. In a minute, perhaps, the
pulse sinks, the face becomes pale, the hands cold, the respi-
ration is performed with a sigh, or after lying quiet for a
little, a long sigh is fetched, and the patient seems as if try-
ing to awake from a slumber. She exclaims she is sick, and
immediately vomits, she throws out her arms, turns off the
bed-clothes, and seems anxious for breath ; she complains of
cold, or perhaps is restless, and begs not to be disturbed,* or
lies in a state approaching to syncope, or gazes wildly around
her, and is extremely restless, breathes with difficulty, and
quickly expires. The danger of flooding is universally
known, and the consternation excited by it, is in many cases
great. One exclaims the patient is dead, another she is dy-
ing, one is wringing her hands, another running for cordials,
and it requires no small steadiness and composure in the
practitioner to prevent mischievous interference, or procure
necessary aid.
The torpor of the uterus is sometimes so great and univer-
sal, that when the hand is introduced, it passes almost up to
the stomach. At other times, a circular band of fibres con-
tracts spasmodically about the middle of the uterus, inclosing
the placenta above it, whilst the rest of the fibres become re-
laxed. This has not inaptly been called the hour-glass
uterus.
From this view it is evident, that flooding is to be prevent-
death may proceed from an organic affection of the heart, such as ossifica-
tion of the valves or arteries, dilatation of the cavities of the heart, or aneurism
of the aorta. The effect of any sudden change in the system, in these cases,
must be known to every practitioner. Whenever we suspect such disease,
the most perfect rest must be observed after dehvery. Should there be any
inequality in the size of the two ventricles, the right being larger, for in-
stance, than the left, then any cause capable of hurrying the circulation,
may make both sides contract to their utmost, the consequence of which is,
that all the blood in the right side is thrown out, but it cannot be received
into the left: rupture of the pulmonary vessels must take place, and I have
known many instances where the patient was immediately suffocated
128
ed by preserving the action of the uterus, and avoiding what-
ever can increase the force of the circulation. A powerful
means of keeping up the action of the womb consists in pre-
venting it from emptying itself too suddenly. It too frequent-
ly happens, when the child is instantaneously expelled by a
single contraction, being in a manner projected from the ute-
rus, or when the body is speedily pulled out, whenever the
head is born, that hemorrhage takes place; and, in a majority
of instances, especially if the labour have been sev ere or pro-
tracted, the uterus contracts on the placenta like an hour-
glass. Delivery then is not to be hurried, the steps of expul-
sion, should be gradual, instead of pulling out the body of the
child, we should rather retard the expulsion when it is likely
to take place rapidly. Those who estimate the dexterity and
skill of an accoucheur by the velocity with which he delivers
the infant, ground their good opinion upon a most dangerous
and reprehensible conduct; and he who adopts this practice,
must meet with many untoward accidents, and produce many
calamities.
Another mean of exciting the uterine action, is by support-
ing the abdomen, and making gentle pressure on it with the
hand immediately after delivery. I do not say that this
practice is in every instance necessary, but it is so generally
useful, that it never ought to be omitted. The circulation is
also to be moderated by the free admission of cool air, by
lessening the quantity of bed-clothes, by a state of perfect
rest, and by avoiding the exhibition of stimulants. If these
directions, which are few and simple, be attended to, we shall
seldom meet with hemorrhage after the delivery of the child.
Some women, no doubt, are peculiarly subject to this acci-
dent. They are generally of a lax fibre, easily fatigued
and fluttered, and subject to hysterical affections. When a
woman is known to be subject to hemorrhage, we should
give her a full dose of laudanum immediately after delivery,
and, on the first appearance of discharge, perhaps in some
instances whenever the child is born, we ought to introduce
the hand into the uterus, which excites its action, and pre-
vents flooding. We arc not to meddle with the placenta, or
129
endeavour to extract it, our object is to excite the contrac-
tion of the womb, and make it in due time expel the secun-
dines. This gives little pain, and may be attended with
most important consequences to the future health or comfort
of our patient. I need scarcely, I think, add, that in every
case, more especially in those where the labour has been
tedious, or the woman has been subject to hemorrhage, we
ought not to leave the bed-side, but should examine frequently,
to ascertain that there is no unusual discharge.
The instant a woman is seized with hemorrhage after de-
livery, we ought to take steps for exciting the contraction of
the uterus, upon which alone we place our hopes of safety.*
Two very powerful means are at all times within our reach.
The application of cold, and the introduction of the hand in-
to the cavity of the uterus.
The retention of the placenta is not in general the cause of
the hemorrhage, but a joint effect, together with it, of the
torpor of the uterus. Our primary object then is not to ex-
tract the placenta, but to excite the uterus to brisker action.
How improper and dangerous then must it be to thrust the
hand into the uterus, grasp the placenta, and bring it in-
stantly away; or to endeavour to deliver the placenta by
* It is not my intention to advise immediate interference, although the
discharge be a little more than usual; but whenever it is considerable, or is
affecting the pulse, or producing other perceptible effects on the system, we
ought not to delay. It is a fatal error to wait until dangerous symptoms ap-
pear : many weeks of suffering, perhaps death itself may be the conse-
quence. I cannot therefore agree with the ingenious M. Le Roy, in the fol-
lowing directions respecting hemorrhage after the birth of the child.
" Quand la femme n'est pas delivr^e et qu'il survient une perte, il faut attendre
patiemment voir s'il ne se manifeste aucun symptome alarmant parce que
cette perte cesse quelquefois d'elle-meme. Mais quand les symptomes sont
alarmans et qu'on craint pour la vie de la femme, lorsque la matrice s'engorge
et se de"gorge alternativement, lorsqu'enfin la femme se plaint d'eblouisse-
mens dans les yeux de tintemens d'oreilles; que les yeux, &c. deviennent con-
vulsifs; que le pouls devient trop petit; que les extremit£s sont froides ; le
visage d'une paleur mortelle; que le sang traverse le lit; qu'on entend dans le
ventre des grouillemens qui annoncent la resolution des forces vitales; alors il
faut employer des moyens propres a redonner du ressort a la matrice."
Lecons, p. 57.
VOL. II. s
130
pulling forcibly at the umbilical cord.. By the first prac-
tice, we are apt to injure the uterus, and certainly cannot
rely upon it for checking the hemorrhage. By the second,
we either tear the cord or invert the uterus.
When we introduce the hand, we conduct it to the placen-
ta, using the cord only as a director. We do not attempt
to bring it away, but press upon it with the back of the
hand, to excite the uterus to separate it; or, if it be already
detached, and lying loose in the cavity of the womb, we
move the hand gently to stimulate the uterus, but neither
withdraw it, nor extract the placenta, until we feel the womb
contracting.
The contraction of the uterus will be powerfully assisted
by the application of cold. The quantity of clothes should
be lessened; but our principal object is to apply cold as a
topical remedy. Cloths dipped in cold water should be laid
suddenly upon the belly, or cold water may be thrown upon
it. In obstinate cases it has been found useful to project it
forcibly with a syringe. We may in desperate cases dip a
sponge or a piece of cloth in cold water, and carry it in the
hollow of the hand up to the fundus uteri. Nay, ice itself
has, with happy effects, been introduced into the womb. In
general, however, the external application of cold will be
sufficient to save the patient. I feel confident in advising it,
and can say, without reserve, that I have never known any
bad consequence result from it.(g)
(9) It appears from a late publication, that a novel mode of restraining
uterine hemorrhage, (taking place after parturition) has been attended with
success, in Paris. It has been introduced by M. Evrat, and is as follows:—
A lemon is deprived of its rind and skin, and its cells exposed over its whole
surface. This is introduced into tlie cavity of the uterus, in tlie hand of tlie
operator; by this means the blood flowing over the surface of the lemon,
can wash off only the juice that it meets with, but the innumerable cells of
which the fruit is composed, remain untouched. The contraction of the
uterus is soon excited by the presence of the hand, and some drops of the
citric acid. It is at this instant, that by forcibly squeezing the lemon, its
pure juice flows, without any admixture or dilution; and acts immediately
on the internal surface of the uterus. M. Evrat advises, that in withdraw-
ing the hand, the remainder of tlie lemon should be left in the uterus, sup-
posing that it will excite the regular tonic contraction of the uterine fibres,
131
The uterus may contract spasmodically like an hour-glass,
either before or after the expulsion of the placenta. This
spasm of the uterus is accompanied with severe pain in the
back, great depression of strength, and a very feeble pulse,
sickness, and paleness, and last of all, uterine hemorrhage,
which occurs early, and is often profuse; but it is not the
sole cause of the sinking and debility, for these often precede,
even internal hemorrhage, though they are speedily increas-
ed by it to an alarming degree. We are immediately to give
a full dose of laudanum in a little wine, and repeat the latter
cautiously at intervals, if necessary." We must also without
loss of time, introduce the hand into the uterus, and slowly
and cautiously dilate the stricture, so as to get the hand into
the upper cyst of the uterus, thus stimulating to universal
and regular contraction; and, in doing so, we shall be great-
ly assisted by applying cold water to the abdomen, or dash-
ing water smartly on it from a cloth. If the placenta be
still retained, it is to be slowly detached, and after keeping
it and the hand for some time in the under part of the womb,
both may be withdrawn. Afterwards, the same attention
is to be paid to the contraction of the uterus as in the former
case.
When it happens that part of the placenta adheres pretty
firmly to the uterus, we are not to be rude in our attempts to
separate it, but should remember that there can be no dan-
ger in being deliberate. It is too much the practice with
some midwives, to trust more to their fingers than to the
contraction of the uterine fibres; the consequence of which
is, that they tear the placenta, and irritate the womb. Yet
it is certain, on the qther hand, that gentle attempts to sepa-
rate it are sometimes necessary; but these should be so
cautiously and deliberately made, as not to lacerate the pla-
centa. The fingers should be very slowly and gently in-
sinuated betwixt the uterus and the placenta, so as to over-
come the adhesion, which is seldom extensive. I have known
and thus prevent any return of the hemorrhage. The uterus, when it con-
tracts completely, will expel the compressed lemon, as happened in a case
related in the work alluded to.
132
the placenta retained for four days, by an adhesion not larger
than a shilling. This case proved fatal by loss of blood,
which continued to take place, I understand, in variable
quantity during the whole time. No attempts were made to
relieve the woman, until she was dying.
We can in general easily save the patient in flooding, if
we are on the spot when it happens ; but if much blood have
been lost before we arrive, the strength may be irreparably
sunk. In those cases where great weakness has been pro-
duced, we must not only endeavour to excite the uterine con-
traction in order to prevent further injury, but we must also
husband well the power which remains. The band is to be
immediately introduced into the womb, and must be kept
there, moving it gently, until the fibres contract; and until
this take place, neither the hand nor the placenta should be
withdrawn. Cold water is to be dashed on the abdomen,
gentle pressure is to be made by the hand on the region of
the uterus, and the whole belly firmly supported with a ban-
dage, provided that can be applied without moving the pa-
tient much. But as every exertion is dangerous, motion
must be avoided; and upon no account is the patient to be
shifted or disturbed for some time. By imprudent attempts
to raise the patient,^>r «to make her more comfortable,-" she
has sometimes suddenly expired.(r)
The state of the stomach is to be watched, preventing, as
far as we can, that feeling of sinking which is apt to take
place in all floodings. This is to be done by keeping up the
action of that important organ with soup, properly seasoned,
and given in small quantity, but pretty frequently repeated.
Cordials, as for instance, Madeira, diluted or pure, should
be given in small doses regularly for some time to support
the strength; but after recovery begins to take place, and
the pulse steadily to be felt, they should be omitted or de-
creased ; for if persisted in to the same extent, fever or in-
(»■) Le Roy thinks the position of the patient in hemorrhages, is worthy
of consideration; in uterine hemorrhage, the horizontal position of course
must be preferred, and consequently tlie feet should be more elevated than
the head.
133
flammation may be excited. Opiates are of greater service
in all cases of uterine hemorrhage after delivery. They are
among the safest and best cordials we can employ, and must
in every instance be exhibited. The dose ought to be pro-
portioned to the urgency, varying from fifty to sixty drops.
In some instances, when the debility was great, a hundred
drops of the tincture, or five grains of solid opium, have been
given at once, and afterwards three grains every three hours
till the patient was out of danger. Nor does this practice
ever prevent the contraction of the uterus, or produce after-
wards any bad effect. Opiates supply the place of wine, and
are infinitely safer.
We must be careful neither to give nourishment nor cor-
dials so frequent as to load the stomach, which produces sick-
ness and anxiety, until vomiting remedy our error. This last
symptom, when moderate, is not always unfavourable, for it
sometimes excites more powerfully the contraction of the
womb. The rising of the pulse, and relief of the patient
after it, is to be ascribed not so much to any direct power
which this operation has of invigorating the system, as to the
consequent removal of sickness and oppression. If this effect
do not follow from vomiting, the case is very bad. Solid
opium is the most effectual remedy against repeated vomiting.
It must be given in the dose of at least three, and in some
cases, four grains.
When the hemorrhage has produced complete syncope, the
state of the patient is very alarming. Yet the danger is not
the same in every case, for some women faint from slighter
causes than others. La Motte relates one case where the
patient fainted no less than twenty times in the course of the
night. She is to be preserved in a state of the most perfect
rest, the face is to be smartly sprinkled with cold water, and
a little wine or brandy, or spiritus ammonise aromaticus,
given after the opiate, rouse the system. Afterwards, warmed
spiced wine may be given in small quantity, and warm cloths
applied to the feet. Friction on the region of the stomach,
with some stimulating embrocation, as hartshorn and spirits,
may be useful. I need not add, that the patient must, in
134
these awful circumstances, be carefully watched; and that,
if the expression be allowed, we must obstinately fight against
death.
It was at one time the practice to prevent the patient from
sleeping, or indulging that propensity to drowsiness which
often follows hemorrhage.* But we can surely, at short
intervals, give whatever may be necessary to the patient,
without absolutely preventing sleep, or rather slumber, for
the patient never sleeps profoundly. We are to attend so
far to the advice, as not to allow the slumber to interfere
with the administration of such cordials or nourishment as
may be requisite.
When the placenta is rashly extracted immediately after
the delivery of the child, or suddenly taken away upon the
accession of hemorrhage, then we find that the uterus does
not contract properly, and the vessels pour out blood plenti-
fully. This in part escapes by the vagina, but much of it
remains in the cavity of the uterus, where it coagulates, and
hinders the free discharge of the fluid by the vagina. But
blood may be still poured out into the cavity of the womb,
which becomes distended, and that often to a great size.
Thus it appears, that after delivery the hemorrhage may be
sometimes apparent, sometimes concealed. When it flows from
the vagina, it is always discovered by the patient; but when it
is confined in the uterus, it is only known by its effects; the
pulse sinks, the countenance becomes pale, the strength de-
parts, and a fainting fit precedes the fatal catastrophe.
Even when the placenta has not been rapidly extracted,
hemorrhage may come on, and most frequently it, in this
case, proceeds from rash exertion, or much motion. In an
uncivilized state of society, we find that almost immediately
after delivery, the parent is able to walk about; but women
brought up in the European modes of life, cannot use the
same freedom. Motion not only disorders the action of the
* Even some modern writers have an opinion that sleep is directly injuri-
ous. " Somnus ejusmodi hemorrhagias recrudescere facit." Stoll Prelec-
tioncs, Tom. ii. p. 400.
135
uterus, and impairs its contraction, but also powerfully ex-
cites the circulation.
The continued application of a great degree of heat, men-
tal agitation, and the use of stimulants, may also contribute
to the production or renewal of hemorrhage.
A partial or complete inversion of the uterus, is another
cause of hemorrhage, and which can only be discovered by
examination.
Sometimes a partial or irregular contraction of the uterine
fibres takes place, and the person is tormented by grinding
pains, accompanied by repeated hemorrhage.*
The retention of a small portion of the placenta, which has
firmly adhered to the uterus, is also a cause of hemorrhage,
and the discharge may be renewed for many days, until the
portion be expelled.
It may also happen that, from some agitation of mind or
morbid state of body, the uterus may not go regularly on in
its process of contraction or restoration,! to the unimpregnat-
cd state. In this case, the cavity may be filled with blood,
which forms a coagulum, and is expelled with fluid discharge.
The womb may remain stationary for a considerable time,
and the coagula be successively expelled, with slight pains,
and no small degree of hemorrhage. These symptoms very
much resemble those produced by the retention of part of the
placenta, and cannot easily be, with certainty, distinguished
from them. We have, however, less of the foetid smell, and
we never observe any shreds or portion of the placenta to be
expelled, whilst the coagulum, if entire, has exactly the shape
of the uterine cavity.
* When the abdomen has been bandaged too tightly, the parts within are
injured. The patient is restless and uneasy; the pulse is frequent; she com-
plains of pain about the uterus; and numbness in the thighs. Sometimes the
lochia are obstructed; sometimes on the contrary, pretty copious hemorrhage
is produced. Relief is obtained by slackening the bandage; by giving an
anodyne ; and, if there be no hemorrhage, by fomenting the belly.
■j- This, at first, is owing to muscular contraction; afterwards, absorption
forms part of the process. But if these operations shall be interrupted, or
injured, then the vessels, which are still large, not being duly supported, will
be very apt to pour out blood.
136
Lastly, we find, that if exertion have been used before the
uterus has been perfectly restored, there may be excited a
draining of blood, which does not come, in general, very ra-
pidly ; but, from its constant continuance, amounts ultimate-
ly to a considerable quantity, and impairs the health and
vigour of the woman. This has been called menorrhagia
lochialis.
When hemorrhage, whether external or internal, takes
place, in moderate quantity, immediately after the expulsion
of the placenta, and when the system does not seem to suffer
materially, we may be satisfied with firmly supporting the
uterus by external pressure, and applying a dry cloth closely
to the orifice of the vagina. The blood thus coagulates in
the uterus, which being supported by the external pressure
or bandage, does not distend, and the action of its fibres is
soon excited. After-pains are to be expected, but the fear of
hemorrhage is removed. In some instances, when we have
had no external hemorrhage, and the blood has been s!owly
poured into the uterine cavity, little inconvenience is pro-
duced for some time. But presently, by the pressure of the
womb on the neck of the bladder, a retention of urine is
caused, attended with much pain in the belly. This is in
general instantly removed by introducing the finger into
the vagina, and raising up the uterus. If it should not, the
catheter must be employed.
But whenever hemorrhage takes place to such an extent
as to endanger the patient, and produce the effects I have al-
ready mentioned, then we must interfere more actively: and
I need not attempt to prove, that the only security consists in
uterine contraction. This is to be excited by the application
of cold, and by the introduction of the hand, not simply to
extract the coagula, but to stimulate the uterus, and rather
make it expel them. Should this be tedious, it may be assist-
ed by the injection of cold water into the womb. We must
also proceed with opiates, cordials and nourishment, upon
the rules formerly stated for recovery ; and we shall do well,
not to be in a hurry to quit our patient, for the hemorrhage
137
may be renewed, and the woman be lost before we can see
her.
When the hemorrhage proceeds from irregular action of
the uterus, and is attended with grinding pain, a full dose of
tinct re of opium is of advantage, and seldom fails in reliev-
ing the patient.
If the placenta have been torn, and a portion of it remain
attached to the uterus, the hemorrhage is often very obsti-
nate. Both clotted and fluid blood will be discharged repeat-
edly. An offensive smell proceeds from the uterus, and at last
the portion of placenta is expelled in a putrid state, after the
lapse of many days. By examination, the os uteri will be
found soft, open, and irregular.
If by tlie introduction of the fingeir we can feel any thing
within the uterus, it should be cautiously extracted; but we
are not to use force or much irritation either in our examina-
tions or attempts to extract, lest we inflame the womb. It
is more advisable to plug the vagina, and even the os uteri,
so as to confine the blood, and excite the uterine contraction.
We may also inject some cold and astringent fluid for the
same purpose, or throw a full stream of cold water into the
uterus, from a large syringe, by way of washing out the por-
tion of placenta, if it have become nearly detached. A gen-
tle emetic sometimes promotes the expulsion. The bowels are
to be kept open, and the strength supported by mild and nou-
rishing diet; but we must take care on the other hand not
to fill the vessels too fast. If febrile symptoms arise, the
case is still more dangerous, as I will presently notice.
When the hemorrhage proceeds from an interruption of
the process of restoration, our principal resource consists in
exciting the contraction of the womb by the use of clysters—
by friction on the abdomen—by injecting cold and astringent
fluids into the womb—by the exhibition of a gentle emetic—
and by throwing cold water from a syringe upon the abdo-
men when the womb is expelling the coagulum. We also
check the hemorrhage, and save blood, by the prompt appli-
cation of the plug, and diminish the action of the vessels
themselves, by allaying or removing every irritation; by
VOL. II. t
138
avoiding the frequent use of stimulants, or attempts to fill
the vessels too quickly. The feeling of sinking, sickness,
tendency to syncope, &c. are to be obviated by the means al-
ready pointed out.
Lastly. The menorrhagia lochialis is to be cured by rest,
cool air, the use of sulphuric acid or other tonics, bathing
the pubis or back with cold water, and injecting an astringent
fluid three or four times a day into the uterus. If the pulse
be frequent, the exhibition of the digitalis for a short time
will be of advantage. Pain in the back generally attends this
disease, and is sometimes so severe as even to affect the breath-
ing. In this case, a warm plaster applied to the back is often
of service; and, if the pulse be soft, an anodyne should be
administered. In slight cases, the application of cloths dip-
ped in cold vinegar, to the hack, does good.
CHAP. III.
Of Inversion of the Uterus.
Inversion of the uterus implies, that the inside is turned
out, and down into the vagina. It may take place in different
degrees. When complete, it protrudes out of the vagina, and
exactly resembles the uterus after delivery, only the mouth
is turned upward. The vagina, is, in this case, also partly
inverted, so that the tumour is of considerable length. When
it is partial, the tumour is retained altogether, or chiefly with-
in the vagina, and the fundus only protrudes to a certain de-
gree through the os uteri, forming a firm substance, some-
thing like a child's head.1 When the uterus is inverted,
the woman feels great pain, generally accompanied with a
bearing-down effort, by which a partial inversion is some-
times rendered complete. The pain is obstinate and severe,
the woman feels very weak, the countenance is pale, the pulse
feeble, and often imperceptible, a hemorrhage very generally
attends the accident, and often is most profuse. But it is
139
worthy of notice, that complete inversion sometimes is not
accompanied with hemorrhage,* whilst a very partial inver-
sion may be attended with a fatal discharge ; although there
be little hemorrhage, the face is pale, and the pulse wreak and
rapid. Fainting, and convulsions, are not unfrequent atten-
dants, although the hemorrhage have been trifling. Inver-
sion is suspected to exist from the symptoms mentioned, and
on examination, the womb is felt more or less protruded like
a mass of flesh, whilst no hard uterus can be discovered in
the hypogastrium.
Inversion in a great majority of instances, depends upon
the midwifef endeavouring to extract the placenta, by pull-
ing the cord.(s) Sometimes the uterus is directly pulled
down, and the placenta still adheres; in other cases, it is
separated. It may also happen, if the child be allowed to be
rapidly expelled; for if the cord be short, or entangled about
the child, the fundus may receive a sudden jerk, and become
inverted.
Inversion may terminate in different waysi It may prove
rapidly fatal by hemorrhage; or it may excite fatal syncope,
or convulsions; or it may operate more slowly, by inducing
inflammation, or distension of the bladder; or after severe
* This was the case, in the instance related by Dr. Hamilton, Med. Com.
for 1791, Vol XVI. p. 315.—In the case by Mr. Brown, the hemorrhage was
considerable. Annals of Med. Vol. II. p. 277.
J Chapman relates a case of inversion, where the midwife pulled forcibly
at the uterus, and excited convulsions, fainting and death. Case 29. p. 123.
t (a) Or probably, by pulling at the cord before that contraction of the ute-
rus which is to expel the placenta from its cavity, takes place :—hence may
be deduced a general rule worthy of the attention of young practitioners, to
wait, after the delivery of the child, until the woman complains of pain,
(which generally indicates the contraction of the uterine fibres) before they
attempt to co-operate in the extraction of the placenta, and even then to act
with caution.
An exception may nevertheless occur to this rule to be noticed here, viz.
that sometimes the same contraction that expels the child, may detach the
placenta, and propel it into the cervix uteri and vagina; this is to be deter-
mined by examination •, and if found to be the case, we proceed to immediate
extraction.
14U
pains and expulsive efforts, the patient may get the better of
the immediate injury, the uterus may diminish to its natural
size, by slow degress, and give little inconvenience ;2 or it
may discharge foetid matter, and give rise to frequent debili-
tating hemorrhage; or hectic comes on, and the patient
sinks in a miserable manner.
If inversion be discovered early, the uterus may be replaced.
If it have protruded out of the vagina, it is, first of all, to be
returned within it; if it have not, we proceed directly to en-
deavour to return it within the os uteri, by cautiously grasp-
ing the tumour in the hand and pushing it upwards, within
the os uteri. This may be facilitated by pressing up the
most prominent part of the fundus in the direction of the axis
of the uterus, so as gradually to undo the inversion, or re-in-
vert the protruded womb: a piece of wood with a round head
has by some been used in this way ; but the fingers are safer.
If we push directly without compressing the tumour, we
sometimes bring on violent bearing-down pains. These are
occasionally attended with increase, or renewal, of flooding,
and in all cases on pressing the uterus, small vessels spout
like arteries in an operation. If we succeed, we should carry
the hand within the uterus, aud keep it there for some time,
to excite its contraction. If the placenta still adhere, we
should not remove it until we have reduced the uterus ; after
which, we excite the contraction of the womb to make it
throw it off.* It is sometimes long before the pulse becomes
steadily to be felt.f Occasionally, after the reduction, when
the patient is seeming to do well, she is seized with a fit and
dies4 Or, she may remain long weak, and have swelled
feet§
If inversion have not been discovered early, it is more dif-
* In a case related in Memoirs of Med. Soc. Vol. V. 202, the placenta was
allowed to remain five days after reduction, but this is a hazardous practice.—
Perfect, case 71, brought it away after four hours.
t Case by Dr. Duffield, in Trans, of Coll. at Phil. 167.
* Case by Dr. Albert. Annals of Med. Vol. V. 390.
§ Mi-. White's case, Med. Comment. Vol. XX. 247.
141
ftcult, nay, sometimes impossible to reduce it, owing chiefly
to contraction of the os uteri.(/) Dr. Den in an says, that he
has found it impossible to reduce it, even four hours after it
took place; and in a chronic inversion, he never once suc-
ceeded. In such cases, it is not prudent to make very violent
efforts to reduce the uterus, as these may excite convulsions,
&c. We must in every instance alleviate urgent symptoms,
such as syncope, retention of urine, or inflammation, by suit-
able means. I may further observe, that when a patient,
after delivery, complains of obstinate pain, or bearing-down,
or suppression of urine, or is very weak, we should always
examine per vaginam. If the uterus be inverted we may feel
the tumour, and we may find the hard womb to be absent in
the belly, or lower down than it should be. If this examina-
tion be neglected, the patient may be lost. I have known the
first intimation given to the practitioner, to be his finding no
uterus in the belly, when it was opened after death. Exami-
nation is of the utmost consequence.
When the uterus cannot be replaced, we should at least
return it into the vagina. We must palliate symptoms, ap-
ply gentle astringent lotions, keep the patient easy and quiet,
attend to the state of the bladder, support the strength, allay
irritation by anodynes, and the troublesome bearing-down by
a proper pessary; the bad effects of neglecting or removing
this are to be seen in La Motte's 385th case. If inflam-
mation come on, we must prescribe blood-letting, laxatives,
&c. In this way, the uterus contracts to its natural size,
and the woman menstruates as usual, but generally the health
(<) In cases of partial inversion, where it has been found impracticable to
reduce the uterus, it has been advised to grasp the portion which has
passed through the os uteri firmly with the hand, and render the inversion
complete, by bringing the whole of the uterus into the vagina, and keeping
it there. By this means, the danger of strangulation from the stricture oc-
casioned by the contraction of the os uteri on the body of that viscus, is pre-
sumed to be prevented. This plan appears to have succeeded in a case
related by Dr. Dewees, in the Philadelphia Medical Museum, Vol. VI. p. 20,
'and seq. Case 2nd.
142
is delicate. Sometimes the uterus becomes scirrhous, or
gangrenous sloughs take place.*
If the uterus discharge foetid matter, and hemorrhage take
place, the strength is apt to sink, and the patient dies hectic.
Astringent applications, with attention to cleanliness, good
diet, and the occasional use of opiates may give relief; but if
they do not, we are warranted to prefer extirpation of the
uterus, to certain death. This operation has been repeatedly
successful,3 and is performed by applying a ligature high up,
and cutting off the tumour below. But it must also be re-
membered, that in some cases where the inverted uterus has
been either intentionally extirpated, or mistaken for a poly-
pus,! death has followed.
Inversion, when long continued, may be confounded with
prolapsus, or polypus: from the first, it is distinguished by
the shape and by the absence of the os uteri; from the se-
cond, by examination, and finding the os uteri embracing the
polypus4 The history will likewise assist in the diag-
nosis, (u)
CHAP. IV.
Of Jifler-pains.
Few women proceed through the early part of the puer-
peral state, without feeling attacks of pain in the belly, which
* Schmucker's Surgical Essays, art. xvii.—A case is given in Med. Journ.
VI. 367, where appearance of gangrene, from strangulation, took place. The
womb was scarified, and the swelling quickly disappeared. The patient re-
covered.
y In a case related in Recueil des Actes de la Societe de Sante, de Lyon,
the uterus was taken for a polypus, and the ligature applied. The mistake
being discovered, it was instantly withdrawn, but the woman died in a few
days.
* In one case tlie os uteri adhered to tlie neck of the polypus, and gave
rise to appearance of inverted uterus. Mem. of Med. Soc. Vol. V. p. 14.
{u) Inversion of the uterus may be occasioned by the weight of an ex»
143
are called after-pains. These are generally least severe after
a first labour. They proceed from the contraction of the
uterus in an irregular manner, excited by the presence of co-
agula, or other causes, and each severe pain is generally fol-
lowed by the expulsion of a clot. They come on usually very
soon after delivery, and last for a day or two. They are
often increased, when the woman first applies the child to
the breast. They are distinguished from inflammation of tlie
uterus or peritoneum, by remitting or going off. The belly
is not painful to the touch, the uterine discharge is not ob-
structed, the patient has no shivering nor vomiting, the milk
is secreted, and the pulse is seldom frequent. When the
pulse is frequent, then we must always be on our guard; for
if this be the case before the accession of the milk-fever, the
patient is not out of danger, and if any other bad symptom
appear, we must be prompt in our practice. After-pains may
also be caused by flatulence and costiveness, which we know
by the usual symptoms; but a combination of this state, with
uterine after-pains, is often attended with a frequency of the
pulse, and may give rise to a fear that inflammation is about
to come on, but other symptoms are absent. Uterine after-
pains are relieved by opiates(a?) and fomentations, and if
protracted, by a purgative, and this is always proper when
the pulse is frequent. A severe constant pain in the hypo-
gastric region is sometimes produced by an affection of the
heart, and proves fatal, yet the uterus is found healthy.
Upon this subject, it may not be improper to mention, that
crescence of the nature of polypus, depending from the fundus of the ute-
rus—For a case of this kind together with an illustrative plate, see Denman's
Collection of Engravings, tending to illustrate the generation and parturi-
tion of animals, and of the human species.
The fundus of the uterus was completely inverted, and dragged through
the os uteri into the vagina. This case is worthy of consultation.
(x) It is frequently necessary to give the opiate in pretty large doses, and
repeat it every few hours; as for instance, 2 grains of purified opium, or 50
or 60 drops of laudanum, where these fail, the best effects are sometimes
experienced from an enema of 80 or 100 drops of laudanum, in four table-
spoonfuls of thin starch, or infusion of flax-seed. When these do not smc-
ceed, the strong infusion or tincture of hops may be tried.
114
a young practitioner may mistake spasmodic affections or
colic pains for puerperal inflammation; for in such cases
there is often retching and sensibility of the muscles, which
renders pressure painful. But there is less heat of the skin,
the tongue is moist, the pulse, though it may be frequent, is
soft, the feet are often cold, the pain has great remissions if
it do not go off completely, there is little fulness of the belly,
and the patient is troubled with flatulence. It requires laxa-
tives, antispasmodics, anodyne clysters, and friction with
camphorated spirits. Oil of turpentine acts both as a laxa-
tive and antispasmodic. In doses of half an ounce, it often
relieves spasmodic pain in the stomach or bowels. Blood
drawn in this disease, after it has continued for some hours,
even when the woman is not in child-bed, is sizy; and it is
always so in the puerperal as well as the pregnant state, al-
though the woman be well.
It is necessary to attend carefully to the duration and
situation of pain after delivery, and to the symptoms con-
nected with it. For it may proceed from inflammation of
the viscera; or in some cases it is felt near the groin, and
may be the forerunner of swelled leg; or about the hip, end-
ing in a kind of rheumatic lameness; or in consequence of the
application of cold, pain may be felt in some part of the recti
or oblique muscles, which, if not removed by fomentations
and frictions, may end in abscess, which frequently is long
of bursting, and excites hectic fever. It ought to be opened
with a lancet or caustic.
Rheumatism, affecting the muscles of the abdomen and
pelvis, is accompanied with less fever than puerperal inflam-
mation, and wants the other symptoms. The pain is shift-
ing and aching, or gnawing, though sometimes it is pretty
sharp, like a stitch. It is relieved by friction, withjaudanum,
by sinapisms, and by mild diaphoretics, bark, and the usual
treatment. When speaking of rheumatic pain, it may not
be improper to mention, that chronic rheumatism, especially
of the extremities, is very troublesome when it occurs after
parturition. It requires the usual remedies. Cod-liver oil,
in doses of half an ounce, three times a-day. has been much
145
recommended. I have formerly noticed those pains in the
limbs which may succeed the use of the crotchet.
CHAP. V.
Of Hysteralgia.
By hysteralgia, I understand uterine pain proceeding from
spasm, and not from inflammation. This may occur soon
after delivery, and is marked by severe pain in the back and
lower belly, frequent feeble pulse, sickness, and faintness.
This is sometimes accompanied with discharge, or succeeded
by expulsion of a coagulum. It requires an opiate imme-
diately. Another modification of this comes on later, but
always within three or four days after delivery, and attacks
in general very suddenly. Perhaps the patient has risen to
have the bed made, becomes sick, or vomits, and is seized
with violent pain in the lower part of the belly, or between
the navel and pubis. There is no shivering, at least it is
not a common attendant, and the pulse becomes very rapid,
being sometimes above a hundred and twenty, the skin is
hot, the lochia usually obstructed, and the uterine region
is somewhat painful on pressure. After some hours, the
severity abates, and presently by proper means the health is
restored.
As the lochial discharge is usually obstructed, this obstruc-
tion has been considered as the cause of the pain and other
symptoms; but it is merely an effect, and sometimes does
not exist. The cause appears to consist in a deranged state
of action in the uterus, which is productive of spasm in the
uterine fibres, and sometimes of the intestines. This is more
apt to occur after a severe or tedious, than after an easy
labour, but it may occur in any case, especially if exposed to
cold. The symptoms will vary a little in severity and in ap-
pearance, according as the uterus alone is affected, or as
spasm of the bowels is combined with the uterine pain. It is
distinguished from inflammation by the sudden nature of the
vol. n. v
146
attack, the absence of shivering in general, the pain becom-
ing speedily more severe than it does at the same period of
inflammation; and frequently it greatly remits or goes almost
entirely away for a short time. It is possible however, for
this state, especially if it be neglected, to excite inflammation,
which is marked by an attack of shivering, constant pain,
more or less severe, according to the part affected, and an
obstinate continuance of the fever.
The first thing to be done, is to administer a turpentine
clyster to open the bowels. Then the belly is to be fomented,
and if speedy relief be not obtained by these means, an ano-
dyne injection is to be given, and the saline julap is to be
taken freely, with the addition of a little antimonial wine, in
order to excite a free perspiration. If the symptoms continue,
purgatives are useful, and a blister must be applied to the
pained part of the belly to prevent inflammation.
CHAP. VI.
Of Retention of Part of the Placenta.
If either the whole, or a considerable portion of the pla-
centa, be left in utero for some time, the patient is exposed to
great danger. Hemorrhage is not the only risk, for in many
cases, severe head-ache, hysterical affections, sickness,
nausea, prostration of strength, and fever have taken place,
and continued until the placenta have been expelled, after
which the patient has begun to recover. On the other hand,
it has, though more rarely, occurred, that the placenta, hav-
ing been retained for a length of time, has been expelled,
before these symptoms have become urgent; but they have
afterwards gradually increased, and carried off the patient*
Sometimes the symptoms run so high, or the portions of the
* In a case related by Mr. Whyte, the secundines, after a clyster, came
away in a putrid state on the fifth day. On the sixth, tlie patient was much
oppressed, had foetid breath, &c. on tlie twelfth, an eniption appeared, and
she died on the twenty-second.
147
placenta are so Obstinately retained, that the patient sinks
under the disease, as in ordinary cases of hectic, with frequent
small pulse, burning heat of the hands and feet, profuse per-
spirations, and universal emaciation ; or dies with symptoms
similar to those of putrid fever; or is carried off suddenly by
a convulsion, or an attack of hemorrhage.
These symptoms have a very indefinite duration, for some-
times the patient dies in a very few days; in other instances
they are protracted for two or three weeks.* Sometimes no
hemorrhage takes place during the whole course of the dis-
ease ; but occasionally, repeated hemorrhages do occur, add-
ing greatly to the debility of the patient. In several cases,
inflammation has come on, and spread to the intestines. In
some of these, the placenta has been afterwards expelled, in
others extracted; but very few have recovered. On inspect-
ing the uterus, it has either been found black, as if it had
been gangrenous, or in a state of high inflammation, or of
suppuration, whilst the parts in the vicinity were in various
stages and degrees of inflammation.
Now, when these symptoms have taken place, our object
ought to be to remove the cause, and support the patient
under the disease. I am aware, that some have attributed
these symptoms not to the placenta, but to concomitant cir-
cumstances, such as injury done with the hand in endeavour-
ing to take it away. But we find that they take place when
the whole of the placenta has been left, without any attempt
having been made to remove it. They are produced when
any substance is left to corrupt in utero.f They continue as
long as it remains, and they usually cease when it is ex-
pelled.
It may be proper to examine, with the finger introduced in-
to the os uteri, whether any portion of the placenta can be
* Dr. Perfect relates a case, in which the secundines were retained till the
eighth day, when the patient died. Her stomach rejected all food and me-
dicine, she had weak quick pulse, hiccup, and subsultus tendinum. Vol. II. p.
390.—In another case, the placenta was retained till the thirteenth day, and
the woman died on the twentieth, p. 381.
f Similar symptoms have been produced by the head of the child being
left in utero. Perfect, Vol. D. p. 80.
148
felt and removed; but generally this cannot be freely done,
for the uterus itself, as well as its mouth, is hard and con-
tracted, and no violent or painful attempt with the hand or
finger ought to be made. But when we can easily feel and
act upon a portion, wegought slowly and gently to endeavour
to bring it out; and if the whole of the placenta have been
left, such attempts are still more necessary, and likely to
succeed. The os uteri often affords considerable resistance
to the introduction of the hand, in cases where the retention
has subsisted for some days; but by very slow and gentle
efforts, such as are scarcely felt by the patient, it may be di-
lated, and sometimes it yields very easily, or is not at all
contracted. If, however, it be rigid and unyielding, we must
not use violence; but this condition is rarely conjoined with
retention of the entire placenta.
When a portion of the placenta is retained, we may de-
rive advantage, from injecting, frequently, warm water, or
warm infusion of chamomile flowers, or water with a very
little muriatic acid added to it. These injections may be
made, by fixing a female catheter to an elastic-gum bottle;
or a syringe with a long pipe may be employed.
Sometimes natural or artificial vomiting assists the expul-
sion.
The patient should be allowed the free use of fruit and
vegetable acids, and light mild diet should be given in small
quantity at a time. The bowels ought to be kept open, and
opiates should occasionally be given to allay irritation.
Vomiting and nausea may be checked or mitigated when
urgent, by effervescing draughts. Bark, in small doses, has
been given, but I cannot place much confidence in it. When
there is a fulness about the abdomen, and tendency to inflam-
mation, purgatives are of service. When the nervous system
is much disturbed, the camphorated mixture may be given in
its usual dose.
149
CHAP. VII.
Of Strangury.
After severe labour, the neck of the bladder and urethra
are sometimes extremely sensible ; and the whole of the vul-
va is tender, and of a deep red colour. This is productive of
very distressing strangury, which is occasionally accompanied
with a considerable degree of fever. It is long of being re-
moved, but yields at last to a course of gentle laxatives, opi-
ates, and fomentations. Anodyne clysters are of service.
CHAP. VIII.
Of Pneumonia.
It is unnecessary to detail the symptoms of inflammation
of the lungs or pleura. It is sufficient to say, that this disease
is not uncommon in the puerperal state; and if there be such
a state of the lungs during pregnancy, as tends toward
phthisis, that disease is exceedingly apt to be rapidly induced
after delivery.
Pleurisy requires on the first attack copious blood-letting,
laxatives, and blisters, which are never to be omitted. If
the early stage have passed over, the use of the lancet is
doubtful, and it is better to trust to digitalis given freely, and
the application of blisters. Laxatives are also not to be ne-
glected.
CHAP. IX.
Of Spasmodic and Nervous Diseases.
Palpitation is not an uncommon disease after delivery. It
usually attacks the patient suddenly, and often after a slight
alarm. She feels a violent beating in the breast, and some-
150
times has a sense of suffocation; she has also a knocking with-
in the head, with giddiness, and a feeling of heat in the face.
The pulse is extremely rapid during the fit, and the patient
is impressed with a belief that she is going to die. After the
paroxysm, the mind is left timid, and the body languid.
Sometimes it is succeeded by a profuse perspiration; and
should the fits be frequently repeated, the temperature is va-
riable during the intervals, and the stomach is filled with gas.
This is often a very obstinate, but it is not a dangerous dis-
ease, unless it proceed from uterine disease, marked by pain
and swelling of the belly. It is to be relieved by giving,
during the paroxysm, a liberal dose of ether and laudanum ;
and during the intervals, antispasmodics, laxatives, and
tonics are to be employed. As soon as possible, the patient
should remove to the country.
Hysteric fits, hiccup, syncope, and dyspnoea, are to be
treated upon general principles, by full doses of opium, and
other antispasmodics, and clearing out the bowels with pur-
gatives.
There is a species of dyspnoea, that depends upon exertion
of the muscles of respiration during labour, or distension of
the abdominal muscles. When the abdominal muscles are
affected, the person often feels the difficulty of breathing,
chiefly during expiration. It is relieved, by tightening a
little the compress round the belly, and giving thirty drops
of laudanum. When the diaphragm is affected, the uneasi-
ness is usually greatest during inspiration ; and there is of-
ten a pain in the side, or in the back, or about the pit of the
stomach, which may be very severe. It is attended, some-
times, with a sense of stuffing in the breast; in other cases,
with an acute feeling of suffocation, or very sharp pain
across the lower part of the thorax, with deadly paleness,
and the pulse is extremely rapid. A very large dose of lauda-
num, with ether or volatile tincture of valerian removes the
spasm ; if not, a sinapism must be applied. These affections
come on within a few hours after delivery. The spasm of
the diaphragm is to be distinguished from pleurisy, by its
coming on suddenly, and being very acute: whereas, inflam-
151
lbation comes on more slowly, and is often preceded by a
shivering fit; there is more cough, and the pulse at first is
not so frequent, but is sharp.
Dyspnoea is also occasionally produced by the roller being
too tight.
Colic may occur within a few days after delivery. It at-
tacks suddenly, and generally in the evening. It is not pre-
ceded by shivering, but is sometimes accompanied with sick-
ness. The pulse may at first be either slow or of the natural
frequency, but soon becomes frequent. The pain is subject
to exacerbation and remission, but sometimes does not en-
tirely go off for several hours. The chief risk of this dis-
ease is the induction of inflammation, if the irritation be not
soon removed. The best remedy is, half an ounce of oil of
turpentine. I was led to employ this remedy in painful af-
fections of the stomach and bowels not dependent on inflam-
mation, from witnessing its excellent effects in the hands of
veterinary practitioners, and from observing its safe and pur-
gative quality on the human bowels, when given as a cure for
taenia. If tlie turpentine fail, a large dose of laudanum is to
be given in a clyster, and fomentations arc to be used at the
same time. It is generally beneficial to precede the anodyne
by a saline clyster. If the symptoms do not go entirely off,
the saline julap with laudanum is of service. If there be
much flatulence, tincture of asafoetida and hyoscyamus are
proper. Cramp in the stomach is very dangerous, when it
occurs within three weeks after delivery. It requires the
immediate exhibition of turpentine, and if that fail, of at
least sixty, perhaps a hundred drops of laudanum, with a
drachm of sulphuric ether, or two drachms of spiritus am-
moniac aromaticus ; a sinapism is also to be applied to the
region of the stomach.
Pain in the region of the kidney sometimes proves very
troublesome for two or three days after delivery. It comes
in paroxysms, which are relieved by sinapisms, fomentations,
clysters, purges, and opiates.
152
CHAP. X.
Of Ephemeral Fever or Weed.
The increased irritability of the system, as well as the de-
licacy of particular organs after delivery, render women at
that time peculiarly liable to febrile affections. Some of these
seem to arise from the general irritability of the whole ner-
vous system, others from local affection of the breasts, the
bowels, or the uterus. The first of these symptomatic fevers,
is generally pretty easily recognised by the sensibility of the
breast; the others, particularly that connected with the state
of the womb, are often more ambiguous, the local symptoms
being in many cases insidious.
The ephemera, or weed, as it has been called, is a fever
usually of short duration; the paroxysm being completed
generally within twenty-four, and always within forty-eight
hours; for if it continue longer, it becomes a fever of a dif-
ferent description. It proceeds from great susceptibility of
the nervous system, by which slight exposure to cold, mental
agitation, or similar causes, excite a universal disorder of
the frame. It consists of a cold, a hot, and a sweating stage;
but if care be not taken, the paroxysm is apt to return : and
we have either a distinct intermitting fever established, or
sometimes, from the co-operation of additional causes, a con-
tinued, and very troublesome fever is produced.
This disease, which in its simplest form is very much of
a nervous nature, generally makes its attack within a .veek
after delivery. It may be excited by exposure to cold, ir-
regularities of diet, fatigue, exhaustion, passions of the mind,
or want of rest. It is sometimes directly ushered in with a
fit of palpitation, or is excited by a frightful dream, from
which the patient awakes in a shivering fit, with a rapid
pulse; or the chill comes on, accompanied with pain in the
back and head, after some slight alarm, or injudicious ex-
posure to cold. When the cold stage has continued for some
time, the hot one commences, and this ends in a profuse per-
spiration, which either carries off the fever completely, or
153
procures a great remission of the symptoms. The head is
usually pained, often intensely, especially over the eyes, in
the two first stages. The pulse is extremely rapid, until the
third stage has continued for some time; it is also subject to
very great irregularities, and is very changeable in its de-
gree of frequency. The thirst is considerable, the stomach
generally filled with flatus, and the belly bound. The miml
often is weakened, and the patient is much afraid of dying.
In some instances, she is slightly delirious; in others, she has
shifting pains in the abdomen. If the paroxysm be repeated,
the secretion of milk is diminished.
The paroxysm continues for some hours, and then may
completely go off, not to return again. But in other cases,
it recurs frequently, being always preceded by a cold fit, and
often with a pain in the back; and sometimes the fit begins
regularly one or two hours sooner every succeeding day. It
is more favourable when the fit postpones. When this disease
is not combined with any local injury, it is less dangerous
than most fevers occurring in child-bed; but if it recur very
frequently, and be attended with much debility, the danger
increases in proportion to the continuance of the disease.
Local derangement is apt to take place very suddenly in the
course of this ailment; the breasts are peculiarly liable to be-
come inflamed. A fatal termination is usually preceded by a
coma, or vomiting of dark-coloured matter.
Delicate women, and those who have suffered much in par-
turition, are chiefly affected with this disease, but all are
more or less liable to it
It is distinguished from symptomatic fever arising from
local inflammation, by the absence of the particular pain, and
other specific symptoms, which attend these fevers, whilst in
them the pulse is usually at first not so rapid as in the ephe-
meral fever.
In the cold stage, we give small quantities of warm fluid,
and apply a bladder filled with warm water to the stomach,
or a warm flannel to the back, on the commencement of the
chilliness; or, if the patient be sick, and have a foul tongue,
a gentle emetic of ipecacuanha will be useful. If this be not
VOL. II. x
154
required, we give a smart dose of calomel amongst the first
acts of our practice. Having hastened on the hot stage, we
lessen very cautiously the number of the bed-clothes, and
give saline julap with diluents, to bring on the sweating stage.
When this is done, we are careful not to encourage per-
spiration too much, which increases the.weakness, or brings
out a miliary eruption, and renders the disease more obstinate.
On the other hand, if the perspiration be too soon checked,
the fever continues, or recurs more severely; a gentle sweat
may be kept up for five or six hours by tepid fluids. Then
we refrain from them; and when the process is over, the pa-
tient is to be cautiously shifted, the clothes being previously
warmed. After the fit, if the patient is exhausted, a little
wine may be given. In the whole paroxysm, we must watch
against the sudden application of cold, which, in the two last
stages, renews the shivering. When the fits recur, we may
sometimes check them, by giving an opiate an hour before
the expected time of accession, and applying warmth to the
bade and stomach the moment the chilliness is felt. It is of
great consequence to keep the bowels open, by aloes combined
with hyoscyamus, calomel, &c. Tonic medicines, such as
bark, sulphuric acid, and chalybeates, are useful; and in
some cases valerian may be joined to these with advantage.
Sleep is to be procured by opiates. During the whole time,
the strength must be supported by suitable diet; and as soon
as possible, the patient should be carried to the country. If
the fits return often, it is generally necessary to give up
nursing.
If derangement of any Organ should take place by the re-
currence of this disease, or during the course of a first
attack, it must be treated on general principles; and it is to
be recollected, that the nature of the complaint is now
changed, and the organ which is disordered claims our chief
attention. Very frequently the breasts suffer, or the womb
itself may be attacked. But we must be careful to distinguish
such a modification of weed from a symptomatic fever, be-
ginning like weed, but altogether arising from the state of
the womb, or other organs. The distinction is important,
155
'that no time be lost in combating the disease; which in the
one case does' not at first exist, in the other, is present ab ori-
gine. When the local affection is acute, the diagnosis is easy;
but I wish it to be impressed on the mind of my reader, that
it may also be mild, and require attentive inquiry to ascer-
tain it satisfactorily*
CHAP. XI.
Of the Milk Fever.
The secretion of the milk is usually ushered in with a
slight degree of fever, or, at least, a frequency of the pulse.
But sometimes it is attended with a smart febrile fit, preced-
ed with shivering, and going off with a perspiration. This
attack, if properly managed, seldom continues for twenty-
four hours; and during this time, the breasts are full, hard,
and painful, which distinguishes this from more dangerous
fevers. Sometimes, during the hot fit, there is a slight de-
lirium. A smart purge generally cures this disease, and is
often used, in plethoric habits, on the third day after deli-
very, to prevent it. Mild diaphoretics, during the hot stage,
are also proper. Applying the child early to the breast is a
mean of prevention.
CHAP. XII.
Of Miliary Fever.
The miliary fever begins with chilliness, sickness, lan-
guor, sometimes amounting to syncope, and frequency of
pulse, with heat of the skin. There is also a sense of prick-
ing or itching on the surface; and sometimes the extremities
are numbed. The febrile symptoms usually continue for
some time, before the eruption appears, often for four or six
156
days. Previous to the eruption, the patient feels very much
oppressed, and has a great weight about the chest; the spi-
rits are low, and a sour smelled perspiration takes place in a
profuse degree. The eyes are occasionally dull and watery,
or inflamed, and the patient has ringing in the ears. The
tongue is foul, and its edge red as in scarlatina. Aphthae
sometimes appear in the throat. The lochial discharge is di-
minished or suppressed. Before the eruption is seen, the
skin feels rough like the cutis anserina. Presently a num-
ber of small red pustules appear like millet seeds, vv hich are
felt with the finger to be prominent. In a few hours, small
vesicles form on their tops, containing a fluid, first straw co-
loured, and then white or yellow. In two or three days
small scabs form, which fall off like scales. The pustules
are generally distinct, but sometimes they form clusters.
They appear first about the forehead, neck, and breast, and
then spread to the trunk and extremities, but very rarely
affect the face. Different crops of pustules may come out in
the same fever. Burserius, and others, divide the pustides
into several varieties; but most writers are satisfied with two,
taken from the general appearance, the red and the white,
and the first is attended with a milder disease than the
second.
Tins disease is peculiarly apt to attack those who are weak-
ened by fatigue, evacuations, or other causes: and hence we
can easily explain, why women in child-bed should be sub-
ject to it.
Some have considered the eruption as altogether depend-
ent on the perspiration. Others consider it, as in many
cases, idiopathic; and both, perhaps, at times are right. We
can only consider the disease as idiopathic, when the eruption
mitigates the symptoms, when the fever goes off as the pus-
tules arrive at maturity, and there is no other puerperal dis-
ease present, acting as an exciting cause. It does not appear
to be contagious, unless connected with a-fever which is so of
itself, such as typhus.
Miliary eruption also occurs during child-bed, as a symp-
tom connected with puerperal diseases. It often accompanies
15?
the milk-fever, or the weed, when the perspiration is injudi-
ciously encouraged; and this is by far the most frequent form,
under which the febris miliaris appears. It never alleviates
the symptoms. It may also accompany fevers connected
with a morbid state of the peritoneum or brain, which gene-
rally prove fatal; death being preceded by vomiting of dark-
coloured fluid. Women, much reduced, have also partial mi-
liary eruptions, generally of the white kind, without fever,
which require no particular treatment.
Whether the miliary fever be idiopathic, or symptomatic,
the treatment is the same. We endeavour, at first, to check
or remove the fever, by means which I have pointed out in a
former chapter.
When profuse perspiration, with or without eruption, takes
place, we must cautiously abate it, by prudently lessening the
quantity of bed-clothes, or making the bed-room cooler.
The rest of the treatment consists chiefly in removing irri-
tation from the intestines by the use of laxatives, and sup-
porting the strength by light nourishing diet, whilst we use
tonics, such as sulphuric acid or bark. These tend also to
abate the perspiration, which is scarcely ever to be encou-
raged. The linen should be frequently changed. When the
eruption suddenly recedes, we have been advised to renew
the perspiration, apply blisters, and give musk and cordials,
especially when convulsions are threatened. This dangerous
retrocession, however, I have not met with, and apprehend
that it very rarely occurs.
CHAP. XIII.
Of Intestinal Fever.
We shall presently have an opportunity of observing, that
the state of the bowels frequently produces in children a very
troublesome species of fever, which, though proceeding from
a cause which has been some time in existence, makes its ap-
158
pearance suddenly. The same holds true with regard to
women in child-bed, who, either from previous torpor or cos-
tiveness of the bowels during the end of gestation, or some
error in diet after delivery, are seized, within eight or nine
"days, generally earlier, with fever, which passes for weed.
After an attack of shivering and chilliness, the patient be-
comes sick, oppressed at the stomach, and loathes food. The
pulse is frequent, and the skin, except at the feet, feels, from
the very first, hot to the touch of another person, though the
woman herself complains of being cold. Afterwards she
feels very hot, especially in the hands and feet;—she has no
appetite,—is thirsty, has a white slimy tongue, is sick,—and
occasionally vomits phlegm or bile, and is troubled with
flatulence. The pulse is quick; she does not sleep, but
rather slumbers, and is tormented with dreams and visions,
and talks during her slumbers. Generally she complains of
throbbing, often of confusion, but seldom of continued pain
in the head, though for a short time head-ache may be severe.
She has no fixed pain, nor any tumour in the belly, but com-
plains rather of stitches or griping. The bowels may either
be costive or loose; but in either case, the stools are foetid
and dark-coloured; and in general, laxatives operate both
early and powerfully. The lochial discharge is not neces-
sarily obstructed, nor does the secretion of milk, in many in-
stances, suffer for several days. The eye and the counte-
nance are nearly natural. The belly sometimes, in the
course of the disease, becomes full and soft, as if the bowels
were inflated, and this size occasionally continues during life.
These symptoms may be complicated with others, proceed-
ing from nervous irritation, such as palpitation, starting,
&c. or in the course of the disease, new ones arising from
injury of the function of the womb, may supervene, and are
marked first by pain, and afterwards by tumefaction of the
lower part of the belly, and pain in making water, or on
passing the faeces. The duration of this fever varies from a
few days to a fortnight.
On the first- appearance of this fever, a gentle emetic of
ipecacuanha should be administered ; and afterwards, when
159
the operation is over, we determine to the surface, by giving
the saline julap with tepid drink. Then, in a few hours, we
administer a dose of rhubarb and magnesia to remove offen-
sive matter from the bowels; or, if necessary, we give a suit-
able dose of castor oil, or calomel. After this, if there be
considerable griping, or a tendency to much purging, we give
an opiate-clyster, and repeat this every night till the bowels
are less irritable, taking care, if they become costive, or the
stools foetid, to interpose, occasionally, gentle laxatives. The
great principle indeed on which we proceed, is the early and
prompt evacuation of the offensive matter, whether bilious
or feculent, from the bowels, and the prevention of re-accu-
mulation, and this must be done by such doses as are re-
quired. The diet must be very light, such as beef-tea,
calves feet-jelly, arrow root, &c. and if there be no diarrhoea,
ripe fruit may be given. Ginger wine and water forms an
excellent drink, and in a few days, such a quantity of Ma-
deira wine may be given, as is found to impart a comfortable
feeling, without inducing heat or restlessness. When the
tongue becomes clean, small doses of colomba, or other bit-
ters will be useful. If there be much nervous irritation or
palpitation, or tendency to delirium, the camphorated julap
is proper.
CHAP. XIV.
Of Inflammation of the Uterus.
Inflammation of the womb may appear under two forms,
the slight and the extensive. This is a distinction which those
who are not much conversant in practice, may not be dispos-
ed to admit; but it will, nevertheless, be useful to describe
them separately. The first begins within the 9th day, very
like the ephemeral fever, and is considered by the nurse as a
weed. The patient shivers, feels cold, is sick, and perhaps
vomits. The pulse is frequent, but not hard nor sharp, the
160
skin becomes warm, and between the cold and the establish-
ment of the hot stage, the patient complains of a dull pain in
the lower part of the belly. It is not constant, and is apt to
pass for after-pains. The lochial discharge continues, and
the secretion of milk is not checked. The pain at first, and
usually during the whole course of the disease, is slight, it is
generally felt near the pubis, but it may also extend a little
to one side, or toward the groin. Sometimes there is pain
in the back, but frequently there is none, unless when the pa-
tient sits up. The pain in the belly very soon is not perceived
when she lies still, but is felt when she turns, or when pretty
considerable pressure is made with the hand, or occasionally
one or two sharp pains dart through the uterine region.
There is no hardness to be felt, and the belly is not tender,
but becomes a little full; the lochial discharge gradtally di-
minishes, but does not of necessity stop, and the milk some-
times continues plentiful. There is considerable thirst, no
appetite, and the sleep is disturbed. The pulse, which at first
is very frequent, falls in a day or two to 100, or varies from
90 to 108. The head is confused rather than painful, slight
wandering pains may be felt in the belly or sides. The bowels
arc generally affected, being at first rather bound, afterwards
loose or irregular, and the feeces dark, slimy, or foetid. Some-
times there is a degree of strangury. In the course of a fort-
night, the pulse becomes slower, the appetite gradually re-
turns, and these circumstances are preceded or accompanied
with a slight discharge of blood from the womb, or of puru-
lent matter by the rectum, or from the vagina. Sometimes
the disease is much shorter in its course, being little more
protracted than an ephemera, the symptoms yielding com-
pletely to the treatment; or they may be removed in so far,
as that all fever and pain go off; but when the patient comes
to rise, she feels a pressure like prolapsus uteri, which con-
tinues for many days or even weeks, so that she cannot
stand, but has an instinctive desire to run to a seat. It is
not easy to distinguish this state from prolapsus, except by
examination. The uterus is felt in its proper altitude, but
often the os uteri is turned a little to one side, and the vagina
161
is not lax, but may be rather rigid: pessaries give little or
no relief. The complaint continues obstinate, preventing
the patient from walking, though she is in good health, until
a little purulent matter, or still more frequently, a little blood
like the menses is discharged, and then she is almost instant-
ly cured.
The treatment of this species of uterine inflammation con-
sists in exciting early a free and pretty copious perspiration,
fomenting the belly, and opening the bowels with a smart
purge. If the pains be more permanent, blisters may be ne-
cessary, and blood-letting, early employed, is useful, but most
cases of this partial nature recover without the use of the lan-
cet, merely by cuticular and intestinal evacuation.
The more serious and extensive inflammation of the uterus,
may be excited in consequence of rude management, or other
causes. The disease usually begins between the second and
fifth day after delivery, but it may take place at a later period.
It is pointed out by a pain in the lower part of the belly,
which gradually increases in violence, and continues without
intermission, though it is subject to occasional aggravations.
The uterine region is very painful when it is pressed, and it
is a little swelled. There is, however, no general swelling
of the abdomen with tension, unless the peritoneum have be-
come affected. But the parietes are rather slack, and we
can feel distinctly the uterus through them, to be harder than
usual, and it is very sensible. There is also pain felt in the
back, which shoots to the groins; and there is usually a diffi-
culty in voiding the urine, or a complete suppression, or dis-
tressing degree of strangury. The situation of the pain will
vary according to the part of the uterus first and principally
affected. The internal parts also become frequently of a
deep red colour, and the vagina and uterus have their tem-
perature increased. The lochial discharge is very early sup-
pressed, and the secretion of milk diminished or destroyed.
Nearly about the same time that the local symptoms appear,
the system becomes affected. The patient shivers, has head-
ache, often is sick, and vomits bilious or dark-coloured fluid.
The pulse very early becomes frequent, and somewhat hard,
vol. ir. y
163
and the skin is felt to be hot. The tongue is white and dry,
the urine high-coloured and turbid, and if the bladder be
affected, it may be suppressed. The vomiting in some cases
continues, and the bowels are at first bound, but afterwards
the stools are passed more frequently. If the peritoneum
come to partake extensively of the disease, then we have
early swelling, and tenderness of the abdomen, and the
danger is greatly increased.
If the inflammation do not extend along the peritoneum,
this disease is more easily cured, than other visceral inflam-
mations in the puerperal state. It may terminate favourably
by a free perspiration, a diarrhoea, or a uterine hemorrhage;
which last is the most frequent and complete crisis. If the
pain abates, the pulse come down, and the lochia and secre-
tion of milk return, we consider the patient as having the
prospect of a speedy cure. But in many other cases the
disease is more obstinate, the fever continues, the pulse be-
comes more frequent, but is full for a day or two, after
which, it becomes small, the tongue is redder, but dry, the
pain does not abate, and in some days shiverings take place,
and the pain becomes of the throbbing kind. The face is
pale, unless when the cheeks have a hectic flush; the urine,
which was formerly high-coloured, now deposits a pink-
coloured sediment, in great abundance. The nights are spent
without sleep, and the patient is wet with perspiration. After
some time, matter is discharged from the vagina, or by the
bladder or rectum, but oftenest from the rectum. The hectic
symptoms continue for many weeks, and may at last prove
fatal. Sometimes the disease early proves fatal, the pulse
increasing in frequency, the tongue becoming very red, and
the strength sinking; but even in this case, it will generally
be found, that suppuration has taken place. Pus is contained
often in the ovaria and tubes, and sinuses of the uterus.
Mortification is an extremely rare termination. This is a
fact, of which my dissections convince me, and it is farther
confirmed by the opinion of Dr. Clarke. Little or no serous
effusion takes place into the abdomen.
This disease calls for the early use of the lancet, which is
163
the principal remedy; and the quantity of blood which we
take away, and the repetition of the evacuation, must depend
on the constitution of the patient, the effects produced, and
the period of the disease. If two or three days have passed
over, the pulse may be full and frequent; but this is an indi-
cation that suppuration is going on, which will be ascertained
by throbbing pain, &c. In this case the lancet is hurtful.
Mild laxatives are also highly proper. Fomentations, sina-
pisms, and embrocations, are useful. Diaphoretics ought to
be administered, such as the saline julap, with the addition
of antimonial wine and laudanum. This is the best internal
remedy I think we can employ. Emollient clysters, or
sometimes anodyne clysters give relief. In the suppurative
stage, we must keep the bowels open, give light nourishment,
apply fomentations, and allay pain with anodynes. When
the matter is discharged, a removal to the country will be
useful, and tonic medicines should be given.
Sometimes the round ligament suffers chiefly, and the pa-
tient complains of pain and tenderness at the groin, increased
by pressure. The lower part of the belly is, after a little,
swelled and uneasy. Fever attends this disease, and j^me-
times the stomach becomes irritable. It is often caused by
hasty extraction of the placenta. It requires the early use
of laxatives; and if the symptoms are violent, it is proper to
take blood from the arm, and apply leeches to the groin,
which should seldom be omitted. Afterwards we can employ
fomentations and blisters. If neglected, the disease may
end in suppuration, or in a painful swelling, at the ring of the
oblique muscle, which lasts a long time. This is sometimes
removed by issues. Anodynes should be given, to allay irri-
tation, and the strength must be supported under the fever,
which resembles hectic.
161
CHAP. X\.
Of Peritoneal Iiiflammation.
The peritoneal lining of* the abdomen, or the covering of
the intestines, may be inflamed alone; or this disease may be
combined with inflammation of the uterus.
Peritoneal inflammation may be caused by v iolencc during
delivery, or the application of cold, or the injudicious use of
stimulants. It may not come on for three weeks after deli-
very, but it usually commences on the second day, and earlier
than inflammation of the womb; and it may often be observed,
that the pulse continues frequent from the time of delivery.
It is preceded or attended by a shivering and sickness, or vo-
miting, and is marked by pain in the belly, which sometimes
is very universal; though, in other cases, it is at first confined
to one spot. The abdomen very soon becomes swelled and
tense, and the tension rapidly increases. The pulse is fre-
quent, small, and sharp, the skin hot, the tongue either clean,
or white and dry, the patient thirsty; she vomits frequently,
and the milk and lochia are obstructed. These symptoms
often come on very acutely, but it ought to be deeply im-
pressed on the mind of the student, that they may also ap-
proach insidiously. Wandering pain is felt in the belly,
neither acute nor altogether constant. It passes for after-
pains, but it is attended with frequency of pulse, and some
fulness of the belly, and a little sickness. But whether the
early symptoms come on rapidly or slowly, they soon in-
crease, the belly becomes as large as before delivery, and is
often so tender, that the weight of the bed-clothes can scarce-
ly be endured; the patient also feels much pain when she
turns. The respiration becomes difficult, and sometimes a
cough comes on, which aggravates the distress; or it appeal's
from the first attended with pain in the side as a prominent
symptom. Sometimes the patient has a great inclination to
belch, which always gives pain. The bowels are either cos-
tive, or the patient purges bilious or dark coloured faeces.
These symptoms are more or less acute, according to the ex-
165
tent to which the peritoneum is affected. They are, at first,
milder, and more protracted, in those cases where the in-
flammation begins in the uterus; and in such the pain is often
not very great, nor very extensive, for some time. If the
disease is to prove fatal, the swelling and tension of the belly
increase, so that the abdomen becomes round and prominent,
the vomiting continues, the pulse becomes very frequent and
irregular, the fauces are aphthous, death is marked in the
countenance, the extremities cold, and the pain usually
ceases rather suddenly. The patient has unrefreshing slum-
ber, and sometimes has delirium mite, but she may also re-
main sensible till the last. The disease usually proves fatal
within five days, but may be protracted for eight or ten days,
or even longer. If the patient is to recover, the swelling does
not proceed to a great degree; the pain gradually abates,
the vomiting ceases, the pulse becomes fuller and slower, the
breathing easier, so that the patient can lie better down in
bed, and she can turn more easily. Sometimes this disease
ends in suppuration, and the abscess points and bursts exter-
nally. Dr. Gordon, in his treatise on puerperal fever, relates
three cases of this kind. In one of these, the matter was dis-
charged from the umbilicus, a month after the attack; in
another, six weeks after delivery; and in the third, after two
months it came from the urethra. Similar cases have come
under my own observation.
Upon dissection, the peritoneum is found in a state of high
inflammation, but it is rare to find it mortified. A consider-
able effusion of serous fluid, mixed with curdy substance, is
found in the belly.
The patient is only to be saved by vigorous, means, and
great attention. If the pulse continue above a hundred in
the minute, for twenty-four hours after delivery, there is
reason to apprehend that some serious mischief is about to
happen; and therefore, unless the frequency depend decided-
ly on debility, produced by great hemorrhage, &c. we ought
to open the bowels freely, and give a diaphoretic. We must
carefully examine the belly, and if it be full, or painful on
pressure, or if the patient be inclined to vomit, we ought to
166
open a vein, and use purgatives. I know that many are un-
willing to bleed women in the puerperal state, and the con-
dition of the pulse may seem to young practitioners to for-
bid it. But in cases of peritoneal inflammation, not con-
nected with typhoid fever, I must strongly urge the neces-
sity of blood-letting, at a very early period; and the evacu-
ation is to be repeated or not, according to its effects, and
the constitution of the patient.* If she have borne it ill,
and is not relieved, when it is used first, I apprehend that
the case has not been simple peritoneal inflammation, but
puerperal fever. If she bear it well, and the pulse become
slower and fuller, and the pain abate, we are encouraged to
repeat it. I wish to impress on the mind of the student in
the most earnest manner, the fatal consequence of neglect-
ing blood-letting in this disease. How many women fall a
sacrifice to the timidity or inattention of their attendant!
The lancet is the anchor of hope: it may indeed be pushed
too far; it may be used by young practitioners in cases of
spasm, mistaken for peritonitis; but the error is safer than
the contrary extreme, for of two evils debility is more easily
removed, than inflammation. After the lancet has been freely
used, if pain continue, leeches, or the scarificator may be ap-
plied to the most painful part The bowels are at the very
first to be opened freely with calomel, or some other purga-
tive, which we require to give in a large dose, particularly
calomel, for ordinary doses do no good. Dr. Armstrong
gives half a drachm of calomel, and afterwai'ds a purgative
draught of senna and salts to work it off, and I think the
practice safe. In an advanced stage of the disease, after ef-
fusion has taken place, we must employ purges alone, rather
than blood-letting. Sinapisms and blisters are also proper.
Digitalis has been given, either to abate inflammation, or
promote absorption, after effusion has taken place; but I
have not found it useful. After effusion has taken place, and
* This is correct practice. Bleeding may be as safely employed in in-
flammation connected with the puerperal state, as under any other circiun-.
stances. C.
167
debility is produced, cordials, of which wine is the best,
should be given, and anodyne clysters are to be adminis-
tered.
Chronic, or slow inflammation of the peritoneum, is not
very unfrequent, and may last for some weeks. It is attend-
ed with constant pain in some part of the abdomen, but it is
not unbearable; the belly is tender, the pulse frequent, the
thirst urgent, and often the mind is affected as in hysteria;
or a train of hysterical symptoms supervenes, which may
lead off the attention from the seat of the disease. It requires
at first blood-letting, and then the frequent use of laxatives,
with repeated blisters.
CHAP. XVI.
Of Puerperal Fever.
Puerperal fever begins sometimes in an insidious man
ner, without that shivering which usually gives intimation of
the approach of a serious malady. In other cases, the shiver-
ing is perceived, and varies considerably in degree, being
either slight or pretty severe. The first symptoms, inde-
pendent of the shivering, are frequency of pulse, oppression,
nausea, or retching, pain in the head, particularly over the
eye-brows. The night is passed with little sleep, much con-
fusion, and occasionally some delirium. Even at this time,
or very soon afterwards, pain is felt in the belly, at first slight,
but it presently increases; and in some instances, the abdo-
men becomes so tender, that even the weight of the bed-
clothes is productive of distress. A general fulness of the
belly accompanies this from the first, and it usually increases
pretty rapidly, and may proceed so far as to make the pa-
tient nearly as large as she was before delivery; and in such
cases, the breathing becomes very much oppressed: indeed.
in every instance, the respiration is more or less affected:
the free action of the abdominal muscles, which are concert <
168
ed in that function, being productive of pain. The face is
sometimes flushed at first, or the cheeks are suffused, but the
countenance in general, is pale and ghastly, the eyes are
without animation, and the lips and angles of the eyes are
white. The whole features indicate anxiety and great de-
bility. Vomiting occasionally occurs at the very commence-
ment, and in that case it is bilious. In the course of the dis-
ease, it sometimes becomes so frequent, that nothing will stay
in the stomach; and towards the conclusion of the fever, the
fluid thrown up is dark-coloured, and frequently foetid. This
is a symptom, which, so far as I have observed, always, if it
do not proceed from a morbid structure, indicates, in what-
ever disease it occurs, an entire loss of tone of that organ.
.But to proceed with the history. There is great dejection
of mind, languor with general debility of the muscular fibres,
and the patient lies chiefly on her back; or there is so much
listlessness, that she sometimes makes little complaint. The
skin is not very hot, but is rather clammy and relaxed. The
tongue is pale or white at firsts but presently becomes brown,
and often aphthae appear in the throat, or mucus is secreted,
which excites a cough. The pulse, even at first, is very
frequent, and is, at that period, fuller than in simple pe-
ritoneal inflammation, but it soon become feeble. Tlie
thirst is not always great, at least the patient is often care-
less about drink. The bowels are often at first bound; but
afterwards, especially about the third day, they usually be-
come loose, and the stools are dark, foetid, and often frothy.
This evacuation seems to give relief. The urine is dark-co-
loured, has a brown sediment, and is passed frequently, and
with pain. The lochial discharge is diminished, and has a
bad smell, or is changed in appearance, or gradually ceases;
and it is observable, that the re-appearance of the lochia, if
they had been suppressed, is not critical. The secretion of
milk stops, and the patient inquires very seldom about the
cliild. In some cases, I have met with pleuritic symptoms.
As the disease advances, the pulse becomes more frequent and
weaker, or tremulous. In bad cases, the swelling of the
belly increases rapidly, but the pain does not always keep
169
pace with the swelling, being sometimes least, when the
swelling is greatest, and in the end, it generally goes entirely
off. The breathing becomes laborious, in proportion as the
belly enlarges. The strength sinks, the throat and mouth
become foul, the stools are passed involuntarily, low delirium
sometimes takes place, and the patient usually dies about the
fifth day of the disease, but in some cases not until the four-
teenth ; in others so early as the second day.
This fever attacks generally on the second or sometimes
on the third day after delivery, but it has also occurred so
late as after a week. The earlier it attacks, the greater is
the danger, and few women recover who have the belly much
swelled.
On dissection, there is found in the abdomen, a consider-
able quantity of fluid, similar to that met with in peritonitis.
The omentum and peritoneum are inflamed, but perhaps
very slightly, and gangrene is unusual. The swelling is
neither proportioned to the inflammation nor effusion, nor in
every instance dependent on these, but on that inflation of the
bowels which results from the relaxation of the muscular
fibres of the bowels which is so common in the puerperal
state, particularly in puerperal disease. The uterus is not
more affected than the intestines. In some cases, the thoracic
viscera are inflamed.
It is most frequent, and most fatal, in hospitals. In pri-
vate practice it is less malignant, though still very danger-
ous. It is sometimes epidemic, but I do not know that it
has ever appeared, as a prevailing epidemic, in this city,* nor
have I been able to trace the contagion from one woman
to another. In hospitals, as well as in the private practice
of individuals, in other places, it has appeared as a conta-
gious disease. There has been much dispute whether the
contagion was one sui generis, or that of typhus or erysipelas,
or hospital gangrene; or if the disease depended on some
noxious state of the atmosphere, conjoined with the absorp-
tion of putrid matter. The disease appears to depend on in-
* Glasgow.
VOL. II. Z
470
flammation of the peritoneum, conjoined with the operation
of some debilitating poison, probably, in most cases, more or
less contagious.
It is important to distinguish this disease from simple peri-
tonitis, which may generally be done by attention. In puer-
peral fever, the abdominal pain is not the most prominent
symptom. There is more despondency, debility, and head-
ache ; less heat of the skin, less thirst, and less flushing of
the face. In the peritoneal inflammation, the pain in tlie
belly usually increases rapidly after it begins, and the swel-
ling increases along with it. Pressure gives very great pain.
The fever is inflammatory. Inflammation of the uterus has
its proper symptoms.
This disease is dangerous, in proportion to the malig-
nancy of the cause, and the situation of the patient. All
writers agree, that in hospitals it is peculiarly fatal, and
that few recover from it. In private practice, the disease
is milder, but still it is most formidable. With regard to
the best mode of treatment, there has been a great differ-
ence of opinion, as will appear in the notes,1 which partly
depends on giving the name of puerperal fever to different
disorders. I am sorry that I find it much easier to say,
What remedies have failed, than what have done good. I
have stated, that in peritoneal inflammation, blood-letting and
laxatives are the principal remedies; but in this disease,
blood-letting seldom does good, and often is hurtful. I am
convinced, that if it is to be used at all, it must be very early,
and that it ought not to be pushed far. If the symptoms
of depression of strength, and the characters of puerperal
fever, be very decided, we must not bleed ; but if the debility
be less obvious, if the pain and inflammatory symptoms be
considerable, and the case has a mixed appearance, approach-
ing to simple peritonitis, and we are called early, a vein
must be opened ; but if the pulse speedily become small, or
the patient feel faintish, we must not continue the evacua-
tion, and arc upon no account to repeat it merely because the
blood is huffy. Whether we bleed or not, it will be proper
immediately to give a smart dose of some purgative medicine,
171
particularly calomel, succeeded by Epsom salts, afterwards
we begin the use of the bark, giving it as liberally as the
stomach will bear, or administering it in the form of a clys-
ter. Opiates, given after purgatives, have the effect of abat-
ing irritation and pain, and of restraining immoderate diarr-
hoea, should that come on. Diarrhoea should not be allowed
to continue long, and is always to be restrained, unless it
evidently give relief, and the faeces be very foetid. In this
case, calomel and diluents should be employed. If there be
tenesmus, anodyne clysters should be given, after the use of
the calomel. In all cases, we are to attend much to the
bowels, using brisk purgatives and clysters, where there is
no diarrhoea; milder doses administered with opiate clysters,
where there is. Vomiting is to be restrained by solid opium,
and by an opium plaster applied to the region of the stomach:
sometimes saline draughts are of service. Nausea has been
supposed to indicate the necessity of an emetic ; but if no re-
lief be obtained from natural vomiting, which most practi-
tioners admit, I do not see that artificial vomiting can be use-
ful, nor does experience support the practice. Fomentations,
and anodyne or rubefacient embrocations, sometimes abate
the pain in the abdomen. The repeated application of blis-
ters has been extolled by some, but I am much inclined to
concur with Dr. Clarke, in thinking, that they rather excite
an injurious irritation. The strength should be supported
by light nourishment, and a moderate proportion of wine, or
other cordials. Digitalis and other diuretics have been given,
to carry off the effused fluid, but they have no effect. Eme-
tics and antimonials, I am afraid, do more harm in general
than good. Upon the whole, wre trust chiefly to tonics, in
the cure of puerperal fever; we support the strength, and re-
gulate the state of the alvinc discharge, preventing accumula-
tion of morbid faeces on the one hand, and restraining immo-
derate evacuation on the other.* Most authors have laid
* On no subject, perhaps, are pract'tioners more divided than respecting
the treatment of puerperal fever. From different views of the nature of the
disease, two modes of practice have indeed been deduced almost diametrical-
ly opposite. Whatever may be the propriety of the plan, recommended by
172
down distinct and formal indications to be fulfilled; but it is
much to be doubted, if the means proposed be adequate to the
effect intended to be produced; or if all the parade of science
has done more than show, that, with the addition of remedies
for removing particular symptoms, one class of practitioners
have trusted to the lancet as the chief engine of cure, and
another to the use of bark and cordials. Peritonitis is much
more frequent than puerperal fever.fjfl
CHAP. XVII.
Of Swelled Leg.
The swelling of the inferior extremity, in puerperal wo=
men, is usually preceded by marks of uterine irritation, and a
tender state of the parts within the pelvis. About a fortnight
after delivery, sometimes a little earlier, or even so late as the
fifth week, the patient complains of pain in the lower belly,
increased by pressure, and occasionally has pain and difficulty
in making water. The uterine region is somewhat swelled.
The pulse is frequent, the skin hot, the thirst increased, and
these symptoms are often preceded by shivering. Stiffness
Mr. Burns, applicable to puerperal fever in Europe, it would, undoubtedly,
be mischievous, if adopted here.
The disease in this country is very generally a fever of increased action,
and requires for its cure pretty copious depletion. Bleeding freely, purging
actively with the neutral salts, and blisters to tlie region of the abdomen,
are the remedies which have succeeded best in my hands. C.
(#) It is most probable that the low form of fever here described, under
the name of puerperal fever, is comparatively a rare disease in tlie United
States of America, even in our large towns, but more especially so in situa-
tions in the country; and that what has by some been considered as that dis-
ease, and in which depletion has been found so useful, has been a species of
peritonitis. Of this the Editor thinks he has known more than one instance.
On tlie subject of fevers attacking puerperal women, he would particularly
recommend to tlie student, the attentive perusal of the excellent essays of Dr.
John Clarke, on the Inflammatory and Febrile diseases of lying-in women.
Also, the valuable writings of Gordon of Aberdeen; Hoy of Leeds, and Arm-
strong of Sunderland, on the puerperal fever which prevailed as au epidemic
in those places.
173
and pain are now felt in one of the groins, near the passage
of the round ligament, or the exit of the tendon of the psoas
muscle, or in some cases about the origin of the sartorius and
rectus muscles. The pain is attended with swelling, and these
two symptoms may proceed gradually down the limb ; but
more frequently, pain is felt suddenly in the calf of the leg,
or at the knee, near the insertion of the sartorius muscle, and
is most acute in the course of that muscle; it also darts down
to the heel. Within twenty-four hours after the pain is felt
the limb swells, and becomes tense; it is hot but not red; it
is rather pale and somewhat shining. The swelling sometimes
proceeds from the groin downwards; in other cases, it is first
perceptible about the calf of the leg, and proceeds upwards.
It generally procures an abatement of the pain, but does not
remove it. On the contrary, the patient cannot move the
leg, and it is tender to the touch. The inability to move it,
however, does not depend altogether on the pain, but also on a
want of command over the muscles. The pulse is very fre-
quent, being often 140 in the minute, and generally is small
and feeble, but sharp; the tongue is white and moist, the
countenance has a pale chlorotic appearance, the thirst is
considerable, the appetite is lost; the bowels are either
bound, and the stools clay-coloured, or they are loose, and
the stools very foetid or bilious. The urine is muddy; the
lochial discharge sometimes stops, or becomes foetid, in other
cases it is not at all affected. The nights are spent with-
out sleep, and the patient perspires profusely. All the parts
within the pelvis are tender, and the os uteri is open, but not
more painful when touched, than the sides of the vagina or
the internal muscles.
The period at which the swelling reaches the acme is va-
rious, but often it is accomplished in twenty-four or forty-
eight hours. It seldom makes the limb above double its
usual size. Generally in ten days, sometimes in even two
or three, the febrile symptoms, swelling, &c. aliate; but it
may happen that they are protracted longer, and they do not
go off entirely for some time. When they go off, the patient
is left feeble, and the limb stiff, weak, and often for a time
17*
powerless. In the course of the cure, we frequently feel hart!
bumps in different parts of the limb, especially on its back
and inside. These are not glands; some consider them as
indurated lymph, others as muscular contractions. At the
top of the thigh, the inguinal glands are often felt swelled,
even at the beginning of the complaint; but in some cases,
I have found them not at all affected.
If the skin be punctured, no serum is effused, at least not
in the same way as in anasarca, and the swelling is not in-
creased in a depending posture.
In some cases, the disease begins like rheumatism affect-
ing the back and hip joint.(«) Then the upper part of the
thigh becomes painful and swelled, and next the calf of the
leg suffers; sometimes the limb at first feels colder than the
other. Occasionally the disease is very mild, and attended
with little swelling. This is more apt to be the case when
it is late of occurring, and is vigorously attacked at first.
In one or two instances, suppuration has taken place: mor-
tification has also happened.
If the disease run its usual course, it is always a length of
time before the patient recover, for the swelling does not go
soon entirely away, and the strength is long of returning. In
some instances, the limb remains permanently swelled and
feeble.
After one leg has been affected, and even before the com-
plaint has completed its course there, the other may become
diseased; and this has no influence on the progress of the first.
The second attack is sometimes the worst of the two, owing.
perhaps, to the previous debility. A coldness is often felt in
the second leg, before the paroxysm comes on, and pain in the
belly precedes the attack. The first leg may be a second time
attacked.
(z) It is an opinion entertained by some respectable and experienced
practitioners, that this disease is in fact, a variety of rheumatism, and is to
be managed on the general plan of treatment that is found to be successful
in rheumatic fever. After the inflammatory stage is over, it is by them
considered as running into the chronic state of rheumatism, and to he
treated accordingly by the remedies appropriated to that form of d^.-ase.
175
This is not generally a fatal disease, but it is tedious, and
is often accompanied with hectic symptoms. Death, however,
may be caused by suppuration or gangrene; or by exhaustion,
proceeding from the violence of the constitutional disease;
or from exertion made by the patient, which has sometimes
proved suddenly fatal.
The production of this disease does not seem to depend on
the circumstances of the labour, for it appears both after easy
and difficult deliveries. Those who give suck, and those who
do not, the strong and the weak, are affected by it. But if it
be late of occurring it is generally in those who have suffered
from mammary abscess. It has succeeded an abortion, or sup-
pression of urine. I am inclined to Consider the cause to be
an irritated or slightly inflamed state of the parts within the
pelvis, which sometimes produces merely a stiffness and swell-
ing at the passage of the round ligament, sometimes an irrita-
tion of the nerves which pass to the leg. Puzos and Levret
consider the disease as proceeding from a depot of the milk.
Most modern writers attribute it to an affection of the lym-
phatics, which are ruptured, or have their circulation inter-
rupted by swelling of the inguinal glands. Dr. Hull considers
the disease as an inflammatory affection, suddenly succeeded
by effusion. I refer, for a view of the different opinions, to his
Treatise on Phlegmatia Dolens. The disease seems to con-
sist partly in inflammation, and partly in nervous irritation,
producing both pain and a temporary species of palsy; and
the cure consists in lessening the one, and allaying the other.
The treatment naturally divides itself into that of the limb,
and that of the constitution.
Our first object is to check the disease within the pelvis.
For this purpose, leeches ought to be applied to the groin,
and we should immediately open the bowels with a purga-
tive. A small blister should then be applied to the groin, or
sinapisms may be applied to the groin, inside of the thigh,
and near the knee on the leg, and afterwards cloths, wet with
tepid solution of acetate of lead, or with warm vinegar.(c)
(a) It is the practice at one of the best regulated lying-in hospitals in
London, to apply flannel, well soaked in hot vinegar, to the groin of the af-
170
These means may prevent the swelling, or render it milder.
If the disease have already taken place in the limb, fomenta-
tions, and gentle friction, with anodyne balsam, or campho-
rated oil, will be useful, and should be frequently repeated.
The bowels should still be kept regular, but the patient is not
to be purged. Opiates are useful, to allay irritation. When
the acute symptoms are over, we endeavour to remove the
swelling, and restore the tone of the part, by friction with
camphorated spirits, and the use of the flesh brush, and a
roller applied round the limb. The liberal use of solution
of cream of tartar is also, in many cases, of service. If the
disease threaten to be lingering, small blisters may be ap-
plied to the groin. If much weakness of the limb remain,
the cold bath is proper, or sometimes a bath of warm sea-
water.
Besides these means, we must also employ remedies for
abating the fever, and constitutional affection. At first we
use saline draughts, but these are not to be often repeated,
and must not be given so as to procure much perspiration.
In a short time they should be exchanged for bark, sulphuric
acid, and opiates, which tend to diminish the irritability. In
the last stage, we give a moderate quantity of wine. When
the pain shifts like rheumatism, bark, and small doses of
calomel, are useful. If the uterine discharge be foetid, it is
proper to inject tepid water, or infusion of chamomile flowers
fectcd limb, as well as to the hmb itself; and it is asserted, that no other
remedies beyond those necessary to keep the bowels open, are ever used.
(Vide Vol. V. of Lond. Med. and Phys. Journal.] The editor can, from ex-
perience, add his testimony in favour of the beneficial effects of this treat-
ment.
Dr. John Clarke, recommends laying the whole leg affected, in a soft
poultice, made as follows: To a peck of well dried bran, he adds an ounce
of hot olive oil, and a pint of strong soap lees; these being well mixed to-
gether, says the Doctor, form a poultice, which in these cases may be used
with the greatest advantage; it has tlie good effect of keeping up a gentle
perspiration, and forms the softest pillow which can be imagined, never fail-
ing to bring relief.
Dr. Hosack of New York, in this disease, strongly recommends the exhi-
bition of a combination of squills and calomel, wliich he thinks has often
produced the best effect
177
into the vagina. Exposure to cold, during the first stage of
recovery, may cause a relapse. The treatment thus consists
chiefly in palliating symptoms, and supporting the strength.
I cannot, however, agree with those who, in the very outset
of the disease, give wine liberally, as there certainly does, at
that time, exist an inflammatory tendency. The diet should
be light and nutritious.*
CHAP. XVIII.
Of Paralysis.
Some women after delivery, lose for a time the power of
the inferior extremities, although they may have had a very
easy labour. This paralysis may exist in different degrees,
and in some cases the muscles are painful. Sometimes it is
attended with retention of urine. It is not accompanied with
any cephalic symptoms. In general, the disease wears off in
a few weeks. Friction, the shower-bath, tonics, and gentle
exercise on crutches, are the means of cure. The bowels are
also to be kept open.
After a severe or instrumental delivery, the woman may
complain of excessive pain about the loins and back, attend-
ed with lameness, or even palsy. This is sometimes a very
tedious complaint, but usually it is at last removed. The
tepid bath, with anodyne embrocations, relieve the pain; and
at a more advanced period, sea-bathing is proper, f
* I have met with but two cases of this strange affection, which I treat-
ed, very successfully, by copious bleeding, by very active purging, and by
blisters applied to the groin, and extending up the abdomen. In these cases
there was every appearance of high inflammatory action, accompanied with
much pain. If the preceding remedies should fail, and the disease run on
obstinately to the second stage, I would recommend large doses of opium to
allay the pain, and calomel in the ordinary quantity, with a view of exciting
salivation. C.
j- Active purging is very useful in this disease. I have also known much
of management, but in the progress of the
complaint, it may by prudent efforts be aided in convales-
cence, by cheerful conversation, light reading, music, and
afterwards by daily walking and change of scene.*
* In the management of this disease, we are to observe the same rules as
are applicable to mania generally. It would seem, however, to be more fre-
quently attended with extreme nervous irritation, than inflammatory action.
in the former state, I have seen the most manifest advantage from large and
repeated doses of the tincture of hops, where opium only aggravated the
symptoms. In the latter state, we should bleed and purge as long as there
is increased excitement Blisters to tlie head, and to the extremities, in
either state will be beneficial. They will alike allay nervous irritation, or
subdue inflammatory action, and thus produce calmness and ease. They are
eften, especially in mania, if applied in the proper condition of the system,
180
Some are peculiarly liable to this disease after delivery,
in consequence of the irritable state of the nervous system at
that time. In such cases, the patient must be carefully
watched after parturition. Every irritation must be removed,
every source of alarm or agitation obviated, and the cam-
phorated julap with gentle laxatives will be proper remedies,
these being the most powerful means of diminishing the ex-
cessive irritability of the nervous system. The diet is also
to be regulated. If the patient do not sleep well, hyoscya-
mus should be given. It is often of service to get the patient
up as soon as can be done with safety, and have the mind
occupied with such amusements and pursuits as keep it equal-
ly exercised, without risking any irritation.
Melancholy usually comes on later than furious delirium.
The disease differs nothing in appearance and symptoms
from melancholy madness occuring at other times. It is ob-
stinate, but generally goes off after the child is weaned, and
the strength returns. It is therefore proper to remove the
child, and send the patient to the conntry as soon as possi-
sible. In some instances, both kinds of madness seem to be
dependent on a morbid irritation, such as inflammation of
the mamma, &c. Here our attention must be directed to the
cause.
Inflammation of the brain usually appears still earlier than
delirium, from irritation. It may be caused by determina-
tion of blood to the head, or preternatural irritability of the
sensorium, or may occur in consequence of a constitutional
tendency to mania. It must be distinguished from puerperal
delirium which is seldom dangerous, whilst this is a most
fatal disease. It generally appears within the third day
after parturition, but it may also take place later. The pulse
usually continues frequent from the time of delivery. The
patient does not sleep soundly, and indeed is watchful. She
soon complains of throbbing within the head, or in the throat,
or ears; then of confusion, hears acutely, dislikes the light,
and speaks in a hurried manner, and often is unusually in-
which is after the excitement is a Uttle reduced by previous blood-letting,
the best of our anodynes. C.
181
terested about some trifle. Then all at once furious delirium
comes on. She talks rapidly and vociferously, the eyes
move rapidly, are wild and sparkling, and very sensible to
the light, This state may continue, with little interruption,
till symptoms of compression appear, or there may be a
short interval of reason, but presently the furor returns, and
alternates perhaps with sullenness. The case is in these
respects modified according to the inflammation ; for some-
times it comes on rapidly and to a great extent, at other
times it proceeds more slowly. The lochia are not sup-
pressed, nor are the bowels bound, but the secretion of milk
ceases. In three or four days, she becomes paralytic in one
side, and then sinks into a low comatose state; the extremi-
ties become cold, the breathing laborious, and sometimes
convulsions precede death. This disease requires the prompt
and early use of the antiphlogistic treatment, general and
local blood-letting, the use of purgatives, and the application
of a blister to the scalp. The inflammatory symptoms being
subdued, the delirium abates, or goes off, by the use of reme-
dies formerly pointed out.
CHAP. XX.
Of Bronchocele.
Swelling of the thyroid gland takes place, so much more
frequently after parturition, than under other circumstances,
that it may with propriety be noticed here. It appears with-
in a few days after delivery, and is often attributed to expo-
sure to cold. In other cases, the woman feels during labour,
as if something had given way about the throat. It may re-
main long in an indolent and stationary state, being produc-
tive either of no material inconvenience, or only of a slight
difficulty of swallowing. In other instances, it augments in
size, and becomes dangerous from its pressure on the neigh-
bouring parts; or it inflames, forms a large abscess, and
182
bursts. Enlargement of the left lobe is more dangerous than
that of the right.*
Various remedies have been employed, such as burnt
sponge, calomel, muriate of lime, &c. but these have seldom
much effect. Repeated blisters, and long continued friction,
are more useful. If the tumour threaten to enlarge, which
it often does, after every succeeding pregnancy, or even in-
dependent of gestation, it has been proposed to extirpate the
tumour, or to tie the arteries going to it. If there be a ten-
dency to suppuration, it ought to be encouraged, and treated
on general principles.
* There is an intimate connexion between the thyroid gland and the brain.
It is well known, that, very generally, one of the most remarkable symp-
toms of bronchocele is a gradual, though certain, decay of the intellectual
faculties. This is strikingly exemplified in the Cretans of the Alps. The
goitre, with this miserable race of people, is commonly, if not always, attend-
ed with idiotism. In the lower animals, if the gland be removed, a train of
nervous affections will speedily follow, and finally fatuity, or a total extinc-
tion of mind. This has been proved by a series of experiments made, as
I have understood, by the celebrated Mr. Cooper of London. As soon as I
heard of these facts, it occurred to me as being not at all improbable, that
one of the hitherto unknown uses of this organ, might be to stay tlie circula-
tion in cases of undue determination of blood to the head. I was assisted
to this inference by the recollection of having seen it somewhere remarked,
that in the cases alluded to, the gland is uniformly swelled more or less with
blood. If, as it now seems to be admitted, that tlie brain requires a certain
proportion of blood for the regular performance of its functions, and that
these will be equally impaired by any excess or deficiency of it, we can have
no difficulty in conceiving how the brain becomes affected, either by an en-
largement or total extirpation of the gland.
With respect to the production of puerperal bronchocele we have an ob-
vious explanation. During parturition, and particularly if it be laborious,
there is very frequently an afflux of blood to the head, and, as may be ob-
served, a considerable distension of the thyroid gland. By this distension,
which occasionally is so great, as to induce the woman to believe, " that
something lias given -way about her throat," the gland is relaxed ; it receives
thereby a larger quantity of blood, which necessarily nourishes a morbid
growth of the part. C.
183
CHAP XXI.
Of Diarrhoea.
If the patient have been costive before delivery, large mas-
ses of faeces may come down afterwards, producing violent
pains in the belly, piles, tenesmus, or uterine hemorrhage ;
or the same cause may excite diarrhoea with the passage of
scybala. Both states require the use of gentle laxatives.
Diarrhoea may also occur without previous costiveness; the
stools are then foetid or bilious. In this case the diet is to
be' strictly regulated; gentle laxatives are to be first given
to evacuate the offensive matter, and then opiates are to be
immediately resorted to. If neglected, great weakness,
uterine hemorrhage, or other serious consequences may be
produced. When it is accompanied with bilious vomiting,
and cramps or spasms, opiates are the principal remedy,
and these must, if vomited, be given in the form of clysters.
CHAP. XXII.
Of Inflammation of the Mamma, and Excoriation of the Nipples.
Inflammation of the mamma may take place at any
period of nursing, but is most readily excited within a month
after delivery. It may be excited by the direct application
of cold, retention of the milk in consequence of sore nipples,
mechanical injury, or it may occur in that febrile state, called
weed. In general, the inflammation, however extensive it
may afterwards become, is at first confined to a small spot.
It may take place in the cellular substance alone, or it may
affect the gland; it may be attended with much general swel-
ling of the breast, or the tumour may be very circumscribed;
it may run its course rapidly, or very slowly; and when
abscess forms, and the integuments burst we may have mat-
184
ter alone discharged, or there may be a slough of considera-
ble magnitude found within the abscess. This proceeds from
the destruction of one or more of the glands, which, if the in-
flammation run high, do not suppurate, but die. Usually,
there is a considerable degree of fever attending the com-
plaint, and the pain is often severe, especially when the
breast is extensively affected. It is a very difficult thing to
prevent this inflammation from ending in suppuration. It is
to be attempted, however, by purgatives, and the application
of cloths wet with pretty strong solution of acetate of lead,*
which, however, ought not to be cold, as that might excite
shivering ; or we apply a tepid saturnine poultice. If there
be only a little diffused fulness with some degree of pain,
gentle friction with warm oil is useful. If the breast be dis-
tended with milk, it will be proper to have a little taken away
occasionally, provided this can be done easily, and without
increasing the pain. Our object in doing so, is to diminish
the tension, and prevent farther irritation from accumulation
in the vessels. The breast is also to be carefully supported,
and indeed the patient will be easiest in bed. When the pain
becomes throbbing, a warm bread and milk poultice is proper
to assist the suppurating process. After matter is formed,
it ought to be freely let out, by an opening of sufficient
size, provided there be no appearance of the abscess burst-
ing soon of its own accord. This prevents insinuation of
matter in the cellular substance of the breast. If the punc-
ture be followed by a troublesome oozing of blood from the
wound, dry lint and compression must be used. In one in-
stance, 1 knew the hemorrhage prove fatal. After the abscess
bursts, or is opened, there is for some time a discharge of
purulent matter, which frequently is mixed with milk; then
the surrounding hardness gradually abates. The poultice
may be continued for several days, as it promotes the absorp-
tion of the indurated substance; but if it fret the surface, and
encourage a kind of phagedenic erosion, it is to be exchanged
I know of nothing so good in these cases, as bathing tlie breast with a
mixture of laudanum, brandy, and hartshorn. C.
185
for mild dressings. A little fine lint is to be applied on the
aperture, but not so firmly as to confine the matter; and over
this, a cloth spread with spermaceti ointment; great attention
is to be paid to the evacuation of the matter, and the preven-
tion of sinuses.
In some instances the milk soon returns, and the patient
can nurse with tlie breast which was affected, but more fre-
quently it does not, and the child is brought up on one breast.
It may even be requisite, if the fever and pain be great, and
the secretion of milk much injured, to take off the child al-
together.
If the management be negligent, or the constitution bad, it
sometimes happens, that extensive suppuration, or numerous
abscesses take place. The breast becomes altogether consi-
derably diseased, and the discharge is very foetid. In such
eases, hectic fever, and great debility are induced. It is in
general proper to remove the patient to the country, and give
bark or tonics internally, with nourishing diet and wine. Si-
nuses must be laid open from the bottom, or counter-openings
must be made, and the sores dressed according to the general
rules of surgery. Even although there be not much ulceration
or any appearance of scrophulous induration, the strength
may, from an extensive abscess, or protracted sore, be much
diminished, and hectic induced, which is to be removed by
the means commonly employed, or already pointed out.
Sometimes, although the abscess heal readily, and have
been small, an induration remains, which either may con-
tinue long indolent, and cause apprehension respecting future
consequences, or it may occasion a relapse. It is to be re-
moved by gentle friction with camphorated spirits three times
a-day, and the application, in the interval, of cloths wet with
camphorated spirits of wine, with the addition of a tenth part
of acetum lythargyri. In more obstinate cases, mercurial
friction, or a gentle course of mercury may be tried, but I
cannot speak with any confidence of the effect. The bowels
should always be kept open.
After, an abscess heals, it is not uncommon for the breast
to swell a little at night from weakness, and the same cause
vol. it. B B
186
renders a relapse easy. It is therefore proper to invigorate
the system, and defend the breast for some weeks more
carefully than usual from cold. When a relapse takes place,
especially if**the patient be not nursing, the tumour is some-
times pretty deep or indolent, is for a long time hard to the
feel, and gradually extends more through the breast, form-
ing a pretty large substance, not unlike a scirrhous or scro-
phulous gland. But during this time, suppuration is slowly
going on, though there may be little pain. At last a more
active change takes place, the pain increases, becomes throb-
bing, the skin red, and, finally, the abscess bursts. This
state requires the application of warm poultices and hot
fomentations.
Excoriation of the nipple is a very frequent affection, and
often excites that disease we have just been considering. The
ulcer may be extensive, but superficial; or it may be more
circumscribed, but so deep as almost to divide the nipple.
When the child sucks, the pain is severe, and sometimes a
considerable quantity of blood flows from the part. In some
instances, an aphthous state of the child's mouth excites this
affection; in others, excoriation of the nipple affects the
child. A variety of remedies have been employed. Spiri-
tuous, saline, and astringent lotions have been used previous
to delivery, with a view of rendering the parts more insensi-
ble ; they have not always that effect, but they ought to be
tried.(6) When excoriation takes place, fifteen grains of
sulphate of zinc, dissolved in four ounces of rose water, form
a very useful wash, which should be applied frequently. So-
lutions of sulphate of alumine, acetate of lead, sulphate of
copper, nitrate of silver, &c. in such strength as just to smart
(6) In one instance which has been related to me by a respectable phy-
sician of this city, the suction of the nipple by a young puppy for about one
montli preceding parturition, had the most complete success in preventing
the excessive soreness and sufiering to which the.lady hud been subjected,
in consequence of her previous labours. This, though to some it may per-
haps appear an unpleasant preventive, yet is certainly worthy of the at-
tention of those who have often experienced the .extreme anguish arising
from this variety of disease.
187
a little, arc also occasionally of service; and it is observa-
ble, that no application continues long to do good. Frequent
changes, therefore, are necessary. The nipple should al-
ways be bathed with milk and water, before applying the
child. When chops take place, dressing the part with lint,
spread with spermaceti ointment, is sometimes of use. A
combination of white wax, with fresh butter or melted mar-
row, with or without vegetable additions, form popular ap-
plications. Stimulating ointments, such as ung. hyd. nit.
diluted with axunge, are sometimes of service; or the parts
may be touched with burnt alum.(c)
It is often useful to apply a tin case over the nipple, to
defend it, or a chalk cup, which absorbs the discharge, or
broad rings of lead or ivory. It is also proper to make the
child suck through a teat fixed on a metallic nipple, that the
irritation of its tongue or mouth may be avoided. This
often is of great service, but it does not always succeed;
and some children cannot suck through it. The assistance
of a nurse to suckle the child through the night is useful.
But although the nipples ought to be saved as much as pos-
sible, yet if we keep the child too long off, or permit the
breast to become much distended, inflammation is apt to
take place. When all these means fail, it is necessary to
take off the child, as a perseverance in nursing exhausts the
strength, and may excite fever. The part then heals rapidly.
Venereal ulceration of the nipple or areola, accompanied
with swelled glands in the axilla, and a diseased state of the
child's mouth, require a course of mercury.
It may be proper, before concluding this chapter, to add
some remarks on causes disqualifying a woman from nursing.
If the nipple be very flat, and cannot by suction be drawn out,
so that the child can get hold of it, the woman cannot nurse.
A glass pipe, however, frequently used, sometimes remedies
this defect. A deficiency of retentive power, so that the milk
(c) Richter recommends touching the ulceration of the nipple with the
lunar caustic, and Dr. Ilartshome informs me he has tried this with success
in several cases, where every other application had failed giving relief. The
caustic should be applied once every two day.
188
runs constantly out, is another disqualification, and it is not
easy to find a remedy. When the milk disagrees with the
child, having some bad quality, we are also under the neces-
sity of employing another nurse. If the mother be very deli-
cate, or be consumptive, or affected with obstinate melan-
choly, or have her eyes much inflamed, or the sight injured
hy nursing, or if the secretion be v ery sparing, she must
give up nursing. Some delicate women suffer so much from
nursing, that chlorotic, or phthisical symptoms are induced.
In this case, she must take off the cliild. Opiates are useful
at bed time, to procure sleep, and the bowels are to be kept
open. Many women, after deli very, are subject to disorders
of the alimentary canal, especially diarrhoea and worms.
These impair the health, and diminish the secretion of milk.
They are to be treated with the usual remedies. Anasarca,
jaundice, erysipelas, &c. may also occur in the puerperal
state, and prevent nursing. The ordinary methods of cure
are to be employed.
When a woman weans a child, or from the first does not
suckle it, it is usual to give one or two doses of some purga-
tive salt, by way of lessening the secretion of milk. The se-
cretion is also checked by keeping off the child ; but if the
breasts be very much distended, so much must be taken
away occasionally, by suction, or milking the breast, or ap-
plying a warm glass bell, as relieves the feeling of tension or
pain. If this be neglected, inflammation may be excited.
CHAP. XXIII. .
Of Tympanites.
In consequence of affection of the menstrual action, or
after confinement, especially if the patient be exposed to cold,
the bowels become inflated, and the belly is slowly distended,
without pain. This may also happen during nursing, or to-
wards the cessation of the menses, giving rise in either case
to an idea that the woman is pregnant. This complaint is not
189
productive of bad health, but occasionally it causes acidity,
and other dyspeptic symptoms, and it is moreover very un-
seemly. The enlargement is always increased about the
menstrual period, if menstruation continue. It arises from a
relaxation of the muscular fibres of the intestines, and may
not only appear as a peculiar disease itself, but also accom-
pany many puerperal affections, particularly of the febrile
kind, although there be no inflammation of the bowels.
It is best prevented by keeping the bowels in a regular and
active state, paying attention to the application of an abdomi-
nal binder after confinement, and avoiding exposure to cold,
and other exciting causes of disease.
After it has taken place, it is exceedingly difficult to accom-
plish a cure. Brisk purgatives, the regular use of aperients,
so as to excite a uniform, but not powerful action, carmina-
tives, squills, turpentine, mercury, Harrowgate waters,
stimulating embrocations, regular compression, tonics, and
sea bathing, have all been tried, but upon none of them can
I place any great reliance.
CHAP. XXIV.
Of the signs that a woman has been recently delivered.
We discover that a woman has been recently delivered, by
finding that the external parts are relaxed, and redder, or of
a darker colour than usual. There is a sanguineous or lo-
chial discharge. The uterus is enlarged, and has neither the
shape of the gravid nor unimpregnated uterus; the cervix is
indistinct, and the os uteri is nearly circular, and will admit
two or more fingers. The abdomen is prominent, and the in-
teguments relaxed, wrinkled, and covered with light-colour-
ed broken streaks. The breasts are enlarged, have the areola
very distinct, and contain milk; but it is possible for this se-
cretion to take place independently of pregnancy.
By examination per vaginam, within a fortnight or three
weeks after delivery, the uterus may still be felt larger than
190
usual, its lips softer, and capable of admitting the point of
the finger without much difficulty. The milk at this period
will not have left the breasts, which are firm, and have a dark
areola round the nipple. A question here occurs. May not
all these appearances take place merely from hydatids? I re-
ply, that hydatids certainly may produce the same effects
with gestation, because they do very frequently spring from
conception. It is, however, very rare for the belly to be en-
larged to the same degree as in the end of pregnancy, and
when the mass is expelled, as it is soft, the perineum cannot
be injured. If then it can in a criminal case be proved, that
the woman had the belly greatly enlarged, and if afterwards
she is found with the breasts containing milk, the uterus
large, and its mouth soft and open, and part of the perineum
torn, or the fourchette torn, there can be little doubt that she
has borne a child. Other circumstances may also concur in
confirming the opinion of the practitioner; as, for instance,
if the patient give an absurd account of the way in which her
bulk suddenly left her, ascribing it to a perspiration, which
never in a single night can carry off the great size of the
abdomen in the end of a supposed pregnancy.
Vevy contradictory accounts have been given by ana-
tomists, of the appearance and size of the uterus, when in-
spected at different periods, after delivery. If the woman
die of hemorrhage, or from any cause destroying her, soon
after delivery, the uterus is found like a large flattened pouch,
from nine to twelve inches long. The cavity contains co-
agula or a bloody fluid, and its surface is covered with re-
mains of the decidua. Often the marks of the attachment of
the placenta are very visible. This part is of a dark colour,
so that the uterus is thought to be gangrenous, by those who
are not aware of the circumstance. The surface being clean-
ed, the sound substance of the womb is seen. The vessels
are extremely large and numerous. The fallopian tubes,
round ligaments, and surface of the ovaria, are so vascular,
that they have a purple colour. The spot where the ovum
escaped, is more vascular than the rest of the ovarian sur-
face. This state of the uterine appendages continues until
the womb has returned to its unimpregnated state.
191
A week after delivery, the womb is as large as two fists.
At the end of a fortnight, it will be found about six inches
long, generally lying obliquely to one side. The inner sur-
face is still bloody, and covered partially with a pulpy sub-
stance, like decidua. The muscularity is distinct, and the
orbicular direction of the fibres round the orifice of the tubes
very evident. The substance is whitish. The intestines
have not yet assumed the same order as usual, but the dis-
tended cacum is often more prominent than the rest.
It is a month at least, before the uterus returns to its un-
impregnated state, but the os uteri rarely, if ever, closes to
the same degree as in the virgin state.
We know that the woman has had a recent miscarriage,
by the state of the breasts, the sanguineous discharge from
the vagina, the size of the uterus, and the softness and dila-
tation of its mouth. If the woman die, the womb is found
enlarged, its inner surface covered with the decidua, or ma-
tern. 1 portion of the placenta. The vessels are enlarged, the
tubes and ligaments very vascular; the calyx of the ovum is
bloody. This at a more advanced period, forms a kind of
cicatrix, or a dusky yellowish body, called corpus luteum.
This mark may exist, although the woman have not bo*-ne a
child, for the ovum may be blighted, perhaps even in the
ovarium. It has been conjectured by some, that it may be
produced even without sexual intercourse, but this point I
cannot determine. I apprehend, however, that in such cases,
the marks are not real corpora lutea; they have not ever
been injected.
These appearance during life, or after death, which occur
from a miscarriage, may also arise from the expulsion of hy-
datids, which usually are produced by the destruction of an
ovum, in which case, even a distinct corpus luteum may be
discovered.
BOOK rv.
OF THE MANAGEMENT AND DISEASES OF CHILDREN.
CHAP. I.
Of the Management of Children.
§ 1. OF THE SEPARATION OF THE CHILD AND THE TREAT-
MENT OF STILL-BORN CHILDREN.
When a child is born, the first thing to be done is to as-
certain if it breathe or be alive. If it cry or breathe vigorous-
ly, then it may be safely separated from the mother.* This
is done, by tying the navel-string about half an inch from the
navel ;(rf) another ligature is applied an inch nearer the pla-
centa, and the cord is divided between these with a pair of
scissars. In some countries, the division is made with a
sharp flint, in others, by means of fire. The necessity of ap-
plying a ligature has been denied by different practitioners;
* Dr. Denman, from observing that some children, after they had begun
to breathe, had respiration checked, and died after the cord was tied, ad-
vises, that the ligature should never be applied till the pulsation cease. But
when the child is vigorous and cries lustily, there is no occasion for delaying
so long; nor have I ever known any bad effect result from this practice. It
has been supposed, that as long as pulsation continued, the function of re-
spiration was imperfect; but it is not so : the pulsation depends more on
the continuance of the vitality or action of the placenta, than on the state of
the lungs.
(«/) This is rather too near the navel, for in case of the ligature cutting
tlirough the cord, and hemorrhage consequently taking place, which has
sometimes been known to occur, there will scarcely be room left to apply
another ligature between the former one, and the abdomen of the child. It
is best therefore to apply the ligature, in a general way, at about three fingers
breadth from the navel; this leaves sufficient space for the application of
another ligature if necessary.
193
but it has sometimes been found, that when the ligature had
become slack, a considerable quantity of blood was lost, and
even fatal hemorrhage has taken place.
When a child does not breathe soon after it is born, it is
not always easy to say whether it is alive, for we have, at this
time, no criterion of death except putrefaction; and, there-
fore, it behoves us always, unless this" mark be present, to use
means for preserving the child, by which some have been
saved, after being laid past as dead. Children may be born
apparently dead, in consequence of the head having remained
long in the pelvis, or having been squeezed in a deformed
pelvis; or owing to the cord having been compressed, either
during the process of turning and delivering a child, or from
its having descended before the presenting part of the child,
or being so situated during labour, as to be compressed by
the uterus. Some children die, owing to the head being born,'
covered with the membranes, sometime before the body.
This is the consequence of inattention, for, if the membranes
be removed from the face, there is no risk of the child. In
whatever mode children are still-born, the effect is referable,
either to compression on the cord, first suspending, and then
destroying animation; or to pressure on the brain; or to a
state of insensibility and feebleness, preventing the action of
respiration from taking place after birth.
In determining on our treatment of still-born children, our
first object ought to be, to ascertain if the circulation be still
going on in the cord.
If the pulsation have stopped, no good can accrue from al-
lowing the child to remain connected to the mother. The
cord is to be immediately separated, and means used as
shall immediately be mentioned, for the induction of respira-
tion.
If pulsation continue, the child is not in danger from want
of respiration, for the foetal mode of living is continuing.
The cause of stillness, then, is most likely a kind of syncope,
or torpor, which prevents the action of respiration from being
established; or it may be from compressed brain. In both
cases, the skin is purple, from the blood not having been ar-
VOl. II. c c
194
terialised, and we have no mark of distinction till respiration
begin. It is very common, in the first case, for the child to
be still for a minute or more; then it makes a slight sob, and
breathes low, with a sound of fluid in the throat; and then,
of a sudden, respiration becomes perfect. In the second case,
respiration, after it begins, continues longer oppressed, and
may perhaps stop, the child dying in a short time.
When the cord pulsates at the time of birth, we are never
to be rash in dividing it. It is of importance to keep up the
foetal circulation, till the new mode of acting can be establish-
ed, and we ought not completely to divide the cord in such
cases till pulsation stop; because, if respiration should flag,
we have the placenta as an auxiliary, if the connection still
exist, and the pulmonary action being suspended, the foetal
mode will continue, and support life till respiration become
Vigorous; for the two modes of changing the blood are not
incompatible. Pulsation will no doubt at length stop, either
from the heart of the child stopping, or the placenta being
detached from the uterus, and its function being lost; but as
long as pulsation continues, and the child does not breathe
perfectly and regularly, no ligature should be applied. If,
however, respiration do not begin, we are to open with a lan-
cet or scissars, one of the umbilical arteries, from which
blood spouts in a small stream ; and, in a short time there-
after, breathing commences. If it should not, some method
must be adopted for exciting respiration, such as WTapping
the cliild in warm flannel whilst it is still in bed; friction,
especially over the thorax, with the hand, or strong spirits ;
'applying spirits to the nostrils with a feather ; or giv ing a
gentle concussion to the body, as, for instance, by slapping
the back. But the most effectual remedy is inflating the
lungs, by blowing either through the barrel of a quill, or ap-
plying the mouth directly to the child's mouth, at the same
time that the nostrils are held, and the cartilages of the
trachea pressed gently back to obstruct the oesophagus. The
attempt at inflation is to be alternated with pressure on the
thorax, to force the air out again. If, by this time, the pul-
sation have stopped in the cord, and the child do not recover,
195
the cord is to be divided, for connection with the placenta is
useless after the circulation stops. The cord is not to be
tied, but only a loose ligature put round it; then it is to be
divided, and the child removed to the fire, or put in warm
water, and the artificial respiration sedulously continued.
An injection is also to be administered, and if electricity
could be employed, there is ground for thinking that it would
be beneficial. Should the child, by these means, or after a
longer time, begin to breather a little blood will most proba-
bly issue from the cord, and the quantity will increase. If
this seem to assist the breathing, and make the child more
active, it is to be permitted to proceed to the extent of
two or three tea spoonfuls : but if it do not manifestly pro-
duce a good effect soon, it is to be stopped with a ligature,
that it may not throw the child back into a state of inaction.
Even when it is of service, it must be kept within bounds,
otherwise dangerous debility will be the consequence.* It
will be chiefly useful when the breathing does commence, but
is slow and oppressed, with stupor, indicating affection of the
brain.
If the shape of the head be much altered, it has been pro-
posed, whilst other means are employing, to attempt slowly
and gently to press it into a more natural shape, but of the
good effect of this I cannot speak from my own experience.
In footling cases, it has been supposed, that extension of the
spine was a cause of death, but this, I apprehend, is seldom
the case.
It often is desirable to know, whether a child has been
born alive, and destroyed afterwards; but the signs are ex-
tremely uncertain. When, therefore, the life of the mother
is at stake, we must be very circumspect in forming our
opinion. If the lungs be solid and sink in utero, the child
certainly has not breathed; and although respiration may,
from the first, be prevented by the midwife, it cannot by the
mother. If the head be much misshapen, there is additional
* It is occasionally of service, inweakly performed respiration to give some
gentle cordials or stimulants.
196
ground for believing the child to have been still-born, and
if clothes have been made for the infant, it is to be presumed,
that the mother intended to have preserved it. When, on
the other hand, the child ha3 a healthy look, and has been
recently born, the lungs swim in water, and their air-cells
universally contain some air, giving a frothy appearance to
the mucus squeezed out of them, there is no doubt that the
child has breathed. But we cannot from these circumstances
say, that it has been intentionally deprived of life. Some
corroborating facts must be necessary to fix this point, such
as the birth having been concealed, and no preparation made
for preserving the infant; the cord being untied, by which
it has been allowed to bleed to death; or its being cut longer
or shorter than would have been done by a midwife, marks
of violence on the child, with the total want of all excul-
patory evidence, (f)
When the child has not been recently born, or is putrid,
the lungs are also putrid, and contain air, although the child
have never breathed. They swim in water, and the investing
pleura is emphysematous.
§ 2. OF CLEANLINESS, DRESS AND TEMPERATURE
After the child is separated from the placenta, it is to be
wrapped up in a piece of soft flannel called a receiv er, and
given to the nurse. Next, the soft white incrustation, which
(e) For a more full, and extensive view of this subject, and its application
to questions of Medical jurisprudence, the reader is referred to a very in
teresting Memoir "On the Uncertainty of the signs of Murder, in tlie 'case
of bastard children; by the late William Hunter, M. D. &c. Medical Obser-
vations and Inquiries, by a Society of Physicians in London. Vol. VI p 266
& seq." As also, to those chapters of Mahon's and Fader's works, wliich
treat on the same subject From the valuable paper above referred to it
will be seen, that the physician who in these cases, makes up his opinion
with the greatest caution and circumspection, and in deciding, where a leeal
dedsion is called for, leans rather to tlie side of mercy, will most probably
act so as to satisfy his own conscience, as well as the demands of enlighten-
toZT 4^ ** Mah°U MedeCi"e ^^ V0L 1L Art' Dodmas^ PuI"
197
generally covers the skin, is to be gently and delicately re-
moved, by ablution with tepid water, and the use of a sponge,
and sometimes of a little soap. It is not necessary to remove
every part of this, nor make such attempts as will fret the
skin; but in every instance, and especially if there be reason
to suspect that the mother has had gonorrhoea or chancre,
the surface should be washed. It is also customary, with
many nurses, to bathe the body, or at least the head, with
spirits, a practice which can serve no useful purpose, but may
be attended with mischief. The child being dried, it is usual
to wrap a bit of soft rag round the remains of the navel
string, and retain this by means of a bandage brought round
the belly. It is alleged, that this is necessary to prevent um-
bilical hernia; but hernia does not take place because the
child is not bandaged, but because the umbilicus is unusually
wide; and in those countries where no compress is used,
hernia is not a frequent complaint. A tight bandage pro-
duces pain, difficulty of breathing, and other deleterious ef-
fects. The only purpose to be derived from a bandage is to
retain the rag, which is, for the sake of cleanliness, applied
round the cord.
It was at one time the practice to wrap the child very
tightly round the whole body, and to stretch both the arms
and legs, whilst the head was secured by tapes, passing from
the cap to the body. A more easy method is now adopted,
and it seems to be agreed upon, that the more simple and
loose the dress is, the more comfortable will the child be.
Nurses are peculiarly afraid of the head being cold, and
therefore are apt to keep it too warm. In summer one cotton
cap, I believe, is sufficient to preserve the heat, but in winter
an under cap may be added, but neither of these ought to be
secured by pins. Soft tapes are preferable, for this and every
other part of a child's dress. The rest of the clothing con-
sists of a short shift and a wrapper of fine flannel, which is
better for a week or two than the separate pieces of dress em-
ployed by many, and which add to the time and trouble of
shifting the child. All children cry when shifted and dressed,
therefore the shorter and simpler that the process can he
198
made, the better. Last of all, a cloth is to be applied, to re-
ceive the faces or urine, and this is to be removed the mo-
ment it is soiled. By attention, a child may very early be
taught to give indication when he wishes to void urine or
faeces, and can then be held over a pot or bason. It is pro-
per to encourage the child to use these at regular intervals.
Children should have their bottom and thighs washed and
wiped dry, always after soiling themselves. The whole body
ought likewise to be regularly washed, morning and evening,
with a sponge and water, at first rather tepid, but soon
brought to be cold, at least of the temperature that cold water
has in summer. But although this is a general practice, yet
some children do not agree with it, being languid, cold, and
pale, after being washed, and these ought to have the water
warmed a little. Plunging the child into cold water, is per-
haps, in this country, for some weeks, rather too violent a
shock, but about the third month, it will be proper to do so
daily.
The temperature in which children are kept, should be such
as neither to increase nor diminish the natural heat of the sur-
face. The child in utero is placed in a temperature of about
96 or 98 degress ; but its power of generating heat is proba-
bly much less than after birth. The heat of the room, and
the quantity of bed-clothes, should be nearly such as would be
agreeable to a healthy adult. Depressing heat is to be avoid-
ed on the one hand, and exposure to cold on the other. The
apartment should be well ventilated, but the infant ought not
to be exposed to the open air, for nearly a month in winter,
as it is apt to produce convulsions, or catarrh, with fever,
or bowel complaints.
§ 3. OF DIET.
It is customary to give some food before the child be ap-
plied to the breast, and very frequently medicine also, such as
salt, magnesia, or manna, to purge off the meconium. The
absolute necessity of either of these practices may perhaps be
questioned, especially if the mother be able to suckle at the
199
usual time. A little milk and water is at all events sufficient;
and with respect to laxatives, I believe that they are seldom
necessary. If, however, the meconium do not come freely
away, and the child have no stool in twelve or sixteen hours,
or seems to be oppressed, or troubled with pains, a little man-
na may be given with much advantage;(/) but generally the
milk which is first secreted, called colostrum, is sufficiently
powerful. When the bowels begin to act, and the bile is
plentifully secreted, it is usual for the child, in consequence
of absorption of bile, orperhaps of meconium, to have a yel-
low tinge on the skin which is called the gum. This is some-
times attended with a drowsy state. Jf it require any medi-
cine at all, it is a gentle laxative.
All children are intended to be brought up on the breast,
and they ought to be applied early, generally, betwixt twelve
and twenty-four hours after birth. Some mothers, however,
cannot, and others will not, suckle* their children, but em-
ploy another nurse,1 or bring the child up on the spoon. If
the latter mode is to be adopted, it is necessary to determine
the proper diet, and the best mode of giving it.
It is evident that the diet which will be most suitable for an
infant, is that which most nearly resembles the mother's milk.
It is not sufficient that we merely give it milk, it must be
milk similar to that of the human female. It is certain, that
the lacteal secretion of each species is best fitted for the
young of that species; and we know that there is a great
diversity both in the flavour, and proportion of the component
parts, of different milk. Yet, in many cases, the milk of one
animal will agree with the young of a very different species.
Thus a levret has been suckled by a cat. Milk consists of
cream, curd, and whey; and the whey, the greatest portion
of which is water, is the only part that becomes sour. The
quantity of cream is greatest in ewe's milk, next in that of
(/) Or what is much better, a little mild oleum ricini, or even olive oil.
* Van Helmont, and after him, Brouzet and others, have advised, that chil-
dren should not be brought up on the breast, but fed on asses and goats
milk, or a panado made of bread boiled in small beer, and sweetened with
honey.
200
women, the goat, the cow; and then the ass and the mare.
The proportion of whey is greater in the milk of mares and
women, than of the cow or the sheep. With regard to the
caseous part, it is greatest in the milk of sheep, the goat, the
cow, the ass, the mare, in the order which they stand; and
it is little in that of women. Sugar again is most abundant in
the milk of the mare and woman, and less so in that of the
goat, the sheep, and the cow. Women's milk contains more
cream, than cow's milk, yet no butter can be made from it
It contains much whey, and yet it scarcely ever becomes sour
by exposure to air, and does not pass either to the vinous or
putrefactive fermentations. Acids do not coagulate human
milk.
From these remarks it follows, that if a child is not suckled,
the best food will be milk, resembling that of women, and the
nearest is asses; but as this cannot always be procured, we
must change that of cows, so as to diminish the proportion
of curd, and increase that of sugar and cream, which is done
by adding an equal quantity of water, or sometimes of new
made whey, a sixth part of fresh cream, and a little sugar.(#)
This is to be mixed just as it is required, for by standing it
acquires bad properties. It is not to be given with the spoon,
but the child is to suck it, of a proper heat, out of a tea-pot
which is made for the purpose, and which has a piece of soft
cloth tied over the perforated mouth. This diet may be oc-
casionally alternated with a little weak veal or beef soup.
Panado, made with crumb of bread, is not proper; and food,
made with unbaked flour is still worse. In the third month,
we may, besides the milk and water, and light soup, give oc-
casionally a little spoon-meat, such as panado made with the
crust of fine bread, and a little salt, which is better than
sugar, care being taken to break down the lumps completely.
(g) Or a very good substitute may be found in the combination of equal
parts of barley-water, and fresh cow's milk sweetened with the best refined
loaf-sugar. And here we may mention, that brown sugar should never be
used in the food of infants, as it readily runs on into fermentation, generating
gaseous flatulency, in the primx \\x and often producing great uneasiness
and colicky pains. When the child is habitually costive, the food may be
sweetened with manna instead of sugar.
201
This to be mixed with milk. Sago, salep, calves-feet jelly,
&c. are also very proper; and as the child advances in life,
eggs in the form of light custard, &c. are allowable. Some
have proposed a panado made with the flour of wheat malt.
By attention, a child may be taught to eat at pretty regular
hours,* especially after he is a few months old; and great
care should be taken, that he do not eat too much at a time.
If the child is not suckled, we ascertain that the artificial
diet is agreeing with him, if he be lively and easy, and the
bowels are correct. But when it does not suit, as is too
often the case, he is either dull and heavy, or cries much,
and often the bowels are either bound or too loose; and
in both states the stools are foetid, and have a bad ap-
pearance. If this condition of the bowels cannot be cor-
rected by medicines, the child in all probability will be lost,
if a nurse be not procured; convulsions, or diarrhoea will
carry him off.
When a child is brought up on the breast, there is no occa-
sion, if the supply be abundant, to give him any other nou-
rishment for three or four months. After this time, however,
it will be proper to give a little food of the kinds mentioned
above, and the proportion ought to be gradually increased, as
we proceed to the time of weaning, by which the organs of
digestion are enabled to accommodate themselves better to
the change of diet which then takes place. With regard to
the age at which a child should be weaned, it is not possible
to give any absolute rule. In general, the longer it is de-
layed, the better does the child thrive, provided the milk be
good. At all times, delicate, should be nursed longer than ro-
bust, children; and, if possible, weaning should not be made to
interfere with the development of teeth, nor be attempted in
the prospect of, or soon after the cure of, any debilitating
disease. If the mother's health permit, children may be
suckled from nine to twelve months. After the child is wean-
ed, the diet must be carefully attended to, and should consist
* It is also of advantage, that when a child is brought up on the breast, he
be not apphed at all hours indiscriminately; and no child should be allowed
to suck whilst the nurse is asleep, as he is apt to surfeit himself.
VOL. II. H B
202
of light soup, eggs, bread, and milk. In Ireland, potatoes
form a principal part of the diet. In Scotland, oat-meal por-
ridge is a common diet, and with many agrees very well;
but it is, notwithstanding, apt to be heavy and binding, un-
less it have an admixture of barley-meal, which corrects it.
As soon as teeth sufficient to masticate appear, a little animal
food may be given once a-day.
The dress of children, as they grow up, must be regulated,
in some respect, by the custom of the country, and the season
of the year. It ought always to be easy and warm. Mr.
Locke advises, that a child should wear thin shoes, and get
wet feet, that he may become hardy; but experience proves,
that the children of the poor, who are exposed to many priva-
tions and hardships, are not improved thereby. Cleanliness
is essential to health, and the whole surface should be washed
once a-day at least, and the hair daily combed and brushed,
which may prevent scald-head. The exercise should be pro-
portioned to the age. Infants sleep much, and can take no
exercise, if we except that given by their nurses; but when
they are about two months old, they may be placed on the
carpet, and encouraged to creep. When they are able to
walk, they should be allowed to run about freely; and it will
be of great advantage, where circumstances permit, that the
first years of life be spent in the country.
CHAP. II.
Of Gongenite and Surgical Diseases.
§ 1. HARE-LEP.
When a child is born, it is necessary to ascertain that it
have no congenite imperfection, or have met with no accident
during birth. I can here only make a few short remarks on
some of the most frequent and important imperfections. The
first I shall notice, is the hare-lip, which may exist in different
degrees, and be accompanied with a vacancy in the palate.
Sometimes, an operation has been performed soon afterbirth,
303
but it often fails, and occasionally the child dies. It is better
to delay it for ten or twelve months, or even longer. In the
meantime, the child must be brought up on the spoon, unless
the defect be so trifling, as to permit the child to suck a large
nipple.
§ 2. IMPERFORATED ANUS, &c.
Imperforated anus may exist in different degrees. There
may be an appearance of anus, but an obliteration a little
higher up. This is discovered, by introducing a bit of oiled
paper rolled up, which ought always to be done when the
child is long of voiding the meconium. If the paper be soil-
ed with faces, we may be sure that the rectum is pervious.
A blunt probe, cautiously introduced, will also ascertain the
state of the gut. Sometimes the anus is covered with a thin
membrane only. In other cases, a great part of the rectum
is wanting, or it terminates in the bladder of the male, or
vagina of the female, which last is not a fatal deviation. It
is proper always to make an incision at the anus, or at the spot
where it ought to open, if there be no mark of it; and this is to
be carried about half an inch or an inch deep. If no intestine
be found, a trocar or lancet may be passed a little deeper in
the proper course of the rectum. If, by any of these means,
the bowel be opened, a tent should be employed, to keep the
aperture from closing.* But if it be not readily found, we
are not to prosecute the dissection farther, but must form an
artificial anus, by making an incision at the lower part of
the left iliac region, sufficiently large to allow the colon to be
brought out, opened, and the extremity retained to the
wound.f
* In a case operated on by M. Cervenon, where the incision was obliged
to be carried an inch high, it was necessary to use a bougie for a year.
The child was enabled to retain the faeces, but the anus appeared as if it were
sunk an inch deeper than usual. Recueil Period. Tom. I. p. 36.
■j- Vide observations on this subject, by Dumas and Allan, in the Recueil
Period. Tom. III. p. 46, and 133, and a case in point by Duret, in Tom. IV.
p. 45.
30i<
Imperforated urethra is chiefly met with in the male sex,
and is to be remedied by an artificial opening in the proper
direction, if the urethra seem to be pervious to a certain ex-
tent. But if it be altogether wanting, relief in the meantime
must be obtained, by puncturing the bladder. Retention of
urine, not dependent on malformation, is readily removed,
by introducing a probe into the bladder. Deviations in the
• structure of the vagina and hymen have already been consi-
dered.
Imperforated meatus auditorius is very rare, and can sel-
dom be remedied, except there be merely a membrane stretch-
ed across the canal. Adhesion of the eye-lid is often com-
plicated with a defect in the eye-ball itself; but when this is
not the case, an operation will be advisable.
§ 3. UMBILICAL HERNIA.
Sometimes the umbilicus is peculiarly large, and hernia
takes place soon after birth, but still more frequently betwixt
the second and fourth month. Two modes of treatment may
be adopted. The first is compression, carefully maintained,
which should be always tried. This, in some instances, pro-
duces a radical cure; the umbilical opening contracting,
which it never does in adults. The second mode is, reducing
the intestine, and tying the sac with a single or double liga-
ture. It has also been proposed, to open the sac, and close
the umbilical aperture by pins or stitches; but this has no
advantage over the double ligature. Sometimes, a very
great portion of the intestines is found protruded at birth,
into the sheath of the cord. This may be complicated with
an imperfect or transparent state of part of the abdominal
parietes; but whether it be or not, the child generally dies
within forty-eight hours. The abdomen is too small to re-
ceive back the intestine quickly; and even although it could
be reduced, the child, if we may judge from experience, has
no great probability of existing. In one case, Mr. Hey
found the tumour burst during labour.
Other species of hernia are to be treated on general prin-*
205
ciples. The bowels are to be kept open, and violent exertion
avoided. The propriety of endeavouring to retain the bowel
with a bandage is doubtful, and unless it could be done very
effectually, it is evident that pressure must do harm. For the
bowel protrudes, and is pinched by the pad. This produces
pain arid local inflammation, and not unfrequently convul-
sions.
§ 4. SPINA BD7IDA.
Spina bifida is an imperfection of the vertebral canal and
the spinal marrow. The bone is deficient generally about the
lumbar vertebrae : a tumour is formed externally, which con-
tains a fluid, and the skin is usually livid. The marrow
stops at the commencement of the tumour, but sometimes
begins again below it; or small nervous twigs arise from the
inner surface of the sac, and pass out to form the nerves of
the inferior part of the body. This is a fatal disease, and
death is generally preceded by inflammation or gangrene of
the tumour. In some instances, the sac is open at the time
of birth. The tumour may either be or not be connected with
hydrocephalus internus. If the head be enlarged, there can
be no doubt of the existence of the latter disease, and nothing
ought to be done to the tumour of the spine. If the urine or
fseces be expelled involuntarily, or the inferior extremities
be paralytic, or the tumour have burst, or sloughed, no at-
tempt need be made for relief. Where these unfavourable
circumstances are absent, then two modes of treatment offer
for consideration, palliative and radical. The first consists
in treating the tumour as a hernia, that is gradually getting
the contents to retire within the vertebral sheath, if they are
not so great as to produce compression of the brain, and then
a compress or truss is applied. Or if the tumour be larger
than to permit of this, then a hollow compress, or hollow
piece of plaster of Paris, may be applied, at least in the fii-st
instance. This plan is only palliative, and never cures the
complaint, but it prevents increase. The second exposes the
patient to great danger from constitutional irritation, but if
206
it succeed, the cure is radical. It consists in repeatedly
puncturing the tumour with a needle, and drawing off the
water. At last, adhesion of the sides of the sac is produced,
and the opening from the spine is closed, the spine hanging
shrivelled over it, or becoming puckered at the part.(/»)
§ 5. MARKS.
Marks and blemishes are very frequent, and may be placed
(h) The very ingenious Astley Cooper, in some observations published in
the Medico-Chirurgical Transactions, Vol. II. has recommended two modes
of treating spina bifida, which in his hands have been attended with very
encouraging success ; one mode may be considered as palliative only, the
other as radical.
The first consists in treating the case as a hernia, and applying a truss to
prevent its descent. This truss, in the first instance, may consist of a piece
of plaster of Paris, somewhat hollowed, and that hollow partly filled with a
piece of lint, which is to be placed upon the surface of the tumour : a strip
of adhesive plaster is then to be applied, to prevent its changing its situa-
tion, and a roller is to be carried round the waist, to bind the plaster of
Paris firmly upon the back, and to compress the tumour as much as the child
will bear; after some months, a truss may be apphed, similar in form to
that which is sometimes used for umbihcal hernia in children, which must be
constantly worn.
The second mode of treatment, which is to be considered as radical, con-
sists in producing adhesion of the sides of the sac, so as to close the opening
from the spine, and stop the disease altogether. This is done by punctur-
ing the tumour with a needle, or any very fine pointed instrument, and thus
discharging the fluid contained in it Pressure by means of a roller, &c. is
then to be applied, and the operation of puncturing is to be repeated as of-
ten as the fluid re-collects.
The first mode Mr. Cooper observes, is attended with no risk. The truss
forms an artificial vertebra, when the natural is defective, a buttress which
supports the part, and prevents the increase of the disease ; but in this mode
of treatment, the truss is required in future life; for if discontinued, the tu-
mour re-appears, and will grow as hernia does, to great magnitude, but with
more fatal consequences. On the contrary, the adhesive mode of cure ex-
poses tlie patient to much constitutional irritation, but leaves him without
the apprehension, of the future return of the disease. It may also be ob-
served, that this mode does not prevent the subsequent attempt at the palli-
ative treatment, if the radical should not be successful. Nevertlieless, it is
confessed, that there are many cases of spina bifida, which do not admit of
a cure by these, or any other means. See Eclectic Repertory, Vol. III. p.
■HS, and seq.
207
on any part of the body. They are of two kinds: First,
simple discoloured patches, generally of a red colour, and not
elevated. These are not dangerous, but rarely admit of
cure. Second, elevated discoloured marks, which are of a
purple hue and very vascular. These are apt to increase,
and at last bursting, a fatal hemorrhage may take place.
They may be seated on the face, or in the lip, eye-lid, &c. or
on the spine, resembling spina bifida, but are more solid or
spongy, and the bone is not deficient. These ought to be
extirpated, as soon as they begin in the smallest degree to
increase. Small marks have occasionally been removed by
raising the skin with a blister, and then applying mild escha-
rotics, or by means of caustic*
* These congenite deformities have hitherto been considered as incura-
ble. This is true with regard to many cases; but there are others which
may undoubtedly be relieved. They seem to consist, as has been very in-
geniously suggested by Mr. J. Bell, in an aneurismal enlargement of the
vessels of the part. Adopting this suggestion, the celebrated Mr. Aber-
nethy has deduced a very plausible mode of treating these affections. There
can be no doubt, he says, " that the repletion, distension, and consequent
enlargement of the dilated vessels, depend upon a kind of inflammatory ac-
tion of the surrounding arteries; for if that be wanting, the mark ceases
to enlarge, and if present, it increases in size in proportion to the degree
of inflammatory action." The success of his practice is shown by the fol-
lowing cases.
A child about two months old was brought to St. Bartholomew's Hospital,
says Mr. Abernethy, with this unnatural enlargement of vessels, distributed
every where, beneath the fore-arm, from the wrist to the elbow; in a short
time it had swollen to that degree, that the circumference of the affected
fore-arm was twice the size of tlie other, the vessels being large and con-
torted.
The skin was of a dusky hue, and had not its natural smoothness of sur-
face. The heat of this fore-arm was much greater than that of the corres-
ponding sound one. Pressure forced the blood out of the vessels, and tem-
porarily diminished the bulk of the limb, and made it of a paler colour. The
effect of the following treatment, which it appeared to Mr. Abernethy, right
to institute, was tried. First, He was desirous of ascertaining whether a per-
manent and equable pressure would not prevent the distension, and conse-
quent enlargement of the turgid vessels; secondly, whether reducing the
temperature of the limb would not diminish the inflammatory action, upon
which their repletion seemed to depend. These two intentions admitted of
being readily accomplished. A many-tailed bandage of sticking phs' r
208
§ 6. SWELLING OF THE SCALP.
Children may, especially after tedious labour, be born with
a circumscribed swelling on the head. This seems to con-
tain a fluid, and has so well defined hard edges, that one,
who, for the first time saw a case of it, would suppose that
the bone was deficient. It requires no particular treatment.
seemed adequate to effect the first, and wetting the limb with water the
latter. These measures were judiciously carried into effect; the pressure
was first made slightly, and afterwards more forcibly, as the part seemed to
bear it without inconvenience. A roller was apphed over the plaster and
kept wet, if the limb felt hotter than natural, so as to regulate its temperature.
The success of these measures exceeded the most sanguine expectations.
The size of the limb gradually diminished, and its temperature became na-
tural. After six months, the bandages were removed, which it was not ne-
cessary to continue any longer. The limb was in some degree wasted from
pressure and disease, but it soon gradually re-acquired its natural size. After
the bandages had been left off for a month, the skin was pale, and had a
slightly shrivelled appearance The contorted vessels felt like solid chords
interposed between it and the fascia of tlie fore-arm.
A child had this unnatural state of the vessels in the orbit of the eye.
They gradually increased in magnitude, and extended themselves into the
upper eye-lid, so as to keep it permanently closed. The clustered vessels
also projected out of the orbit, at the upper part, and made the integuments
protrude, forming a tumour as large as a walnut. Of course, the removal
of this disease did not seem practicable. Pressure to any extent was here
evidently impossible; but the abstraction of heat, and consequent diminu-
tion of inflammatory action, might be attempted. Folded linen, wet with rose
water, saturated with alum, was bound on to the projecting part, and kept
constantly damp. Under this treatment, the disorder as regularly receded
as it had before increased. After about three months it had gradually sunk
within the orbit, and the child could open its eye. Shortly after all medi-
cal treatment was discontinued, and no appearance of this unnatural struc-
ture remains.
A third case of a very extensive mark of this description, covering the
back and shoulder, appears to have gotten well by the same treatment. It
appears probable, from the foregoing cases, that if the preternatural disten-
tion of the vessels could be prevented, the blood might coagulate in them ;
and thus this unnatural contexture of vessels, being rendered impervious,
might become obliterated. C.
Vide Abernethy's Surgical Observations on Injuries of the Head, and on
Miscellaneous Subjects. [Art. on tlie treatment of one species of Njevi Ma-
rcrni.] page 140, Dobson's Edition.
209
By applying cloths dipped in brandy, the effused fluid is soon
absorbed.
§ 7. DISTORTION OF THE FEET.
Distortions of the feet are not uncommon. They are
called vari, when the foot is turned inwards; valgi, when
outwards. These and similar deviations are to be cured by
pressure, applied with proper bandages adapted to the nature
of the case. They must operate constantly, but gradually,
and ought to be applied as early as possible. It is a bad case,
indeed, which cannot thus be cured by a good mechanic.
§ 8. TONGUE-TIED.
When the frsenum linguse is too short, or attached far for-
ward, the child can neither suck well, nor speak distinctly'.
It is very rare in its occurrence. I have not seen two children
where it was really necessary to perform any operation; for
in all the rest the child sucked the finger,(i) or a good nip-
ple very readily. The operation consists in dividing, to a
sufficient extent, the frsenum, with a pair of blunt pointed
scissars. If the artery be imprudently cut, the hemorrhage
is to be checked by compression or cautery.
§ 9. MALFORMED HEART.
Imperfection or malformation of the heart is a very fre-
quent occurrence; or the foetal structure may continue long
after birth. If the imperfection be great, the symptoms come
on almost immediately after birth; but if slight, or consist-
ing merely in a continuation of the foetal structure, they may
not come on till the child begin to walk, or get teeth, or
even later. The child is dark-coloured, or the skin has
a dirty appearance, the nails and lips are livid, the breathing
is more or less difficult, and he is subject to attacks of asthma,
or a kind of suffocating cough, like that in peripneumonia,
fi) This is a good test; for, if upon the insertion of the finger into the
child's mouth it sucks it readily, division of the frxnum cannot be necessary.
VOL. II. E E
210
or hooping cough; and whenever this attacks an infant, I
augur very ill. I have no remedy to propose. Comparative
case may be obtained, by keeping the child as quiet as pos-
sible, avoiding a loaded stomach, or costive state of the
bowels. For an account of the different kinds of malforma-
tion, I refer to my brother's excellent Work on the DiseaseB
of the Heart.
§ 10. SWELLING OF THE BREASTS, &c.
Children have sometimes a swelling of the breasts after
birth. This is chiefly owing to secretion of a milky fluid,
and much injury is often done by attempting to squeeze it out.
Gentle friction with warm oil is of service; but if inflamma-
tion come on from rude treatment, a tepid poultice must be
employed.
Hydrocele generally goes off, by applying compresses dipt
in solution of muriate of ammonia. A puncture is rarely
necessary. Phymosis requires astringent lotions. Dis-
charges of bloody or serous fluid from the vagina or urethra,
are easily cured by ablution. Prolapsus ani is to be cured,
by keeping the bowels open, using the cold bath, and return-
ing the gut whenever it protrudes. Incontinence of urine
during the night, often depends on a bad habit, and is to be
treated accordingly. When it continues long, the cold bath
is proper.
Excoriation of tlie navel yields readily to cleanliness, and
dressing with cerussa ointment; but if the constitution be
bad, gangrene may take place. This is to be managed, by
applying camphorated spirit of wine, supporting the strength,
and keeping the bowels open with calomel. Hemorrhage
from the navel, after the cord falls off, is to be checked by
compression or caustic.
Scalds and burns arc best cured, by applying instantly
cloths wet with strong vinegar. This is the proper practice
whatever part is injured; but when the face or neck are
scalded or burned, it is of the utmost importance to prevent
a mark, and nothing does so more effectually than the instant
%i\
application of strong vinegar. This, if the injury be slight,
prevents the part from blistering, or only a very slight vesi-
cation takes place. After a few hours, the vinegar may be
discontinued, and the part dusted frequently with cerussa, or
we dress with cerussa ointment, or anoint the spot with this,
and then make it dry with cerussa or chalk. The part is to
be washed at least once a-day, to remove any irritating mat-
ter which might fret it.
If vesications have formed, they are to be opened with a
very small puncture to let out the fluid, and then vinegar is
to be applied; or if this give much pain, a thin cloth dipped
in oil, may be interposed between the tender parts and the
vinegar.(fe)
In more extensive and severe burns, oil of turpentine alone,
or mixed with unguentum resinosum, forms the best dressing
for some time, and then the sore is to be covered with pow-
dered chalk, which is to be continued till it heals. It re-
presses fungus, and forms an artificial scab. In all cases,
pain is to be allayed by opiates, and the bowels are to be kept
open.
Ear-ache is a very frequent and painful disease of chil-
dren. It is discovered, if the child be old enough, by his
complaining of his ear; but if he is too young to do this, it
may be suspected, by his being seized with a sudden and se-
vere fit of crying, as if he had colic, and like it, the pain
seems to remit occasionally. He does not, however, spur
with his feet, nor is the belly hard, but he is restless with his
head, and complains if his ear be touched. In some time he
falls asleep, and next day perhaps his cap is stained with
matter. Nothing gives so much relief as heat. Warm oil,
or a warm poultice is to be early applied, or the outside of
the ear is to be rubbed with warm laudanum. If a foetid dis-
charge succeed this disease, and the child is deaf, the ear is
(k) A very mild and usefid application in burns, particularly in those of
children, is a liniment composed of equal parts of mild olive oil and hme
water, well mixed together by agitation; this may be laid on with a featlier,
and afterwards a piece of fine old linen, dipt in the liniment applied to the
part which is to be constantly kept moist by means of the feather.
SIS
to be daily waslied out with milk and water by means of a
syringe. Small blisters may be applied behind the ear, and
the constitution is to be invigorated. The bowels in particu-
lar are to be kept regular. Many children have occasional
discharges of matter from their ears, upon catching cold,
without much pain, and at that time, they are deaf. But by
keeping the ear warm, and by scrupulous attention to clean-
liness, the discharge stops, and the hearing returns.
§ 11. FffiTlD SECRETION FROM THE NOSE.
The mucous secretion of the nostril is sometimes exceed-
ingly foetid, so that it is disagreeable to come near the child.
The mucus dries, and comes away in thin pieces. Astringent
injections, stimulating liniments, and a variety of local ap-
plications, as well as internal remedies, such as tonics, mer-
cury, &c. have been tried. These have not always however,
a good effect. At the age of puberty, the foetor sometimes
spontaneously ceases.
Foetid discharge from the ears generally is accompanied
with a destruction of the membrana tympani, and a caries of
the small bones. It is usually attended with deafness, and is
very obstinate. Great attention is to be paid to cleanliness,
and to the state of the constitution.
§ 12. OPTHALMLV
Infants are subject to inflammation of the eye, which is
most frequently of the kind called purulent opthalmy. This
begins with redness of the eye-lids, which soon swell so much
as to prevent their being opened. Then a copious and con-
stant discharge of thick yellow matter takes place. This is
found also spread over the eye. If the disease continue, ul-
ceration of the eye, or a speck on the cornea, is produced, or
the eye itself may burst. In bad cases, the eye-lids are also
turned out, especially when the child cries. Both eyes are
generally affected. This disease is cured sooner by astrin-
gent applications than by other treatment. A solution of sul-
213
phate of zinc in rose water, may be injected with a small
syringe into the eye, two or three times a-day. Mr. Ware
recommends four ounces of sulphate of copper and of arme-
nian bole, with an ounce of camphor, to be mixed. Of this
an ounce is to be added to four pounds of boiling water, and
allowed to settle. A drachm of the solution is to be added to
an ounce of water. When the eye-lids are turned out, he
advises a poultice to be applied, made with equal parts of
curd, formed by adding alum to milk, and lard or alder oint-
ment. The bowels are to be kept open.(J)
§ 13. SPONGOID DISEASE OF THE EYE.
Children are subject to spongoid disease of the eye. The
ball becomes slowly diseased, and its structure changed, so
that all the parts are confounded, and the optic nerve be-
comes black or brown. The tumour bursts, and a fungus
shoots out. The bones become carious, the disease spreads
to the brain, and the patient dies, after much suffering. This
has been improperly called cancer. It admits of no cure, ex-
cept by very early extirpation. Every operation that I have
seen has been too long delayed, and the patients have all had
a relapse.
§ 14. SCROFULA.
Scrofula is dependent on a peculiarity of constitution, de-
rived at conception. This is often marked by a very fine
skin, light hair, large blue eyes, with dull sclerotica, and de-
licate complexion. Others have the skin darker, or of a
rough dirty appearance, the hair is dark, tbt upper lip tumid,
and the countenance sallow, and sometimes swelled. When
the scrofulous constitution is not strongly marked, the per-
son may pass through life without any inconvenience. But
when it exists in force, different parts of the body are apt,
(/) Our author has omitted to mention among the methods of cure, the
application of leeches, and of small blisters to the temples, and even occa-
sionally over tbc eye-lids; these have sometimes produced the best effects.
21$
without any evident cause, to have their action deranged ;
their structure is changed, and then inflammation slowly
takes place. The glands are most frequently affected, but
the joints or viscera may also suffer. I do not think it ne-
cessary to describe these changes, especially as I have else-
where entered pretty fully into this subject. I shall merely
state what ought to be done as a preventive, or as a cure. In
the first view, we advise whatever can strengthen the sys-
tem, and preserve the different parts vigorous and in health;
such as the cold bath daily, gentle friction over the whole
surface for half an hour every evening, regular exercise in
the open air, great attention to cleanliness, an open state of
the bowels, and good nourishing diet, with a small propor-
tion of wine. Animal food is much recommended. Sea-
bathing is useful. When the glands are swelled, or other
parts are enlarged, it is of service to rub them gently with
oil for half an hour three times a-day, and apply, in the in-
tervals, pledgits dipped in a solution of cerussa aceteta. Hem-
lock poultices are also useful. Electricity or Galvanism are
sometimes of service. When the tumours tend to suppurate,
that process should be assisted by poultices, blisters, and
electricity. The abscess should be early opened, and then
stimulants are proper. The constitution is to be treated iu
the way already mentioned. Muriate of lime, or of barytes,
cicuta, bark, and great variety of medicines, have been
advised, but I do not know that any one can be depended on.
Medicines are chiefly useful to obviate existing symptoms,
such as costiveness, &c.
Diseases of the joints and spine are to be managed chiefly
by issues.
§ 15. RICKETS.
The disease called rickets is characterized by flabby mus-
cles, relaxed skin, sallow or bloated countenance, debility,
listlessness, and softening of the bones, so that the long bones
become more or less curved, and their extremities enlarged.
The ankles and wrists swell first, then the back changes its
215
shape, and the breast protrudes. The bones of the pelvis ap-
proach more nearly together, the sacrum coming forward.
The head is increased in size, and the belly likewise becomes
large and hard. The appetite and digestion are impaired,
the bowels are bound, or foetid stools are passed. The pulse
is weak and frequent. The teeth are late of appearing, and
are not good. The mind is often prematurely advanced.
This disease may prove fatal, by ending with water of the
head, convulsions, or hectic fever; but it often is cured spon-
taneously, or with assistance. It usually attacks betwixt the
sixth month and second year, but it has been known to affect
even the foetus in utero. It is to be treated by a course of
laxatives, to bring the bowels into a proper state, the cold
bath, regular exercise, nourishing diet of animal food, gene-
ral friction over the body, chalybeate medicines, and warm
clothing.
CHAP. III.
Of Dentition.
The formation of the teeth is begun long before the foetus
leaves the uterus. It is carried on slowly, and is not com-
pleted for several months after birth. The parts concerned
in this process, are the jaw, the gum, and the soft rudiments
of the tooth itself. The jaw, at first, has only a channel run-
ning along its surface; but this afterwards is divided by trans-
verse septa, into separate cells, which are the origins of the
alveolar processes. In each of these is lodged a membranous
bag, containing a soft pulp. The bags con.-hi of two lamina,
both cf v, liich, especially the outer one, are vascular. These
sacs adhere firmly to the gum, so that if it be pulled away
from the jaw, the sacs come with it: the pulp is also vascu-
lar, and assumes nearly the size and shape which the body
of the tooth is to have when ossification has commenced
The tr^th consists of two parts, bony matter, and cortex
striatum, or crystallized enamel, covering the bone. The
216
bone is formed on the pulp, which gradually ossifies; and
in the eighth or ninth month of the foetal life, all the pulps
have begun to ossify, and at birth the shell is considerably
advanced. Soon after this process begins, the inner surface
of the sac deposits a soft earthy substance, which crystallizes
and forms enamel. When ossification is advanced so far as
to form the shell of the body of the tooth, the lower part be-
comes contracted, so as to form the neck; and as the shell
thickens, the pulp, though diminished in quantity, protrudes
through the neck, forming a kind of stalk or mould for the
fang. If the tooth is to have two fangs, then a septum is
stretched across the cavity of the neck, and the pulp pro-
trudes in two divisions. As ossification advances on the root,
the body rises in the socket, and the sac rises with it; but in
proportion as the enamel is crystallized, the sac becomes less
vascular and thinner, and at last is absorbed; and when the
tooth has acquired its proper height, the whole membrane is
destroyed. Thus it appears, that the sac is not stretched,
and bursts by distention, but is absorbed, and being fixed to
the neck of the tooth, and not to the jaw, it rises with the
tooth.
There are only twenty teeth evolved in infancy, ten in each
jaw, and these are not permanent. They are shed, to give
place to others more durable and more numerous, as the
jaws are longer in the adult. The permanent teeth begin
to be formed even before birth. Like the fang of the tooth,
they are set off from the body of the temporary tooth. A
small process or sac is sent off backwards. This is lodged
at the back part of the socket, where a little niche is first
formed for its reception, and then a distinct socket Hence
the temporary and permanent teeth are connected together,
and this connection remains for a considerable time. In the
foetus, there are, besides the temporary teeth, the rudiments
of the two first permanent grinders, therefore there are twelve
sacs in each jaw. The sac of the anterior permanent grinder
sends, when the jaw lengthens, a process backward, to form
the next grinder; and it again, in course of time, sends off
the third grinder.
217
Generally teeth cut the gum, about the sixth or eighth
month after birth. The two middle incisors of the lower
jaw first appear, and in about a month those of the upper
jaw come through. Then the two lateral incisors of the
lower jaw, and next those of the upper one, appear. About
the twelfth or fourteenth month, the anterior grinders of the
lower, and soon those of the upper jaw, cut the gum. Be-
tween the sixteenth and twentieth month, the cuspidati ap-
pear ; and from that period to the thirtieth month, the pos-
terior grinders come through; so that the child, when about
two years and a half old, usually has all the first set of teeth.
These continue till the sixth or seventh year; and as the
permanent teeth are in progress all this time, we find, be-
sides the twenty teeth which are visible, twenty-eight below
the gums. At this time, the two first permanent grinders
appear at the back part of the jaw, and the middle incisors
of the lower jaw loosen and drop out; and by degrees, all
the milk teeth give place toothers which are larger, stronger,
and better adapted to the increased size of the jaws. In this
curious process, which strongly displays the wisdom of God,
we are early taught the perishable nature of our frame. But
it is also a pleasing reflection, that dissolution is succeeded
by a state of greater perfection.
Many children cut their teeth with great ease and regular-
ity, but some suffer considerably. It is usual for the child to
have some irritation of the mouth during dentition. The gums
are hot and itchy, and somewhat swelled or full over the tooth,
and the anterior edge is not sharp as formerly, but is rounded,
and the investing membrane unfolded. The secretion of sa-
liva is increased ; and the stomach and bowels sometimes are
rendered irritable. The symptoms seldom continue urgent
above ten days at a time. If the child be very irritable, and
the tooth advance fast, or several teeth come forward at the
same time, very unpleasant effects may be produced, such as
severe bowel complaints, or fever, or spasmodic cough, or
convulsions; or the skin is affected, an eruption appearing
on different parts, which is a much more trifling effect than
any of the former. When the first grinders and cuspidati are
VOL. II. F F
218
cutting, and come forward quickly, there is great danger,
for there are then, as Mr. Fox observes, eight teeth making
pressure on the gums. In every case of troublesome denti-
tion, we have three indications to attend to. First, to allay
local irritation. Second, to alleviate urgent or symptomatic
complaints. Third, to support the strength.
Theirs/ is accomplished most effectually, by dividing the
gum with a lancet, completely down to the teeth, if it be
considerably advanced. Even when it is not so far advanced,
as to be near the surface, the division of the gum gives tem-
porary relief. Gum-sticks act something in the same fuga-
cious manner; by enabling the child to press, or rub the
gum a little, he obtains a short relief. All children in-
stinctively, thrust their fingers into the mouth, and this may
be permitted : nor is there any risk of a bad habit being
induced. This is as useful as the gum-stick, and safer; for
a hard gum-stick is apt to be thrust into the eye, or the gum
may be bruised by it. A crust of bread is often used, but
part of it may break off, and choak the child. An ivory ring
is safer.
Second, We allay general irritation, or fretfulness, by keep-
ing the bowels open, and exposing the child freely to cool
air. The cold bath is also useful every morning, and at
night, the child, if hot, may be sponged with cold water. If
this do not prove effectual, we may rub the spine and belly
with laudanum, which acts as an opiate without inducing the
injurious effect on the stomach, which the internal exhibition
too often causes. Fever if high, is to be abated by the use
of the tepid bath morning and evening; the bowels are to be
kept open, and if the child be plethoric and drowsy, besides
giv ing a smart purge, either one or two leeches ought to be
applied to the fore-head; and if the determination to the
head continue, the scalp should be shaved, and a small blister
laid upon it. Diarrhoea, if considerable and detrimental, is
to be abated by those means, which w ill hereafter be pointed
out; and especially, if it be severe, by opiate clysters : at
the same time, that we, if the stools are very bad, give small
doses of calomel at proper intervals, to bring the bowels into
219
a better state. The greatest number of children who die
during dentition, perish in consequence of obstinate or ne-
glected diarrhoea. Sickness, loathing at food, and ill smelled
breath, require a gentle emetic. Spasmodic and convulsive
affections require the warm bath, antispasmodics, and the
general treatment which will hereafter be pointed out. It is
not easy to describe the different symptoms which occur
during dentition, or may be connected with it; but one
general rule must be laid down, namely, to treat them, as we
would do in any other circumstance, with the additional prac-
tice of cutting the gum. Delicate and slender children suf-
fer chiefly from bowel complaints, and spasmodic affections;
stout or plethoric children, are more apt to suffer from acute
fever, with determination to the head.
Third, We support the strength directly by the breast
milk, arrow root, beef tea, or, if necessary, by clysters of
veal soup, or calves-feet jelly ; and indirectly by restraining
immoderate evacuations. If the child have been recently
weaned, it is often of service to apply him again to the
breast.
CHAP. VI.
Of Cutaneous Diseases.
In the following short account of cutaneous diseases, I may
perhaps have committed some errors respecting the names of
eruptions. Nosological writers unfortunately, do not agree
in giving uniformly the same name to the same disease, and
perhaps it is not always easy to give a perfect definition by
words alone. I have, however, endeavoured to detail faith-
fully, so far as I am able, the symptoms characterizing the
eruptions which I describe, by whatever name they may be
called, and also to point out the mode of treatment commonly
employed.
220
$ 1. STROPHULUS INTERTINCTUS.
The first eruption which I shall mention, is well known un-
der the name of red gum, and is described very accurately
by Dr. Willan, as his first variety of strophulus, a papulous
eruption. The strophulus intertinctus, or red gum, consists
of a number of acuminated elevations of the cuticle, of a
vivid red colour, not in general confluent, and sometimes even
pretty distant from each other. The papula? are surrounded
with a red base. This redness is often the most evident part
of the eruption in very young infants, and the disease much
resembles measles. It covers a great part of the trunk, and
keeps almost entirely off the face. In the centre of the spot,
we may observe a very minute elevation or papula, with a
clear top. There is no fever, nor has the child catarrhal
symptoms. The eruption comes out irregularly, and is either
more durable, more fugacious, or more partial, than the
measles. On the feet, the papulae are still more distinct.
The papulae of strophulus are often intermixed with small
red specks, not elevated above the surface. They are hard,
and contain no fluid, or only a very small quantity under the
cuticle at the apex, giving it a glistening appearance; but
they seldom discharge any fluid, and scarcely ever form pus.
This eruption appears generally on the face and superior ex-
tremities, but sometimes it spreads universally over the body.
On the back part of the hand, the papulae occasionally con-
tain a little yellow serum, but this is presently absorbed, and
the cuticle is thrown off like a slight scurf. This variety of
strophulus generally appears during the first ten weeks* of
life, and is not productive of any inconvenience. It seems to
be connected with the state of the stomach and bowels; and
any uneasiness the child may suffer during the continuance of
the eruption, or previous to its appearance, seems referable to
this source. The particular connection existing betwixt the
chylopoetic viscera, and the surface, I do not pretend here to
* Sometimes a few spots of this kind may be observed on the forehead of
children at the time of birth.
221
explain or investigate. I hold the fact to be established, and
from no circumstances more decidely than these, viz. that in
adults, certain kinds of foods do, with individuals, invariably
produce an eruption on the surface; and that in children,
where all the system is much more irritable, trifling irritation
of the bowels is followed by cuticular eruptions, whilst the
sudden disappearance of the eruption, on the other hand, is
succeeded generally by sickness and visceral disorder. I am
inclined to attribute to a cause within the abdomen, all those
eruptions which are not produced by the direct application
of irritations to the surface.* The affection at present un-
der consideration requires no particular remedies. It is suffi-
cient to avoid the application of cold, which might suddenly
repel the eruption ; and filth or other irritation, which might
increase it, or superinduce another affection. Should the
stomach or bowels be affected, or the child be oppressed, a
very gentle laxative may be occasionally administered; or
should the bowrels be too open, and the child flabby, a little
tincture of myrrh, or myrrh with lime-water, may be given,
and, if necessary, an opiate. If the eruption be repelled, and
the child thereafter be disordered, the warm bath, with a gen-
tle laxative, will be proper.
§ 2. STROPHULUS ALBIDUS.
The next variety is the strophulus albidus, which is an
eruption consisting of minute whitish specks, hard, and a little
elevated; sometimes, but not always, surrounded by a very
slight and narrow border of redness. No fluid is contained
in the papulae, which appear chiefly on the face, neck, and
breast. This generally is met with after the period at which
children are subject to red gum; it remains rather longer, but
requires no peculiarity of treatment. Sometimes children, at
a more advanced period, have this kind of eruption on the
* Dr. Underwood is inclined to think, that when children are subject to
repeated eruptions, the milk does not agree with the stomach, and ought t»
be changed. I am very much disposed to adopt his opinion.—See also Tin-
ner on the Diseases of the ?kin, p. 69.
222
neck, wliich is exposed to the sun in warm weather. It has
sometimes been mistaken for the itch.
§ 3. STROPHULUS CONFERTUS.
The strophulus confertus is a very frequent affection
during dentition, but seldom appears before that period,
though it may continue after it. It consists of papulae, often
set extremely close together, forming patches, varying from
the size of a six-pence to a dollar. Such, at least, is the ap-
pearance on the face and arms, to which part it is often con-
fined, especially to the former. But it sometimes appears on
the trunk, and there the papulae are larger, flatter, and sur-
rounded with more inflammation, than those on the face or
arms, looking at a distance like measles. This eruption not *
only varies a little, according as it appeal's on the trunk or
extremities, but also according to the age of the child. For
after the seventh month, we find, especially on the arms, the
papulae pretty large; and either red, with scarcely any ap-
pearance of lymph at the top, or of a light yellow colour, but
the base surrounded with a halo or inflamed rim. These pa-
pulae may on some parts be distinct from each other, whilst
elsewhere they form clusters so close, that the redness sur-
rounding one, communicates with that of another, forming
altogether a large inflamed ground-work. In some cases,
the red patch is the prominent feature ; it may be as large as
a dollar, with innumerable little dots within it, like pin
heads, with clear or watery-looking tops, or larger red hard
papulae. This eruption is sometimes preceded by sickness,
and, in certain circumstance, has been mistaken for measles;
but it is attended with little or no fever, and has nune of the
catarrhal symptoms met with in measles. By not attending
to the characters of the two diseases, they may be confound-
ed; and not unfrequently, when young children take measles,
the strophulus confertus appears on the amis, previous to the
proper eruption, or even along with it. Dr. Underwood says,
this eruption does not dry off like measles: but as Dr. \> illan
remarks, it often does terminate with a slight exfoliation of
223
the cuticle. A variety of this disease appears like red patches
on different parts of the body, particularly on the arm, and
often coming out in succession. They are as large as a split
pea, and a very little raised toward the centre. By near ex-
amination, several small papulae may be discovered, which are
something like vesicular points. In three or four days, the
patches become yellowish or brown, and covered with small
scurf. This is denominated by Dr. Willan, strophulus vo-
laticus, and is said not to be very common, but I think it is
frequently met with. It is seldom necessary to give any
medicine for this complaint. If, however, it be troublesome,
it is usual to prescribe gentle laxatives, and testaceous
pow ders. Some advise emetics, and the use of the bark; but
neither, 1 believe, are in general necessary.
§ 4. STROPHULUS CANDIDUS.
Strophulus candidus consists of papulae having a smooth
shining surface, which appears of a paler colour than the rest
of the skin, and the base is not surrounded by any inflamma-
tion It is described by Dr. Underwood as resembling itch,
but is neither red nor itchy. It generally either attends den-
tition, or succeeds some acute disease of children, and is just-
ly considered as a very favourable symptom. It is most fre-
quently met with on the trunk of the body, the arms, or fore-
head. In a few days the papulae die away. No particular
treatment is necessary.
§ 5. LICHEN.
A different eruption from any of the foregoing is the lichen,
a term restricted by Dr. Willan, in his elaborate work, to a
papulous eruption, chiefly affecting adults. It may, how-
ever, appear also in children ; and I have seen it succeed
some of their febrile diseases, as, for instance, measles. It
consists of numerous distinct papulae, some of which are pale
at the top, but very slightly red at the base; these are gene-
rally small like pin. heads. Others are larger and flatter, and
224
more inflamed, but have always at first a clear apex, and do
not end in ulceration, but die away in slight scurf. Some-
times on the body, there are small shining or silvery looking
patches, from exfoliation of the cuticle; or the skin may peel
off more extensively, as if it had been blistered. They re-
semble often the papulae in strophulus, but seldom form in
clusters, and have not, in general, any diffused redness con-
necting one papula to another. There is, however, some-
times about the joints or fore-arm, a considerable degree of
red efflorescence, covered with scurf. This eruption may be
produced by exposure to heat, and by drinking cold water
when heated, or other less obvious causes. It is frequent in
warm w eather, and a species of this is known under the name
of prickly heat. It is preceded often by febrile symptoms,
and the eruption itself may last for more than a fortnight,
but in a few cases it goes off in a day or two. These papulae,
at different stages, bear a resemblance to two very dissimilar
diseases, the itch and the measles; but it is not pustular like
the itch, neither does it ulcerate; it is not very itchy, and if
scratched so as to take off the top, it does not yield matter,
but a little bloody scab is formed. It differs from the measles,
in being papulous, and having on the spots, before they form
slight scurf, a clear looking top; it in general lasts longer
than the measles, and is not attended with catarrh. Farther,
it is sometimes accompanied with abroad scurfy efflorescence,
about the elbow joint, or other flexures. A suitable dose of
calomel is the best remedy, or, should the patient be oppressed,
an emetic and saline mixture may be given. When there is
no febrile affection, it will be sufficient to keep the surface
clean by means of the tepid bath.
§ 6. INTERTRIGO.
Intertrigo is a kind of erythematic affection of those parts
of the body where the skin forms folds or sinuosities, as, for
instance, the joints of fat children. It also is very common
about the nates and inside of the thighs, in consequence of the
urine fretting these parts. The Inflamed surface ought to be
225
washed occasionally with tepid milk and water, and the child
should never be allowed to remain wet, but ought to be bathed,
and gently dried after making water, when the thighs are
affected. Afterward the parts are to be dusted with some
cool powder, such as tutty, white lead, levigated flowers of
zinc, &c. It is not usual for intertrigo to end in gangrene
or suppuration, but sometimes the form of the disease
changes, and tlie cellular substance inflames; either of these
terminations may then take place, and will require the usual
treatment.
§ 7. CRUSTA LACTEA.
Crusta lactea, or milk blotch, is a scabby eruption, which
appears generally first on the cheeks or forehead, and then ex-
tends over a considerable part of the face, and even the scalp.
This disease belongs to the achores, or pustules containing a
fluid something like honey. The pustules arc red, and the
top soon becomes covered with a laminated scab. Sometimes
the pustules are large and distinct, but often small and con-
fluent, so as to form a considerable patch.* A succession of
pustules may appear on the same place. They are not in ge-
neral painful, but are occasionally itchy, especially at night.
In some cases, the eruption spreads to the neck, breast, arms,
and legs. During dentition, especially if the child be pletho-
ric, this eruption is frequently met with on the face, while the
body is covered with papulae, like prurigo or small achores.
Inflamed pustules first form on the face, containing a yellow
viscid fluid, and having red margins, then they grow larger,
and thick elevated crusts form, of a yellow or brown colour.
When the crust is rubbed off by the child, the part is dark-
coloured, and watery-looking, with little bits of crust adhering
to it. This disease leaves red blancs for a time. The skin
about the neck has sometimes a scurfy herpetic appearance.
Strack remarks, that in crusta lactea, the urine has a particu-
lar smell, like that of a cat. Lory describes a variety of this
• " Incipit a vesiculis numerosis cohxrentibus, oleoso succo turgidis."
Plenk, 71.
VO.L. II. G c
226
disease, under the name of ignis sylvestris or volaticus; and
says it goes off in blisters or thin crusts, without any incon-
venience, except a degree of itching. He remarks, that it may
attend the cutting of every tooth, and may even continue for
years, but this circumstance I have not met with. He has
observed, that when the glands of the neck swell, the eruption
goes off, and when they subside the eruption returns. This
is a disorder which is often met with w7hen the child is on
th;j breast. It has been attributed to the richness of the milk,
and generally goes off after one or two teeth have made
their appearance.* It is not attended with any danger,
scarcely with inconvenience, and never leaves any mark or
scar behind it. But having been sometimes, at an early
stage, mistaken for syphilitic blotches, it has caused much
unnecessary alarm. With respect to the treatment, very
little is necessary, except keeping the bowels open, or giving
purges occasionally; and if the child be plethoric, making
the diet more sparing. In general, strong local applications
are improper; but if any particular part be very sore, a lit-
tle weak solution of acetate of lead may be safely applied for
a short time. In obstinate cases, sulphur-vivum ointment
has been found serviceable. Lime-water is also proper, or
weak solution of muriate of ammonia, or ung. hyd. nit. Dr.
Armstrong advises the lac sulphuris, in such doses as keep
the bowels open, and Dr. Underwood recommends Harrow-
gate water; both of which will be found of benefit. Stoll
proposes, after Strack, a decoction of the viola tricolor in
milk, to be taken internally. Frank observes, externis hoc in
tinea remediisvix locus est: quce illam exsiccant, cum damno
admoventur.
§ 8. ANOMALOUS ERUPTIONS, &c
During dentition, or in consequence of affections of the
bowels, different anomalous eruptions may appear, which
are not distinctly referable to any well defined species.
* Some have considered this as a scrofulous disease. Vide Stoll Prelec-
tiones.—Frank de Morb. Curand, &c.
227
Sometimes we find upon the arm, one, two, or three inflamed
portions of the skin, something like small-pox, but rather
larger, with a small acuminated speck of lymph beneath the
cuticle at the apex, or sometimes the top is flattened and
shrivelled. Occasionally, a greater number of pustules apr
pear on the body, pretty large, hard and inflamed round the
base, with a white top. This kind of eruption is not attend-
ed with fever, and is neither painful nor itchy ; it goes off in
a few days without any medicine.
In general it should be a rule in the treatment of eruptions
to wash the surface, once a-day at least, with tepid water,
and keep the bowels open. In obstinate cases, preparations
of sulphur, antimony, calomel, and arsenic, have been em-
ployed ; but the last is too dangerous to be admitted into
practice. Sometimes the juice of the sium aquaticum, in
considerable doses, or the decoction of the woods, will be of
service ; and in indolent eruptions, the tincture of cantharides
has been beneficial. As external applications, lemon juice,
the decoction of hellebore, or of stavesacre, infusion of to-
bacco, as a partial lotion to the part, sulphureous baths and
lotions,* sulphur ointment, ung. acid, nitros. ointment of
nitrated mercury, or weak solution of corrosive sublimate, or
of acetate of lead, or camphorated liniment, or the applica-
tion of cloths wet with butter milk, are employed, sometimes
with benefit. Sea-bathing is frequently of service, and a
bath of warm sea-water often does great good.
§ 9: POMPHOLYX PEMPHIGUS, &c.
Authors describe some other eruptive diseases, which may
be noticed here with propriety : one of these, called pompho-
lyx, consists of a number of vesications of different sizes, ap-
pearing on the belly, ribs, and thighs, and containing a
sharp lymph; they may appear during teething, or in bowel
complaints, and continue for several days. These vesica-
• Diluted hepatised ammonia, but especially solutions of the sulphuret of
lime or potash, may be employed for this purpose
228
tions are not uncommon in very warm weather; and I think
boys are most subject to them, especially about the ankles
if they do not wear stockings. Lory considers this disease
as a kind of erysipelatous affection, produced by the heat of
the sun. It requires no medicine, but the lymph ought to
be let out by a small puncture.
A similar appearance, generally attended with fever, and
sometimes with aphthae, is more serious, and is called pemphi-
gus infantilis. The vesicles, at first small, soon become pretty
large and oval, and their contents become turgid. They ap-
pear soon after birth, generally in emaciated infants, affect
both the trunk and extremities, are surrounded with a livid
inflamed halo, and when broken, are succeeded by spreading
ulceration. Notwithstanding bark and cordials, the fever
and irritation generally prove fatal in about a week; and
only those children are saved, who were previously possessed
of a tolerable degree of strength. This may be mistaken for
syphilis.
Another kind of eruption attacks children above two years
of age, suddenly covering the greater part of the body. It
consists of red elevated spots, at first sight, something like a
kind of pock. The spots are distinct and most numerous on
the thighs and legs. They are of a dark red colour, pretty
flat, with a smooth flatted vesicular top, which is dry, and
does not burst, nor discharge matter, but gradually dries
and desquamates. The eruption is scarcely painful or itchy,
and is not attended with fever. It may continue for four or
five weeks, and is sometimes combined with lichen, or other
cutaneous diseases. The bowels should be kept open, and
some advise antimonial wine to be given, with a little tinc-
ture of cantharides.
§ 10. MILIARY ERUPTION.
Sennertus describes, under the name of sudamina, an erup-
tion like millet seed, fretting the skin, and affecting children
about the neck, arms, &c. Plenk defines it in tlie following
terms. Sunt vesiciUce granis milii magnitudm et similis, su-
229
Uto absque febre erumpentes. The child should be bathed oc-
casionally in tepid water. This eruption often takes place in
hot weather. A similar eruption, attended with fever, is also
met with, which I find very well described by Dr. Willan, in
his reports on the diseases of London, under the name of
acute miliaris. It does not affect infants, but children old
enough to take active amusement. It begins with a febrile
attack, attended with head-ache and pain in the back. The
tongue is of a dark red colour at the edges, with the papillae
prominent as in scarlatina; the rest of the tongue is covered
with white fur. The pulse is small and frequent. Presently
the patient complains of heat and pricking at the surface, is
sick at stomach, and perspires freely through the night. At
a period varying from the third to the sixth day of the fever,
an eruption appears, of small pustules like millet seeds.
These are of a red colour, but contain at the top a white
lymph, and are either diffused over the body, or collected in
patches on different parts, especially the back and breast;
they may alternately appear and disappear, and though the
same pustule does not continue long, it may be speedily re-
placed. They may sometimes be combined with small red
efflorescences, and generally vesicles appear on the tongue
and fauces, ending in aphthous ulceration. The complaint
often terminates in about ten days, but it may be prolonged
even to twenty. It is frequently the consequence of being
overheated, or drinking cold water in that state. It requires
first of all an emetic, and then a purgative. During the
course of the disease, the patient should be kept moderately
cool, and use acidulated drinks freely.
§ 11. PRURIGO.
Itchy eruptions are frequently met with on children, but
these are not always the true itch, nor the consequence of
infection. The prurigo mitis, described and delineated very
accurately by Dr. Willan, is a disease often met with in
spring. It appears without any previous indisposition, and
consists of soft smooth elevations of the skin, or papulae, dif-
230
fering in colour very little from the surrounding integuments.
When they do become red, it is in consequence of friction.
If the top be rubbed off, a clear lymph oozes out, which
forms a thin scab, of a dark or almost black colour. The
eruption is itchy, especially on going to bed, and if scratched,
it may become pustular and contagious, which it is not in its
early stage. At first, it may be removed, by washing fre-
quently with tepid water and a little soap, or lemon juice;
but if neglected, it requires the application of sulphur..
A variety of this disease consists of minute red acuminated
papulae, with a very small vesicle at the top, terminating not
in suppuration, but yielding, when scratched, only a little
clear serum. Sulphureous preparations give relief, and time,
with attention to cleanliness, confirms the cure. Sometimes
very little itching attends this eruption, and it disappears by
using the tepid bath.
§ 12. ITCH.
The scabies,* or true itch, is contagious, and consists of
small pustules, which have a hard hot base, with a watery-
looking to]). They are attended with an intolerable desire
to scratch; in consequence of which, the tops are rubbed off
the pustules, and scabs come to be formed, partly by blood,
and partly by a kind of matter, furnished by the little ulcers.
But if the pustules be not disturbed, but removed by proper
applications, they end in a slight desquamation of the cuticle,
"quae vixfurfur aliquod ostendat." The itch first appears
betwixt the fingers, on the wrists and hams, but if neglected,
it may spread over the whole trunk and extremities, and. in
consequence of the continual irritation, impairs the health;
nay, some children die in consequence of it. In neglected
cases, the inflammation surrounding one pustule spreads to
another, and the part becomes universally red, vvith pustules
or scabs, according to circumstances, scattered over it. This
* Children, in consequence of handling mangy dogs or kittens, are some-
times affected with an obstinate itchy eruption, which is not scabies, but may
be cured by the remedies used for the itch.
231
is often the case on the back of the hand, and fore-part of the
feet. Sometimes small boils and phymata appear in the
course of the disease, on the thighs or body, or about the
face. The cure may generally be accomplished, by frequent
ablution, and rubbing the parts affected with sulphur-vivum
ointment,* which, in obstinate cases, may be rendered more
effectual by the addition of powdered hellebore, or sal-am-
moniac. Rosenstein says, that the hands are very soon
cleared, by washing them with a strong decoction of juniper*
berries; and that when the eruption is great, as, for instance,
on the feet, he has applied cabbage leaves with advantage.
They cause at first a great discharge, but the parts heal after-
wards.
Sometimes the friction excites an eruption different from
itch, and kept up by the remedies intended to cure it. M.
Burdin remarks respecting this, that it consists of small
round pustules, " qui se remplissent quelquefois de serosite, et
<« dont la cicatrice laissele plus souvent une tache d'un rouge
« brun, le prurit qu'elle occasione est aussi moins fort que
" celui de la gale." In inveterate cases, the use of Harrow-
gate water is of great benefit. In order to avoid the smell of
sulphur, other applications! have been employed, such as
sulphuric acid, or nitrous acid combined with hog's lard,
ointment of nitrated mercury, camphorated ointment, helle-
bore, or corrosive sublimate, mixed with hog's lard, &c.
These often fail, and even when they do remove the erup-
tion, the cure is said frequently not to be permanent. Itch
may be combined with other diseases, such as herpes, syphilis,
&c. in which cases, it is more obstinate than usual, and may
sometimes require the use of mercury.
* Dr. Joseph Clarke considers it as dangerous to use sulphur ointment
with infants, lest the eruption be suddenly repelled; and advises rather tc
boil a piece of stick brimstone in water, in order to make a bath.
■j- M. Becu advises the following lotion: Take of tobacco leaves two
pounds, sal-ammoniac one ounce, ammonia two ounces, water three Paris
pints. Infuse for two hours.
232
§ 13. HERPES.
Herpes has been divided into different species. It has been
described under a variety of names, and sometimes confound-
ed with lichen, or its different appearances described under
the name of impetigo. Strictly speaking, the eruption in
herpes is vesicular, the base surrounded with erysipelatous
redness, the top terminating in a thin scab or scale, and the
vesicles in general small and confluent, and disposed to
spread. But some diseases which consist rather of small
pustules than vesicles, and others which have neither vesicle
nor pustule, have been admitted as species of herpes. Plenk
and others have described a great number of species; but we
may be satisfied with enumerating the following, though, in
strict nosology, they are not all referable to the same genus.
1st, The herpes farinosus, dartres farineuses, or dry tetter.
This, which is infectious, consists of efflorescent patches of
various sizes, covered with scurf or small scales. The patches
appear like flat red and slightly elevated portions of the skin,
having a distant resemblance to the blanes of the small-pox
about the twentieth day of the eruption, but darker in colour,
and very soon covered with scurf, through the interstices of
which the surface is seen to be red. The shape is irregidar,
and the size generally varies from that of a small split pea
to that of a shilling. These spots usually begin like small
pimples, slightly raised with a very small vesicle at the top.
They gradually extend into flat dark red spots, covered with
slight scurf. Often they extend like a ring, or increasing
circle which is red and scurfy, or vesicular, whilst the centre
becomes sound. Sometimes there are many small vesicles
near each other, which contribute to the formation of these
patches. They are not painful, but itchy. The patches may
be very few, or may be numerous, coming out on great part
of the surface, but especially on the extremities and face;
sometimes on the trunk, and about the arms. They frequent-
ly occur on the scalp, which becomes bald at the part, and
Hie baldness increases, as the red circle extends. Within the
233
circle the skin is whitish and a little scurfy. They are also
to be met with on the soles of the feet. When the scurf falls
off, the skin below, as Pinel observes, is generally sound,
but continues discoloured for a length of time; and often the
scurf is renewed, or new patches come out in other places.
Sometimes, however, the parts become excoriated, and even
fissures may take place, or the cuticular lines become more
distinct, without excoriation. In consequence of excoriation,
or from scratching, a fluid exudes, which forms rough irre-
gular scabs of a yellowish colour, scattered over a pretty ex-
tensive portion of red skin, which is dry, but not smooth.
Sometimes in the vicinity of this, we may observe a thick
cluster, apparently of white papulae, giving the skin a dirty
white rough appearance. These, however, are vesicles, con-
taining a very limpid fluid. Their base is white and hard.
In young children, the nostrils are apt to become obstructed;
and when the upper part of the face is much affected, the
eye-brows and eye-lashes fall off. It requires considerable
attention, in many cases, to distinguish this disease from
syphilis. In some instances, especially in spring and sum-
mer, a variety of this is met with, the characteristic of which
is, that the spots are smaller, and come out suddenly, and are
occasionally preceded by slight fever. They are of a red
colour, inclined to yellow, have little scurf, and continue for
some time after the scurf falls off. This is sometimes com-
bined with intertrigo and strophulus. Another form, met
with frequently in adults, but seldom in children, is an uni-
versal affection of the extremities, and sometimes of the trunk
also; the skin being covered with small scales, or scurfs,
which are found in considerable quantity in the bed in the
morning.
2d. Herpes miliaris,* or wild-fire, which, when it appears
* Some have ranked under this the phyma and ecthyma, but these are in-
flamed pustules. Others, with more propriety, have included the eczema, or
eruption of small vesicles, with inflammation, produced in summer by the
rays of the sun. The larger vesicle, called pompholyx, is different. In these
eruptions, a hiument, composed of sweet almonds and hog's lard, has been
VOL. II. II II
234
on the lips, has been called exanthema or herpes labialis.
This consists of minute pimples, or vesicles like millet seeds,
which are confluent, appearing in clusters, or sometimes like
rings. They contain a lymph of a glutinous nature, which
exudes, and forms rough yellow scabs; and from the quantity
of the fluid, the linen is very apt to stick to the part. When
the scab falls* off, it is apt to be renewed, or still more fre-
quently the disorder spreads in a kind of circling direction.
These rings or clusters may become very numerous, and some-
times invade pretty quickly ; so that Lory is disposed to rank
this among acute diseases. The parts are generally very
itchy. This disease is not always confined to the surface, but
mav also attack the throat. In this case, the local symptoms
are preceded by fever for a day or two, and then vesicles ap-
pear on the fauces, which are soon followed by a herpetic
eruption about the mouth, and inside of the lips. The inter-
nal affection ends in slight ulcertion, the external in the for-
mation of scabs, and the complaint is removed in about a
week. If not known, it is mistaken for a more malignant
disease. Dr. Willan has described this under the name of
angina herpetica.
Another species of herpes appears on different parts of the
body, but especially on the face. It consists of a pretty large
portion of inflamed skin, covered with different broad thin
scales, which, when removed, are soon replaced. This is de-
scribed as being a variety of ignis sacer. It is not so common
with children, as in women, and it is very obstinate.
3d. The phagedenic herpes, or herpes exedens, differs
from the former species, in ulcerating and destroying the
skin, sometimes spreading along the surface, sometimes
penetrating deep. It generally begins with small painful pus-
tules, or phlyctaenae, with dark erysipelatous margins, which
discharge sharp matter, run together, are hot and itchy, and
seem to eat away the skin, forming an ulcer called noma.
found useful. Sometimes heat, or otlier causes, produce a different kind of
eruption, already described under the name of lichen.
* If the scab be forcibly picked off, the part below is found raw and glossy,
without apparent granulation.
235
When the herpes farinosus is confined to a small part of
the body, it will in general be sufficient to apply frequently to
the spot, a little of the ung. hyd. nit. or ung. acid nitros,* or
ung. sulph. viv. with daily ablution with soft soap and water.
Should the spots resist this application, it may be useful to
touch them with a weak solution of nitrated silver, or a strong
solution of muriate of mercury, or lime-water, and afterwards
apply the ointment. If the herpes be extensive and obstinate,
internal remedies are sometimes necessary, such as decoction
of sarsaparilla, with a little antimonial wine; or Stoll advises
cow's milk whey, with the juice of nasturtium. In all such
cases, the daily use of the warm bath, succeeded by gentle
friction with a dry cloth, will be highly proper. In obstinate
cases, sulphureous baths are beneficial. In sudden eruption
of herpetic spots, if attended with any slight degree of fever
or sickness, an emetic, followed by gentle doses of calomel,
will be of service.
The herpes miliaris, like the former, is often cured by the
ointment of nitrated mercury, or by being bathed with water
containing a small quantity of nitrous acid. When extensive
and obstinate, sudorific decoctions may be required and sti-
mulating or astringent local applications, such as ointment of
red nitrated mercury, lime-water containing muriate of mer-
cury, or solutions of the sulphate of zinc, or acetate of lead.
Sometimes it is necessary, by fomentation's or poultices, to
loosen and remove the scabs, previous to making these appli-
cations. Calomel is useful.
The spreading herpetic ulcer generally requires strong
stimulants, such as caustic, butter of antimony, camphorated
spirit of wine, resinous ointment, ol. tcrebinthinae, &c. If,
however, the ulceration be very superficial, an ointment,
containing white calx of lead, or calx of zinc, is often of ser-
vice ; and sometimes the spreading may be stopped by cau-
terizing a narrow rim of skin round the ulcer. The internal
• Frank recommends the tobacco cerate, for which he gives the follow-
ing recipe: R. succi nicotians, cerx flavse, a jiii; resins pini, gissj tere-
binth. ?ss; ol. mj-rrhx, q.'s.'jiat ceratum. Uc Morb. Cur. Tom. IV. p. 154
—With children this must he ivcd cautiously.
236
use of nitrous acid may likewise, in this kind of herpes, be
made trial of.
§ 14. ICHTHYOSIS.
Children are sometimes affected with ichthyosis, a disease
in which the skin becomes dry, and covered with scales re-
sembling in their distribution, and sometimes in their ap-
pearance, those of a fish. This disease may come on at any
period of life ; it may even be connate, but this is very rare.
It is proper to employ the warm bath, and during its use, to
pick off the scales. Their regeneration is to be prevented by
friction, and repeated bathing. Sometimes children have this
disease conjoined with boils.
§ 15. PSORIASIS.
The scaly tetter, dry itch, or psoriasis of Dr. Willan, con-
sists of red rough spots, which are very soon covered with a
laminated scale, sometimes as thick as paper, but generally
thin, and very like a bit of the scale of a herring dried. They
are irregular in their shape and size, occasionally not larger
than a coriander seed; sometimes as large as the nail of the
little finger, resembling a dried fish scale pasted on the skin:
and frequently they are interspersed with shining silvery-
looking portions of the surface. These scales are formed by
the exudation of a whitish matter, which is very glutinous,
and, as Sylvius observes, stiffens the linen, when it happens
to exude in sufficient quantity. The spots on children gene-
rally begin like papulae, of small size, and vesicular at the
top. These end sometimes in scurf, oftener in thin scales,
as has been described. On the back of the hand, the vesi-
cles are sometimes pretty large; whilst in the palm of the
hand, the eruption is rather pustular, and ends in broad
thin rough scabs of a yellow colour. In the eai'ly stage, it
is sometimes combined with strophulus. The parts are itchy,
but when they are scratched, matter does not come out by
thc removal of the scales, but a little blood flows. This
237
eruption often begins on the face or neck, and spreads to the
body and extremities. It is very obstinate, and sometimes
destroys the nails. When it has continued for some time,
the skin, especially about the hands and feet, is found to be
universally red, with dark-coloured scales interspersed. The
skin looks as if it had been scalded, and partly covered with
thin scabs or scales, in different degrees of adhesion ; and in
some cases, the whole of the extremities, and even the body
itself, or the head, becomes red, partially excoriated, and
covered partly with scales and scurf, and partly with scabs,
which are yellow, and pretty thickly set, often loose and
easily detached. Sometimes on different parts of the body,
particularly on the arms or legs, there are many soft red
indolent bumps, more especially if the child have been seized
with this disease soon after the small-pox or chicken-pox.
The appearance on the head is nearly the same as in pity-
riasis, but it in general wants the white scurf. It is rare not
to find the head affected in this disease.
Excoriation sometimes also takes place about the anus,
with a slightly elevated state of the surface; inconsequence
of which, and the disease of the skin taking place soon after
birth, I have beeir-consulted respecting children given out to
nurse, who were apprehended to have syphilis. Dr. Willan
remarks the syphilitic appearance of this disease, but justly
observes, that all other marks are absent. The syphilitic
form of this disease is attended with hoarseness, and the
patches are of a livid colour, with a slighter degree of scali-
ness. and the margin is sometimes higher than the centre.
It is not, like the itch, very contagious, nor is it easy to
say what occasions it; but we know, that inattention to clean-
liness is favourable to its production. The application of
preparations of sulphur, and ointment of nitrated mercury,
with the use of the tepid bath, especially made with sea-
water, daily, will often cure this disease; but in obstinate
cases, we must give some sudorific, such as antimonials, or
decoction of sarsaparilla, alone or with calomel, or have re
course to the Harrowgate or Moffat waters, which have
great efficacy. They should be, used both externally and in-
238
ternally. Solutions of soap, or of alkali, or of sulphuret of
potash, form very useful baths. Decoctions of hellebore, or
solution of muriate of ammonia or of oxy-muriate of mercury
are also proper, as external applications. The application
of cloths wet with butter-milk, or a poultice of butter-milk,
and oat-meal, sometimes facilitates the cure.
§ 16. IMPETIGO.
Impetigo is a term differently applied by writers, and hence
uncertain in its meaning. By this term, I understand a dis-
ease, which consists of broad vesicles about the size of a
split pea, circular in general, but with a shelving jagged mar-
gin. These are surrounded with diffused redness, and contain
purulent-looking matter. Sometimes the top is dark-colour-
ed, as if it were filled with bloody lymph, and the margins are
of a livid red colour. Some are of an irregular shape; and
the contained fluid being very small, the general appearance
of the whole blotch, is livid. These vesicles are very numer-
ous, especially on the extremities, and soon form crusts, or
thin flat rough scabs, of a yellowT colour, inclining sometimes
to brown or red. The scab is surrounded by a diffused
redness, of irregular shape; and this red portion of skin
seems a little radiated or puckered, as if drawn toward the
scab. This disease is attended with itchiness, and, if much
scratched, the parts may be fretted and ulcerate. It is oc-
casionally attended with a rough, scaly appearance of the
palm of the hand. Sulphureous preparations are useful, or
the parts may be frequently bathed with solution of oxy-
muriate of mercury, or the ung. hyd. nit. may be applied.
The tepid bath should be used to promote cleanliness.
§ 17. PITYRIASIS.
The pityriasis is a disease known commonly under the
name of the dandriff. It consists of a dry, scurfy, and scaly
eruption on the head, amongst the hairs. Near the fore-
head, the skin is covered with a thick white scurf, which can
239
be removed in a powdery form; farther back, larger scales
are formed. This is cured, by cutting and shaving the hair,
and brushing the head daily with a hard brush, and wash-
ing it with soap and water. If neglected, ulcers may form,
and the disease be converted into the one next to be de-
scribed. Pityriasis is sometimes infectious. A variety of it
appears like small red marks on the scalp. The circum-
ference extends, and continues red, whilst the centre be-
comes pale and scaly. It is accompanied with falling off of
the hail'.
§ 18. PORRIGO.
The porrigo is a collection of pustules, containing a yel-
lowish-coloured fluid, something in colour and consistence
like honey, and ending in a white or yellow scab. The pus-
tules are numerous, forming about the roots of the hair; they
are itchy and contagious. They are not unfrequently ac-
companied with an eruption on the face, and other parts of
the body, which has been taken for the itch; and indeed this
disease has been called scabies capitis. But the pustules are
larger and more solitary than those of the itch, contain a
straw-coloured thick fluid, and form crusts, which, especially
on the hands, are flat and ragged, and resemble, in miniature,
the scabs on the head. On the body there will be found many
small pustules or pimples, with a red base and lymphatic top;
and these also appear on the face, which is seldom the case
in itch.* Often about the back of the neck, the skin is very
red, with small scabby pustules. Sometimes scabs form on
the chin, and the glands below suppurate. Many rank the
crusta lactea with porrigo, and consider both as scrofulous.
It differs from the pityriasis or dry scab, in being pustular
* This is sometimes accompanied with considerable inflammation round
the small pustules on the face, which are intermixed with herpetic spots and
vesicles. This affection is very itchy. An eruption of papula like porrigo,
or of small vesicles with inflamed margins, sometimes appear at the same
time on the arms. This requires tlie application of an ointment, containing
camphor and sulphur.
%m
and humid. In order to cure this disease, it is useful to re-
move the hair. This has been proposed to be done, by pull-
ing it out, by means of a pitch plaster; a method certainly
effectual, but not very gentle, and never necessary. In mild
cases, it will be sufficient to cut the hair very close, and ap-
ply a poultice or some emollient ointment, to loosen the scabs,
and set free the hair. The head is then to be washed with
soap and water, and as much of it shaved as can be done;
and thus, by a repetition of the process, at the same time
that proper applications are made, the whole head may at
last be cleared. If, however, the disease be more extensive
and obstinate, some depillatory* may be employed; but this
is rarely required. For this purpose, a combination of the
ung. picae, and white hellebore, has been proposed, and is
recommended by Dr. Underwood. It is to be rubbed warm
upon the head, for near an hour at a time : and then a blad-
der is to be put over the scalp, to prevent the cap from stick-
ing. After three or four applications, the scabs, and even the
hairs, are loosened, and these are to be removed by degrees;
after this new hair will grow, without any scab at the bulb
or root.
Various applications have been proposed, whether the hair
be or be not taken out. Some employ lotions,f others oint-
ments. A very useful preparation is made, by combining
the sulphur vivum, camphor, and oil of bays. This is a very
effectual application, and ought to be applied morning and
evening. Before each application, the parts should be washed,
with a weak solution of oxy-muriate of mercury, or muriate
«f ammonia or potash, or with soap and water, or a lotion
composed of two drachms of sulphurate of potash, a drachm
of soap, and six ounces of water. The ung. picae, and ung.
hyd. nit. are employed with advantage. Sulphur ointment,
* Quick-lime is sometimes employed for this purpose, and enters into the
composition of many of the oriental depillatories.
f Dr. Underwood recommends the decoction of tobacco, or lotio sapo-
uacea; Dr. Frank, urine; and Mr. Barlow, the following lotion: R. kali.
sulph. 2jiii; sap. alb. -iss; aq. calcis, -viiss; spt vini, =ii. >f^Dr. Heber-
den recommends the decoction of white hellebore.
211
with the addition of a little white precipitate of mercury, or
the weak mercurial ointment, have been likewise found of
service. In some obstinate cases, caustic, or cantharides
ointment, or ointment containing verdigris have been used;
and afterwards lime-water, or solution of sugar of lead, have
been applied to heal the scalp. Internally lime-water, de-
coction of the woods, sulphur, and small doses of calomel,
have been given, and all of them, I think, occasionally with
benefit, though Dr. Heberden remarks, that he has found
little benefit from internal medicines. When an eruption
like itch appears on the body, along vvith porrigo, it will be
useful to wash the parts with lime-water alone, or with the
addition of a little oxy-muriate of mere ry, or with a sul-
phureous lotion; or anoint the parts with camphorated lini-
ment, ung. acid. nitr. ung. hyd. nit. or sulphur ointment,
and use the tepid bath occasionally. Sea-bathing is of great
benefit.
§ 19. SCABS FROM VERMIN.
The bloody scabs which are formed on different parts of the
head, especially in the hollow near the neck, in consequence
of vermin, are cured by combing and washing the hair daily,
and rubbing some mercurial preparation on the scabs;
whilst an ointment, composed of oil of bays and stavesacre,
should be rubbed over the scalp among the hair, or the pow-
der of stavesacre may be dusted in among the hair.
§ 20. BOILS AND PUSTULES.
Many children are subject to boils or inflammatory pus-
tules, which have received different names according to their
size and contents. We may chiefly notice two kinds; those
containing pus, and those containing a more solid substance,
which suppurate very slowly. The first are properly called
pustules, and they are of difterent sizes. They generally are
attended with a considerable degree of inflammation, and
end in suppuration. The small abscess bursts, and a little
VOX. II. J 1
2*2
scab forms, after which the inflammation dies away. Such
a pustule has been called ecthyma, or sometimes terminthus.
It requires in general little treatment, except the application
of some soft ointment when the situation permits it. But if
the pustules be numerous, as is often the case, after small-
pox and other acute diseases, it will be necessary to use bark
and the cold bath, especially sea-bathing; and the most
painful and largest pustules may be hastened on by a poultice.
The bowels are to be kept open.
The second are a kind of tubercles, called also boils, and
by some are divided into the furunculus or acute boil, and
the phyma which is rather more tedious. They are hard,
with an extended base, are usually flat, and of a purple colour.
These, like the pustules, are sometimes solitary, and often
large; occasionally, though not very frequently, they are
scattered in great numbers over the body. It is proper to
apply a poultice of bread and milk, or of boiled turnips,
until the top open, which happens sometimes by a kind of
sloughing. Scarcely any matter is discharged, but a white
or yellow core is found within, which is gradually thrown
out, and then the boil heals like a pustule. During this
process the ung. resinosum forms a very proper dressing,
and sometimes the application of precipitate accelerates the
separation.
There is a kind of small and very itchy pustules, begin-
ning with a black spot on the skin, and containing a sebace-
ous fluid, which can be squeezed out in a worm-like shape.
Such pustules have been called crinones, and were supposed
to proceed from worms. They have been cured by washing
with soap lotion, and applying the ung. hyd. nit.
§ 21. PETECHLE.
Purpura, or petechiae sine febre, is a disease not uncom-
mon with cliildren, particularly those who live in confined
houses, or are fed on poor or improper diet. It consists of
an eruption of small purple spots, which are circular, not at
all elevated, seldom larger than the diameter of a coriander
243
seed, more frequently of the size of the head of a pin. They
are scattered over the whole body, and even over the hairy
scalp. They come out suddenly, without any fever or ap-
parent indisposition, and go off slowly. They are not in
general attended with foul tongue, spongy gums, or foetid
breath; and the faeces do not become unnatural, but they
sometimes are so before the disease takes place, and the
belly may be very tumid, but these are not essential symp-
toms. By good diet, the use of acids, and removal to the
country, together with moderate exercise in the open air,
this disease is easily removed, or sometimes it goes off with-
out any particular change being made in the mode of treat-
ment. I have never seen this disease affect children till after
they were weaned. This eruption is sometimes intermixed
with hard papulae, forming a disease described separately,
under the name of lichen livid us, by Dr. Willan. These con-
tinue for a considerable time, and end by slight exfoliation
of the cuticle, but afterwards may be succeeded by a new
crop. No peculiarity of treatment is required. A worse
species of this disease affects children as well as adults, and
attacks more slowly. For a considerable time before the
spots appear, the patient is languid, and feels uneasy at the
stomach. Then red spots, larger than in the former species,
appear on the extremities, especially the legs, which are
painful before the eruption comes out. The body is next af-
fected, and the spots very soon become livid; sometimes
vibices are also observed on the skin. This disease is at-
tended vvith frequent and daily hemorrhage from the nose,
mouth, alimentary canal, or vagina, and sometimes even
from the toes. This species occasionally proves fatal, but it
is often cured by the use of bark, wine, acids, good diet, and
country air. It is, however, frequently very tedious. In
worse cases, and in feeble children, the disease often begins
with livid blotches on the scalp, which presently have the
skin abraded; and then we may find some of them moist,
and discharging blood or bloody matter; others dry, but
without any scab or a cuticle; others covered with a thin
black crust. Gangrenous sores form behind the ears; and
&H
the gums, especially near the symphysis of the jaws, become
foul, and covered with a brown lymph. An eruption of
petechiae then suddenly appears, and the child generally dies.
§ 22. ERYSIPELAS AND ERYTHEMA.
Erysipelas* sometimes affects children, and even infants
very soon after birth.f This disease appears to have been
noticed by Av icenna, under the name of undimiam, or humid
erysipelas, and afterwards at different times by other writers;
but was first accurately described by Drs. Underwood, Garth-
shore, and Broomfield. Dr. Underwood conceives, that it
rarely makes its attack after the child is two months old,
oftener a few days after birth. Dr. Broomfield, however,
saw it in a child much older, and I have met with the same
circumstance. It makes its attack in general quickly, and the
worst kind begins about the pubis, and spreads along the belly
and down the thighs. There is not a great swelling, but
the parts become hard, purple, and often end in mortifi-
cation ; so that the parts of generation drop off. This kiud
most frequently proves fatal, the peritoneum and intestines
partaking of the disease. A milder kind, which I have met
with much oftener, begins about the hands and feet, or not
unfrequently the neck or face; and it is worthy of observa-
tion, that this frequently ends in suppuration; and on the
neck especially, a very large collection of matter may be
formed. Flour, or chalk is proper, as a local application;
or if the heat be great, a cloth wet with weak solution of
acetate of lead, may be safely applied. If suppuration take
place, the matter should be early let out, and the parts gently
supported with a proper roller, applied over mild dressings.
* Erysipelas is attended with fever, and the part affected is red and hot,
with soft diffused swelling. The redness disappears when pressure is made
with the finger, but immediately returns when that is removed. There is a
tendency to the formation of vesicles, which bursting, form either scabs or
troublesome ulcers.
f Dr. Underwood says, he once saw a cliild born of healthy parents, with
subhvid inflammatory patches, and ichorous vesications, about the belly^md
thighs; but by the use of bark, and especially the mother's milk it recovered.
245
The strength is to be preserved by means of a good nurse,
and giving cordials, as for instance, white wine whey. In
the worst kind, the early application of camphorated spirits
of wine has been recommended with great propriety by Dr.
Garthshore. Ammonia, given early in doses of from five to
ten grains every three hours, has been of service; but I have
derived more advantage from calomel, in such doses as to
act on the bowels, than from any other medicine. Green
foetid stools are generally brought away. Bark has also
been given, but the precise degree of advantage derived
from this medicine in infantile diseases is not yet fully ascer-
tained.
Erythema, according to nosologists, differs from erysi-
pelas, in not being attended with the same diffused swelling,
nor having the same tendency to form vesications; neither is
it preceded or accompanied by any regular fever, though the
system may be occasionally disordered during its appearance.
In some cases, the inflamed part seems at first to be rough,
as if covered with innumerable papulae, but this appearance
presently goes off. The treatment is nearly the same as in
erysipelas. Sometimes small irregular erythematic patches,
accompanied with oedematous swelling, appear about the
joints, eye-lids, or different parts of children,* with fretful-
ness or feverishness. They in general require only to be
kept clean, by being bathed with tepid milk and water, and
dusted with some cool absorbent powder, or bathed with
vinegar. Calomel is of service, and should be given pretty
freely.
After the cow-pox, erythematic patches sometimes appear,
not only on the arm, where the inoculation was performed,
but even on more distant parts. This is most apt to take
place after the vesicle has arrived at the height, or is on the
decline. The inflammation sometimes ends, if not in gan-
grene, at least in a livid state of the parts, with fatal debility.
Spirituous applications are then of service. When the part
• The erythematic patches produced by the bites of bjigs, &c. in those
whose skin is delicate, are distinguished by having a small mark or speck in
the middle.
246
becomes livid, the strength must be carefully supported, and
the bowels op ned. In the commencement of this affection,
saturnine lotions are proper, and often remove the disease.
Calomel is useful. Dr. Willan describes this as a species of
roseola.
There is a species of erythema, erythema nodosum of Dr.
Willan, in which the patches are raised toward the centre.
This elevation takes place gradually. In a few days, hard
and painful tumours are formed, which threaten to suppurate,
but they presently subside, soften, and end in desquamation.
These are most frequent on the chin, but they may affect any
part of the body. Laxatives are proper.
§ 23. EXCORIATION BEHIND THE EARS.
Excoriations frequently take place behind the ears, espe-
cially during dentition. The skin under the lap of the ear
is covered with small pustules, and the inflammation extends
from one to another. Sometimes a kind of erythematic in-
flammation takes place without pustules, and ends in vesica-
tions, which discharge thin matter. This complaint is not
generally dangerous, but it is sometimes troublesome and
causes swelling of the lymphatic glands about the jaw and
neck. Occasionally, however, the parts become first livid,
and then gangrenous; and in such cases the child generally
sinks, even although the sloughs begin to separate. In mild
cases of sore ears, it is seldom necessary to do more than
wash the surface frequently with milk and water, and apply
a little lint spread with spermaceti ointment, mixed with the
white oxydc of mercury. If the part be very itchy, and not
healed by this application, it may be bathed with rose-water,
containing a little tincture of opium, or weak solution of
acetate of lead; but astringent lotions, or such applications
as tend to heal the surface speedily, if it have been long
abraded or discharging much, are, unless purges be frequent-
ly given, justly esteemed dangerous, and apt to excite disease
within the cranium, especially in those who are predisposed
to convulsions or hydrocephalus.
24?
If other applications are necessary, the citrine ointment, or
liniments containing acetate of lead, calyx of zinc, juice of
scrophularia, cerussa, &c. have been employed.
When the parts become livid, or threaten to mortify, cam-
phorated spirit of wine should be applied, and afterwards,
when slough has formed, the fermenting poultice. The
strength must be carefully supported. The bowels should be
kept regular.
§ 24. ULCERATION OF THE GUMS.
The gums, about the time of dentition, or sometimes when
the first set of teeth are shedding, become spongy and ulcer-
ated, discharging a quantity of thin foetid matter. This at
first may generally be stopped, by applying a mixture of mu-
riatic acid and honey, in such proportions, as to taste pretty
sour ; or the parts may be frequently washed with equal parts
of lime-water and tincture of myrrh, or with a solution of sul-
phate of zinc.
If neglected, the ulceration becomes either fungous, and is
called scorbutic ;* or sometimes of the kind which resembles
sloughing phagedena, that is, a foul foetid spreading ulcer,
destroying the gums, and in some cases the jaw-bone and
cheek ; so that if the child survive, no teeth are afterwards
formed in that part of the jaw. Occasionally, from the very
first, this disease assumes a malignant form, beginning with
some degree of inflammation of the gum, generally where the
incisors should appear. The part is not swelled, but bright,
and of a pale red colour, and this extends along the gums a
considerable way. This soon ulcerates, forming a line along
the gum, marked by white or brownish slough; whilst exte-
rior to this, the surface is inflamed, and this inflamed part
next ulcerates; so that inflammation precedes ulceration, till
the mouth and cheeks be affected, and a large foetid sore
formed, which soon injures the bones. This disease has
* In this case, some have recommended stimulants and astringent lotions
others compression. M. Barthe advises the part to be cut off; and Capde-
ville proposes actual cautery.
248
been called the canker. It is attended with considerable dis-
charge of saliva, and the breath is very foetid. Good diet,
the internal use of acids, and great attention to cleanliness,
at the same time that we use acid or spirituous applications
locally, are the most likely means of cure.
§ 25. EROSION OF THE CHEEK.
Another corroding disease begins in the cheek itself, or
the lip. It commences with some degree of swelling, which
is hard, and firm, and shining. It generally begins on the
cheek, which becomes larger than the other, and the upper
lip becomes rigid, swollen, and glossy. On some part of
the tumefied skin, generally on the cheek, we observe pre-
sently a livid spot, which ulcerates and spreads, both laterally
and downwards. Being generally seated near the mouth,
it soon reaches the gums ; and even the tongue partakes of
this disease, which is of horrible aspect. We often find a
great part of the upper or under lip destroyed, perhaps only
a flap or portion of the prolabium left, all the rest being
eaten away. The gums are foul, the teeth loose, the tongue
thickened, partly destroyed, and lying so close on other dis-p
eased parts, that we cannot say what is tongue or what gum,
except by the child moving the tongue: and the mouth itself
is filled with saliva. The ulcer is foul, shows no granula-
tions, but appears covered with a rough irregular coat of
brown lymph. The surrounding parts are somewhat swelled:
near the ulcer, they are hard and red ; farther out on the
cheek, they are paler, and have more of an oedematous look.
These local appearances are accompanied with emaciation
and fever, and the cliild is either restless, or lies moaning in
a drowsy state. This disease often proves fatal; sometimes
indeed, the parts cicatrize, or the patient recovers after an ex-
foliation of part of the jaw-bone. This ulcer is best managed
with stimulants, such as diluted muriatic acid, solution of
nitrate of silver, camphorated spirit of wine, tincture of
opium, &.c. but sometimes it is necessary to give these up for
a carrot or a fermenting poultice. The bowels are to be
249
kept open, the strength supported by milk, soups, and wine;
and acids, with ripe fruit, given liberally. Before ulcera-
tion take place, the best application is camphorated spii'it of
wine, or we employ friction, with camphorated liniment. A
course of gentle laxatives is useful.
Another disease, destroying the parts, is called noma,
which differs from the former, in destroying rather by gan-
grene than ulceration. It attacks chiefly the cheeks and labia
pudendi of children, and begins with a livid spot without
pain, heat, or swelling, or with very little; and is not pre-
ceded by fever. It ends in gangrene, which destroys the part,
and the patient often dies in a few days. It is to be treated
with stimulant applications, or a fermenting poultice, whilst
opium and wine are given internally, with or without bark,
according as the stomach will bear. A variety of this dis-
ease appears with scarcely any swelling, but the inner sur-
face of the vulva becomes livid, and then sloughs; so that the
whole of the nymphse and the clitoris may be destroyed, and
the labia seem lined with foetid brown sloughs. This re-
quires the same treatment. It sometimes takes place after
the measles or scarlet fever, and may be conjoined with the
induration of the cheek or lip, previously described. It very
often proves fatal.
§26. APHTHiE.
Aphthae are small white specks or vesicles, appearing on
the tongue, inside of the cheeks, and fauces. They are ex-
tremely common, and almost every child has at one period
or other an attack. This disease appears under two forms.
The mild, in which the eruption on the mouth is slight, and
the symptoms comparatively trifling; and the severe, in
which the local disease is extensive, and the constitution
greatly affected. In the first or milder form, a few scattered
spots appear on the mouth, as if little bits of curds were stick-
ing to the surface of the tongue, or within the lips. These
in a short time become yellowish, and then fall off, but may
be renewed for three or four times. They leave the parts
VOL. II. K K
330
below of a red or pink colour. The child, in this complaint,
is generally somewhat fretful, the mouth is warmer than usual,
and the bowels rather more open, and sometimes griped,
which has been attributed to an acid state of the saliva. The
stools are altered in their appearance, being green, or con-
taining undigested milk, or of an offensive smell. There is
no fever or general indisposition, except what may proceed
merely from * irritation of the bowels. It is most frequent
within the first month, but may occur later.
In the severe or worst form of this disease; a fever* even
of a contagious nature precedes, or attends the aphthae, and
the child is sometimes drowsy and oppressed for some hours,
or even a day or two before the spots appear, and occasion-
ally is affected with spasms. The fever and oppression are
often mitigated on the appearance of the aphthae. The erup-
tion is pretty copious in the mouth, and may become conflu-
ent, so that almost the whole surface is covered with curdy-
looking matter. The stomach and bowels are very much
disordered, and the child vomits and purges. The stools are
generally green, sour-smelled, and sometimes acrid, so that
the anus is excoriated. The aphthae may not be confined to
the mouth, but may descend along the trachea, producing
cough, and great difficulty of breathing; but much oftener
they go along the oesophagus to the stomach, which becomes
very sensible, is painful to the touch, and the child vomits
speedily after sucking. The mouth is likewise tender, so
that the child sucks with pain, and with difficulty, if the
crusts become hard, the tongue being rigid. After a short
time, the aphthae change their colour, and begin to fall off;
but they may be renewed, and the abdominal symptoms may
increase, so that the child is exhausted, and dies. There
are two sources of danger, in bad cases of aphthae : the first
proceeds from the disorder of the alimentary canal, which
always attends the disease; and the second arises from
the particular state of tlie system, connected with the local
disease, as in malignant sore throat, and many otlier dis-
* Dr. Underwood is of opinion, that fever very rarely attends aphtha, when
it appears as an original disease.
251
eases. It behoves us then, in forming our judgment, ta at-
tend to the sensibility of the stomach and bowels, and
pay attention to the egesta. Frequent vomiting, repeated
thin stools with griping, and a tender state of the abdomen,
with or without tumour, are very unfavourable; drowsiness,
oppressed breathing, moaning, spasms, and great languor,
with frequent pulse, are likewise dangerous symptoms. With
regard to the local disease, we find, that if the spots be
few and distinct, and become a little yellow, and then in three
or four days fall off, leaving the part below clean and moist,
we may expect that the eruption will not be renewed, or will
become still more mild. But if the aphthae turn brown or
black,* which last is not a common colour, the prospect is
not so good, and is worse in proportion to the rapidity with
which they change. The longer that the aphthae adhere, the
more apt are they to become brown ; and the case is worse,
than when one crop succeeds another more speedily. If the
succeeding crop be more sparing than the former, we augur
well, and vice versa. When the aphthae fall off, we expect
their renewal, if the parts below are parched and look foul.
If, however, in this state, the eruption do not take place, and
the oppression, weakness, and drowsiness continue, the dan-
ger of the case is increased; and in such circumstances, it
has been observed, if the eruption afterwards appear, the
child is relieved. It is also unfavourable, if a new eruption
come out before the former one be thrown off. When the
aphthae fall off, the mouth becomes very tender, so that the
mildest fluids sometimes give pain. Occasionally a salivation
takes place, and the inside of the cheek bleeds. Dr. Arm-
strong remarks, that he has seen the tongue covered with a
crust of aphthae, and the cheeks and gums full of angry pus-
tules, and little fungous excrescences.
Now with regard to the causes, we find, that this disease
is produced by derangement of the stomach and bowels, ex*
cited by improper diet, exposure to cold, &c. and sometimes
slight attacks are occasioned by giving spoon-meat too warm.
* Sometimes mortification takes place, and even the palate bones have
been known to suffer.
253
The tongue and mouth sympathize very much with the state
of the alimentary canal, in every period of life; but in early
infancy, the changes produced in the membranes lining the
mouth, by derangement of the function of digestion, are great
and sudden. Whenever the diet is deficient, or improper, or
the action of the stomach is impaired, aphthae are produced,
especially during the first month; afterwards, at least when
the infant is considerably older, the tongue merely becomes
foul or furred, when the digestion is injured. It is rather
with the stomach than the bowels that the mouth at first sym-
pathizes, but the bowels also are generally affected, either
from a propagation of diseased action from the stomach to
them, or from the operation of causes, directly on them, as
well as on the stomach. Hence the stools are generally bad,
when the mouth is aphthous, and hence a change of diet, or
medicines, which stimulate and invigorate the whole tract of
the canal, remove the affection of the mouth. If a child be
brought up on the spoon, or the milk be bad, one of the most
early indications of injury is the appearance of aphthae, or
white exudations on the tongue. Some particular states of
the atmosphere would seem either to excite this disease, or
predispose to it, for it is most frequent in damp situations,
and in spring and autumn; and Van Swieten tells us, that it
is peculiarly prevalent in Holland. It would appear also to
be produced by sucking an excoriated nipple; and on the
other hand, an aphthous mouth may infect the nurse. It has
been said by Dr. Moss, that a healthy child, sucking a breast
immediately after a diseased child, receives the infection; and
I believe it to be the case.
In the treatment of aphthae, the cause is often overlooked,
and local applications are expected to remove the disease.
The first object, however, is to remove the cause, which most
frequently is resident in the stomach and bowels. For this
purpose, strict attention ought to be paid to the ingesta, for
many nurses, instead of bringing the child up at first entirely,
or almost entirely on the breast, give spoon-meat, and that
in too great quantity, and not unfrequently combined with an
anodyne, to keep the child quiet Emetics have been strongly
253
recommended by Arneman and others, in this disease. A lit-
tle of the vinum ipecacuanhae may be employed, which is pre-
ferable to antimony. This may be given early in the disease,
if it require interference with active medicines, or do not yield
to mild laxatives; but if relief be not soon obtained, it should
not be repeated. Gentle laxatives are highly proper, such as
manna, cassia fistularis, or a little magnesia; indeed, Dr. Un-
derwood seems to trust chiefly to absorbents. A small propor-
tion of rhubarb may, together with an aromatic, be occa-
sionally added to the magnesia. Small doses of calomel may
be given with advantage. The remedy I chiefly recommend
is laxatives, such as rhubarb, magnesia, or calomel, given
so as to evacuate all offensive matter, and excite the action of
the whole canal. The operation is to be gentle, but must
perhaps be repeated for some days. Emollient clysters, made
pretty large, and without stimulating ingredients, are like-
wise useful. Milk or soup may also be injected, to support
the strength, when the child does not suck or take food by
the mouth. If, however, the child have a purging, then we
must proceed according to the directions which will be given
respecting diarrhoea. In the worst species, we must very
early give a gentle laxative, or a mild emetic, if the child be
much oppressed; and afterwards the bowels must be regu-
lated, and medicine given according to the appearance of the
faeces, and the state of sensibility. Nourishment is to be given
carefully, or if the child cannot suck, clysters must be ad-
ministered twice a-day. Where the debility is considerable,
the strength must be supported by cordials, such as white-
wine posset. The bark has been recommended when the
debility is great, and especially when the mouth has a sloughy
gangrenous appearance, or tendency thereto. Children,
however, cannot take it, so as to do good; and therefore,
when it is employed, it should be in the form of clyster mixed
with starch* or mucilage, but I cannot speak decidedly as
to its benefit. Small doses of calomel, with opiates, are useful.
* From a scruple to a drachm of bark may be given to a young child,
mixed with half an ounce of fluid. Sometimes a little laudanum may be
added to the clyster, to make it be retained.
ad*
Local applications have been always employed, and in
slight cases are trusted to by the nurse, without any internal
medicine. The most common remedy is borax, in the form
of a saturated solution in water, or mixed with honey or
syrup; or a little of the powder may be put into the mouth,
and it seems to have a better effect than could be expected
from its sensible properties. It cannot, however, as Dr.
Bisset observes, be expected to remove the aphthae until they
are about to separate, when it ought to be employed, and may
prevent a renewal. Until this period, a little veal soup, or white
of egg beat up with water, may be given. Van Swieten re-
commends syrup of turnips. Applications which force off
the aphthae prematurely, do harm to the part, and seem to
produce a renewal of the exudation. A solution of the sul-
phate of zinc, or diluted muriatic acid have been proposed
as lotions, and may occasionally be of service; but it is highly
improper to wash the mouth roughly with a cloth dipped in
these or any other lotions.
§ 27. APHTH.E ON THE TONSILS.
Aphthae sometimes appeal' on the tonsils of children and
adults, with or without fever; and from an apprehension of
the existence of a malignant sore throat, give much alarm.
There is, however, very little inflammation, and no lividity
of the parts; the fever is very moderate, the strength not
impaired, and the aphthae do not spread, but, becoming
brown, presently fall off. This is cured by acid gargles and
laxatives. Another kind of sore throat is attended with the
usual symptoms of inflammation, accompanied with an
exudation of tough yellow mucus. It yields readily to the
same treatment.
§ 28. EXCORIATION OF TONGUE, &c.
About the time of dentition, the tongue, gums, and inside
of the lips are sometimes spotted over with superficial ex-
coriations. They are seldom larger than a coriander seed,
255
of an irregular shape, and covered with yellow or brownish
mucus, adhering so firmly, and being so thin, as to resemble
the solid base of the sore itself. They are tender, and
generally accompanied with salivation. They are cured by
being touched with alumen ustum, or lightly with a pencil,
dipped in weak solution of nitrate of silver. Borax also, or
tincture of myrrh, seem to do good. But perhaps these would
always heal easily, if left to follow their own course.
§ 29. SYPHILIS.
Infants may be affected with syphilis, in different ways.
They may be diseased in utero, in consequence of the state of
one or both of the parents. They may be infected by pass-
ing through the vagina, when the mother has chancres; or
by sucking a woman who has the nipple affected. Of all
these methods, the first is the most frequent; and it is wor-
thy of remark, that this mode of infection may take place,
when neither of the parents has at the time any venereal
swelling or ulceration, and perhaps many years after a cure
has been apparently effected. I do not pretend to explain
here the theory of syphilis, but content myself with relating
well established facts.
In such cases, it is very common for the mother to miscar-
ry, or have a premature labour, without any evident cause;
and when this takes place, the child is found to have the
epidermis wrinkled, or peeled off, as if it had been macerated,
and sometimes deeper ulcerations are discovered. The liquor
amnii is turbid and foetid. We are not, however, to suppose,
in every instance, where these appearances are met with,
that the child is syphilitic; for any cause, producing the
death of the foetus, a considerable time antecedent to its ex-
pulsion, will produce nearly the same appearance. The diag-
nosis then, must depend much upon the repetition of the pre-
mature labour, the circumstances attending it, the history of
the parents, and the distinct appearance of ulceration. In
such cases, the parent originally affected ought to undergo a
mercurial course; and if the other parent have any suspicious
256
symptoms, mercury should be administered to both. Some-
times the disease seems to wear itself out, without any reme-
dies being employed; and the children, born in future, are
healthy. But it often happens, that the child, though it have
received the venereal disease in utero, and probably possessed
it as a peculiarity of constitution from the time of conception,
is born alive, and has even no apparent disease on the skin,
or in the mouth. Frequently, indeed, it is born before the
time, and perhaps it has been preceded by one or two dead
children. It may be clean and healthy, and continue so for
even a month or two, but oftener it is feeble, and rather ema-
ciated; and sometimes it has at the time of birth, or soon
afterwards acquires, a wrinkled countenance, having the ap-
pearance of old age in miniature, so very remarkably, that
no one who has ever seen such a child can possibly forget
the look of the petit vieillard. In such a case, the child has
scarcely any hair upon the head, but may have pretty long
hairs on the body; it cries in a low murmuring tone, and ap-
pears so weak, that it cannot suck for a minute at a time.
But whether the child be apparently healthy or emaciated
at the time of birth, other symptoms presently appear;1 and
of these, the most frequent and earliest is generally an in-
flammation of the eyes, accompanied with ulceration of the
tarsi, and purulent discharge. This appears a few days after
birth. The eye presently, if neglected, becomes ulcerated,
and the cornea, opaque. Copper-coloured blotches, ending
in ulceration, appear on the surface; or numerous, livid,
flat, suppurating pustules, cover the surface; or many clus-
ters of livid papulae appear, which presently have the top
depressed, and then end in ulceration. These papulae are
sometimes attended by an eruption of pale shining pimples
on the face, which enlarge, become red, and often run
together. Children have sometimes an eruption of herpetic-
looking spots which I have formerly described, and which
resemble syphilis. The syphilitic blotches are of a darker
colour, are more apt to end in ulceration than in scurf, or to
form crusts or scabs, and seldom disappear without the use of
mercury; or if they do, they soon return, and become worse
857
by continuance, and presently are combined with additional
symptoms of the disease.
The genitals and anus* become ulcerated, and sometimes
excrescences sprout out from these parts. Foul sores, having
retorted edges, and a centre pale and like lard, cover the in-
side of the mouth; and chancrous ulceration takes place on
the lips, especially about the angle of the mouth. These sores
and chops are often surrounded pretty extensively with a
whiteness of the skin, as if the part had been scalded, or re-
cently rubbed with lunar caustic, and perhaps, from this cir-
cumstance, these sores have been called, though improperly,
aphthae. They may, however, be combined with aphthae.
In some cases, the white or dusky patches cover the
whole palate and inside of the cheeks, whilst the gums are
ulcerated, or even nearly gangrenous. The ulceration of the
gums has always a very angry look. The nostrils become
stuffed, and discharge purulent matter. On the face and
hands we see obstinate sores covered with pus, others vvith
crusts, whilst the intervening skin is sallow. The child is
hoarse, and the glands of the neck, with those below the jaw,
are swelled. Children, like adults, have in general the sur-
face first affected, and then the mouth and throat. They sel-
dom live long enough to have the bones diseased. They are
always in great danger, and those who are much diseased
never recover. Mahon, with great justice, ranks among in-
curable symptoms, the old decrepid visage, great destruction
of the globe of the eye, chancres on the middle of the lip,
spreading to the fraenum, and extensive ulceration of the
mouth. It must be remembered, that syphilis not only may
appear under its own peculiar characters, but may also exist
under the form of some of the eruptions, common to children;
such as crusta lactea, herpes, psoriasis, &c. These are known
to be venereal, by their being of a more livid colour than
usual; they tend slowly to ulceration, and when the scab or
crust with which they are furnished comes off, a foul honey-
comb-like ulceration is observed below. But the best diag-
nostic is, that they are soon attended with other symptoms,
such as' hoarseness, ulceration of the mouth and throat, &c.
VOL. H. LI
258
We must make up our judgment slowly, and with delibera-
tion.
When a child is infected during delivery, the disease ap-
pears more promptly on the surface, in the form of ulcers ;
and the usual train of symptoms follow, the mouth and geni-
tals becoming presently affected. The disease generally ap-
pears within a fortnight after delivery, sometimes so early as
on the fourth day.
If the child receive the infection from the nurse, we dis-
cover ulcers on her nipples, and the disease appears on the
child's mouth, before the surface of the body be affected.
It has been proposed to cure this disease by giving mercury
to the nurse alone, but this mode is now abandoned, mer-
cury being given directly to the child; and it ought to be re-
membered, that this medicine produces less violent effects on
the bowels in children, than in adults, and scarcely ever
excites a salivation. But if given too long or too liberally,
it may kill the child by its irritation, or may excite convul-
sions. Calomel is very often employed, and'with great be-
nefit, a quarter or half a grain being given three times a-day.
Others advise frictions, which are equally useful. Fifteen
grains of mercurial ointment are rubbed on the thighs alter-
nately once in two days, until the mouth be found hot, when
it is intermitted or continued, according to the state of the
system, and the effect on the disease; it must be used till the
disease be removed. It has been remarked, that children,
apparently cured when on the breast, have had a relapse
after being weaned. If the child be griped, a gentle purge,
and then an opiate, will give relief. Some have used the
ung. acid, nitros. in place of the mercurial ointment, but it is
not to be depended on. It is, however, useful, as an auxiliary,
when applied to the affected part of tlie surface. It often
happens, that after all appearances are removed, the disease
returns some weeks or months afterwards. It is, therefore,
necessary to continue the medicine for some time after an
apparent cure.
Sometimes, in consequence of the use of mercury, a pecu-
liar eruption, called the eczema mercuriale, takes place. This
25Q
generally begins on the lower extremities, and spreads to the
body. It consists of very small vesicles, which at first are like
papulae. Each vesicle may with a glass be seen to be sur-
rounded with redness ; and if they are not disturbed, they
acquire the size of pins heads, and then their contents become
opaque. They are attended with heat and itching, and a gene-
ral tumefaction of the part affected. Presently, even if not
scratched, the vesicles burst, discharging thin acrid fluid,
which stiffens the linen, and sometimes excoriates the part.
When the discharge ceases, the cuticle becomes of a pale
brown colour, and then blacker; and separating in pretty
large flakes, leaves the skin below of a bright red colour. Af-
ter this, the skin comes off in scales or scurfs, perhaps two
or three times. The disease ceases of itself, sometimes within
ten days; often, however, it is protracted longer. Those
parts which are first affected, are first cured. Relief may be
obtained, by applying saturnine lotions, or weak saturnine
ointment.(?u)
§ 30. SKIN-BOUND.
The disease termed skin-bound, may be divided into the
acute and chronic, the last being chiefly met with in private
practice. The acute species generally appears soon after
birth, and proves fatal in the course of a few days. The best
description of this disease is given by Dr. Underwood, and
by M. Andry, as it appeared in the hospitals of London and
Paris. In London, the children were seized at no regular
period; but it was observed, that, whenever the disease ap-
peared, several children were attacked within a short time,
and especially those in the last stage of bowel complaints, in
which the stools were of a clayey consistence, and of which
the induration of the skin appeared to be only a sequel.
The skin was of a yellowish white colour, like wax, and it
felt hard and resisting to the touch, but not (edematous. It
(m) Vide Alley on Hydrargyria, and Mathias on the Mercurial Disease,
also Spens on Erythema Mercuriale in Edin. Med. and Surg. Journal, Vol. I.
*nd M'Mullins in same work, Vol. II.
260
was so fixed to the subjacent flesh, that it would not slide,
nor could it be pinched up. This state was found to extend
over the body, but the skin was peculiarly rigid about the
face and extremities. The child was always cold, did not
cry but made a moaning noise, and had constantly the ap-
pearance of dying immediately. In the French hospitals,
the disease differed, in being more frequently attended with
spasm, or tetanus, and always with erysipelas, especially
about the pubis, which, though purple, was very cold. These
erysipelatous parts rarely suppurated, but sometimes morti-
fied. The legs were oedematous, and the children died on
the third or fourth day, or at farthest, on the seventh day
from birth. This disease differs, then, principally from that
observed in this country, in being combined with erysipelas
and tetanus, which are by no means essential symptoms; and
perhaps the erysipelas of children has sometimes been mis-
taken for the disease called skin-bound.
In private practice, the disease appears under a more
chronic, though not less dangerous form. The children af-
fected are generally delicate; and in such cases as I have
seen, the skin, from birth, was not so pliable as it generally
is, being most rigid about the mouth, which had more of the
orbicular shape than usual. The skin gradually becomes
tight, hard, and shining, and of a colour a little inclined to
yellow. In some cases, the whole skin is thus affected; in
others, chiefly that about the jaws, neck, and joints. The
scalp is often bald and shining, and the veins of the head
peculiarly large and distinct. In some instances, parts of the
skin are rough and slightly herpetic. The appetite, at first,
is not greatly impaired, and the bowels are sometimes uni-
formly regular. Presently the child becomes dull and list-
less, and moans, and gradually sinks, or is carried off by fits.
The complaint lasts for several weeks. In some cases, the
disease is less severe, the appearance of the child being
healthy, and the thickening and rigidity of the skin confined
to the joints of the extremities.3 No light is thrown on the
nature of this complaint by dissection, which simply discovers
a deficiency of oil in the cellular substance, with induration.
261
In the acute species, the liver has been found enlarged, and
the gall bladder distended. Sometimes more children than
ohe in the same family have been affected; and in such cases,
they have been always of the same sex. A variety of reme-
dies have been made use of, such as mercury, laxatives, baths,
and emollient frictions; but seldom with any advantage. A
course of calomel powders has, however, appeared to do good,
when the affection is confined to the extremities. Decoction
of sarsaparilla, with the frequent use of the warm bath, de-
coction of mezerion, and a variety of diaphoretics, might be
tried; and in cases where more children than one in the same
family, have been affected with the chronic species of this
disease, it might be worth while to try the effects of mercury,
and some other medicines, on the parents.
§ 31. SMALL-POX.
The small-pox begins with a febrile attack, which com-
mences generally about mid-day. It is marked by chilliness,
listlessness, pain in the back and loins, drowsiness, vomiting,
pain in the region of the stomach, which is increased by pres-
sure, starting, and coldness of the extremities. As the fever
advances, the pulse becomes more frequent, the skin hotter,
the face flushed, the eyes tender, and the thirst considerable.
The child starts, grinds his teeth, or has one or more epilep-
tic fits, or sometimes complains of severe cramp in the legs,
or lies in a kind of comatose state.4 On the evening of the
third, or morning of the fourth day, an eruption appears on
the face, and then on the neck, from which it spreads to the
body. In mild cases, the eruption is completed by the even-
ing of the fourth, but sometimes not till the fifth day, or even
later, if the pustules be very numerous; and then the fever
declines, or goes off altogether. The eruption consists, at
first, of small hard red pustules, of a fiery appearance. On
the second day, the top is clear, and a very small vesicle is
observed to be forming. On the face, we frequently find
patches like measles, but containing many minute vesicles.
Next day, if the eruption is to be copious, the number of pus-
262
tules is farther increased, especially on the face, where we
often find more patches. These patches, and the succeeding
confluent vesicles, seldom appear in the inoculated small-pox,
or in the natural small-pox, when very distinct. They are
numerous, in proportion to the tendency to the confluent form
of the disease. The pustules on the body are more raised
and rounder, though in some places they are flatter, and
more extended. The base is surrounded with an inflamed
rim; and presently, if the eruption be copious, this inflamma-
tion spreads from one pustule to another, so that all the sur-
face appears to be red. The cuticle of the vesicle, at this
time, is somewhat opaque, but its contents are limpid, like
water. On the fourth day, if there be any patches on the
face, they are evidently covered with flat confluent vesicles;
on the body and arms, the vesicles are larger and rounder
than the day before. The surrounding redness is a little
paler, the skin of the vesicle is whiter, and more of the pearl
appearance; so that, at the first glance, the eruption seems
to consist of white elevations. The vesicles are full and
smooth. On the fifth day, they are rather flatter. On the
sixth day, the skin of the vesicles, on the body and extremities,
is drier and harder, and the contents still limpid; all those
on the body are entire, but about the chin some have broken,
and crusts are formed. If there have been patches on the
face, these are now covered with flat vesications. On the
seventh day, the vesicles on the body and extremities are of
a dead white colour at the circumference, but more glossy,
like candied sugar, at the centre. Their contents are a little
turbid; more crusts are formed on the face. On the eighth
day, the fluid on the extremities is whitish. On the ninth
day, the crusts on the face are more numerous, and they
begin to be formed about the bend of the arm, occ. The pus-
tules on the extremities are whiter, as if filled with pus, but
the fluid is thin and milky; the skin of the vesicles is thick.
On the tenth day, the pustules on the face are covered with
scabs, and many are formed on the extremities. On the
breast, the vesicles are prominent, like two-thirds of a sphere,
but compressed, and have no redness around them. Many
263
vesicles are empty, and covered with thin brown skin. Scabs
are formed, by the skin becoming dry, hard, and brown, or
sloughing. The contained fluid is partly absorbed, and part-
ly effused by exudation, so as to add a crust to the slough of
the vesicle.
When the scabs are picked off, about the seventeenth day,
the base of the mark is in general elevated above the rest of
the skin, but the centre is depressed a little below the margin.
The colour is light red. On the twentieth day, the blanes on
the body and extremities are smooth, flat, or slightly scurfy,
so that they somewhat resemble herpetic spots.
The process is not always regular; for, in very mild cases,
the suppuration is indistinct, and the scab thin; the pustule
dries without forming much matter, so that inoculators can
scarcely get their lancet wet. This is a favourable condition.
Sometimes the matter, though considerable in quantity, does
not exude to form a scab, but is absorbed, and the vesicle re-
mains for a time entire, forming what has been called variola
siliquosa.
About the seventh or eighth day of the disease, when the
pustules are numerous, the face swells; but about the tenth or
eleventh, it subsides, and then the hands and feet swell. It is
also common, about the sixth or seventh day, for the throat
to become sore, with sneezing, and some degree of hoarse-
ness or cough; and, in unfavourable cases, the secretion
about the throat becomes tough and thick.
When the pustules are numerous, a return of the fever may
be expected about the eleventh day. This is called the se-
condary fever; but in mild cases it is very trifling, and does
not last long.
Such is a general history of the distinct small-pox: but the
disease may also appear under a different form, known under
the name of the conffeent small-pox. In this case, the erup-
tive fever is more setvere, attended with greater pain in the
loins, and often with coma. It differs also from the former,
which is of the inflammatory kind, in being of the typhoid
type, so that sometimes petechias appear. The eruption
264
comes out earlier, generally on the morning of the third day,
and is sometimes preceded by erythematic inflammation of
the face or neck. The eruption is copious, and at first,
more like measles than small-pox; so that some practition-
ers have, at this stage, mistaken the one disease for the
other. The pustules, which are not so much elevated as the
variola discreta, become confluent, especially on the face;
and though they may be confluent only on the face, yet those
on the body are not of a good kind. They form matter ear-
lier, do not retain the circular form, and, instead of having
the interstices of the skin, where they do not coalesce, of a
red colour, as in mild small-pox, these spaces are pale and
flaccid. The coalescence is most remarkable on the face,
which often seems as if covered with one extensive vesicle.
The matter which these pustules form is not thick and yel-
low, like good pus, but either of a whitish brown, or black
colour. Scabs generally form about the eleventh day of the
disease, but these do not fall off for a length of time, and
leave deep pits. The swelling of the face is greater and
more permanent than in the former species, and the eruptive
fever does not go off when the eruption is completed; it only
diminishes a little, till the sixth or seventh day, when it in-
creases, and often proves fatal on the eleventh.
The treatment of the distinct is different from that of the
confluent small-pox. During the eruptive fever, the antiphlo-
gistic regimen must be carefully enjoined, the diet must be
light and sparing, the surface kept cool and clean, and the
bowels loose. Emetics, at an early stage of the fever, are
often serviceable, and it is generally proper to gin; laxatives.
Epileptic fits are relieved by opiates and cool air. When the
eruption is coming out, the cool regimen should still be per-
sisted in, and the bowels kept open. After the pustules have
appeared, the fever generally abates*:, and then, although
heat should be avoided, the cooling and purging plan need
not be carried so far as formerly. But if the fever still con-
tinue, these means should be also continued. The diet must
be sparing, and plenty of ripe fruit should be given. If se-
265
condary fever supervene, it is to be removed, chiefly by lax-
atives and cool air: or if there be oppression at the stomach,
a gentle emetic may be given.
In the confluent kind, during the eruptive fever, the cold
plan should be diligently employed, and cathartics are of es-
sential benefit. When the eruption appears, the cooling re-
gimen should still be persisted in, and both vegetable and
mineral acids ought to be given freely. Bark is also pro-
per, provided that it is not productive of sickness or vomit-
ing. When the fever is aggravated, at the height of the
disease, emetics have been sometimes given with advantage;
but in general they are not necessary, and more benefit
is derived from laxatives and clysters. Opiates are useful,
for abating irritation; and wine, with nourishing diet,
should be prudently given, to support the strength, which
is apt to be completely exhausted under the constant fever
and irritation. On this account also, it is necessary to re-
strain diarrhoea, when it is frequent, and adds to the weak-
ness. Blisters have been advised as stimulants, but they
are only useful when deep seated inflammation exists.
Sometimes the brain seems to be affected, the head being
pained, the eyes impatient of light, and the patient deli-
rious. In this case, leeches may be applied to the temples,
and a blister put on the head. When the lungs are af-
fected, blisters on the sides or breast do good. When the
stomach is very irritable, if saline draughts and opiates
do not give relief, a small blister should be applied over
the stomach. If the swelling of the face subside quickly,
and be not followed by tumefaction of the feet and hands,
blisters have been applied to the wrists, but sinapisms are
better, though it is not decided, that either are of great utili-
ty. When the throat is much affected, and filled with viscid
phlegm, gargles are of use, and sometimes a very gentle eme-
tic gives relief.
If the eruption suddenly subside, cordials tend to bring
back a salutary inflammation ; or if it altogether recede, the
tepid bath, with ammonia, and other internal stimulants, will
be proper. The boils and inflamed pustules, succeeding vari-
VOL. IT. M M
266
ola, are very troublesome, and sometimes prove fatal. When
large, suppuration should be hastened with a poultice; when
small, unguentum resinosum may be applied; or if they be
indolent, gentle friction, with camphorated liniment, and
bathing with laudanum, is of benefit. The strength must be
supported, and, as soon as possible, sea-bathing should be re-
sorted to.
The violence of the variolous disease is generally lessened
by inoculation,* which was first introduced into this country
in the year 1721. The operation itself is very simple, con-
sisting merely in abrading the skin on the arm or leg with
the point of a lancet, and then applying on the small scratch
a little of the variolous matter, which should be taken early,
as, when it is delayed until the pustules are collapsing or
scabbing, it sometimes produces a spurious inflammation.
By the third day, we are sure of success, by observing a
slight redness on the arm at the incision, which resembles,
from the coagulated blood, a little black speck. On the
third or fourth day, the part is hard to the touch. The red-
ness gradually increases for the two succeeding days, and
then a small vesicle may be perceived. By the eighth, or
at farthest the tenth day, the pustule has completely the va-
riolous character. It forms a circular elevation, surrounded
with circumscribed redness, and the vesicle is a little flatted
on the top. The constitution, at this time, becomes affected;
and the earlier that the eruptive fever appears, the milder in
general is the disease. The character of the succeeding dis-
ease may, it is supposed, be foreseen, even before the erup-
tion take place, or be completed, by examining tlie arm :
and on this subject, Dr. Adams has given us some remarks,
which will be found in the notes.5
The safety of the practice of inoculation is greatly increas-
ed, by having the system as free as possible from every dis-
eased state; and, therefore, children are not inoculated dur-
ing dentition, at least if they cut their teeth with any tron-
• Inoculation, even after exposure to infection, is capable of producing p.
mild disease.
267
ble. Very young children are not considered as favourable
subjects; Dr. Fordyce observing, that two-thirds of those
who died from inoculated small-pox were under nine months.
If we have our choice, the best age is said to be from twTo to
four years, but it is dangerous to wait so long, lest the child
should take the casual small-pox; and Dr. Adams informs
us, that of three thousand children inoculated at the hospital
in one year, two thousand five hundred were under two years
of age, yet only two out of that number died. Full plethoric
children should be frequently purged, and fed sparingly, be-
fore the operation. Some particular modes of preparation
have been often employed, such as giving calomel or antimo-
ny, but these have very little effect.(n) The attention ought
chiefly to be directed to bring the body into a state of good
health, if previously delicate, or diseased: and, on the other
hand, if requisite, diminishing plethora and inflammatory dis-
position by the obvious means. After the inoculation, the
bowels must be kept open, and all stimulants avoided; and
when the eruptive fever commences, the antiphlogistic regi-
men is to be strictly practised, and often has so good an ef-
fect, that few or no pustules come out; or if they do, they do
not maturate, and we have no secondary fever. In general,
the arm heals kindly ; but when it forms a sore, it should be
exposed to the air, or dusted with chalk ; or if it threaten
gangrene, it should be bathed with camphorated spirits, or
tincture of myrrh.
§ 32. COW-POX.
As a preventive of the small-pox, the vaccine inoculation is
now universally practised. This is productive in general, of
a very mild and safe disease, consisting of a single vesicle,
forming on the place where the inoculation was performed.
On the third day, the scratch is slightly red, and, if pressed,
with the finger, feels hard. Next day, the red point is a little
(n) In so far as they operate as laxatives, their effects occasionally must be
beneficial, and children are more easily induced to take them, as they are
not so nauseous as some other cathartics.
268
increased, and somewhat radiated. On the fifth day, a small
vesicle appears, but it is still more easily seen on the sixth.
This gradually increases, till it acquire the size of a split pea.
The colour of the vesicle is dull white, like a pearl. Its
shape is circular, or slightly oval, when the inoculation has
been made with a lengthened scratch, acquiring about the
tenth day, a diameter equal to about the third or fourth part
of an inch. Till the end of the eighth day, the surface is un-
even, being depressed in the centre; but on the ninth day, it
becomes flat, or sometimes rather higher at the middle than
at the edges. The margins are turgid and rounded, pro-
jecting a little over at the base of the vesicle. The vesicle is
not simple, but cellular, and contains a clear limpid fluid,
like the purest water. On the eighth or ninth day, the vesi-
cle is surrounded with an areola of an intense red colour,
which is hard and tumid. About this time, an erythematic
efilorescence sometimes takes place near the areola, and
spreads gradually to a considerable part of the body. It con-
sists of patches, slightly elevated, and is attended with febrile
symptoms. On the eleventh or twelfth day, as the areola
decreases, the surface of the vesicle becomes brown at tlie
centre, and is not so clear at the margin; the cuticle gives
way, and there is formed a glossy hard scab, of a reddish
brown colour, which is not detached, in general, till the
twentieth day. When it falls off, we find a cicatrix, about
half an inch in diameter, and with as many pits as there
were cells in the vesicle. During the progress of the vesicle,
there is often some disorder of the constitution ; and occa-
sionally, a papulous eruption, like strophulus, appears near
the vesicle.
As security against the small-pox is not procured by spuri-
ous vaccine vesicles, it becomes necessary to study carefully
the character of the genuine disease, which I have briefly
described. A very frequent species of spurious cow-pox, is
rather a pustule than a vesicle. It increases rapidly, instead
of gradually. From the second to the fifth or sixth day, it is
raised toward the centre, and is placed on a hard inflamed
base, surrounded with diffused redness. It contains opaque
209
fluid, and is usually broken by the end of the sixth day, when
an irregular yellowish brown scab is formed. If the vesicle
be regular in its progress, and have pretty much of the gene-
ral aspect of the vaccine vesicle, but contains, on or before the
ninth day, a turbid or purulent matter, it cannot be depended
on; and the security will be still less, if the scab be soft.
Besides these, Dr. Willan has characterized three spurious
vesicles. First, A single pearl-coloured vesicle, less than
the genuine kind; the top is flattened, but the margins are
not rounded nor prominent. It is set on a hard red base,
slightly elevated, with an areola of a dark rose-colour. The
second is cellular, like the genuine vesicle, but somewhat
smaller, and with a sharp angulated edge. The areola is
sometimes of a pale red-colour, and very extensive. It ap-
pears on the seventh or eighth day after inoculation, and
continues more or less vivid for three days; during which,
tlie scab is completely formed. This is less regular than
the genuine scab, and falls off sooner. The third is a vesicle
without an areola. These forms of the disease do not give
security against the small-pox; and it would appear that a
vesicle, which is even regular at first, or which runs
through the whole course with regularity, may fail to
secure the constitution; for there are well authenticated
cases, where the small-pox has thus succeeded the cow-pox.
Professed writers on this subject, have enumerated three
causes of failure. 1st, From matter having been taken
from a spurious vesicle, or from a genuine vesicle at too late
a period. The best time for taking matter is about the eighth
day; and after the twelfth,(o) or when it becomes purulent,
(o) It has been satisfactorily determined by the experience of the physi-
cians of this city, that the genuine Vaccine scab, after the usual process of
separation from the arm, will, when properly used, communicate the real
Vaccine disease.
This valuable fact was first brought before the medical public in the year
1802, by James Bryce, of Edinburgh, surgeon to the Vaccine Institution Of
that place. The student is also referred to a paper on this subject, with
directions for tlie proper mode of using the scab, or crust, by Dr. Samuel
Powel Griffitts, Eclectic Repertory, Vol. I. p. 362. Dr. G. has used with
success, a scab, which he had possessed for eleven months. As it appears
370
it cannot be depended on; or the same effect will be pro-
duced by any cause which can disturb the progress of the
vesicle. 2d, From the patient being seized, soon after vac-
cination, with some contagious fever, such as measles,^car-
latina, influenza, or typhus. 3d, From his being affected, at
the time of inoculation, with some chronic cutaneous disease,
such as tinea, herpes, &c. The precise circumstances under
which these causes produce their effect, or the degree to which
they must be present in order to operate, have not yet been
determined with certainty. It has also been supposed, that
puncturing the vesicle in order to take matter from it, may,
by disordering the process, sometimes prevent its efficacy.
Even where none of these causes exist, and when the vesi-
cle runs its course with distinctness, it does, though very sel-
dom, happen, that the constitution is not rendered unsuscepti-
ble of the variolous action. It were much to be wished, that
some test could be discovered, by which the security could
be determined. The constitution is often manifestly disor-
dered during some part of the vaccine progress, and such
children are most probably secure; but sometimes the disor-
der is too slight to be discovered, and therefore this sign is
lo be a matter of importance to the young practitioner to understand this
subject well, we shall take the liberty of subjoining from the paper above
alluded to, the most essential circumstances to be observed in the use of the
scab in vaccinating.
" The most perfect vesicles which go on to the state of crust, or scab,
without any deviation from the proper character, and wliich when they fall
off are somewhat transparent, smooth, of a mahogany colour, and rather
brittle than tenacious in their texture, are to be chosen to propagate the in-
fection. It should be the first scab that falls off; this should be wrapped up
in a piece of white paper, and kept in a cool dry place. When used, the
margin wliich is of a hghter colour, shoidd be removed with a knife, and a
portion of the remaining dark, hard internal part is to be shaved off, reduced
to powder on a piece of glass, and moistened with a small quantity of cold
water, mixing it well together, and then introducing it in the arm on the
point of a lancet, leaving also a small portion of the scab on the scratched
part. No more of the scab must be moistened at one time, than what is used,
and no greater portion should be shaved oft" from tlie scab, than what is
wanted for the present occasion, as it appears to retain its strength better by
continuing in the undetached state. It is believed that the livid vesicle and
especially the unopened one is most powerful."
271
not to be relied on. We are also assured, that even when
no constitutional disorder has taken place, the child is se-
cured. Other means, then, have been resorted to, in order
to discover if the system be affected, so as to have a complete
change induced by the inoculation. These are two in num-
ber : 1st, If a second inoculation be performed on the fifth or
sixth day after the first, a vesicle will arise as usual, but it
will be surrounded with an areola nearly as early as the first
one. 2d, If a second inoculation be performed any time after
the twelfth day after the first inoculation, some degree of in-
flammation will be induced; but if the system have been af-
fected, no regular vesicle will be produced. But the most
satisfactory method is, to inoculate with small-pox matter,
which produces most frequently a small pustule, generally
totally unattended with constitutional affection; but some-
times, even although the constitution have been changed by
the vaccine inoculation, a slight febrile affection may be ex-
cited, either without any secondary pustules, or attended by
an efflorescence on the skin, or an eruption of small hard
pustules, which disappear in about three days. It unfor-
tunately happens, however, that parents in general do not
think it necessary to adopt any of these means; and inocula-
tors, perhaps, trust too much to their own power of dis-
crimination, in determining how far a vesicle is capable of
producing the desired effect. Some test is the more requisite,
as vaccination is often performed in a very careless manner,
and by people ignorant of the character of the disease.
It has been said, that if a child, properly vaccinated, should
afterwards take the small-pox, the pustules are papulous, or
tuberculated, and do not suppurate, but end in desquamation.
I have, however, seen a very distinct case of suppurating
small-pox, in a girl who, some years before, had gone through
the vaccine process in the most satisfactory manner; of which
I am certain, having attended her on both occasions. In a
considerable number of instances, I have found variolous ino-
culation produce some degree of fever, followed by papulous
eruption, and pretty universal efflorescence like measles. The
variola occurring after vaccination is contagious, producing
272
the unmodified disease in other children. I do not, from
these remarks, mean to depreciate the cow-pox; on the con-
trary, it is only by ascertaining the precise power of vaccina-
tion, that its full benefit can be derived to mankind: and al-
though the warmest friends of this discovery must admit, that
it is not always successful, yet it has hitherto failed in so few
instances, that we must consider it as justifiable to rely upon
it, and adopt it, in preference to the variolous inoculation.(p)
Experiments have been made to ascertain the effects of ino-
culation with a mixture of variolous and vaccine matter; and
the result has been, that sometimes the cow-pox, sometimes
the small-pox, have been thus produced. When a person is
inoculated with variolous and vaccine matter at the same
time, the incisions being very near each other, the vesicles
enlarging, join into one; and matter, taken from the one side,
will produce cow-pox, from the other small-pox. When a
person is inoculated with the two kinds of matter at the same
time, or within a week of each other, both diseases will be
communicated to the patient, whether the incisions be near
or remote, and small-pox pustules will be produced on the
body; but they seldom maturate, and the disease is generally
mild. When, however, the variolous inoculation is perform-
ed more than a week, as, for instance, nine days before vac-
cination, the vaccine pustule becomes purulent, and sometimes
communicates the small-pox even in a very bad form. When,
on the other hand, variolous matter is introduced nine days
after vaccination, its action is altogether prevented. From
(p) Numerous cases have of late years been undeniably adduced, of the
variolous virus producing its full effects twice in the same system, so that a
similar objection will apply to variolous inoculation as to vaccination, as it
regards the after security of the patient It might perhaps be considered as
superfluous to refer to partipular instances in proof of this position; but the
curious reader may find a very interesting case of this kind, related by E
Withers, surgeon, in tlie Memoirs of the Medical Society of London, Vol
IV. The patient's face was severely pitted with the first attack, and he died
nearly 50 years afterwards in consequence of the second. See also a case of
secondary small-pox, with references to some cases of a similar nature, by
T. Bateman, M.D. F. L. S. Physician to the public Dispensary, and to the
Fever Institution. .Medico-Chirurgical Transactions, Vol. II. p. 31. and seq.
273
these observations, it follows, as an important conclusion,
that when a child has been exposed to small-pox contagion,
vaccination, though it may not prevent, will yet generally
mitigate the subsequent disease. <
It only remains to take notice of two objections to vacci-
nation. The first is, that it is apt to be followed by a very
sore arm. This, however, applies in a greater degree to
small-pox; and in general, the vaccine sore heals, by being
dusted with chalk or hair powder; and even when tedious,
seldom requires any other application. The second is, that
it is followed by cutaneous diseases. But these occur sel-
domer, than when the variolous inoculation was performed;
for then inflamed pustules and boils, with herpetic and im-
petiginous eruptions, frequently succeeded the disease.
Doubtless, children, after vaccination, may have crusta
lactea, herpes, &c. but it does not thence follow, that these
are the consequences of inoculation; and it is not unworthy
of remark, that no new cutaneous disease has been produced
by the introduction of the cow-pox.( IV
J positions, viz.
Of which
there are
IV
positions, viz.
03
03
Ills
ma
.S o g
C3 as "S
CD -el W
The Back of the "1 Of which
Neck L there are
presenting IVf
at the Os Uteri. J positions, viz
The Back "1 Of which
presenting [ there are
at the IV
Os Uteri. J positions, viz.
The Lumbar Region^ Of which
presenting L there are
f IV
J positions, viz
to the
Os Uteri.
'43
O
-d c-
The Side
of the
Neck
presenting
at the
Os Uteri.
The Shoulder,
Elbow,
or
Arm and Hand,
presenting
at the Os Uteri.
One of the
Sides
of the Child
presenting
at the
Os Uteri.
One of the
Hips
of the Child
presenting
at the
Os Uteri.
Of which
there are
r iv
positions, viz.
Of which
there are
IV ^
positions, viz
Of which
there are
IV
positions, viz.
Of which
there are
iv <;
positions, viz,
fist. The lower part of the Face on the Pubes; the upper part of the Breast on the projection of the Sacrum.
J 2d. The Breast over the Pubes and the Face towards the Sacrum. - -
i 3d. The Face on the anterior part of the left Ilium, and the Breast on the right Ilium.
, t_4th. The Face on the anterior part of the right Ilium, and the Breast on the left.
fist. The fore part of the Neck over the Pubes, and the Abdomen over the Sacrum.
J 2d. The fore part of the Neck over the base of the Sacrum, and the Abdomen over the Pubes. -
1 3d. The Neck and Head resting on the left Ilium; and the Abdomen on the right Ilium.
. t_4th. The Neck and Head resting on the right Ilium; the Abdomen on the left.
fist. The Breast above the Pubes; the inferior Extremities above the Sacrum. -
J 2d. The Breast above the Sacrum; the inferior Extremities above the Pubes. -
i 3d. The Breast resting on the left Ilium; the Thighs and Knees on the right Ilium.
. l_4th. The Breast resting on the right Ilium; the Thighs and Knees on the left. -
fist. The Knees above, or on one side of the projection of the Sacrum; the Abdomen above the Pubes;
the Breast and Face to the anterior portion of the Uterus.
J 2d. The Knees over the anterior brim of the Pelvis; the .Breast and Face to the posterior portion of the?
j Uterus. y
3d. The Knees to the concavity of the right Ilium; the Breast to the left Ilium.
4th. The Knees to the concavity of the left Ilium; the Breast to the right Ilium.
fist. The Occiput over the margin of the Pubes; the Back above the Sacrum.
J 2d. The Occiput on one side of the projection of the Sacrum; the Back above the Pubes.
} 3d. The Occiput to the left Ilium; the Back to the right Ilium. - - -
, L.4th. The Occiput to the right Ilium; the Back to the left Ilium. ..- - - - - -
fist. The back of the Neck over the margin of the Pubes; the Lumbar Region above the Sacrum.
J 2d. The Lumbar Region over the Pubes; the back of the Neck over the posterior margin of the Pelvis.
| 3d. The Occijmt on the left Ilium; the Lumbar Region on the right Ilium. - k
t_4th. The Occiput on the right Ilium; the Lumbar Region on the left Ilium. - -
fist. The Back above the Pubes; the Thighs above the Sacrum.
J 2d. The Thighs and Feet above the Pubes; the Back and Head towards the Sacrum. -
"\ 3d. The Back on the left Ilium; the Thighs and Feet on the right Ilium. - - - 0 -
, t_4th. The Back on the right Ilium; the Thighs and Feet on the left Ilium. - .
"1st. The Ear and angle of the lower Jaw to the Pubes; the Shoulder towards the Sacrum. The Face towards >
the left side of the mother when the right side of the Neck presents, and vice versa. $
2d. The Ear and angle of the lower Jaw towards the Sacrum; the Shoulder towards the Pubes. The Face?
towards the right side of the mother when the right side of the Neck presents, and vice versa. $
i 3d. The side of the Head upon the left Ilium, and the Shoulder on the right Ilium. The Face towards the?
Sacrum when the right side of the Neck presents; towards the Pubes when the left. $
4th. The side of the Head upon the right Ilium, and the Shoulder on the left Ilium. The Face towards the ?
Pubes when the right side of the Neck presents; towards the Sacrum when the left. 5
1st. The side of'the Neck on the Pubes, and the Side over the Sacrum. The Breast towards the left Ilium,")
when the right Shoulder or Arm presents, and towards the right Ilium wh|en the left Shoulder or i-
Arm presents. ] ■ J
2d. The side of the Neck over the Sacrum, and the Side over the Pubes. The Breast!towards the right Ilium >
when the right Shoulder presents, and vice versa. 5
3d. The Neck and Head on the left Ilium; the Side and Hip on the right Ilium. The Back to the fore part of?
the Uterus when the right Shoulder presents, and to the back part when the left presents. $
4th. The Neck and Head on the right Ilium; the Side and Hip on the left Ilium. The Breast to the fore part ?
of the Uterus when the right Shoulder and Arm presents, and vice versa. 5
"1st. The Axilla over the Pubes; the Hip over the Sacrum. The Breast towards the left Ilium when the right?
Side presents, and vice versa. $
2d. The Axijla over the Sacrum; the Hip over the Pubes. The Breast towards the right Ilium when the right?
Side presents, and vice versa. $
1 3d. The Axi la on the left Ilium; the Hip on the right Ilium. The Breast towards the back part of the Uterus 5
when the right Side presents, and vice versa. )
4th. The Axilla on the right Ilium; the Hip on the left Ilium. The Breast towards the fore part of the Uterus ?
whence right Side presents, and vice versa. 5
1st. The Thighs towards the Sacrum; the Spine of the Ilium towards the Pubes. The; Breast towards the left?
side of the Uterus when the right Hip presents, and vice versa. , $
2d. The Thighs towards the Pubes; the Spine of the Ilium towards the Sacrum. The Breast towards the right ?
side of the Uterus when the right Hip presents, and vice versa.
3d. The Thikhs towards the right side; the Spine of the Ilium towards the left side.
posterior part of the Uterus when the right Hip presents, and vice versa.
4th. The Thighs towards the left side; the Spine of the Ilium towards the right side
anterifir part of the Uterus when the right Hip presents, and vice versa-
The Breast towards the ?
The Breast towards the ?
Either the right or left hand of the practitioner, indifferently, to be introduced to turn the Child.
The right hand to be introduced when the Face is on the right side of the vertebral column, and vice versa.
The left hand to be introduced to reach the Feet and turn the Child, &c.
The right hand to be introduced, &c. &c.
Either the right or left hand, indifferently, to be introduced.
The right hand to be introduced when the facQ is on the right side of the vertebral column, and vice versa.
The left hand to be introduced, &c. &c.
The right hand to be introduced, &c. &c.
The right or left hand may be introduced, indifferently, &c.
The right or left hand, indifferently, may be introduced.
The left hand to be introduced towards the right side of the Uterus.
The right hand to be introduced towards the left side of the Uterus.
The right or left hand, indifferently, may be introduced.
The right or left hand, indifferently, may be introduced.
The left hand to be introduced towards the right side of the Uterus.
The right hand to be introduced towards the left side of the Uterus.
Either the right or left hand, indifferently, to be introduced, &c.
Either the right or left hand, indifferently, to be introduced.
The light hand to be introduced towards the left side of the Uterus.
The left hand to be introduced towards the right side of the Uterus.
The right hand to be introduced towards the left side of the Uterus.
The right hand, &c. &c.
The right or left hand, indifferently, &c. &c. ,
The right or left hand, indifferently, &c. &c. |;
The right hand to be introduced, &c. &c.
The right hand, &c. &c.
The left hand to be introduced towards the right Ilium.
The right hand to be introduced towards the left Ilium.
The right hand to be introduced when the right side of the Neck presents; the left hand when the left
side, &c.
The left hand to be introduced when the right side of the Neck presents; the right hand when the left side.
The right hand to be introduced when the right side of the Neck presents, &c.
The left hand to be introduced, &c.
The right hand to be introduced when the right Shoulder; the left when the left Shoulder presents.
The left hand to be introduced when the right Shoulder presents; the right hand when the left Shoulder, &c.
The right hand to be introduced when the right Shoulder presents: the left hand when the left Shoulder, &c.
The right hand to be introduced when the right; Shoulder presents; the left hand when the left Shoulder, &c.
The right hand to be introduced if the right Side presents; the left hand if the left Side presents.
The left hand to be introduced if the right Side presents; the right hand if the left Side presents.
The right hand to be introduced if the right Side presents; the left hand if the left Side presents.
The right hand—if right Side----the left haajd if left Side. - %
The right hand to be'introduced when the rigU Hip presents; the left hand when the left Hip, &c.
The left hand to be introduced when the right Hip presents; the right hand when the left Hip, &c.
The left hand to be introduced in both varieties of the position.
The right hand to be introduced in both varieties of the position.
.Vote.—It is to be observed that Baudeloque, and the French practitioners generally, in preternatural Labours, or where the operation of Turning, or the application of the Forceps becomes necessary, place the Woman in a Supine Position, yfith the Breech brought to the Edge or Foot of the Bed, SO that the
Goccix and Perinseum may be free, the Thighs and Legs half extended, th£ Feet resting on Two Chairs placed properly, or supported by Assistants. I
UR,
•ruber 1797, to the Slst July, 1806, inclusively.
Infants born - - - 12,751.
n of their mothers into the Hospital, or with such haste,
j from five to six, which reduces the number to 12,633, of
; of the uterus, in the course of the labour and delivery,
s, and their Positions.
4th. Position.
40
5th. Position.
6th. Position.
Positions
not
ascertained.
rions are admitted to exist.
. . 6 . . . 1 . . 0 . . . 17 . . 0 . . . 0 . . 0 . . . 0 . . 1 . . 13 . . . 8 . . 1 . . . 0 • ■ • 1 1 1 1 1 1
48 8
S
<>
s
379
Comparative statement of the Labours which were accomplish-
ed by Nature aUme, with those in which the aid of Art was
necessary.
Of twelve thousand seven hundred and fifty one cases of La-
bour, 12,573 at least were accomplished naturally, and but
one hundred and seventy-eight, at most, required the assistance
of art; some by means of the hand alone, others with the for-
ceps, or with the crotchet, after the perforation of the Cra-
nium, which is in the proportion of 1 to 71 2-3.
Cases in which it became necessary to give assistance by
the hand alone, either because of the unfavourable situation
of the child, or on account of the mal-conformation of the
pelvis, or from accidental circumstances, which render the
labour complex,
One hundred and thirty-two in all—which in proportion to
the whole, is as 1 to 96 3-5. *
Viz: The child presenting
The face 18
The shoulders - - - 38
The crown of the head with the umbilical
cord 15
The breech - - - 22
The feet 11
The other parts specified in the table - 24
On account of convulsions and floodings 4
Total 132
The forceps were applied in thirty-seven cases, which is
as 1 to 344 2-3.
The child presenting the face - 2
The crown of the head - - 35
In ten on account of the exit of the cord;
ten on account of the exhaustion of the
woman's strength.
Six on account of convulsions.
Seven on account of the unfavourable
situation of the head, which had been
thrown backwards, &c.
Two on account of the mal-conforma-
tion of the pelvis.
The crotchet was employed, or the cranium perforated in
nine—which is in the proportion of 1 to 1,416 2-3:
Viz: 1 on account of hydrocephalus in the child.
8 on account of great deformity of the pelvis.
One by gastrotomy to extract an extra-uterine foetus.
Of these latter
the forceps were<
applied.
380
Remark.—Of 42 children in whom the face presented,
16 were born without any assistance,
6 were brought to one of the positions of the vertex,
after which they were delivered without assistance.
Of 198—where the breech or thighs presented, 176 were
born without extra aid.
Of 147—where the feet presented, 136 were born in the
same way.
Of 12,751, the cord first came out but 36 times, viz: 35
times when the vertex presented, and only once with the feet.
Sex of the children.
Children born 12,751. 6,524 Boys. 6,227 Girls.
Children dead 530; viz: before the period of labour 412;
during labour, or shortly after birth, 118.
The relative proportion of children still-born, and of those
who survived but a few moments after birth, to 12,751, is as
1 To 24 1-2.
Weight of the children.
7,077 were weighed with the greatest accuracy $ and of
this number,
34 weighed from 1 lb. to 1 1-2 lb.
69 from 2 lb. to 2 3-4 lb.
164 from 3 lb. to 3 3-4 lb.
396 from 4 lb. to 4 3-4 lb.
1,317 from 5 lb. to 5 3-4 lb.
5,799 from 6 lb. to 6 3-4 lb.
1,750 from 7 lb. to 7 3-4 lb.
463 from 8 lb. to 8 3-4 lb.
82 from 9 lb. to 9 1-2 lb.
3 10 lb.
It would appear, from the result of the experience of the
superintendants of the Hospital, from which the above table
has been taken, that preternatural and difficult cases occur
more frequently in certain years, than in others.
NOTES.
BOOK II.
CHAP. II.
NOTE 1. p. 12.—"The Greenlanders, mostly, do all their common busi-
ness just before and after their delivery; and a still-born or deformed
child is seldom heard off." Crantz's History of Greenland, Vol. I. p. 161.
Long tells us, that the American Indians, as soon as they bear a child go
into the water and immerse it. One evening he asked an Indian where his
wife was; " he supposed she had gone into the woods, to set a collar for a
partridge." In about an hour she returned with a new born infant in her
arms, and coming up to me, said, in Chippoway, " Oway saggonash pay-
shik shomagonish ;" or, " Here, Englishman, is a young warrior." Tra-
vels, p. 59.
" Comme les accouchemens sont tres-aises en Perse, de me me que dans
les autres pais chauds de 1'Orient, il n'y a point de sages femmes. Les pa-
rentes agees et les plus graves, font cet office, mais comme il n'y a gueres
de vieilles matrones dans le haram, on en fait venir dehors dans le besoin."
Voyages de M. Chardin, Tom. VL p. 230.
Lempriere says, " Women in this country, (Morocco,) suffer but Uttle
inconvenience from child bearing. They are frequently up next day, and
go through all the duties of the house with the infant on their back." Tour,
p. 328.
Winterbottom says, that," with the Africans, the labour is very easy, and
trusted solely to Nature, no body knowing of it till the woman appears at
the door of the hut with the child." Account of Native Africans, &c. Vol.
n. p. 209.
The Shangalla women " bring forth children with the utmost ease, and
never rest or confine themselves after delivery; but washing themselves
and the child with cold water, they wrap it up in a soft cloth, made of the
bark of trees, and hang it up on a branch, that the large ants with which they
are infested, and the serpents, may not devour it." Bruce's Travels, Vol.
n. p. 553.
In Otaheita, New South Wales, Surinam, &c. parturition is very easy, and
many more instances might, if necessary, be adduced. We are not how-
ever to suppose, that in warm climates women do not sometimes suffer ma-
terially. In the East Indies, "many of the women lose their lives the first
time they bring forth." Bartolomeo's Voyage, chap. 11.
Undomesticated animals generally bring forth their young with consider-
able ease, but sometimes they suffer much pain, and, when domesticated,
occasionally lose their lives.
■382
NOTE 1, p. 34.—Dr. Smellie relates two cases of this kind. In the first
he brought away the indurated portion, but the woman died from hemorr-
hage. In the second he left the adhering portion, and the woman recover-
ed. Coll. 23. c. 1. and 2. See also Gifford's cases, c. 119 and 127; and La
Motte, c. 358 and 362. In these, although the adhesion was very intimate,
he brought away the placenta in pieces.
CHAP. VI.
NOTE 1, p. 86.—Although it was the opinion of those who first described
the forceps, that it was the instrument used by Chamberlain; yet of late
some have supposed, but without very positive proof, that he employed the
lever. This last instrument was about the same time used as a secret prac-
tice, by Rhoonhuysen, but was not divulged until about the middle of the
last century. It was so constructed, as to be a very unsafe instrument, es-
pecially in rash hands. Mr. Giffard, in the beginning of the century, had
repeatedly used one of the blades of his extractor or forceps, to draw or
pull down the head; and much about the same time, Mr. Chapman, in one
instance, performed a similar delivery. "Side Treatise, p. 186. It has been
said, that Chamberlain sold the secret of the forceps to Rhoonhuysen, who,
finding that he could deliver with one of the blades, improved on it, and
converted it into a lever; but the dissimilarity of the two instruments at that
time, is an objection to that opinion. Plates of the different forceps and le-
vers at present in use may be seen in Savigny's engravings ; and a very con-
cise account of all the different improvements and alterations of these in-
struments from their discovery to the present time, may be found in Mulder's
Hist. Liter, et Critica Forcipium et Vectium Obstetricorum. I do not think
it necessary to describe the forceps, nor do I consider the slight variations
made by different practitioners as of great importance. I prefer those, how-
ever, proposed by Dr. Lowder and Dr. Pole, to others. A particular kind
of forceps, with three blades, was employed by Dr. Leak, but it is never
used. M. Asaltni has altered the forceps somewhat, and I understand,
makes the junction at the extremity of the part which is held by the ope.
rator, and not at the union of the blade and handle as we do.
NOTE 2, p. 96.—The signs of a dead child have been described to be a
feehng of weight, or sensation of rolling in the uterus, want of motion of
the child, pallid countenance and sunk eye, coldness of the abdomen, with
diminution of size, flaccid breasts which contain no milk, foetor of the dis-
charge from the vagina, liquor amnii coloured apparently with meconium,
although the head presents, puffy feeling of the head, want of firm tumour
formed by the scalp when the head is pressed in a narrow pelvis, no pulsa-
tion in the cord, &c. Most of the cases requiring the crotchet cannot be
benefited by any marks characterizing death of the child in the progress of
gestation; and we well know, that tlie child may die during labour, without
testifying this for a length of time by any sensible signs; and that those enu-
merated above are deceitful, I believe every attentive and unprejudiced
practitioner will join with me in maintaining. Nothing but unequivocal
, marks of putrefaction of the child itself can make us certain, and these can-
383
not be discovered for some time. Foetor of the discharge is not a test ov
this. Vide Mauriceau, obs. 281. When a woman bears a child which has
been for some time dead, we must watch lest her recovery prove bad.
I may notice here, that in order to get rid of the crotchet, small forceps
have been apphed over the collapsed head, or a kind of crutch or tire-tete
has been inserted within the cranium. Some have employed a trephine in
place of a perforator.
NOTE 3, p. 100.—This practice was first adopted about the middle of the
last century, by Dr. Macauley in London, and was afterwards followed out by
others. About twenty years after this, it was proposed on the continent by
M. Roussel de Vauzeme; and lately Mr. Barlow, in the eighth Vol. of
Med. Facts, &c has given several cases of its success.—See also Med. and
Phys. Journal, Vols. XIX, XX, and XXI. It may not be improper for me to
mention as a caution, that I have been called to consider the expediency of
evacuating the liquor amnii, where there was no deformity of the pelvis,
but merely a collection of indurated faeces in the rectum.
CHAP. VII.
NOTE 1, p. 105.—I believe few will dispute, that the precise deformity
requiring the csesarean operation, must, to a certain extent, be modified by
the dexterity of the operator. . I shall suppose, that a surgeon, in a remote
part of the country, far from assistance, is called to a patient whose child is
evidently alive, and whose pelvis measures just as much as would render it
barely possible to use the crotchet, were he dexterous; but he has not a
belief that he could accomplish the dehvery with that instrument. Would
that man be wrong in performing the cesarean operation ? In such a case I
would say, upon the principle that a man is to do the most good in his pow-
er, that if no operator more experienced can be had, within such time as
can be safely granted, the surgeon ought, after taking tlie best advice he can
procure, to perform the cxsarean operation, by which he will save one life
at least. By the opposite conduct, there is ground to fear that both would
be lost. In a case related in the Jour, de Med. for 1780, a woman in the
village of Son had the child turned, and even the limbs separated without de-
hvery being accomplished ; four days afterwards, the cesarean operation
was performed, and the woman died.
CHAP. VIII.
NOTE 1, p. 114.—Dr. Bland is rather against delivery, and for trusting to
nature. Dr. Garthshore, Jour. VIII. 359, says, more women have recovered
of this, who were not delivered, than of th se who were violently delivered.—
Dr. Denman concludes, that women, in the beginning of labour, ought not to
be delivered, II. 381, and admits of it only when it can be done easily.—
Baudelocque says, that we ought not to be in haste to deliver, and never to
do it when nature seems to be disposed to do it herself. Dr. Hull, Obs. &c.
p. 245, says, that we should trust to the usual remedies, till the os uteri be
easily dilatable, or be dilated, and then deliver. He informs me, that in every
case which proved fatal, there was no dilatation of the os uteri.
384
NOTE 2, p. 114.—Dr. Osborn, p. 50, says, that no remedy can be used
with any reasonable expectation of benefit, till delivery is completed; and
that therefore it is our indispensable duty to effect it in the quickest possi-
ble manner.—Dr. J. Hamilton, Annals, V. 318, et seq. says, that when con-
vulsions occur during labour, delivery is to be accomplished as soon as possi-
ble.—Dr. Leak, that when they seem to proceed from the uterus, speedy
delivery is useful; but when from " any cause independent of the state of
pregnancy," dehvery would be hurtful, II. 348.
NOTE 3, p. 116.—In a case which I saw, the placenta was retained by a
spasmodic stricture, though the child was expelled; every allowable attempt
was made to extract it, but in vain. The uterus acted from the os uteri to-
wards the rent, which was at the fundus. The woman died. The placenta
was found still in utero. The intestines were inflamed. See also, Crantz,
de Utero Rupto, p. 22; and Dr. Cathral's case in Med. Facts, Vol. VHI. p. 146.
NOTE 4, p. 120.—Vide successful case by Thibault, in Jour, de Med. for
May 1768.—M. Baudelocque relates a case where the operation was twice
performed on the same patient, for the same cause. In Essays Pbys. and
Lit. Vol. H. p. 370, is a case most incredible, where both the uterus and ab-
dominal integuments were torn during labour. The child escaped, and the
woman recovered.
NOTE 5, p. 120.—Astruc. liv. v. chap. iv. quotes a case, where the child
remained in the abdomen for 25 years. In another case, the midwife felt the
child's head, but after a severe pain it disappeared, and the woman complain-
ed only of weight in the belly. It was expelled by abscess. Hist, de la
Societe de Med. Tom. I. p. 388. In Dr. Bayle's case, the child was retained
twenty years. Phil. Trans. No. 139, p. 997. In Mr. Birbeck*s case, the child
was discharged by the navel. Phil. Trans. Vol. XXH. p. 1000. Bromfield's
patient did not get rid of the child, but she lived for many years, and after
death the rent was visible. Phil. Trans. Vol. XLI. p. 696. In Dr. Sym's
patient, the process for expelling tlie child by abscess was in a favourable
train, when by imprudent exertion fatal inflammation was excited. Med.
Facts, Vol. VIH. p. 150. Bartholin also gives cases. Le Dran relates an in-
stance, where the uterus was ruptured on the 23d of April. On the loth of
May the placenta was expelled; on the 16th a tumour appeared at the linea
alba, which was opened, and a child extracted; the woman recovered. Obs.
Tom. H. ob. 92.
NOTE 6. p. 120.—In a case communicated to Dr. Hunter, the forceps were
pushed through the cervix uteri, and the intervening portion between tlie
laceration, and tlie os uteri was afterwards cut The labour was finished
naturally, and the woman recovered. Med. Jour. Vol. VIH. p. 368. Dr.
Douglass relates the successful case of Mr. Manning, in his Observations, p.
6. Dr. A. Hamilton gives a fortunate case, where dehvery saved the mother.
Outlines, p. 384; and Dr. J. Hamilton, relates one in his Case, p. 138, where
the rent had contracted so much, as to give some difficulty to the dehvery.
The case is instructive.
M. Coffiners gives a memoir on this subject, in the Recueil Period. Tom.
v t. in which he remarks, that laceration near the vulva is easily cured; at
385
the upper lateral part of the vagina, rt is dangerous; and at the anterior and
posterior part, near the bladder and rectum, it is generally mortal; but in
one case the woman recovered, although the hand could be introduced into
the bladder. The woman had incontinence of urine afterwards. In his eighth
case, tlie child lay transversely, and the vagina was torn, and filled with
clots; but the peritoneum was still entire, and therefore the wound did not
enter the abdomen. The uterus was supported with a napkin until the child
was turned. Dangerous symptoms supervened, but the woman recovered.
He gives fifteen cases, and of these, six recovered. Several were produced
by attempts to reduce tlie arm of the child.
book in.
CHAP. III.
NOTE 1, p. 138.—Mr. White of Paisley describes it very well, as resem-
bling a printer's ball. Med. Com. Vol. XX. p. 147. Sometimes it does not
pass through the os uteri. Denman, II. p. 351.
Mangetus, lib. IV. p. 1019, relates a fatal case, where the tumour was taken
for the head of a second child. It was at first partially, and then completely,
inverted with excruciating pain.
Mr. Smith relates a case of inversion, where the accident was followed by
syncope, subsultus, &c. The subsultus and frequent pulse continued for
some days, with smart fever, and inability to move. Med. and Phys. Jour.
Vol. VI. p 503. In the same volume, Mr. Primrose gives an instance where
a great part of the uterus sloughed off, and the woman recovered.
NOTE 2, p. 140.—La Motte, 383, mentions a woman who had inversion
for above thirty years. Dr. Cleghorn, Med. Commun. II. 226, relates a case
where the uterus slowly returned to its natural size. This woman still men-
struates, and enjoys tolerable health; it has been of twenty years standing.
The womb is smooth, moist, and gives Uttle pain. Menstruation also conti-
nued in Dr. Hamilton's case, Com. XVI p. 315.
NOTE 3, p. 142.—The inverted uterus has been torn off with the crotchet,
being mistaken for the child's head. Jour, de Med. Tom. XLI. p. 40. A
case of successful extirpation is inserted in the same work for August 1786.
VVrisberg relates a case, where it was cut off by the midwife, who had in-
verted it. A successful case is given by Dr. Clarke, in Edin. Med. and Surg.
Jour. Vol. H. p. 419. Another case is mentioned in the Recueil des Actes
de la Societe de Lyon. Mr. Hunter of Dumbarton gives a successful case,
in Annals of Med. vol. IV. 366. I have particularly examined this woman,
several years after the operation. She was dehvered without any violence,
after having been twenty-four hours in labour. In about an hour the pla-
centa came away. She had considerable flooding and great weakness. She
could not void her urine, which in two days was drawn off with the cathe-
ter and this was frequently repeated. A fortnight after delivery, the womb
VOL. II. 3 D
38ti
came down, with pains. It was replaced, but again came down. A foetid
discharge took place, and the woman was reduced to a state of great weak-
ness. A ligature was applied, which, she says, gave her a good deal of
pain, and the tumour was cut off. Her account differs in some respects
from Mr. Hunter's, probably owing to her speaking from memory alone,
some years after the event; and she does not notice the previous extraction
of any lumps from the uterus, which Mr. Hunter mentions, for most likely
she did not know of that. About two years ago, she had for a length of
time a discharge of thick white matter. At present, the vagina is of the
usual length; and at the top, a transverse aperture is felt, the posterior Up
or edge of which is longer and more tendinous to the feel, than the anterior.
It admits the tip of the finger, and feels softer than the os uteri, in a natural
state. There is no cervix uteri. The mammae are firm, and of good size,
and she has not lost the sexual desire. She is subject to dyspepsia. From
the preparation in the possession of Dr. Jeffray, there can be little doubt
that part of the uterus was extirpated.
Bartholin relates a case, where the inverted womb was torn away, and
found under the bed of the dead patient.—Blasius, a case, where the uterus
was hard and scirrhous; it was tied, but on the third day the patient died.
In the cavity of the portion were found the ovaria and hgaments.—Goulard's
patient died on the 18th day. Mem. of Acad, de Sciences, 1732.
CHAP. IX.
Page 150. When a patient is known to be subject to syncope or spasmo-
dic disease after dehvery, a dose of spt. ammon. arom. combined with tinc-
ture of opium, should be ready for her after the child is expelled, and the
abdomen ought to be duly supported.
CHAP. XVI.
NOTE 1, p. 170.—Dr. Denman, Vol. II. p. 493, considers puerperal fever
as contagious. He strongly advises early bleeding, giving an emetic or an-
timonial, so as to vomit, purge, or cause perspiration; and if this do good,
he repeats the dose, and uses clysters, fomentations, leeches, and blisters.
He gives an opiate at night, and a laxative in the morning; or, if there be
great diarrhoea, he employs emollient clysters. The strength is to be sup-
ported by spt. ether nit. or other cordials.
Dr. Leak, Vol. II. trusts much to blood-letting; if the patient be sick,
he gives a gentle vomit; if not, laxatives, and then antimonials; applies
blisters, and in the end restrains purging with opiates, and prescribes bark.
Dr. Butter purges and bleeds only where there is well marked inflam-
mation, and is satisfied often with taking only three ounces of blood at a
time, when there is an exacerbation.
Dr. Manning very rarely bleeds, but trusts to emetics and purges, and em-
ploys Dr. Denman's antimonial, which is two grains of tartar emetic, mixed
with y ii of crab's eyes, and the dose is from three to ten grains.
Dr. Walsh forbids venesection, and advises emetics, followed by opiates
and cordials.
387
Dr. Hulme trusts to clysters, purges, and diaphoretics, and does ndt bleed
unless there be pain in the hypogastrium, accompanied with violent stitches,
and a resisting pulse. Even then he bleeds sparingly.
M. Doulcet advises repeated emetics, followed by oily potions, and bark,
combined with camphor.
Mr. Whyte is against blood-letting. He gives at first a gentle emetic,
followed by a laxative and diaphoretics. Then he gives bark, with vitriolic
acid, and supports the strength.
Dr. Joseph Clark trusts chiefly to saline purges and fomentations.
Dr. John Clarke, in his excellent Essays, forbids venesection, and advises
bark as freely as the stomach will bear it. Opium is also to be given, to-
gether with a moderate quantity of wine, along with sago. If there be
much purging, the bark is to be omitted, till some rhubarb be given, or a
vomit, if there be Uttle pain in the belly,
Dr. Kirkland bleeds only if the patient have had little uterine discharge,
and the pulse indicate it. He employs laxatives, and in the end bark and
camphor.
Dr. Hull considers this disease as simple peritoneal inflammation, which
may affect three , classes, the robust, the feeble, and those who are in an
intermediate state. In the first he bleeds and purges, in the second he be-
gins with emetics and ends with bark, and in the third he bleeds with great
caution.
Dr. Hamilton advises puerperal to be treated as putrid fever.
Guinot, AUan, and others, recommend carbonate of potash, in doses of ten
or fifteen grains.
M. Vigarous joins with those who consider this as not a fever mi generis,
but one varying according to circumstances. It frequently begins, he says,
before delivery, but becomes formed about the third day after it. He has
five different species. 1st, The gastrobilious, proceeding from accumulation
of bile during pregnancy. The essential symptom of this species is intense
pain in the hypogastrium. He advises first ipecacuanha, wliich he trusts to
chiefly, and then clysters, laxatives, and saline julap. 2d, The putrid bilious.
This is occasioned by bleeding, or neglecting evacuants in the former
species; or even without improper treatment, the fever may from the first
be so violent, that bilious matter is absorbed. It is marked by great debili-
ty, small or intermitting pulse, tumour of the hypogastrium, with sharp pain
and putrid symptoms, aphtha, vomiting, foetid stools, &c. He advises
vomits, laxatives, and bark in great doses, with mineral acids, and clysters
containing camphor. 3d, The pituitous fever, attended with vomiting of
pituita. The surface is pale, the pulse has not the force or frequency it
has in the former species, the heat in general not increased, anxiety,
weight, and vertigo, rather than pain of head, often miliary spots, and the
usual symptoms of pain in the belly, and subsidence of the breasts. He
gives vomits, and afterwards three or four grains of ipecacuanha every three
hours. If he uses purgatives, he conjoins them with tonics. 4th, With
phlogistic affection, or inflammation of the womb, attended with great
weight about the pelvis, swelling pain, and hardness in the lower belly, sup-
388
pression of evacuations, sharp frequent pulse, acute fever, and the counte-
nance not so sunk as in the .putrid disease. He advises venesection, leeches,
and low diet. The same remedies, with blisters, are to be used, if pleuritic
symptoms occur. 5th, Sporadic fever, proceeding from cold, passions of
the mind, &c. Puerperal fever he considers as apt to terminate in milky
deposits in the brain, chest, legs, &c.
Dr. Gordon, p. 77, et seq. depends on early and copious blood-letting,
taking at first from 20 to 24 ounces, and purges with calomel and jalap. He
is regulated rather by the period of the disease than the state of the pulse,
bleeding, though it be feeble.
Dr. Armstrong considers this fever as decidedly inflammatory, and trusts
to the early use of the lancet foUowed by a large dose of calomel, from one
scruple to half a dram, with the subsequent assistance of infusion of senna
with salts.
[Mr. Hey agrees with Drs. Gordon and Armstrong in considering the dis-
ease as of a highly inflammatory nature, his practice also consists in copious
depletion by venesection and cathartics.]
Dr. Brennan has lately published a pamphlet, recommending in place of
blood-letting, the free use of oil of turpentine internally, and tlie external ap-
plication to the beUy of a cloth soaked in it. The subject is worthy of se-
rious attention.
When upon this subject, it may not be improper to mention that a young
practitioner may mistake spasmodic affections, or coUc pains, for puerperal
inflammation ; for in such cases there is often retching and sensibility of the
muscles, which renders pressure painful. But there is less heat of the skin,
the tongue is moist, the pulse, though it may be frequent, is soft, the feet
are often cold, the "pain has great remissions if it do not go off completely,
there is little fulness of the beUy, and the patient is troubled with flatulence.
It requires laxatives, antispasmodics, anodyne clysters, and friction with cam-
phorated spirits. Blood drawn in this disease, after it has continued for some
hours, even when the woman is not in childbed, is sizy, and it is always so
in the puerperal, as well as the pregnant state, although tlie woman be weU.
chap. xvn.
NOTE, p. 173.—In some instances, the patient has been sensible of the
pain, which expelled the cliild, rushing violently down the leg. After a
shon time it has abated, but about tlie usual period this disease has ap-
peared.
CHAP. XXt.
Page 183.—Some women feel, after lying in, a considerable weakness or
sensation of want about the belly, which is frequently increased by nursing.
It is often produced by taking oil' the bandage too soon from the abdomen,
which should not be done for a month at least, and is relieved by the appli-
cation of a broad firm band round the belly. When there is constant aching
in the back and failure of tlie appetite, nursing must be abandoned.
389
Pain in the side, or in the abdomen, which is sometimes produced by
nnrsing, is often relieved by friction, warm plasters, and an invigorating plan.
General weakness require tonics, which must be varied.
BOOK V.
CHAP. I.
NOTE 1, p. 199—In choosing a nurse, it is necesssaryto be satisfied that
she enjoys good health, and has an adequate supply of milk. Certain rules
have been laid down to enable us to ascertain the quality of the milk by it;
appearance ; but it is sufficient that it be not too thick, and have a good taste.
With regard to the quantity, we cannot judge at first, for the milk may be
kept up so as to distend the breast, and give it a full appearance. A woman
who is above the age of 35 years, or who has small flaccid breasts or exco-
riated nipples, or who menstruates during lactation, or who is of a pas-
sionate disposition, should not be employed as a nurse. Those who labour
under hereditary diseases should, at least for prudential motives, be rejected.
The woman's child, if alive, should be inspected, to ascertain how it has
thriven, and both it and the nipple should be examined, lest the nurse may
have syphilis. A woman who has already nursed several months is not to be
chosen as the milk is apt to go away in some time, or become bad. It is
farther of great advantage to attend to the moral conduct of the nurse, for
those who get drunk, or are dissipated, may do the child much mischief.
With regard to the diet of a nurse, it is improper to pamper her, or make
much difference in the quality of the food, from what she has been accus-
tomed to. It is also proper that she be employed in some little duty in the
family, otherwise she becomes indolent and overgrown.
CHAP. IV.
NOTE 1, p. 256.—M. Mahon, from his observations in l'Hospice de Vau-
girard, says that the symptoms appear as follows, the most frequent being
put first. Ophthalmy; purulent spots; ulcerations; tumours; chancres on
the mouth, and aphtha; Uvid, ulcerating, and scabbing pustules; chancres
on the genitals, and about the anus; excrescences; peeUng off of the nails of
the feet and hands.
NOTE 2, p. 257.—Children may have ulceration about the anus, genitals,
and groins,'succeeding intertrigo, owing to neglect of cleanliness, without
any venereal affection. But the absence of other symptoms, particularly
of sore throat, or ulcer of tiie mouth, and the amendment experienced by
the use of lotions, and keeping the parts dry and clean, will enable the prac-
titioner to form a diagnosis, and the aspect of the sores will assist liim.
This fretting of the parts, and even some degree of excrescence may attend
psoriasis, and the herpetic spots of children formerly described; and in this
390
case, especially if the child belong to a poor person, the disease is too often
decided to be syphilis. There is, however, perhaps no individual symptom,
which can decidedly characterize syphiUs in children; and the diagnosis must
be formed by the combination of symptoms, and often by the progress of the
disease. Many children are rashly put upon a course of mercury, who do
not require it; perhaps, because the practitioner thinks it a point of honour,
to determine the nature of the disease at the first glance.
NOTE 3, p. 260.—Adults are sometimes seized with this disease. A very
remarkable case of this kind is recorded in the 48th vol. of the PhiL Trans.—
The subject of it was a girl, aged 17 years. She had excessive tension, and
hardiness of the skin, all over the body, so that she could hardly move. The
skin felt like a dry hide or piece of wood, but she had some sensation when
pressed on with the nail or a pin. It was cold and dry, the pulse was deep
and obscure, but the digestion good. It began in the neck, then affected
the face and forehead, and at last she could scarcely open the mouth.
NOTE 5, p. 266.—If the progress have been very favourable, the arm,
about the eighth or tenth day, will exhibit a circular elevation, flattened on
the surface, and surrounded with circumscribed redness. With this state of
the arm, unattended with high fever, we may be sure that the patient will
do well and probably the secondary pustules will not maturate. If the ele-
vation of the cuticle be less marked, perhaps not circular, but at the same
time not with jagged edges, if the surrounding redness follow the irregular
shape of the pustule at a considerable distance, having, however, its circum-
ference defined and not shaded, then, though the fever may have been higher
than in the former case, yet we may be sure that the danger is over; and if
any pustules appear, they will be late, and probably wiU not maturate. If the
inflammation run high at the arm, with surrounding redness, irregular in its
figure, and shaded instead of being circumscribed at its circumference, we
must examine the arm carefully; if we find a cluster of very small bUsters,
which are only confluent from their vicinity, but are distinct at tlie edges,
where they are more distant, we may, altliough the fever have been con-
siderable, prognosticate that he will have a mild subsequent disease, and that
the arm will heal easily. But if this high inflammation be unattended with
any distinct Uttle bladders, particularly if, instead of rising above the surface,
the inoculated part seems somewhat depressed with a dusky brown skin, as
if drawn lightly over it, the fever wiU be at the same time considerable; and
though all constitutional danger may subside with it, yet we may expect a
mortified part in the arm, but it will be cured by exposing it to tlie air.
Popular View, p. 63, ct seq.
INDEX.
Gt)° The letter n. after the number of the page, indicates that the article referred
to is contained in a note.
A
ABERNETHY, his mode of treating congenite marks, vol. ii.
page 206-7"
Abscess in the labium, i. p. 47
■------mammary, ii. p. 184
Abdomen, distension of, effect of pregnancy, i. p. 204
Abortion, i. p. 217
Acid, citric, to be introduced into uterus in hemorrhage, ii. p.
130 n.
Adams, Dr., his remarks on inoculation, ii. p. 267
After-pains, and treatment of, ii. p. 142 et seq.
■ ------distinguished from inflammation of uterus, &c. ii.
p. 143
Air, cool, proper in uterine hemorrhage, ii. p. 128
Amenorrhcea, i. p. 121
Angina herpetica, ii. 234
Anus, excoriation about the, ii. p. 237
-----imperforated, ii. p. 203
Apoplexy, occurring during labour, ii. p. Ill
Aphthae of children, ii. p. 249
■-------treatment of, ii. p. 252
-------on the tonsils, ii. p. 254
Arrest of head, ii. p. 83 84
Arteries of the pelvis, i. p. 17
Articulation of bones of pelvis, i. p. 7
Ascarides, ii. p. 349
Ascaris lumbncoides, ii. p. 349
Ascites, effect of pregnancy, i. p. 197
Asthma, acute of children, &c. ii. p. 315
-------treatment, ii. p. 316
Axis of the brim and outlet of the pelvis, i. p. 24
B
Baudelocque, his positions of vertex explained, ii. p. 2 and 366
& seq. .
______,____, preternatural presentations—Table, n. p. 378
Bandage to be applied after delivery, ii. p. 122
Bathing, cold, when proper for infants, ii. p. 198
392
INDEX.
Bladder, its distension may produce puerperal convulsions, ii
p. 113
-------- affections of, i. p. 70
-----------------the effect of pregnancy, i. p. 188
Blemishes and marks, ii. p. 206
Blisters to the head proper in puerperal convulsions, ii. p. 113
-------used to remove marks in infants, ii. p. 207
Boils and pustules in children, ii. p. 241
Bowels, constipated, producing fever, ii. p. 157-8
Brain, inflammation of the, ii. p. 180
Breech, presentation of, ii. p. 38
Brim of pelvis, description of, i. p. 20
Breasts, swelling of, in infants, ii. p. 210
Bronchocele, after parturition, ii. p. 181
Bronchitis, infantile, ii. p. 323
-----------treatment, ii. p. 324
Burns and scalds in infants, how cured, ii. p, 210, 211
Bryce, his use of vaccine scab, ii. p. 269 n.
C
Cavity of pelvis described, i. p. 21
Csesarean operation, ii. p. 102 & seq.
Cauliflower excrescence from the os uteri, i. p. 87
Calculi in uterus, i. p. 89
Camphor recommended in puerperal convulsions, ii. p. 115
Cardialgia, effect of pregnancy, i. p. 183
Cathartics proper after delivery, ii. p. 124
Cathartic to be given on 3rd day after parturition, ii. p. 155
>---------proper in intestinal fever, ii. p. 159
Canker or ulceration of gums, ii. p. 247
Catarrh, infantile, ii. p. 323
Cheek, erosion of, in children, ii. p. 248
------gangrene of, ii. p. 249
Chicken-pox, ii. p. 274
Children, on the management and disea>e;. of, ii. p. 192 & seq.
---------still-born, treatment of, ii. p. 193 & seq.
Child-murder, signs of, not decisive, ii. p. 195-6
Chorea, sancti viti, ii. p. 307 •
Citric acid, applied to uterus in hemorrhage, ii. p. 130, n.
Clitoris, description of, i. p. 38
--------diseases of, i. p. 55
Clysters, stimulating, recommended in puerperal convulsions, ii.
p. 113
---------proper after delivery, ii. p. 124
Cleanliness, dress and temperature of children, ii. p. 196 & seq.
Coccyx, os, description of, i. p. 6
Conception, i. p. 139
Contraction, uterine, two kinds, i. p. '256
Coloured spots, effects of pregnancy, i. p. 190
INDEX. 393
Cough and dyspnoea, effect of pregnancy, i. p. 192
Convulsions, effect of pregnancy, 1. p. 193
--------—— in infants, ii. p. 301
------------treatment, ii. p. 304
—■----------attending hooping-cough, ii. p. 321
-——-----■— puerperal, ii. p. 109—venesection recommended in,
n. p. 113—-jugular vein to be opened, ibid.—enema stimulating,
proper, ibid.—blisters to the head, ibid.—purgatives proper, ii.
ibid.—bladder to be evacuated, ii. ibid.—delivery of the child,
when proper, ii. p. 114—opium, musk and camphor, their use,ibid.
—emetics not useful, ibid.—camphor recommended by Hamilton,
ii. p. 115
Cold, the application of, recommended in uterine hemorrhage, ii.
p. 129
Cold bathing, when proper for infants, ii. p. 198
Cooper, Astley, his mode of treating spina bifida, ii. p. 206, n.
Corpus luteum, appearance of, after miscarriage, ii. p. 191
Cord, umbilical, presentation of, ii. p. 58
-----umbilical, how to be tied, ii. p. 192
Coagula, retention of in uterus, and expulsion, ii. p. 135
Contraction of uterus, how produced in flooding, ii. p. 137
Colic, after delivery, ii. p. 151
------in infants, ii. p. 341
Costiveness, effect of pregnancy, i. p. 184
-----------in children, ii. p. 340
Cow-pox, or vaccine inoculation, ii. p. 267
' spurious, ii. p. 268
» . ■ ■ test of, ii. p. 271
Cramp, effect of pregnancy, i. p. 204
-------in stomach after delivery, ii. p. 151
Crinones, a species of pustule, ii. p. 242
Crotchet, of cases requiring the, ii. p. 93
Croup, ii. p. 309
-------treatment, ii. p. 311.
-------spasmodic, ii. p. 315
------------------treatment, ii. p. 316
Crusta lactea, ii. p. 225
Cutaneous diseases of infants, ii. p. 219
Cynanche trachealis, ii. p. 309
---------treatment, ii. p. 311
D
Dandriff or Pityriasis of children, ii. p. 233
Death, sudden, from uterine hemorrhage, ii. p. 126
Decidua, membrana, i. p. 164
Deformity of pelvis from rickets, i. p. 29
_-------from malacosteon, i. p. 31
._________from exostosis and tumours, i. p. 33
Delivery, treatment after, ii. p. 122
VOL. II. 3 B
394
INDEX.
Delivery, speedy, when proper in puerperal couvulsions, ii. p. 114
& seq.
---------recent, sigrts of, ii. p. 189
Denman's spontaneous evolution, ii. p. 51
Dentition, ii. p. 215
---------producing spasm of windpipe, ii. p. 318
Despondency, effect of pregnancy, i. p. 206
Dimensions of the pelvis, i. p. 20
Diet, what proper m the puerperal state, ii. p. 124
----proper for infants, ii. p. 198
Diarrhoea, effect of pregnancy, i. p. 186
---------after parturition, ii. p. 182
---------attending dentition, ii. p. 218-19
---------of children, ii. p. 218 and 329
--------------------treatment, ii. p. 335
Distortion of feet, ii. p. 209
Diseases of organs of generation, i. p. 47
--------of pregnant women, i. p. 177
-------of infants, congenite and surgical, ii. p. 202 & seq-
--------cutaneous, of infants, ii. p. 219
Douglass's case of rupture of uterus, ii. p. 116
Dress of infants, ii. p. 197
Dropsy of the ovarium, i. p. 108
Dyspncea and cough, effect of pregnancy, i. p. 192
——----in the puerperal state, ii. p. 150.
Dysmenorrhcea, i. p. 129
E
Ears, foetid discharge from, ii. p. 212.
----excoriation behind the, ii. p. 246
Ear-ache in infants, how to be treated, ii. p. 211
Ecthyma, a species of pustule, ii. p. 242
Eczema mercuriale, in infants, ii. p. 258-9
Emetics, their use doubtful in puerperal convulsions, ii. p. 114
--------occasion expulsion of portions of the placenta, ii. p. 137.
--------proper in intestinal fever, ii. p. 158.
Enclaveinent or locked-head, ii. p. 83-4
Enemata, stimulating, proper in puerperal convulsions, ii. p. 113
Enteritis of infants, ii. p. 342
Ephemeral fever or weed, ii. p. 152
---------------treatment, ii. p. 153-4
Erythema nodosum, of Dr. Willan, ii. p. 246
Ergot, its use in tedious labours, ii. p. 67 n.
Erosion of the cheek, ii. p. 248
Eruption, miliary, of infants, ii. p. 228
---------anomalous, of infants, ii. p. 226
Erythema of infants, ii. p. 245
Erysipelas of infants, ii. p. 244
Evrat, his mode of checking uterine hemorrhage, ii. p. 130 w.
INDEX.
395
Evolution, spontaneous of foetus, ii. p. 51
Excrescences of the labia, i. p. 51
Extra-uterine pregnancy, i. p. 168
!"----T—;----------— treatment of, i. p. 172
Examination, per vaginam, ii. p. 13
Exanthema, or herpes labialis, ii. p. 234
Excoriation of nipples, ii. p. 186
-----------behind the ears in infants, ii. p. 246
----«-------of the tongue, ii. p. 254
-----------about the anus, ii. p. 237
-------—— of navel in infants, ii. p. 210
Extremities, inferior, presentation of, ii. p. 43
------;-----superior, presentation of, ii. p. 45
Eyes, inflammation of, in infants, ii. p. 210
Eye, spongoid disease of, in infants, ii. p. 213
F
Face, presentation of, ii. p. 54
Fallopian tubes, description of, i. p. 46
Fastidious taste, effect of pregnancy, i. p. 183
Febrile state of pregnancy, i. p. 179
Feet, distortion of, ii. p. 209
Fever, milk, how obviated and relieved, ii. p. 124
------milk, ii. p. 155 »
■ • ■■ treatment of, ii. ibid.
-----ephemeral, or weed, ii. p. 152
---------------treatment of, ii. p. 154
-----miliary, ii. p. 155
-------------treatment of, ii. p. 157
-----intestinal, ii. p. 157
--------------treatment of, ii. p. 158-9
-----puerperal, ii. p. 167
. -----distinguished from peritonitis, ii. p. 170
---------------treatment of, ii. p. 170 & seq.
.-----in infants, ii. p. 356
------remittent, of older children, ii. p. 358
Fits, inward, ii. p. 302
Flooding from a detachment of part of the placenta, i. p. 258
.--------treatment proper in, vide hemorrnage, uterine.
Fluor albus, i. p. 65
Foetus, description of, i. p. 148
.------spontaneous evolution of, ii. p. 51.
------peculiarities of, i. p. 153
Forceps, on cases admitting the use of, ii. p. 80
_______Haighton's described, ii. p. 90 n.
Frcenum of tongue, division of, seldom necessary, ii. p. 209
Furunculus, or acute boil, ii. p. 242
Funis umbilicalis, presentation of, ii. p. 58
____._----------how to be tied, ii p. 195
396
INDEX.
G
Gangrene of the cheek in children, ii. p. 249
Generation, external organs of, i. p. 37
----------internal organs of, i. p. 42
Goldson's case of rupture of uterus, ii. p. 116
Griffitts, Dr., on vaccine scab or crust, ii. p. 269 n.
Gums, on the treatment of, in dentition, ii.p. 218
-----ulceration of, in children, ii. p. 247
Gum, red, or strophulus intertinctus, ii. p. 220
H
Hand, introduced into the uterus in uterine hemorrhage, ii. p. 128
Hartshorn Dr., immense tumours of labia extirpated by, n. 52
Haighton's Forceps described, ii.p. 90 n.
Hare-lip of infants, ii. p. 202
Hemorrhage, uterine, i. p. 255
------------------attending labour, ii. p. 107
------------------from retention of part of placenta, ii. p. 146
------------------causes of, i. p. 259
------------------effects of, i. p. 264
------------------remedies for, i. p. 267
------------------from connexion of the placenta widi os uteri,
i. p. 257
------------------after delivery, ii. p. 125 & seq.
------------------■ symptoms of, ii. p. 127
----------------— apparent and concealed, ii. p. 134
------------------after expulsion of placenta, ii. p. 1S6
------------------pressure and bandage proper, ibid.
------------------cold applications proper in, ii. p. 129, 130—
hand to be introduced, ii. p. 130—placenta not to be hastily ex-
tracted, ii. p. 130—uterus to be stimulated, and how, ibid.—Le
Roy's advice injudicious, ii. p. 129 n.—Ice to be introduced into
uterus, ii.p. 130—Citric acid to be introduced, ibid. n.—rest to be
enjoined, ii. p. 132—opiates proper, ii. p. 133
Hemoptysis, effect of pregnancy, i. p. 195
Heinatemosis, effect of pregnancy, i. p. 193
Head of child, and its progress through the pelvis in labour, i. p. 24
Head-ache, effect of pregnancy, i. p. 193
Heart-burn, effect of pregnancy, i. p. 183
Heart, diseases of, may occasion death immediately after deliverv,
ii. p. 127 n.
-----malformed, ii. p. 209
Hernia, i. p. 53
-------of uterus, i.p. 107
------'umbilical, of infants, ii. p. 204
Herpes of infants, ii. p. 232
------farinosus, ii. p. 232
------miliaris, ii. p. 233
------labialis, or exanthema, ii. p. 234
INDEX. 397
Herpes exedens, or phagedenic herpes, ii. p. 234
Herpetic ulcer, ii. p. 235
Hectic fever, from retention of placenta, ii. p. 147
Hemiplegia, [puerperarum,] ii. p. 178
Hepatitis of infants, ii. p. 353
Hives, or croup, ii. p. 309
-------treatment, h. p. 311
Hour-glass contraction of uterus, ii. p. 1S1
Hooping-cough, ii. p. 318
-------------treatment, ii. p. 320
Hull, Dr., his theory of phlegmatia dolens, ii. p. 175
Hymen and orifice of vagina, i. p. 41
-------diseases of, i. p. 56
Hydatids, of the uterus, i. p. 97
Hysteritis, i. p; 77
Hysteralgia, symptoms of, ii. p. 145 and seq.
-----------distinguished from inflammation, ii. p. 145-6
«----------treatment of, ii. p. 146
Hydrocele of infants, ii. p. 210
Hydrocephalus, acute, history, ii. p. 293
-------------treatment, ii. p. 297
-------------chronic, history, ii. p. 298
■-------------chronic, treatment, ii. p. 300
-------------secondary, ii. p. 300
I
Ice, to be introduced into uterus in hemorrhage, ii. p. 130
Ichthyosis of children, ii. p. 236
Ignis sacer, ii. p. 234
Impaction, or locked-head, ii. p. 83-4
Imperforated anus, urethra, &c. ii. p. 203
Impetigo of children, ii. p. 238
Inflammation of viscera distinguished from after-pains, ii. p. 143
-------------distinguished from hysteralgia, ii. p. 144
.-------------of uterus, ii. p. 159
.-------------slight, ii. p. 159
--------------------■ treatment of, ii. p. 161
-------------of uterus, extensive, ii. p. 161-2
----------------------treatment of, ii. p. 163
-------------peritoneal, ii. p. 164, 342
----------------------'treatment of, ii.p. 165-6, 342
.---------—-—• of the brain after delivery, ii. p. 180
_____________of mammee, after delivery, ii. p. 183
_______------> of pleura, ii. p. 324
_____________of stomach, ii. p. 326
Inferior extremities, presentation of, ii. p. 43
Intestinal fever, ii. p. 157
_____________treatment of, ii. p. 158-9
Intestine, protrusion of, at the umbilicus, ii. p. -204
Inoculation for small-pox, ii. p. 266
39S
INDEX.
Intertrigo, ii. p. 224
Inversion of uterus, a cause of flooding, ii. p. 135, 138 & seq.
■------------------its symptoms and causes, ii. p. 138-9
------------------its termination and treatment, ii. p. 139-140
& seq.
distinguished from prolapsus, &c. ii. p. 142
partial, of uterus, ii.p. 141 n.
its treatment, ii. p. 141 n.
Intus-susceptio connected with diarrhoea, ii. p. 33.3
Invagination of intestines, frequent cause of diarrhoea, ii. p. 333
Itch, or scabies, ii. p. 230
----dry, of children, ii. p. 236
Jaundice, effect of pregnancy, i. p. 190
---------of infants, ii. p. 351
Junction, sacro-iliac, of pelvis, i. p. 8
------■—• vertebral, of pelvis, i. p. 9
Jugular vein to be opened in puerperal convulsions, ii. p. 113
K
Kidney, pain in the region of, after delivery, ii. p. 151
L
Labia, and nymphse, description of, i. p. 38
------. abscess in the, i. p. 47
-------ulceration of, i. p. 48
------ excrescences of, i. p. 51
-------scirrhous tumours of, i. p. 51
------polypous tumours of, i. p. 52
------oedema of, i. p. 53
-------gangrene of, ii. p. 249
Laceration of parts of generation, i. p. 57
Labours, classification of, ii. p. 1-2
Labour, natural, ii. p. 6
■ stages of, ii. p. 6
■ causes of, ii. p. 21
--------management of, ii. p. 23
--------preternatural, ii. p. 37
tedious, ii. p. 63
— premature, ii. p. 34,100
— impracticable, ii. p. 102
complicated, ii. p. 107
Lactation or suckling, observations on, ii. p. 187-8
Laudanum, proper to prevent uterine hemorrhage, ii. p. 128
Lever, on cases admitting its use, ii. p. 80
Le Roy, his advice in uterine hemorrhage, ii. p. 129 n. 132 n.
Lemon juice to be introduced into uterus in hemorrhage, ii. p.
INDEX. 399
l^eg, swelled, or phlegmatia dolens,ii. p. 173
Leg, swelled, treatment of, ii. p. 175 & seq.
Liquor amnii, and membranes, i. p. 163
~-----------redundance of, i. p. 199
Ligaments, diseases of, i. p. 115
Liver, diseased, of infants, ii. p. 353
—;---a diseased state of, frequently attends diarrhcea, ii. p. 334
Lichen, ii. p. 223
------ lividus, ii. p. 243
Locked head, ii. p. 83-4
Lochia, profuse, from rising too soon after deliverv, ii. p. 125
Lochial discharge obstructed in hysteralgia. ii. p. 145
Lumbrici, ii. p. 349
Lymphatics of pelvis, i. p. 19
M
Mastodynia, effect of pregnancy, i. p. 196
Mania, puerperal, ii. p. 178
■ treatment of, ii. p. 179
Mammae, inflammation of, after delivery, ii. p. 183
---------abscess of, ii. p. 184
Malformed heart, ii. p. 209
Management and diseases of children, ii. p. 192 & seq.
Marks and blemishes, ii. p. 206
Marasmus of infants, ii. p. 343
Menstruation, i. p. 116
' Hunter's theory of, i p. 118 n.
■ diseases of, i. p. 121
Menses, cessation of i. p. 137
Menorrhagia, i. p. 131
------------lochialis, ii. p. 136
--------------------treatment of, ii. p. 138
Membranes and liquor amnii, i. p. 163
Meconium, how to be evacuated, ii. 199
Meatus auditorius, imperforated, ii. p. 204
Melancholy, puerperal, ii p. 180
Mercurial disease in infants, ii. p. 258
Measles, ii. p. 285*
_—-— treatment of, ii. p. 288
Milk, secretion of, when it takes place, ii. p. 124.
Milk-fever, and how obviated, ii. p. 155
----------treatment of, ibid.
Milk, as the eiet of infants, ii. p. 199
Miscarriage, recent, signs of, ii. p. 189
Miliary fever, ii. p. 155
___---------treatment of, ii. p. 157
Miliary eruption in infants, ii. p. 228
Moles, i. p. 96.
Monsters and plurality of children, ii. p. 59
100
INDEX.
Monro's case of rupture of uterus, ii. p. 116
Muscles of pelvis, i.p. 16.
Muscular pain, effect of pregnancy, i. p. 203
Musk recommended in puerperal convulsions, ii p. 114
N
Natural labour, description of, ii. p. 6 & seq.
Navel, excoriation of, in infants, ii. p. 210
Navel-string, how to be tied, ii. 192
Nervous and spasmodic diseases in the puerperal state, ii. p. 149
Nerves of pelvis, i.p. 18
Nettle-rash, or urticaria, ii. p. 276
Nipples, excoriation of, ii. p. 186
Nose, foetid secretion from, ii. p. 212
Noma, or gangrene of tlie check, &c. in infants, ii. p. 249
Nymphee, diseases of, i. p. 54
O
Obliquity of pelvis,i. p. 9
(Edema'of labia, i p. 53
--------effect of pregnancy, i. p. 53
Oesophagus, rupture of, ii. p. 328
Oleum tcrebinthinae, recommended in taenia, ii. p. 351 n.
Opium, when proper in puerperal convulsions, ii. p. 114-15
Opiates recommended in flooding after delivery, ii. p. 133
Operation, Csesarean, p. 102
Opthalmia infantilis, ii. p. 212
Os uteri, rigidity of, cause of rupture of uterus, ii. p. 116
-------cauliflower excrescence of, i. p. 87
Ossa innominata, description of, i. p. 2
Outlet of pelvis, i. p. 20
Ovaria, description of, i. p. 46
------dropsy of, i. p. 108
------other diseases, of, i. p. 114
------deficiency of, i. p. 115
Ovum, its connection with the uterus, i. p. 255
i hemorrhage, from its separation, ibid. *
------blood effused in consequence of a partial detachment of, i.
p. 259
P
Palpitation, effect of pregnancy, i. p. 190
.---------after delivery, ii. p. 149
Pains, false, i. p. 298
Parturition, ii. p. I, 2, 3, & seq.
Paralysis [puerperarum], ii. p. 177
---------of children, ii. p. 309
Parrish, Dr. on scrofula interna, ii. p. 325 n
INDEX.
401
Pelvis, bones of, general view, i. p. 1
-------difference of female from male, i. p. 14
■------brim and outlet of, i. p. 20
----— above the brim, i. p. 23
Perinseum, laceration of, i. p. 57
Peritonitis puerperalis, ii. p. 164
----------treatment of, ii. p. 165-6
---------of children, ii. p. 342
Peritoneum, chronic inflammation of, ii. p. 167
Pemphigus of infants, ii. p. 227
Petechiae, sine febre, ii. p. 242
Pertussis, ii. p. 318
■ treatment, ii. p. 320
Phagedenic herpes, ii. p. 234
Phlegmatia dolens [puerperarum] ii. p. 172
■ ■ treatment of, ii. p. 175 & seq.
Phrenitis, puerperal, ii. p. 180
Phymosis of infants, ii. p. 210
Phyma, or tedious boil, ii. p. 242
Philadelphia, success of vaccination in, ii. p. 273, n.
Pityriasis, or dandriff of children, ii. p. 238
Placenta, description of, i. p. 160
---------in twin cases, how managed, ii. p. 61
——----treatment after expulsion of, ii. p. 122
»■ hemorrhage, after expulsion of, ii. p. 125 & seq.
---------not to be hastily extracted in uterine hemorrhage, ii, p.
129-30, 134 r
---------portion of, remaining keeps up flooding, ii. p. 135
-------------------how to be treated, ibid.
---------rashness in extracting, occasions inversion of uterus, ii*.
p. 139
■ retention of part of, ii. p. 137, 146
-------------■----treatment of, ii. p. 148
Plurality of children and monsters, ii. p. 59
Pleurisy in the puerperal state, ii. p. 149
Pleura, inflammation of, in children, ii. p. 324
Pleuritis in infants, ii. p. 324
Pneumonia in the puerperal state, ii. p. 149
Presentation of breech, ii. p. 38
------------of the inferior extremities, ii. p. 43
------------of superior extremities, ii. p. 45
------------of the trunk, ii. p. 53
i of the umbilical cord, ii. p. 58
Presentations requiring turning, table of, ii. p. 378
Polypous tumours of labia, i. p. 52
Polypi of uters, i. p. 90
-----malignant, i. p. 95
Posture erect, improper immediately after delivery, ii. p. 123
Pompholyx of infants, ii. p. 227
Porrigo, or scabies capitis, ii. p. 239
vol,. II. 3 F
403
INDEX.
Pregnancy, extra-uterine, i. p. 168
----------• signs of, i. p. 173
----------general effects of, i. p. 177
----------febrile state of, i. p. 179
Pregnant women, diseases of, i. p. 177
-----------------treatment of, i. p. 217
Premature labour, ii. p. 34, 100
Preternatural labour, ii. p. 37'
Prickly-heat, ii. p. 224
Prolapsus uteri, l. p. 101
--------------from rising too soon after delivery, ii. p. 125
' ■ ani, in infants, ii. p. 210
Prurigo of infants, ii. p. 229
Psoriasis of Dr. Willan, ii. p. 236
Puerperal state, treatment proper in, ii. p. 122 & seq.
---------convulsions, ii. p. 109 & seq.
Purge to be given on third day after parturition, ii. p. 155
Purgatives recommended in puerperal convulsions, ii. p. 115 & seq.
Purpura, or petechise sine febre, ii. p. 242
Pubis symphysis, description of, i. p. 7
-----division of, ii. p. 106
Puerperal fever, ii. p. 167
--------------distinguished from peritonitis, ii. p. 170
--------------treatment of, ii. p. 170 & seq.
Puerperal mania, ii. p. 178
---------------treatment of, ii. p. 179
Pustules and boils in children, ii. p. 241
R
Retention of part of the placenta, ii. p. 146
------------------------------treatment of, ii. p. 148
Respiration, how excited in new-born children, ii. p. 194
Rheumatism distinguished from after-pains, ii. p. 144
Rigidity of the os uteri, cause of rupture of uterus, ii. p. 116
Rickets, ii. p. 215
Roseola annulata, of Dr. "Willan, ii. p. 277
------infantilis sometimes mistaken for scarlatina, ii. p. 281
------ aestiva, ii. p. 290
------autumnalis, ii. p. 292
------infantilis, ii. p. 292
Rupture of the uterus, ii. p. 116
------- of the vagina, ii. 120
Rubeola or measles, ii. p. 285
------ treatment of, ii. p. 288
------ sine catarrho, ii. p. 290
Rye, spurred, its use in tedious labours, ii. p. 67, «.
S
Sacrum, os, description of, i. p. 5
Sacro-iliac junction, i. p. 8
INDEX.
403
Salivation, effect of pregnancy, i. 195
Scirrhous tumours of labia, i. p. 51
Scirrho-cancer in uterus, i. p. 80
Scalp, swelling of in infants, ii. p. 208
Scalds and burns in infants, how cured, ii. p. 210-11
Scabies capitis, or porrigo, ii. p. 239
Scabs from vermin, ii. p. 241
Scab, vaccine, employed in vaccination, ii. p. 269
Scarlatina simplex, ii. p. 278
--------------— treatment of, p. 281-2
----------anginosa, id. p. 279
---- ' ----treatment of, id. p. 282
---------maligna, id. p. 280
------------------treatment of, id. p. 283-4
Scrofula, ii. p. 213
■ treatment of, ibid.
-------interna of infants, ii. p. 325 n.
Scabies, or true itch, ii. p. 230
Separation of the bones of pelvis, i. p. 9
Sectio pubis, ii. p. 106
Secretion of urine diminished, ii. p. 121
Secale cornutum, recommended in tedious labours, ii.p. 67 w.
Shoulder, presentation of, ii. p. 45
Signs that a woman has been recently delivered, ii. p. 189
Sigaultian operation, ii. p. 106
Skin-bound, ii. p. 259
■----------treatment of, id. p. 261
Sleeping not to be entirely prevented in flooding cases, ii. p. 134
Small-pox, distinct, ii. p. 261
---------confluent, id. p. 268
---------re-infection from, ii. p. 271
Sore throat of infants, ii. p. 254
Spasmodic and nervous diseases in the puerperal state, ii. p. 149
Spasms of windpipe in children, ii. p. 318
Spina bifida, ii. p. 205
Spongoid tumour, i. p. 63,86
--------disease of the eye in infants, ii. p. 213
Spleen enlarged in infants, ii. p. 355
Stomach and duodenum, spasms of, i. p. 184
--------to be watched in uterine hemorrhage, ii. p. 132
--------inflammation of, in infants, ii. p. 326
■ treatment, id. p. 327
Sterility, i. p. 166
Stimulants generally improper after delivery, ii. p. 123
Strangury, ii. p. 149
Still-born children, treatment of, ii. p. 194
Strophulus intertinctus, ii. p. 220
------— albidus, id. p. 221
■ confertus, id. p. 222
404 INDEX.
Strophulus candidus, id. p. 223
Suckling, observations on, ii. p. 187-8
Superior extremities, presentation of, ii. p. 45
Suppression of urine after delivery, ii. p. 120-123
Swelled leg of puerperal women, id. p. 172
----------treatment of, id. p. 175 & seq.
Swathing infants, formerly practised, id. p. 197
Swelling of the breasts in infants, id. p. 210
-------of the seal]), ii. p. 208
Swine-pox, id. p. 275
Symphysis pubis, description of, i. p. 7
—————— section of, ii. p. 106
Syncope, effect of pregnancy, id. p. 191
-------produced by uterine hemorrhage, dangerous, ii. p. 109,133
------— treatment proper in, ii. p. 109,133
Syphylis in infants, ii. p. 255
——— treatment, id. p. 257
T
Table of presentations requiring turning, ii. p. 378
Table of cases and presentations at I'Hospice de la Maternite,
ii. p. 378
Tabes mesenterica, id. p. 345
Taenia, id. p. 351
Temperature proper for infants, id. p. 198
Teeth, on the formation and cutting of, id. p. 215 & seq.
Tetter, dry, of infants, id. p. 232
—— scaly, of children, id. p. 236
Terminthus, a species of pustule, id. p. 242
Thyroid gland, swelling of, id. p. 131
Throat, sore, in infants, id. p. 254
Tooth-ache, effect of pregnancy, i. p. 195
Torpor of uterus, occasioning flooding, ii. p. 126 &. seq.
Tongue-tied, id. p. 209
Tongue, excoriation of, in infants, id. p. 254
Tonsils, aphthae on the, id. p. 254
Touching, or examination per vaginam, ii. p. 13
Trunk, presentation of, ii. p. 53
Trismus nascentium, ii. p. 306
Trichuris, or long thread worm, id. p. 350
Tubes, fallopian, diseases of, i.p. 115
Tubercles in uterus, id. p. 84
Turning, table of presentations requiring it, ii.p. 378
Turpentine, oil of, used in expelling taenia, ii. p. 351 n.
Twins and monsters, ii. p. 59
Tympanites of uterus, i. p. 100—ii. p. 188
Typhus fever of infants, ii. p. 356
INDEX.
400
u
Ulceration of the labia, i. p. 48
---------of uterus, id. p. 78
---------of the gums in children, ii. p. 247
Ulcer, herpetic, ii. p. 235
Umbilical, cord, i. p. 157
--------------presentation of, ii. p. 58
■---------hernia, ii. p. 204
Undimiam of Avicenna, or humid erysipelas, id. p. 244
Uterus and its appendages, i. p. 43
------substance of, i. p. 44
------arteries of, id. p. 44
------nerves of, id. p. 45
.....lymphatics of ibid.
> • ■ broad ligaments of, id. p. 46
..... round ligaments of, ibid.
■ aqueous secretion from, id. p. 99
gravid, description of, id. p. 143
> ■ . muscular fibres of, p. 145
------developement of, and state of its cervix, id. p. 144
-——— gravid, ligaments of, id. p. 146
----..... vessels of, id. p. 147
------retroversion of, effect of pregnancy, id. p. 206
-i-----antiversion of, effect of pregnancy, id. p. 213
------rupture of, effect of pregnancy, id. 214
------rupture of, ii. p. 116
———symptoms of approaching rupture of, ii. p. 117 & seq.
•■ hour-glass, contraction of, id. p. 127
------torpor of, produces hemorrhage, id. p. 127
-------inversion of, id. p. 138 & seq.
------------------its symptoms and causes, id. p. 138-139
terminations and treatment, id. p. 139
inflammation of, id. p. 159
■ treatment of, id. p. 161-163
------state of, after recent delivery, id. p. 189
Uterine hemorrhage, i. p. 255
--------------:----after delivery, ii. p. 125 & seq.
__________________symptoms of, id. p. 127
-------contraction, two kinds, i. p. 256
_______. excited by gentle pressure on abdomen, ii
p. 128
Uteri, prolapsus, from rising too soon after parturition, ii. p. 125
Urethra, i. p. 39
-------excrescences in, id. p. 74
.------imperforated, ii. p. 204
Ureter, spasm of, effect of pregnancy, i. p. 204
Urine, suppression of, ii. p. 120
______secretion diminished, id. p. 121
______retention of, how caused by uterine hemorrhage, id. p. 136
Urticaria, or nettle-rash, id. p. 276
406 INDEX.
V
Vagina, description of, i. p. 42
------imperfections of, id. p. 59
------inflammation and gangrene of, id. p. 59
------induration of, id. p. 60
------ulceration of, ibid.
------polypi of, ibid.
------inversion of, ibid.
------watery tumour of, id. p. 61
------hernia of, ibid.
------encysted tumour and varices of, id. p. 62
------erysipelatous, inflammation of, id. 63
------rupture of, ii. p. 116
Varicose veins, effect of pregnancy, i. p. 203
Variola discreta, ii. p. 261
------confluens, id. p. 268
Vaccination, id. p. 267
-----------success of, in Philadelphia, ii. p. 267 u.
Varicella or chicken-pox, id. p. 274
------_. lenticular, id. p. 275
--------conoidal, ibid.
-------— swine or bleb pox, ibid.
Vertebral junction and obliquity of pelvis, i. p. 9
Venesection, when proper in tedious labour, ii. p. 66
-----------recommended in puerperal convulsions, ii. p. 113
and 114
Ventricles of heart, inequality of, may occasion death, ii. p. 127 n.
Venereal disease in infants, ii. p. 255
--------------------—— treatment, id. p. 257
Vermin, scabs from, id. p. 241
Vertex, six different presentations of, described, id. p. 865 & seq.
Vomiting, effect of pregnancy, i. p. 181
--------sometimes useful in uterine hemorrhage, ii. p. 132
---------in infants, id. p. 328
Vulva, gangrene of, in infants, id. p. 249
W
Watery discharge from vagina, effect of pregnancy, i. p. 201
Weed or ephemeral fever, ii. p. 152
------treatment of, id. p. 154
Weaning, treatment of women whilst, id. p. 188
period at which a child should be weaned, id. p. 201
Wine occasionally proper in uterine hemorrhage, id. p. 132
Willan, on cutaneous diseases, id. p. 220 & seq.
Wild fire, [eruption of infants] id. p. 233
Worms in uterus, i. p. 100
-------intestinal, ii. p. 348
THE END.
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