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NATIONAL LIBRARY OF MEDICINE




         Bethesda, Maryland 
 
 
        THE

PRINCIPLES
6f
MIDWIFERY;
INCLUDING THE
DISEASES
WOMEN AND CHILDREN.
            BY JOHN  BURNS,  M. D.
LECTURER OX MIDWIFERY, AST) MEMBER OF THE FACULTY OF PHYSICIAN'S
                AND SCHGEOXS, GLASGOW.
TIffi FOURTH AMERICAN, FROM THE THIRD LONDON EDITION,
                GREATLY ENLARGED.
         WITH IMPROVEMENTS AND NOTES,
      BY THOMAS C. JAMES, M. D.
PROFESSOR OP MIDWIFERY IX THE UNIVERSITY OF PENNSYLVANIA.

                  VOL. II.
                  PHILALiE^PHM.

PUBLISHED BY BENJAMIN WARNER, T.nyARD & RICHARD PARKER, MATUJCW
   CAREY & SOX, BENJAMIN & THOMAS KITE, SOLOMON W. CONRAD,
             AVTHONY FIN'LF.Y, AND viihKH THOMAS.
                  J. R. A. Skerrett, Printer.
1817. 
033
 3»3
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 Carey, Moses Thomas, Anthony
Finley, 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, muck 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..
6  w 
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                       £1
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 
IV
Order 2. From some mechanical impediment   Page  7A

                CHAPTER VI.
             Of Instrumental Labours.
Order 1. Cases admitting the application of the
    forceps or lever       -                      80
Order 2. Cases requiring the crotchet         -     93

                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
       book in.

 Of the Puerperal State.

       CHAPTER I.
Of the Treatment after delivery,     -     122
      CHAPTER II.
    Of Uterine Hemorrhage,      -       125
      CHAPTER III.
  Of Inversion of the Uterus,    -    -  138
      CHAPTER IV.
       Of Jlfter-Pains,     -      -     142 
               V
        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,       178
               CHAPTER  XX.
                 Of Bronchocele,     -      -    181
              CHAPTER XXI.
                 Of Diarrhoea,     -      -    I83
              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 
vu
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, hydr	ocele,	
    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	921
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	Page 238
Section	17.	Pityriasis -	- 238
Section	18.	Porrigo	239
Section	19.	Scabs from vermin	241
Section	20.	Bo^and pustules	241
Section	21.	Petechia -	- 242
Section	22.	Erysipelas and erythema	244
Section	23.	Excoriation behind the ears	246
Section	24.	Ulceration of the gums	247
Section	25.	Erosion of thte cheek	248
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	290
   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,       .      _    333
                 CHAPTER XII.
                  Of Diarrhoea,      -      .    329
                CHAPTER XIII.
                  Of Costiveness,    -      -      340
                CHAPTER XIV.
                    Qf Colic,        .      _    341
                CHAPTER XV.
                  Of Peritonitis,        -        342
                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,
Appendix       ....
Tables      -             -  -
Notes    -     -<*
Index       -
356
365
378
381
^01 
*♦" 
          THE

    PRINCIPLES

           OF

MIDWIFERY.
                      book n.

                 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
purposesof 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. II.                       B 
2
      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 briefly 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
interior 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 fontanel!* 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 Labmirt 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 fatal 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 onder order 5.   Malposition
ofthe 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 wit!i 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 j  five the breech;  two or
three the face; one or two the  ear; and ten shall present
witli 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, 
0
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.(i)

  (b) From the register kept at 1'Hospice 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 proportion of I to 71-f, of these,
                                                            Cases.
The face presented in      -----      -    18
The shoulders    -------        38
The head and umbilical cord ------    1J
The thighs      -------        22
The feet     --------    11
Other parts not specified  ------        24
Convulsions and floodings    -      -       -       .      .       .     4

As 1 to 9Q                                                     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;  of which number  16,286  were
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   -
Proportions.
 to      81-|
 -      59^
 -     296$
 —     336J
      4374J
 -    4374i
 -    4374|
 -    4374|
 -    4374J
 _    5833
 —    5833
 —    58o3
 -    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    ...       i—     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 delivered by
the hand alone, the children being brought by the feet;  49  were delivered
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 the death of the child
was first ascertained.
  The  cesarean operation was performed in two cases, the  diameter of the
pelvis being only one inch six fines 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 fcetas 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  secun-
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 contraction 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 
8
 syncope.   The most regular manner of attack, is for the
 pairs 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 chillness; 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 ; 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
witli 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 lacunar, 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. n.                              o 
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 
IS
 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, costeris 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 rase in those countries where heat conspires to re-
 lax the fibres.  The quality or quantity of the food has much 
1.3
 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. OF 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 montlis 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. 
operation '• taking a pain j" but there is no necessity for giv-
ing directions respecting the proper language to be used, as
every man of sense and  delicacy will  know  how 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. 
19
  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 exactl)
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 oedema- 
16
tous, and this state is often combined with oedema 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
■;low labour, for as long as this state continues, dilatation is
tardy;  a thick oedematous  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
case* 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 the 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.                         D 
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; 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 openeil, 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
tor 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 tilled with blood.
   By examination, we  ascertain the presentation,  and the
progress which the labour has made; hut 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 diiated,  become  forcing,  with an  inclination
to void the urine  or  faeces, 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- 
                          rwA

cess is not likely to be rapid. If, when theos 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 foetus, 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 
33
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 
,21
 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 arc 
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 
2(5
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 rule 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 
87
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 faeces 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 are 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
are 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 rent 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-
 nseum, 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 this 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 he  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.(c)   It  is  then to be divided betwixt them, and the
 child removed.   The hand is next to  he 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 established.   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, 1 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.
  (J) 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 pubis. 
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 plaoenta
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, paticnt.(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;
  "Incidit 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 to
remain 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 wi$h 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 cloth,  dipped in cold water,  to the
belly, has the same effect. The 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. it.                         v 
                          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 ve^ry intimate, we must not, in
order to destroy it, scrape and irritate the  surface of the
uterus, hut 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 cerv ix 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  dc- 
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 he
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 entii'e.  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 uteriiis 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 may be exchanged for the shoulder,!
 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.
  + 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 cliild 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 breadth from 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
elear 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 fourchette.  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, and  bring down the foot;
the knee, in this process, pressing obliquely  on the abdomen 
41
ef 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 turn 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  soon 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. n.                         a 
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 be 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

  * La 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 mputh, 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  utcrus.(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,

   (j>-) 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 child'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 thein 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  body round.  The  management  is the
same as in breech cases.  There is little 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, it is proper to attend that the feet be right and left.
   Sometimes a knee and foot, or the knees  alone, present ;(/&)
and as they  form a larger tumour than the feet,  they may at
first be taken for the breech or the head.  Generally only one
knee presents, and it lies obliquely, with  its  side on  the os
uteri.   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 the 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
the mother, and the legs placed against the sacrum. 
43
         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 pelv is, 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 iliuc
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 tliu
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 iliuc 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, tor 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
both 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,
                                                     i
   * 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. 
47
 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 cowect, 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.
  (fc) 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 
48
not to be delayed, for every pain  endangers the  rupture  of
the membranes.  If they do give way, 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 delivery.  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 
49
 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.  Hav ing 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  there.(i)  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.
   VOL. n.                        H 
50
 been torn or cut off,(ro) 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 difficult 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, I 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 csesa-
 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 child
born with symptoms of life, even after the head has been opened, and the
greatest portion of tiie  brain evacuated, and born ahve, 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 turning1.
  * Vide Memoir by M. Baudelocque, in Recueil Period.  Tome V. table 1.
cases 5 and 15.
  f Peu, 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 perinseum 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 either 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. I. p. 351.—Dr. J. Hamilton's Cases, p. 104.  He found
 it necessary  to separate three of the vertebrae.—Dr. Clarke twisted off  the
 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.
   \ Acta Havn. Tom. H. art. xxiii.
   § Lond. Med. Jour. Vol. V. p. 64.—See also case by Mr. Outnwait,in Ne\v
 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. 
5%
 thirty 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.!

  • 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. Denman 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  cases in which this curious 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
 >t 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 v6ry
 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 thene 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.
  («) Of each of these, Baudelocque has constituted four varieties of presen-
tations, for a synopsis of which 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 hip.  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, which
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 deal's the arch of the pubis, the vertex turning up within
the perinseum 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

   (p) 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. 
5.5
care and patience to prevent laceration.  This presentation
is  difficult to he  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.(<jf)  Of the advantage of this prac-
tice,  I can  speak  from my own observation; and  I have,
even when the head had descended so low as to have the nose
on  a line with the arch of the pubis, succeeded in turning
the face round to the hollow of the sacrum with great promp-
titude, and with  so much  facility,  that the patient  did not
know that I was doing more  than  making an ordinary ex-
amination.  Some have advised, that we should keep up the
forehead during a pain, to  make the vertex descend; or that
we should, with the finger, depress the occiput.
   The fontanelle, or  crown of the head, may  also  present,
although the face be turned to the   sacro-iliac junction.  In
this case it is felt early, and, by tracing the coronal suture,
we may ascertain whether the frontal bones lie before or be-
hind.   It  is a much more  uncommon presentation than  that
noticed  above.   The labour is, at  first, a little slower than
in a natural  presentation, but,  by degrees, the head  becomes

  (5) The editor can also unite from his own experience, in recommending
the attempt at altering and  correcting this malposition of the head, as above
recommended; it has often proved successful in  his own practice. It will be
found  that this  mode of proceeding was first inculcated by Baudelocque,
from observing that nature  herself sometimes obviated difficulties, and acce-
lerated the termination of the labour, by converting the fourtli position into
the second, and the fifth into the first; or, in bringing the posterior  fonta-
nelle from the right or left sacro-iliac symphysis, to the right or left aceta-
bulum. Vide Art des Accouchemens. 
56
 more oblique, the vertex descending; and this may be assist-
 ed, by supporting the forehead with the finger during a pain.
 Should any untoward accident require the delivery to be ac-
 celerated, we have been advised to turn the child, and in do-
 ing so to use the left hand, if the occiput lie on the left aceta-
 bulum, and  vice versa.  But this operation can seldom be
 requisite.
   The crown of the head  may also present with the face to
 the pubis or the sacrum, but these positions are extremely
 rare.(r)   In time, the  head will generally  become  more
 diagonal, and descend obliquely, but we ought not to  trust
 to this. We should rectify the position, for it is by  no means
 difficult to move the head with the finger, if we attempt it
 early.  We  may even  carry the forehead from the pubis to
 the sacro-iliac junction.  The process  is still  more simple
 when  the occiput  is  turned to  the pubis,  if we perform it
 early.  If, however, we neglect  it, we find that in a few in-
 stances the head does  not turn at all, but enters the pelvis in
 the original  direction, and becomes wedged,(s) requiring the
 use  of instruments.   This  is oftenest  the  case, when  the
 occiput is turned to the pubis; for the forehead being broad
 does not by a continuance of labour slip to  the side of  the
 promontory of the sacrum, so readily as the occiput would do.
  2d.  The side of the head may present.   In this case,  the
 presentation is long of being felt, but it  is recognised by  the
 ear.  If,  however, it has been long pressed in the pelvis, it
 is extremely difficult to determine the case.   It is very rare,
 and has even been  deemed to be  impossible.   In some in-
 stances the child has been turned, but it is most common to
 rectify  the position of the head by introducing the hand.
  3d. The occiput may present,  the triangular part of the
 bone being felt at the os uteri.  It is known by its shape, by

  (r) These constitute the third and the sixth positions of the vertex, ac-
cording to Baudelocque. The  comparative infrequency of their occurrency
is illustrated in the table, appended to the chapter on the  Classification of
Labours.
  (*) This by the French writers is termed enslavement, and by the English,
the locked head. 
                           57

 the lambdoidal suture, and its  vicinity to the neck.  The
 forehead rests on some part of one of the psose muscles, and
 from this oblique position of the head, the labour is tedious.
 It has been proposed, in this case, to turn ; but it is better, if
 we do any thing, to rectify the position of the head with the
 hand.  Nature is, however, adequate to the delivery, even if
 not assisted.  Some advise, that the woman  should, by a
 change  of position, endeavour to remedy  the  obliquity,
 making the  child incline, so as to affect the situation of the
 head, but this has not much power in altering  the position of
 the presentation, at least after the water has been evacuated.
   4th. The face may present, with the chin to one of the
 acetabula, or to the sacro-iliac junction, or to the pubis or sa-
 crum.  The two first are the best,  the second is more trouble-
 some, and the last is worst of all.   When the face  presents,
 the  labour is generally tedious and  painful, for it is little
 compressible, and affords a broad surface, not well calculated
 to take the proper turns in  the pelvis.   The head, also, being
 thrown back on the neck,   a larger body must pass, than
 when the chin is placed on  the breast.   By a continuance of
 the pains, the face becomes swelled; and although at first it
 was recognisable by the mouth  and features, yet now it is in-
 distinct, and  has been taken either for a natural presentation
 or the breech.   By rude treatment,  the skin may be torn ;
 and even under the best  management,  the face, when born,
 is very unseemly, and sometimes quite black and elongated,
 so that it has been known to measure  nearly  seven inches.
 This is especially the case  when the chin is directed to the
 sacrum, and some children die  from obstructed circulation,
 owing to the  continued pressure on the jugular veins.
  Face presentations have  been attributed sometimes to con-
 vulsive vomiting, cough, or  frequent examination, but gene-
 rally no evident cause can be assigned; and in the beginning
 of labour, the face itself does not present, but only the fore-
 head :  hence La Motte tells us, that although at first he found
the head present properly, yet, when the membranes broke,
the face came down.
  Some have advised,  that the'child  should  be  turned;
  vor. it.                              i 
58
    others, that the chin should be raised up, to make the upper
    part of the face come down; or that if the head be advanced,
    a finger should be inserted into the mouth,  to bring down
    the jaw under the pubis.   Others leave the whole process
    to nature;  but many endeavour with the hand to rectify the
    position.
      If the presentation be discovered early, there can be little
    doubt as to the propriety of rectifying the position, but if the
    labour be advanced, this is difficult; and then it only remains
    that we should endeavour, if the labour be severe and tedious,
    to make the face descend obliquely, by cautiously but firmly
    supporting with a  finger, during the pains, the chin or end
    which is highest, in order to favour the descent of the lower
    end.  When the chin  has advanced so far  as to come near
    the arch of the pubis, we may  follow a different method, and
    gently depress it,  which assists the delivery, for generally
    the chin is«first evolved.   If, however, the process go on re-
    gularly and tolerably easy, we need not make these attempts.
    As the perinseum is much stretched, we must support  it, and
    avoid all hurry in the exit of the head.
     When the chin is directed to the sacrum,  the labour is
    sometimes so tedious as to require the application of instru-
   ments.


               ORDER 6.  OF THE UMBILICAL CORD.

     Sometimes the cord descends before, or along with the pre-
    senting  part of the child.   This has no influence on the pro-
   cess of delivery, but it may  have a fatal effect on the  child ;
   for, if the cord be strongly compressed, or compressed for a
   length of time, the child shall die, as certainly as if respira-
   tion were interrupted after birth.   If the cord be discovered
   presenting before the membranes burst, or if the os uteri be
   properly dilated when they burst, the best practice is to turn
^the child.  It has indeed been proposed, to  push the cord
i,  beyond the presenting part, or hook it upon one of the limbs;
   but, if the hand is to be introduced so far, it is better at once
    to turn the  child.   If the os uteri be not sufficiently relaxed, 
59
 we must not use force to expand  it; and little can be done,
 except by rest, to prevent as much as possible, the evacuation
 of the water.  As soon  as  the os uteri will admit  the intro-
 duction of the  hand, the child should be turned if it can be
 easily done.   But if the presentation be advanced  before we
 are called, and turning be difficult, then we  must endeavour
 to keep the cord slack, or remove it to that part of  the pelvis
 where it is least apt to be compressed ; or it  will be still bet-
 ter, to endeavour  with  two fingers  to push  the cord slowly
 past the head, and prevent it for two or three pains from com-
 ing down again.(f)   This is less  violent, and safer, than at-
 tempts to turn in an advanced stage of labour.   Should this
 pot be practicable,  and the pulsation  suffer, or the circula-
 tion be endangered, we must accelerate labour by the forceps.
 If the pulsation be stopped, and the child dead, when we exa-
 mine, then labour may be allowed to  go on, without paying
 any attention to the cord.  The sum of tbe practice then is,
 that when the os uteri is not dilated, so as to permit of turn-
 ing, we must not attempt it; when turning is practicable, it
 is to  be performed; when  the head has  descended into the
 pelvis, the cord is to be replaced, or  secured as much as pos-
 sible from pressure; but if the circulation be impeded, the
 woman must be encouraged to accelerate the labour by bear-
 ing down, or instruments must be employed.   When the pre-
 sentation is preternatural, these directions are likewise to be
 attended to, and the practice  is  also  to be regulated by the
 general rules applicable to such labours.

    ORDER 6. PLURALITY OF CHILDREN AND MONSTERS.

   Various signs have been mentioned, whereby the presence

  {*) Mauriceau, in these cases, recommends returning the funis, and push.
ing a piece of soft linen after it, the end of which may remain hanging with-
out.  Dr. Mackenzie, a celebrated accoucheur of London, in a case wh^ere
the funis presented, pulled down  as much as he could, which he inclosed in
a leathern purse ; and thus returned it, pushing them up together into tMft
uterus; in this case the  child was born alive.  He afterwards  pursued th^
same practice,  and sometimes succeeded; and others have since followed
his example. 
60
of a plurality of children in utero might be discovered,  pre-
vious to their delivery.  These are, an unusual size, or an
unequal  distension of the abdomen, an uncommon motion
within the uterus, a very slow labour, or a second discharge
of liquor amnii during parturition.  These signs,  however,
are so completely fallacious, that no reliance can  be placed
upon them, nor can we generally determine the existence of
twins, until the first child be born. Then by placing the hand
on the abdomen,  the  uterus  is felt large,* if it contain  ano-
ther child ;  and, by examination per vaginam, the second set
of membranes, or some part of the child, is found to present.
This mode of inquiry is proper  after every delivery.
  Soon after the  first child is  born, pains usually  come on,
like those which throw off the placenta, but more severe; and
they have not the effect of expelling it,  for it is generally re-
tained till after the delivery of the second child. No intima-
tion of the  existence of another child  is to  be given to the
mother, but the practitioner is quietly to make his  examina-
tion, rupture  the  membranes,  if they  have  not given way,
and  ascertain the presentation.   If it  be such as require no
alteration, he is to  allow the labour to proceed according to
the rules of  art,  and usually the expulsion is very speedily
accomplished.  If the first child present the head, the second
generally presents the breech or  feet, and rice versa; but some-
times the first presents  the arm, and,  in that case,  when we
turn, we must be careful that the feet of the  same  child be
brought down.  This one  being delivered, the hand is to be
again introduced, to search for  the feet of the second child,
which  are to be brought into the vagina, but the delivery is
not to  be hurried.
  It sometimes happens, that after the first child is born, the
pains become suspended, and the second is sot born for seve-
ral hours.   Now this is an unpleasant state, both for the pa-
tient and practitioner.   She must discover that there is some-

  * In a case Telated by Mr. Aitken, the uterus was felt, after delivery, large
and hard, as if it contained another child, but none was discovered.   In the
course of a fortnight the tumour gradually disappeared. Med. Comment. Vol.
II. p. 300.  ■ 
                           61

thing unusual about her, he must  be conscious that  hemorr-
hage, or some other dangerous symptom, may  supervene.
The first rule  to be observed is, that the accoucheur is upon
no account to  leave his patient till she be delivered.  The
second regards the time for  delivering.   Some have advised
that the case be entirely left to the efforts of  nature,  whilst
others  recommend a speedy delivery.   The safest practice,
if the head present, lies between the two opinions.  If effec-
tive pains do not come on in an hour,  the child ought to be
delivered by turning.   The forceps can seldom be required ;
for if the head have come so low  as to admit  of their appli-
cation, the delivery most likely shall be accomplished with-
out assistance.  If  the second child present  in such a way,
as that the feet  are near the os  uteri,  as for instance, the
breech or any part of the lower extremities, then the feet are
cautiously, but without delay, to  be brought down into the
vagina, and the  expulsion afterwards left, if nothing forbid
it, to nature.
  If, however, the position of the second child be such as to
require turning, we are to lose no time, but introduce the
hand for that purpose, before the liquor amnii be evacuated,
or the  uterus  begin to act strongly on  the child.   Turning,
in such circumstances, is generally easy.
   In the event of hemorrhage, convulsions, or  other dan-
gerous symptoms, supervening between the birth of the first
and second child,  the delivery must be accelerated,  what-
ever be the presentation, and managed upon general prin-
ciples.
  When there are more children than  two,  the woman sel-
dom goes to the full time, and the children   survive only  a
short time.  There is nothing peculiar in the management of
such labours.
  It still remains to observe, that we ought  to be peculiarly
careful in conducting the expulsion of the placcntse  of twins.
Owing to the  distension of the uterus, and its continued ac-
tion in  expelling two childen, there is a greater than usual
risk of uterine hemorrhage taking place. The patient must
be kept very quiet and cool,  gentle pressure  should be made 
63
with the hand  externally on the womb, and  no forcible at-
tempts are to be permitted, for the extraction of the placentae,
by  pulling the cords.  If hemorrhage come on, then  the
hand is to be introduced to excite the uterine  action, and the
two placenta; are to be extracted together.   The application
of the bandage, and other subsequent arrangements must be
conducted with caution, lest hemorrhage be excited.
  The placentae are often connected, and therefore they arc
naturally expelled together, but this adds nothing to the dif-
ficulty of  the process.  Sometimes they  are  separate,  and
the one is thrown off  before the  other; or it may  even hap-
pen, that the placenta of the first child  is expelled before the
second child be born, but this is very rare,  and  is not de-
sirable.
  Women, who have borne a plurality  of children, are more
disposed than others to puerperal diseases, and must therefore
be carefully  watched.   It rarely  happens, that they are able
to nurse both children without injury.
  It is possible for two children  to adhere, or for  one child
to have some additional organ belonging to a second, as, for
example, an arm or a  head.   Such cases of monstrosity may
produce considerable  difficulty in the delivery ; and the ge-
neral principle of conduct must be, that when the impediment
is very great, and does not yield to such force  as can be safely
exerted, by pulling that part which is protruded,  a  separa-
tion must be made, generally of that part which is protruded,
and the child afterwards turned,- if necessary.  Unless the
pelvis be greatly deformed, it will be practicable to  deliver,
even a double child, by means of perforation of the cavities, or
such separation as  may be  expedient, and  the use of the
hand, forceps, or crotchets, according to  circumstances.  A
great degree of deformity may render  the csesarean opera-
tion necesasry.
  With respect to children who  are monstrous from de-
ficiency of parts, I may take the present opportunity of ob-
serving, that no difficulty can arise, during the delivery, ex-
cept in  ascertaining the presentation, if the malformation be
to a great extent, as,  for instance, in acephalous children. 
63
                      CHAP. V.

                   Of Tedious Labour.

  ORDER 1.  FROM IMPERFECTION OR IRREGULARITY  OF
                   MUSCULAR ACTION

  If the expulsive force of the  uterus  be  diminished, or the
resistance to the passage of the child be increased, the labour
must be protracted beyond the usual time, or a more than or-
dinary degree of pain must be endured.
  Tedious labour may occur under  three  different  circum-
stances :
  First, The pains may be from the beginning weak or few,
and the labour may be long of becoming brisk.
  Second, The pains during the first stage may be sharp and
frequent, but not effective; in consequence of which the pow-
er of the uterus is worn out before the head of the child have
fully entered into  the pelvis, or come into a situation to be ex-
pelled.
   Third, The pains during the whole  course may be strong
and brisk, but from some mechanical  obstacle, the  delivery
may be long prevented, and it may even be necessary to have
recourse to artificial force.
   Different causes  may retard the process of parturition.
The first and most obvious one, referable to the order at pre-
sent under consideration,  is a weak or  inefficient action of
the uterine fibres.  This may be dependent on general de-
bility or inactivity, but more frequently it proceeds  from the
state of the uterus itself. It is  marked by feeble pains, which
dilate the os uteri slowly,  and are long of  forcing down the
head.   But although the pains be feeble, they may produce
as great sensation  as usual,  for this is proportioned rather
to the sensibility  than to the vigour of the part.   It is, how-
ever, usual, when labour  is protracted  from this cause, for
the pains to be less severe than in natural labour. They may
come much  seldomer, or,  if frequent, they may last much
shorter, and be less acute.  The  whole process of labour is 
61
sometimes equally tedious, but, in most cases, the delay prin-
cipally takes place in one of the stages, generally in the first,
if the cause  exist chiefly  in the uterus.  If, however, it pro-
ceed from general debility,  we often find,  that if the first
stage be tedious,  the powers  are thereby so  exhausted, that
the second can with difficulty be accomplished.  Hence, al-
though consumptive patients often have a rapid delivery, yet
if the first stage be slow, the  head frequently cannot be ex-
pelled without assistance.  It is not always easy to say what
the cause of this slow action  of the uterus is.  Sometimes it
proceeds from contraction commencing rather prematurely;
or from the  membranes breaking very early, and the water
oozing slowly away; or from the uterus being greatly dis-
tended by liquor amnii, or a plurality of children; or from
fear, or  other passions of the  mind operating on the uterus;
or from torpor of the uterine fibres, frequently combined with
a dull leucophlegmatic habit,  or with a constitution  disposed
to obesity; or from general weakness of the system.
  In a state of suffering and anxiety, the mind is apt  to  ex-
aggerate every evil, to foresee imaginary dangers, to become
peevish, or desponding, and to press with injudicious impa-
tience for assistance, which cannot safely be granted.  Great
forbearance, care, and judgment, then, are required on  the
part of the practitioner; who,  whilst he treats his patient with
that gentleness and compassionate encouragement, which hu-
manity and refinement of manners will dictate, is steadily to
do  his duty, being neither swayed by  her fears and intrca-
ties, nor by  a selfish regard to the saving of his own time.
  Some women seem constitutionally to have a lingering la-
bour, being always slow.   In such cases, unless the process
be considerably protracted, or attended with  circumstances
requiring our interference, it is neither useful nor proper to
do  more than  encourage the  patient,  and preserve her
strength.
  A variety  of means were at one time employed for exciting
the action of the uterus, such as dilatation of the  os uteri,
and the  use of emetics, purgatives, or stimulants.  A very
different practice now happily obtains; the patient is kept 
65
cool, tranquil, and permitted  to repose; the mildest drink is
allowed, all  fatiguing efforts are prohibited, and she is en-
couraged by the mental stimuli of cheerfulness and hope, ra-
ther than by wine and cordials.  But, whilst in cases where
labour is only a little  protracted, we trust  entirely to this
treatment,  with the addition of a  saline clyster, which is of
much service, and ought seldom to be omitted, yet, where it is
longer delayed, some other means are allowable, and may be
necessary.
  The pains in tedious labour, connected with defective ute-
rine action, may be continuing regular, but weak, not from
exhaustion, but rather  from the  uterus not  exerting the
power it has ; or there may be a tendency to remit, the pains
coming on  seldom.  In the first of these states, we  have  to
consider whether there be  heat of the skin, full pulse, with
thirst and restlessness.   If so, and especially if the os uteri
be not relaxed, venesection will be of great  benefit, by mak-
ing the uterus  act with more freedom, and its mouth yield
with great  readiness.   We know that in most  cases of ute-
rine hemorrhage, the os uteri, even  where there is no  effec-
tive labour, and scarcely any pain, is not merely  dilatable,
but is actually dilated,  In this instance, however, the bene-
fit of evacuation cannot be derived, for the discharge injures
and impairs  the whole power of the uterus, and in propor-
tion as the os  uteri is extended, the quantity  of the blood
which flows is increased; besides, the evacuation usually be-
gins before labour commences, and pains do not come on till
the loss of blood excite them.   We learn, however, from this
example, the influence  of hemorrhage in  relaxing the  os
uteri, and if we can do  this without impairing the power of
the womb, we have certainly a powerful mean of accelerating
labour; venesection does this in certain cases.  It can do no
good, but much harm  in cases of exhaustion, or  in cases
where the resistance is afforded by a contracted pelvis, and
all other circumstances are right.   But in  cases where the
parts, through  which the child must pass, are  rigid or  dry,
or hot and  tender, or  where the pains are great, but irregu-
lar and inefficient, or the  membranes have given way prema-
  vol. ir.                           k 
66
    turely, the pains are sharp, but abortive, and  the os uteri
    thick or hard, or the patient is feverish, blood-letting is safe,
    and may be expected to do good.   That it  is safe, we know
    from the experience of former ages  and other countries, as
    well as from our own  observation in cases of convulsions,
    where a great quantity of blood  is taken away with present
    advantage and future impunity.   It is, however, a remedy,
    which, if imprudently employed, may do much mischief.  In
    cases of exhaustion, for instance, it must be dangerous ; and
    in every constitution, and  under every circumstance in which
    it would, independent of labour, be improper to evacuate, it
    is evident that it will be hurtful, unless we can thereby save
    the  patient prolonged exertion and exhaustion.  In natural
    labour, it is neither  necessary  nor proper; in labour not
    greatly protracted, nor unusually severe and slow in its steps,
    it is not to be resorted to.  It is better to trust in these cases
    to the use of clysters, to gentle motion and change of posture,
    or to sleep, if it  offer naturally, and the patient require to be
    recruited.
      The effect of venesection in shortening  the  process of la-
    bour, and in rendering the pains in many cases brisker, is to
    be explained by  its power in relaxing the parts, and diminish-
    ing the resistance afforded.  It is a curious fact not sufficient-
    ly attended to, that in many cases a very moderate resistance,
    which we should think the uterus might easily overcome, does
    retard the expulsive process, and render the pains irregular or
    inefficient.   Thus, I know from  experience, that  the mem-
    branes may be so tough as not readily to  give way, and in
    this case the pains do become less effective, and the labour is
    protracted till they are opened.   Whenever the resistance is
    removed, the pains become brisk and forcing.   In the same
    way, relaxing the os uteri by blood-letting  excites the uterine
    fibres to brisker action.
       If the woman be  fatigued or  debilitated,  and the pulse
    weaker than in  lingering labour  we  shall derive advantage
    from the use of  a small clyster,  followed by twenty drops of
i   laudanum, or a  proportional quantity in an injection.  This
    does not suspend the pains, but rather excites them. A simi- 
                             67
                                 «
lar stimulus is sometimes given by a gentle purge, but this is
more slow and uncertain in its effects.
   When  there is a strong tendency in the pains to remit, or
keep off,  we are  to follow pretty nearly the same conduct with
regard to venesection, in  the circumstances which  I  have
pointed out, as admitting of it; but it is much more rarely
required  in those  cases,  than where the pains are less fre-
quent.   When it is employed, it either procures a remission
and sleep, followed by brisk action, or it excites more imme-
diately the pains;  for whatever diminishes the resistance or
obstacles, whatever  produces relaxation, speedily acts as  a
stimulus  to the uterus to contract; cordials and stimulants
are more doubtful in their  effect.   If, however, blood-letting
 be improper, we give a clyster, and then forty drops of lau-
 danum, which either makes the pains effective and brisk, or
suspends them for a  time, till the womb recruit.(w)
   There is another state in which the pains are weak, or re-
mit, or are ineffective from absolute  exhaustion or debility,
 and we distinguish this case by the weak pulse, languor, and
 previous fatigue, and in part by the constitution of the wo-
 man.   If no urgent symptom require delivery, we must sup-
 port the  strength by the prudent administration of cordials
 and nourishment.  This is the  only case  in which cordials

   (w) In cases where the contractions of the uterus are inefficient from want
of energy or irregular action of the uterine fibre, provided the cervix and os
uteri, as well as the external parts are sufficiently dilated or disposed to
dilate ; recourse may be  advantageously had to the ergot, or spurred rye.
Under these circumstances the editor has frequently derived the most de-
cided advantages from its use, given  in fine powder, in the dose of about one
scruple in syrup, and has  seldom had occasion to repeat it.  In about twenty
minutes after the exlubition of the article, the contractions of the uterus are
invigorated, and the process accelerated in some instances probably several
hours.
  In judicious and discriminating exlubition, this article of the materia me-
dica may be considered as a valuable  acquisition in the practice of midwifery;
although, like all other powerful medicines, in rash and inexperienced hands
it may possibly do harm.
  For fuller information on this subject the reader is referred to the papers
ul' l)rs. Stearns, Prescott,  and Bigelow.
  The credit of introducing this medicine into obstetrical practice is exclu-   <('
sively due  to the practitioners of the United States. 
68
are proper, and they must even here be given prudently, lest
they produce a febrile state.  It is also usefid to suspend for
a time the uterine  action, and procure  rest  by an anodyne
clyster.
  If the water be discharged very early in labour, or before
the pains come on, the process is often lingering, but it is not
always so.   The os uteri is, when we first examine, project-
ing, then it becomes flat, but the lips thick; then they become
thinner and more dilated, and presently very thin; and  the
lower part of the uterus is perhaps applied so closely to the
head, that at first it might be taken for the head itself.  These
changes may take  place quickly, but they may also be very
slow, the pains  sharp  and ineffective, and  the water dis-
charged  in  small  quantity with each pain.  The pains are
severe, but produce very little effect, and often  when they go
off, are succeeded  by a most  distressing uneasiness  in  the
back, lasting for nearly a minute after the pain.   A  saline
clyster is of much benefit in this  kind  of labour; and it is
useful to  press up the head, especially during the pains, to
favour the evacuation of the water; for, whenever this is ac-
complished, naturally or artificially, the action becomes much
stronger.   It is also useful to detract blood, if the os uteri be
rigid, the parts not  disposed  to yield, and the pains very
severe.  It is peculiarly proper when the woman has rigours.
When the organs are firm, and the pains lingering, it causes
relaxation, and quickens  the  pains.  If, on  the other hand,
the os uteri be lax and thin, or soft, it  is  both safe and ad-
vantageous to dilate it gently with the finger during a pain.
If this be done cautiously, it gives no additional uneasiness,
whilst the stimulus seems to direct the action of the uterine
fibres more efficiently towards the os uteri, which sometimes
thus clears the head of the child very quickly,  and the pains
which formerly were severe, but in the language of the pa-
tient, unnatural and doing no good, become effective and less
severe, though more  useful.  This advice, however,  is  not
meant to sanction rash and  unnecessary attempts to dilate
the os uteri, which sometimes  render  labour more tedious,
by interrupting the natural process, and also lay the founda- 
69
tion for inflammatory affections afterwards.  When the pains
are irregular, and arc succeeded by aching of the back, if the
state of the os uteri do not indicate venesection, from two to
three grains of opium may be given with advantage.
  If, again, in lingering labour,  the  membranes be entire,
the os  uteri soft,  lax, and well dilated, and the presentation
natural, it is allowable and  beneficial to rupture the mem-
branes ; and this  is more especially proper,  if the uterus be
unusually distended.   The evacuation  of the water is suc-
ceeded by  more powerful  action,  a  circumstance  which,
whilst it points out the advantage  of the practice in the case
under consideration, forbids  its employment in  natural  la-
bour,  where the  process is  going on with a regularity and
expedition, consistent with the views of nature, and the safety
of the woman.
   Sometimes,  after the first stage  is  completed, and the os
uteri is well dilated, the second  does not commence for  some
hours; but  the  first  kind of pains continue in different de-
grees  of severity, without producing any perceptible effect.
If  no particular cause require  our  interference, it is best to
trust to time;  but, if it be necessary to accelerate the labour,
 it  may often  be done  by  rupturing  the membranes,  or, if
 they have already broken, we may place two fingers on  the
 margin of the os  uteri, which  is next the pubis, and gently
 assist it, during  the pains, to slip  over the head.
   When a woman is greatly reduced in strength, previous
 to labour, that process is looked forward to with apprehen-
 sion.   It is, however, often very  easy.   But, if it should be
 protracted, the patient  is to be kept  from every exertion.
 The general plan  of  treatment pointed out for  such cases is
 to  be  followed, and, if the strength  fail,  the child  must be
 delivered.  We  must be particularly  careful that hemorr-
 hage do not take place after delivery, or that it be promptly
 stopped.
   If the head rest long on the perinseum  in tedious labour,
 the pains having little  effect  in  protruding it, especially if
 the first stage have been lingering,  it  comes to be a question,
 whether we shall  deliver the woman.   This case is different 
70
 from that where the difficulty proceeds from a  contracted
 pelvis, for the head is low down, the bones are not squeezed
 nor mishapen, there is only a swelling of the scalp, the fin-
 ger can be passed  round the head, and  two strong pains
 might expel it.   Whilst the strength remains good, there is
 no warrant for delivering.  A soothing treatment, promoting
 rest, restraining voluntary bearing-down efforts, and giving
 a little wine,  or an opiate, if the patient be  exhausted, will
 generally be successful.  But, if the labour be still protract-
 ed, the strength sinks, the pulse becomes weak and frequent,
 the pains useless, the woman complains of head-ache, is rest-
 less, has not the full command of her  mind, and sometimes
 vomiting comes on after every pain.   In such cases, the for-
 ceps must be  employed, as will hereafter  be noticed.  It is
 impossible to determine how many hours  a labour  may be
permitted to  continue,  for time alone is not to be our rule;
we must be regulated greatly by the effects of labour.  Yet it
may not be altogether useless to state the periods, at which
lingering labour has terminated in a large hospital.  From
Dr. Breen's tables it would appear, that, in the Dublin hos-
pital, of 172 women in labour of their child, 102 were  from
40 to 50 hours in labour; 34 from 30 to 40 ; 24 from 70 to
80 ; and 12 from 90 to 100; 121 children were alive.  Of 91,
who had borne children formerly, 48 were from 40 to 50 hours
in labour; 28 from 30 to 40 ; 9 from 70 to 80; and 6 from 50
 to 60; 66 children were alive.
  In tedious labour, it is not necessary to confine the woman
to bed, or to one posture; she may be allowed to sit, lie, or
walk, as she  feels inclined;  and we are not to urge her to
stand long, or use exertion by way of promoting labour.   She
has generally not much inclination for food, but, if the pro-
cess be protracted, it is useful to give some light soup, and a
little wine, if she desire  it.   If the  urine be not regularly
passed in tedious  labour, the catheter ought to be intro-
duced.  It is not necessary that the practitioner remain con-
stantly  with  the patient.  It  will have a better effect upon
her, if he see  her at proper intervals; whilst he is thus pre-
vented himself from being so fatigued, as he otherwise would 
71
be, and is therefore better able to discharge his duty with
firmness and judgment.
   The second general cause of tedious labour is, irregular ac-
tion of the uterine fibres.  After the child is born, the uterus
sometimes contracts like a sand-glass, and retains  the pla-
centa. The  same spasmodic action may occur before the child
be expelled. It is marked by pain coming at  intervals, like
proper pains, but it is confined to the belly, and has little ef-
fect on the os uteri, or in forcing down the child, nay the os
uteri  sometimes seems even to contract during a pain.   The
contraction  does not go off with the pain, it only lessens ;
hence the band of fibres still compresses the child or ovum,
and,  if the  membranes have not broken, they are often kept
so tense,  as at first to resemble a part of the child, and may
mislead the practitioner with respect to the presentation.
There is a frequent desire to void urine,  and the spirits are
generally depressed.   If this affection be  slight, it may soon
go off; but if the spasm be strong, it sometimes continues for
many hours.   A smart  clyster  is often  of  great service.
Blood-letting sometimes does good, but I prefer opening the
membrane if the presentation be good, and the os uteri lax ;
this I have  found very successful.   If, on the contrary, the
 os uteri be  rigid or undilated, and especially if the presenta-
 tion  be not determined, they must be kept entire,  until the
 os uteri will permit of turning, should  the position of the
 child require it.  In such cases, and even when the os uteri
 has been  in such a state as to warrant the  rupture of the
membranes, but this has  not been successful,  we may  derive
advantage from  giving a large dose of solid  opium;  for in
this spasm,  like tetanus, opium may be taken safely in pro-
digious doses.   Even ten grains  have  been given, but in
general from four to  six are sufficient.   After the child is
born, the hand should be introduced into  the uterus,  not to
extract the placenta quickly, but  to come easily in contact
with it, and excite the uterus  to regular  action; for gene-
rally the  spasm  returns, and the placenta may be  long re-
tained, or hemorrhage produced.
   A  frequent cause of tedious labour, is a state of over-action, 
                           73

or unproductive action in the first stage, by which the pow-
ers of the uterus are exhausted, and the  subsequent process
is rendered  very slow.  This exhaustion may also be  pro-
duced by the continuance of debilitated action or feeble and
useless  pains.  In the first case, the  pains are sharp and
frequent, but do not dilate the os uteri properly, nor advance
the process in general.  It  may  be produced  by irregular
action of the fibres, or by premature rupture  of the mem-
branes.   In the second case, the pains are lingering, short,
and usually  weak.   I have already considered  the remedies
for those states; blood-letting, clysters, gentle dilatation  of
the os uteri, &c. and have here  only to observe, that the ex-
haustion of  the uterus, and consequently an additional pro-
longation  of the labour is to be prevented either by suspend-
ing the pains for a time, or by rendering them more  effec-
tive,^) and upon this subject, I refer to what I have already
said in the beginning of this chapter.  Unproductive action
ought never to be  allowed to continue so long  as materially
to impair the action  of the womb.  If we cannot safely ren-
der the  action more efficient, we must endeavour to suspend
it;  by  which the  womb recruits, and the  retarding  cause
may in  the meantime be removed, or cease to exist.
  Another cause of tedious labour is, the accession of fever,
with  or without local inflammation.  Fever is recognised
by its usual  symptoms, and may be produced by the injudi-
cious use of stimulants, heated rooms, irritation of the parts,
&c.   It is to be allayed by opening the bowels, keeping the
patient  cool  in bed,  and giving  some saline julap; at the
same time  that the mind is to be tranquillized.  If these
means do not immediately abate the heat, frequency of pulse,
&c. and render the pains more  effective, it will generally be
proper  to detract blood, especially if the head or chest be
pained.  When local inflammation  accompanies fever, it is
commonly of the  pleura  or peritoneum, or vagina.   The
first is discovered by pain in the thorax, cough, and dyspnoea;
r»
  (x)  Which may very frequently be safely done by the judicious  use of
the  ergot or spurred rye. 
73
the second by pain in the belly, gradually increasing and
becoming constant;  pressure increases it, and in some time
the patient cannot lie down,  but  breathes with difficulty, or
is greatly oppressed,  and vomits.   The labour pains  are
sometimes suspended ;  on other occasions, they do ultimately
expel  the  foetus, but the woman dies in a few hours.  On
the first appearance of these symptoms, blood should be freely
detracted, the bowels opened, and a gentle perspiration ex-
cited.   In all these cases of  inflammation, if immediate re-
lief be not obtained,  the child must be delivered by the for-
ceps.   If the vagina be hot and dry, we are also  to  deliver
immediately, as these symptoms indicate danger from inflam-
mation.*
   Labour may  also be rendered  tedious, by the different
stages not going on regularly, but efforts being prematurely
made  to bear down.   In consequence of these, the uterus de-
scends in the pelvis, before the os uteri is dilated, and the pro-
cess is often both painful and protracted.  In some cases, the
womb prolapses, so  that  its  mouth appears at the  orifice of
the vagina.   This prolapsus may take place during preg-
nancy, or after  parturition begins.  It is often met with, in
a slight  degree, whilst the  os uteri  is not greatly dilated,
and uniformly injures  the labour. We are to prevent  it from
increasing, by supporting the head or  the uterus with two
fingers, during the continuance of  a pain; at the same time
that the woman  avoids,  as much as possible, every bearing-
down  effort, and  remains in  a recumbent posture.  If the os
uteri be slow of  dilating, some blood should be taken away,
and an opiate administered.   It  has happened that,  by ne-

  * I have observed, generally, that women in labour bear well the loss of
blood.  Bleeding, undoubtedly, when used judiciously, facilitates the ex-
pulsion  of the child, and secures a more speedy recovery, or "getting up."
Jt moreover, obviates the  train of unpleasant consequences to which women
are liable from the tendency in their systems to inflammation at the lime.
As a remedy to suspend uterine action  with a view of turning the child,
bleeding is  never to be neglected, provided the woman is not exhausted.
But when it does not produce that  effect, wliich will often happen, then
opium in a large dose may be resorted to  with advantage.  It is correct prac-
tice, however, in most cases to let bleeding precede the anodyne.  C.
   VOL. II.                        L 
74
 glecting these precautions, the uterus has protruded beyond
 the external parts.   In this case, no time is to be lost in at-
 tempting the reduction, which will be rendered easier by
 cautiously pulling back the perinseum.*   If  this cannot be
 done, the os uteri, if lax  and  yielding, must be gently fur-
 ther dilated, the membranes ruptured, the child turned, and
 the uterus replaccd.f The  os uteri has been cut,:j: but this can
 never be necessary, if  the structure of that part be natural.
 When the womb does not  actually protrude, the vagina may
 be inverted like a prolapsus ani.   A soft cloth, dipped in oil,
 should be  placed on  the part, and  pressure  made with the
 hand.  Giesman cut the inverted vagina on a probe, but this
 operation can rarely be required.   If the womb prolapse be-
 fore labour, as happened to Roederer's patient,  we must man-
 age the case  as a simple prolapsus.  She had severe pains,
 although she was not in labour.

      ORDER 2.  FROM SOME MECHANICAL IMPEDIMENT.

   There exists,  naturally, such a proportion between the size
 of the head and the capacity of the pelvis, that the one can
 pass easily through the other.  But this  proportion may be
 destroyed, either by the head being larger or more complete-
 ly ossified, or the pelvis smaller than usual.  In such  cases,
 which are to be discovered  by careful examination, it is evi-
 dent that the labour must be more tedious,  and  more painful,
 than it  otherwise would be.  The first stage of the process
 is sometimes,  but not always slow ;  the second is uniformly
 so; the head is long of descending into the pelvis, it rests
 long on the perinseum, the pains are frequent, severe, and
 often very forcing, but the woman  says they  are doing no
 good.  Now this state requires much patience and discretion.
 The bowels should  be opened with a laxative ; the urine re-
 gularly expelled;  the strength preserved by quietness, avoid-

  * Vide Mem. of Med. Soc. Vol. I. p. 213.
  f Vide  Portal's 10th Obs.; and Ducreux's case,  in Mem. de l'Acad, de
Chir. Tome III p. 368.  See also a case by Saxtorph.
  * Vide case by Dr. Archer, New York Med. Rep. Vol. I. p. 323. 
75
ing unnecessary exertion, indulging any disposition to sleep
which may exist, and taking a little light nourishment occa-
sionally ; the  mind is to  be soothed,  the hopes  supported,
and, if the pains begin to slacken, an opiate  may be given,
to procure rest.  By these means, the child will be at  last
expelled, though, perhaps, not till the woman has been two or
three days  in labour.  If in this,  or indeed in other cases of
tedious labour, we find the head remain so long in the brim of
the pelvis,  as  to obstruct the  circulation in the soft parts, or
irritate them, producing swelling, which is preceded by heat,
dryness, and a feeling of tenderness during examination, with
or  without a  sensation  of tightness  within  the pelvis, and
cramp in the legs, the child must be delivered quain primum.
  Malposition of  the head may likewise retard the labour;
but this has already been considered.
  Another cause of tedious labour is, rigidity of the soft parts,
which may be dependent  on advancement in  life, or  some
local peculiarity;  and these causes generally act more pow-
erfully in a first than a subsequent labour. This rigidity may
exist in the os uteri, in the external parts, or in  both; and if,
along with this, there be premature  rupture  of the mem-
branes, the difficulty is always increased.   When it exists in
the os uteri, that part is very long of dilating; the effect of
the pains, for  a long  time, is rather to soften than to dilate;
and after the  woman has  been many  hours in labour,  it is
found, when the pain  goes off, to be collapsed, and projecting
like the os uteri in the eighth month of pregnancy.  In this
case, the first  stage  is very slow,  lasting sometimes two or
three days; and the second is likewise tedious.   The whole
process takes  up, perhaps, four days or more.   When the ri-
gidity exists chiefly or partly in the external parts, they are
found to be at first  dry, tight  and firm.   By degrees, they
become moister and more relaxed ;  but they may still be so
unyielding as to keep the head for many hours resting on the
perinseum.  Now in these cases, it is to be recollected,  that
generally time and patience will safely terminate the labour.
When the head reaches the perinseum, if the pains be trifling
or ineffective,  it is of service to keep  the  woman for some 
76
time in a kneeling or  erect posture.   Some  methods have
been  proposed for abating the  rigidity ;  such  as baths, fo-
mentations,  and oily  applications;  or digitalis and sicken-
ing medicines  given  internally;  but these  have no good
effects, and some of them do harm.*  Blood-letting has been
employed in such cases.   Dr. Rush informs me,  that in Ame-
rica,  it has  been used  with  great  advantage;  and Dr.
Dewees has politely sent me a dissertation  on  this  subject,
which contains very good cases of its efficacy, when  pushed
freely.  In some  instances, fifty ounces  were taken before
the parts relaxed.  In determining on the use of blood-letting,
we must attend to  the state and habit of the patient.    Debili-
tated women,f and those who are exhausted by fatigue, espe-
cially among  the  lower classes in large cities, are  injured
rather than benefited by this practice.  Robust women, of a
rigid fibre, in  the  middle class of society,  or who  live in the
country, bear  blood-letting better, and derive more  benefit
from it.  In them  it is especially proper, if  any degree  of
fever attend the labour, and  in all cases when the parts are
rigid, if the patient be not previously  reduced, or very deli-
cate,  blood  should be  detracted pro  viribus.   If, however,
the state of the patient forbid this, an opiate clyster may be
substituted.
   In  some cases, the os uteri or external parts, instead  of

  * These remedies are mostly inefficient or injurious. The warm bath is
productive of no advantage, and is apt to detach the placenta, occasioning
thereby dangerous hemorrhages. But I confess, my objections to it arise
rather from what I have learnt of others in whom I can confide, than from
my own experience, having rarely seen the bath employed.  Nauseating me-
dicines, of different kinds, I have tried, but with no good effect. Where
the external organs are rigid, and dry, and swelled, local fomentations, and
oily applications, may, perhaps, be of some service.
   Blood-letting, if regulated by a sound discretion, is undoubedly the remedy
in these cases. It may often be pushed to a considerable extent.  I have
drawn as much as fifty ounces of blood in the course of a  day, or night,
where  the os tincae obstinately refused to yield.  In rigidity  of the vagina,
owing either to natural or acquired causes, and in tumefaction of the exter-
nal parts attended with soreness to the touch, it is equally useful.  C.
   f Dr. Dewees bleeds even delicate women, and those who are disposed ta
faint on being bled, but takes a smaller quantity from them. 
77
being rigid, are tumid, and apparently (edematous.  In these,
the labour is often protracted for several hours,(t/) especial-
ly  when the os uteri  is  affected.  In tedious labour, the os
uteri sometimes becomes swelled, as if blood were effused into
its interstices.   This requires venesection, and then a smart
clyster.
   The os  uteri may be naturally very small.  In some in-
stances, it has with difficulty admitted a sewing needle; and
in two cases, during  labour,  I found it almost impervious,
hard, circular, and with difficulty discovered;  but  it gradu-
ally dilated.  Venesection is in this state of service.   Some-
times it  is hard and scirrhous, so that it has  been  deemed
necessary to make an  incision into the os uteri, to make  it
dilate.*   It is  also possible for the  os uteri to be closed in
consequence of inflammation, so that  it has been necessary to
make an artificial opening.f
   Contraction and  cicatrices in the vagina, likewise retard
labour, and cause very great pain,  until they either relax or
are torn, but it is seldom necessary to perform any operation.
If it should, they must he cut.
   Excrescences proceeding from the os  uteri, an enlarged
 ovarium remaining in the pelvis, or  tumours(5) attached to

   (y) A case of this kind occurred not long since to the Editor, where, in con-
sequence  of  the great tumefaction of the labia and parts in the vicinity, it
became necessary to have recourse to punctures, to prevent the bursting or
laceration of the immensely distended integuments.  The tumefaction was
so great, that the patient could only lay on her back, with her knees drawn
up and her thighs supported by pillows—the canal of the vagina was so les-
sened by pressure from the effusion in the surrounding parts, that the ex-
amination to discover the state of the  labour, was made with considerable
difficulty.  After the punctures in the  labia (which jointly appeared to be '
as large as a child's head,) were made, the fluid continued oozing out for se-
veral hours, and it was supposed, by a judicious assistant, that nearly three
 pints of water had been evacuated.  The labia ultimately were completely
 reduced, and indeed became flaccid, and the labour then progressed and was
accomplished without any great difficulty, but the child was dead.
   * A case of this kind occurred to Dr. Siinson of St. Andrews, and another
to a practitioner in America.
   | Vide Case by Campardon, in Recueil Period. Tom. XII. p. 227.
   (:) A very interesting.paper byH. Park, Esq. of Liverpool, entitled "Ob- 
78
the ligaments, or a stone in the bladder, may all obviously
retard the labour, some of them so much as to requre instru-
ments.   A stone in the bladder ought either to  be pushed up
beyond the head, or extracted.*
  A small vagina may require a long time to be dilated.
  A great degree of obliquity of the  uterus protracts labour.
The os uteri may be turned very much  to one side, but  of-
tener it is directed backwards and upwards, and may be out
of the reach of  the finger.  Time  rectifies this, but it may
also be assisted by the finger.  Retroversion of the uterus may
likewise prove a cause of tedious labour, and can only be re-
medied by cautiously  attempting to  press down the os uteri
from above the pubis.
  Malformation of the  organs  of generation  may afford
great obstacles to the passage of  the child, so that even the
incision may be required as happened  in the case related  by
Mr. Bonnet, in the thirty-third volume of the Philosophical
Transactions.
  By shortness of the umbilical  cord, or still more frequently,
by the cord  being twisted  round  the neck,  the labour may

servations on Tumours within the pelvis, occasioning difficult parturition,"
is to be met with in the second V>1. of the Medical and Chirurgical Trans-
actioi s ; and also in Eclectic Repertory, Vol. IV.
  It would appear from the cases in  this paper, that embryulcia and the
crotchet can be rarely necessary in such instances.
  It has been found sufficient, generally, to puncture  the tumour, or to
make an incision into it, after which the cluld has been expelled with but
little difficulty, and without injury.
  * The dilatability of the female urethra is very remarkable, so as to admit
of the extraction of a calculus of a large size, occasionally, without having
recourse to the surgical knife.  Dr. Heberden says he " saw an  urinary cal-
culus voided by a woman, of an oval form, whose larger circumference was
six inches, and the lesser four inches   She was dehvered of a child the
next day with less pain  than she had felt in parting with the stone."  He-
berden's Commentaries, p. 88.
  In the 6th volume of the Medico-chirurg. Transactions, Dr. Yelloly gives
an account of a very large urinary calculus removed from the female urethra
without operation.  It weighed three ounces, three and ahalf drachms Troy;
it was three inches  and one-eighth long, two  inches broad, one inch and
seven-eighths thick, and seven inches  and three-fourths round in its larger,
and five inches and a half in its smaller circumference. 
79
be retarded, particularly in the latter end of the second stage.
The cord may be on the stretch, but it  never happens that it
is torn, and very seldom  that the placenta is detached.   We
hare no certain sign  of  the existence of this situation; but
there is presumptive evidence of it, when the head  is drawn
up again upon the recession of each pain.(a)  It  often  re-
mains long in a position, which we would expect to be capable
of very quick delivery. By patience, the labour will be safely
terminated;  but it may often he accelerated, by keeping the
person  for some time in an erect posture, on her knees.   Af-
ter the  head is born,  it is usual to bring the cord  over the
child's  head, so  as to set it at liberty ; and this is  very
proper  when  it can easily be  done, as  it prevents  the  neck
from being compressed with the cord  in the delivery of the
child, by which  the  respiration, if it  had begun,  would be
checked, or the circulation in  the cord  be obstructed.  Some
have advised that the cord should  be divided, after applying
the double ligature;  but this  is  rarely necessary, for  the
child may be born, even  although the cord remain  about  the
neck.(6)
   Preternatural strength of the membranes may also to a cer-
tainty prove a cause of tedious labour.  This is at once obvi-
ated, by tearing them, which  is done by laying hold of them
when slack, during the remission of the pains.  It sometimes
requires a considerable effort  to do this.

  (a) This retraction of the head during the recession of a pain, is more fre-
quently owing to the rigidity of re-action of the external parts;  and may of-
ten be obviated, if necessary, by venesection.  We believe it is rarely owing
to the cause here assigned for it by our author.
  (6) In some cases where it has been found impracticable, without  great
danger of rupturing the  cord, to bring it over the head of the child,  it has
answered to pass it over the shoulders of the infant, and thus suffer it to be
born through the noose of the cord. 
80
                       CHAP. VI.

                 Of Instrumental  Labours.

 ORDER 1.  OF CASES ADMITTING THE APPLICATION OF THE
                   FORCEPS AND LEVER.

   The head may be enlarged by disease,  or the capacity of
 the pelvis may be  considerably diminished, by causes which
 have been noticed in the beginning of this work.  Then, from
 the pressure of the head  upon the soft parts in the pelvis,
 and the forcible but opposed efforts of the uterus, severe pain
 is produced, and the sufferings of the patient are protracted
 in proportion to the resistance which is to be overcome.  Now
 we have to consider the danger of such a case, and to recol-
 lect the cause of this danger.   It proceeds from the pressure
 of the child upon  the soft parts of the mother, which, within
 a  certain period,  must produce that kind  of inflammation
 which is speedily followed by sloughing. Besides this source
 of risk,  there  is ground for alarm, lest  the  uterus should
 burst; or abdominal inflammation surpervene ; or a suppres-
 sion of urine take place; or the system become irreparably
 exhausted,  in  consequence of  long and  severe  exertion.
 These dangers  are not all equally  frequent in their occur-
 rence, nor do they take place in the same degree in  every
case. It  is however evident, that  if the resistance cannot
be overcome, and the child be born, one or more of these
causes must destroy the mother; whilst the long continued
pressure upon the  child, the  consequent  injury  which the
head sustains, and the interruption  which may be  given to
the circulation,  must  prove  fatal  to  her  offspring.   But
we likewise know,  upon the other hand, that the regular and
continued efforts of the uterus can overcome a very great
resistance,  and that these efforts,  within certain limits,
are safer for the mother, and more  favourable to the child,
than the application of  artificial  force.   We should, there-
 lore, lay it down as a general rule, that when the deformity 
81
 is not excessive, and no urgent symptom is present, we should
 fully ascertain what the  uterus can  do, before  we  assist it.
 We know, that if  the  pelvis measure,  in its diameter, only
 three inches and a half,  then we must have a painful and
 difficult labour, because,  as the head measures as much in its
 lateral extent, it must  be compressed more or less, in order
 to pass.  If the brim,  however,  measure only  three inches,
 then the head of a child  at the full time cannot pass, until it
 has been pressed so long as to diminish its breadth fully half
 an inch.*   The more,  then,  that the  brim is reduced below
 its natural dimensions, the longer and more painful must the
 labour be, until we come to such  a degree of contraction, as
 will either render expulsion altogether impossible, or delay it
 until great danger has been induced.
   It is difficult to draw the  line  of distinction  betwixt that
 degree of contraction which will  render it impossible for de-
 livery to take place naturally, and that which will only ren-
 der it extremely difficult.  It has been proposed to ascertain
 this, by a rule founded on the dimensions of the pelvis.  But
 this method cannot be brought to a sufficient degree of per-
 fection, for the  result of cases is much influenced by the size
 of the child, the pliability of its head, the vigour of the uterus,
 and other causes.  Besides, it is  difficult, if not impossible,
 to determine, with minute precision, the  dimensions of the
 pelvis in the living subject; and they are apt to vary, accord-
 ing as the soft parts within the pelvis are  more or less
 swelled.  We shall  find it better to judge by the progress
 which the head has been able to make.  If it has not been
 able to enter the pelvis,  or  if only a very small part, after
 great exertion, has been able to enter, then it is not possible
 for the woman  to hear the child, or even to have it brought
 through entire by the forceps or lever,  for these instruments
 either could not be applied,  or, if applied, the resistance

  *  The head can  bear ntten" more pressure before the child is born than
after it has breathed.  Respiration is more under the influence of the brain
than the action of the heart is, and the action of the latter after birth ceases
when the brain is injured or compressed, not because it is directly affected,
but because respiration with what it is associated ceases.
  VOL. II.                          M 
82-
would be so great as to prevent their success.  It has therefore
been laid down as a general rule, that these instruments, and
especially the forceps, ought not to be  applied,  until the os
uteri is fully dilated, and the head so low down as to come in
contact with the perinseum, and to make it easy to feel  an
ear.  The first part of the rule must always be attended to,
and the second is seldom to be dispensed with.  It has, in-
deed, been proposed to increase the length of the forceps, so
as to  operate with  them, whilst the greatest part of the head
remained above the brim of the  pelvis; but the practice is
dangerous and difficult,  in proportion to the height of the
head.   The lever  also may be applied, and acted with, when
only a third part of the head has entered the pelvis, and conse-
quently before the  short forceps can  be advantageously em-
ployed.^)  Nevertheless, necessity, and not choice, leads us
to the use of the lever in that situation. Hemorrhage or con-
vulsions may require it; but in cases of simple contraction of
the pelvis, unattended  with these  symptoms,  instruments
ought not to be applied, until we have fully ascertained that
the head cannot be forced  any lower.  As long as the pulse
is good, and the  pains are strong, and  produce any effect
upon the head, we ought  not to interfere.   It is the natural
consequence of continued uterine action, that after a time the
womb should become fatigued, and  the  pains cease or de-
crease.   I must, however,  remind the reader, that the pains
may very early become suspended, even in natural labour for
hours, without any obvious cause,. and  without  the smallest
appearance of  danger.  No practitioner of discernment can
be misled by this,  when all other circumstances  are natural;

  (c) We are here obliged to dissent from the opinion of our author; we be-
lieve that the forceps can be  more advantageously applied than the lever,
even, " when only a third part of the head has entered the pelvis," provided
we accurately ascertain its position, and apply the forceps accordingly. The
lever, indeed, we would rarely make use of, except to rectify malpositions
of the head.  We agree with Dr.  Osborn, that the " vectis never ought, be-
cause it never can, be used with safety when the child's  head is not suffi-
ciently low to admit the forceps."
  For a full view of the question with respect to the comparative advantage
of the two instruments, we must refer the student to Dr. Osborn's Essays on
the Practice of Midwifery, in natural and difficult labours.  Essay IV. Sect. 2. 
                           83

but if the pelvis be a little contracted, he must be careful to
ascertain that the cessation really has proceeded from pre-
vious exertion, and not from a temporary cause.  When the
action flags, and there is no appearance of the fibres recruit-
ing soon ; when the woman is much fatigued, and perhaps the
pulse frequent and feeble, we can gain no more from delay;
we have ascertained what nature can, and what she cannot
accomplish.  In this case, the head is fixed in the pelvis, the
uterus cannot force it down, and the accoucheur can scarcely,
if he were willing, raise it up.  It is said to be  impacted or
locked in the pelvis, for  it is immoveable; and  at the same
time, from the pressure, the soft parts  are tumefied, perhaps
dry and hot,  the presentation sometimes distorted, and the
bones may be felt making an acute angle with each other.
When the pelvis is contracted or deformed, the bones of the
cranium gradually yield,  and the head  is often lengthened
very considerably.  In, every case where pressure is applied,
the parietal bones form a more acute angle with each other,
their protuberances approaching nearer  together, so that, in
some instances, the transverse diameter from the one protu-
berance to the other does not measure above  two inches and
a half; but the head is not always lengthened in the same
proportion.   Sometimes, the bones  sliding  one under  the
other, its  length  is  even diminished.  Children have been
brought to me, where, either from the application of instru-
ments, or the action of the uterus, the bones have been sepa-
rated, and the one parietal bone forced completely beneath
the other.  From gradual  swelling of the integuments, the
head sometimes  appears to  advance when the bones  are
really stationary.  Now, when  the  head  is stationary, and
especially  if the pains have declined,  there is great  danger
in longer delay, for it is sometimes difficult,  if  not impossi-
ble, to  have the  bladder emptied; and such injury may be
done to the urethra, bladder, and rectum, as to cause slough-
 ing.
   There is  another  state which may require  delivery, but
 which admits of longer delay.   In this case,  the head is not
 locked in the pelvis, but after  entering  it, is stopped or ar- 
84
 rested for a long time, either by a slighter deformity at the
 brim than that which produces locked head, or by some con-
 traction of the outlet, or undue projection  of the spines of
 the ischia, or in consequence of feeble or irregular action
 of the uterus, produced by various causes.   In this case, the
 head is not absolutely immoveable, the finger can be passed
 more freely round it than  in the  former case,  and it  may
 advance a little  during a pain, and recede when  it goes off.
 Delay, in this case, is not attended with the same  risk of
 injury to the contents of the pelv is ; and we may  safely trust
 to time, light nourishment, mild cordials and  rest, until the
 flagging or cessation of the pains prove that the delivery can-
 not be expected from the powers of nature, or  until a hot
 and tender state of the vagina indicate a tendency to inflam-
matory action.   It  is necessary carefully to distinguish be-
 twixt the paragomphosis or locked head, and the case of ar-
rest, for delay is safer  in the latter than in  the  former.
 Some practitioners of great experience,  justly afraid of the
rash application  of instruments, have perhaps spoken too in-
 differently  on this subject.   Dr. Osborn observes,  that  in
 the state indicating the use of the forceps, ■« all  the powers
 of life are exhausted, all capacity  for farther exertion is at
 an end, and the  mind  as much depressed as the  body, they
 would at length  both sink together under  the influence of
 such continued but unavailing struggles, unless rescued from
 it by means of art." Now in  cases of locked head, this prin-
 ciple, if fully acted on, must  often be attended with danger-
 ous consequences ; and even if  restricted to cases of arrest,
 I must  consider  it as by  far too strongly and  rashly ex-
 pressed.
   Wrhen the head is locked  or firm  in the pelvis, and does not
 advance, we must deliver. The precise time, however, at which
 we must interfere, cannot be  determined by any absolute rule
 laid down in a system. We have been told, that the head must
 be allowed to rest on the perinseum for six hours, and then we
 are to deliver.  But much  must depend on the state of the
 pains, and the contraction of  the pelvis.   It is possible, that
 before the action of the uterus be nearly exhausted, the cervix 
85
may be ruptured;  and therefore, in a contracted pelvis, when
the pain is very severe, and chiefly felt in one spot, as the
sacrum, or pubis, when it is acute but unproductive, and the
head firmly wedged, the probability of this dreadful accident
taking  place is so great, as to make it proper to deliver.
When the urine is  long retained, and cannot be drawn off,
we must also interfere sooner than we otherwise  would have
done.   But when  the bladder is not distended, the uterus
not firmly intercepted between the head of the child and the
pelvis,  the pains strong and forcing, or not suspended from
weakness, and the  general strength good, we ought to delay.
As long as the pains have any effect,  however small,  in
pressing down the head, and  no dangerous  symptom ap-
pears, we are warranted in trusting still to nature. But when
they flag, and the  head, after a severe or tedious labour, re-
mains for some hours stationary, it would  be dangerous to
leave the woman longer undelivered.  If the soft parts become
swelled; or if  they be dry, hot, and tender, a state which
precedes swelling,  the child must be delivered; nay, in some
cases, even the  crotchet may, from the tenderness and swel-
ing, require to be employed, although the pelvis be  not ex-
ceedingly deformed.  Delay produces inflammation,  ending
in gangrene.  Some, amongst whom is M. Baudelocque, ad-
vise, that whenever the head is locked, the woman should be
delivered; and  this advice is, upon the whole, a good one, if
we be careful to confine the term « locked" to that state in
which the head cannot be  depressed by the pains, or raised
by the hand; for  then there  is not  only great risk of the
uterus being ruptured, but also of the  soft parts sloughing.
  Too long delay,  as well as the rash and early use of instru-
ments, may prove fatal to the child.
  It is very distressing to attend during the continuance of a
severe and protracted labour, and in  many cases, it is pecu-
liarly delicate to propose  the means of relief.  Women have
naturally a dread of instruments; the very name inspires ter-
ror, and whatever  may be said to the contrary, we know that
their use is attended with pain proportioned to the obstacle to
be overcome. Some patients urge the adoption of any means 
86
which can abridge their suffering, and are inclined to submit
to delivery, in cases where the practitioner can by no means
give his consent   But in  general an opposite state of  mind
prevails, and it is not until after much distress that the patient
is reconciled to the use of instruments.  The result of a la-
bour is for many hours uncertain ;  on this  account, as well
as from motives of humanity, no hint ought, in the  early part
of the process, to be given, of the probability of instruments
being required.  But  as their  necessity becomes more ap-
parent, and the time of their application draws nearer, it will
be proper to prepare the mind of the relations for what may be
necessary,  if  the  delivery be  not naturally  accomplished.
With regard to the patient herself, we must proceed accord-
ing to her disposition.  If she be, from what we have already
learned, strongly prepossessed against interference, it will be
necessary to give such prudent hints, and such explanations
of the practice as relating to others, though  not to herself, as
will prepare her for her consent.   But if we  can perceive
that she is disposed to agree readily to whatever may be ne-
cessary, nothing ought to be said till very near the time, as
the  anticipation of  evil is often as distressing as the enduring
of it.   When we are to deliver, it is useful to explain shortly
and delicately what we mean to  do, which has a great effect
in calming the mind.
  When the pelvis and the child were of a  disproportionate
size, it was the practice before the forceps were discovered,
to endeavour to turn the child, and deliver by the feet, which
allowed the practitioner to use considerable force in pulling
out the head.  But if the resistance was great, the child was
killed in the  attempt,  and often had  the body torn  away
from the head, which was left in the uterus.  This gave rise
to many inventions and directions for the delivery of the head
in these circumstances. If, on the other hand, the child could
not be turned, the head was opened, and the crotchet employ-
ed.   To avoid turning, fillets were used by some; but no ma-
terial improvement was made in practice, until the discovery
of the forceps and the lever,  one or other of which was1 used
first in Britain, by Mr. Chamberlain, about the middle of the 
87
seventeenth century.  Others afterwards employed them, but
still advised turning in preference, if the situation of the head
permitted.  Turning  is now abandoned, and the only point
under discussion by accoucheurs is whether the  forceps or
lever ought to be preferred.  I apprehend, that when the head
has descended pretty low, and especially in cases of arrest, the
forceps may be employed  with great advantage; but when
the head has not advanced so  far  as to  have more perhaps
than a third within the  brim,  the lever will he more advan-
tageous, unless we  use  long forceps, but we  never can be
obliged to use instruments when the head is in this situation,
simply  on account  of contraction of the pelvis; for when the
head can be brought through by either instrument, it is  always
possible for the pains to bring it within reach of the com-
mon forceps, and we  may wait safely for this,  unless convul-
sions or some sudden and  untoward  accident  happen.  The
chief superiority, then, of the lever  is, that it can be  used
earlier than  the common  forceps;  for when the head has
come so low, as in the  generality  of cases requiring instru-
ments, either, but especially the forceps, may  be employed,
with success and safety, by a practitioner accustomed to the
 application, and well acquainted  with the mode of action.
 There is then only one case in which I admit  the lever to be
 more useful than the common forceps, and this of necessity
 rarely occurs.  In the  hands of a prudent and expert opera-
 tor, each instrument is safe,  and capable of  completing the
 delivery.  But in  making a comparison of the properties  of
 the lever and  forceps,  in  order to assist my pupils in  their
 choice, I have long given it as my opinion, that a young
 practitioner would be less apt to injure the woman, and less
 likely to be foiled in his intention, with the forceps, than with
 the lever, in the generality of cases; for if the forceps  be
 once properly applied, he cannot fail in accomplishing the de-
 livery ; but although the  lever be  applied, he may, if embar-
 rassed, go wrong, and  press too much on the soft parts.   It
 has been said, that it is more difficult to  introduce the for-
 ceps than the lever, for there are  two blades in the one case,
 but only one in the other.  We know, however, that the chief 
88
 difficulty is met with in applying the first blade, and that the
 second is introduced in general, very easily.  After a little
 experience, the practitioner may operate with equal facility,
 and certainly very safely with either instrument;  nor do I
 consider it at  all  as a point of honour, that he should uni-
 formly confine himself to one in preference to the other; for
 cases may occur in which particular circumstances may in-
 cline hini to make use of that instrument which he is least in
 the habit of employing.  Students ought to acquire the power
 of using both the lever and the forceps, but, generally speak-
 ing, I give a decided preference to the latter.
  When the  lever is to be employed, we are to apply the ex-
 tremity of the instrument on the mastoid process of the  tem-
 poral bone,* or  side of the  occiput.  The woman may be
 placed on  her left side, in the usual posture; and we  then,
 with the fore finger of the right hand, feel for that ear which
 is next the pubis, and take it  as our guide in  passing the
 lever.   Three  directions must be particularly  attended to.
 The first is,  to keep the point of the instrument, during the
 introduction  and operation, close  to  the  head  of the  child,
 lest  the bladder or rectum  be  injured.   The second is, that
 the concavity of the instrument be kept  in  contact with the
 curvature of  the head, by which it will be much more easily
 introduced than if it be separated to an angle from the head.
 It will, therefore, be necessary  to  keep the  handle  back
 toward the perinseum, in the beginning of the process;  and
 it will be useful, especially to the  young practitioner, to have
 more than  one lever of different degrees of curvature, for he
 may sometimes be able to introduce  one which is very  little
 bent, when one more concave will be applied with difficulty.
 It is a  general remark, that within a  certain range, the
 greater the curvature, the more is the difficulty of introducing
 it, but the greater is its power over the head. The third is,
 to attend to the axis of that part of the pelvis, in which the
 head is placed, and pass the instrument in that course. In the

  * This process is very  indistinct in the foetus, but the direction may still
be retained, as it refers to a well known spot. 
89
usual position, the blade will be placed behind the symphysis
pubis, or perhaps a little obliquely, and the handle will be di-
rected back towards  the perinseum.   As the blade is curved
at its extremity, and as, in order to get it passed, its surface
must be kept in contact with the head, it will be requisite to
direct the handle more or  less backward, according  as  the
blade is more or less curved ; and when it is introduced, the
handle will be brought farther forward.
   When we act with the instrument,  we must not make any
part of the mother a  fulcrum;  and indeed, whatever fulcrum
be employed, we ought not to raise the handle much, or sud-
denly,  in order to wrench down the head.  Instead, at first,
of raising the handle considerably, we rather attempt to draw
down the head, as Mr. Giffard did with the single blade of
his extractor, using the instrument  more like a hook or trac-
tor, than a lever.  With the left hand placed upon the shank
of the blade, we press it firmly against the head, which  both
prevents it from slipping, whilst  we draw down  with  the
right hand grasping the handle, and also serves as a defence
to the urethra, should the handle be a little too much raised
like a lever.   At first, we should pull  or act with the  instru-
ment gently, to see that it is  well  fixed, or adapted to the
head.   Afterwards we act with more  force, But not rashly or
unsteadily.  These attempts will renew the pains if they had
gone off, and then they ought only  to be made during  the
continuance of a pain ; for every practitioner knows, that the
co-operation of pains adds prodigiously  to the utility of the
instrument.  The head being brought fully into the pelvis,
and the face turned into the hollow of the sacrum, we must
act in the direction of the outlet; and  for this purpose, it will
be useful to withdraw the instrument,  and apply it cautiously
over the chin, which, as less force is now necessary, will not
suffer by the operation. Or the forceps may now successfully
be applied, and should be used whenever  there is necessity
for a speedy delivery. Sometimes the natural pains will, with-
out any farther assistance, finish the delivery.  We must be
careful of the perinseum.
   When the forceps are used at first, instead of the lever, we
   VOL. IT.                         N 
90
    must, in like manner, take the ear for our guide, passing the
    first blade over that side of the head which lies to the pubis.*
    With the finger of  one hand we feel for the ear next the pu-
    bis,  whilst with  the  other hand we introduce the blade into
    the vagina, the handle being directed very much backward.
    We  then cautiously insinuate the blade along  the head,  and
    over the ear, moving  it  upwards with a  gentle wriggling
    motion, until it slip between  the  head and the pubis.  It is
    then to be moved on, so as to embrace  the side of the head
    completely, in the direction of what I have, in  the beginning
    of this work, called the line of axis, being applied over  the
    parietal protuberance,  and the ear.   The second blade is  to
    be introduced  behind, on the opposite side of the head, and
    must follow a  corresponding  line upon  it.  After this, the
    handles are to  be locked  ;  and  in doing  this the first blade
    must often be withdrawn a little to be adapted to the second.
    They ought not to be tied.  I beg it to be remembered, that
    in the introduction of the blade, both its point and its hollow
v ,  surface  must be kept  in close  contact with the head, as it

      * I believe that the  short forceps, with a single curve, are as useful, and
    more easily applied, than those which have the blades curved laterally. But
    if these should be  employed, then they  must be so introduced, that the con-
 *  vex edge of the blades shall be next to the face, [when that is towards the
    posterior part of the pelvis, and next the occiput when that is towards the
    hollow of the sacrum.
      By increasing the breadth of the blades, as has been done by Dr. Haigh-
    ton in the forceps which are called after him, a firmer hold is retained when
    applied, and it is not necessary to press back the  perinseum so  far, when
    the blades are introduced into the axis of the superior strait. They are also
    very conveniently portable, which  is  no trivial  advantage, as it regards
    practitioners in the country.
    Dimensions of Haighton's forceps,  as now made by C.  Eberle, Surgeon's
                      Instrument-maker, Philadelphia.
                                                            Inches.
     The whole length.........11$
     Blade from the angle of the joint.......6J
     Handles to the angle of the joint.......5
     Breadth between  the blades in the widest part of the curve -    -     3
     Breadth of the blade near the  point......Ijj
       Do.  of    do.  at its centre.......2$
       Do.  of    do.  near the  handles  -.....2-|] 
91
passes  on, otherwise the bladder may be perforated, or the
uterus torn by one who overcomes resistance, not by art, but
by force.  The blade must be passed in the direction of the
axis of the brim of the pelvis, and when  the instrument is
locked, the handles are inclined backward, and the angle or
junction of the blades correspond to the central portion of the
sagittal suture.   If the handles do not join easily, or if they
be not placed on corresponding lines, we cannot act, but must
adjust  one of  them before operating.  It is apparently un-
necessary to direct that no part of the mother be included in
the lock, but it is of importance to attend to this in practice.
The introduction of the forceps  is sometimes followed by a
gush of liquor amnii, which may  be  foetid and tinged with
meconium, although the child be  alive.
   In this process, we must be deliberate and cautious.   We
must never restrict ourselves in  point of  time, nor promise
that it shall be very speedily accomplished. If we act other-
wise, we shall be very apt to do mischief, or, if we find diffi-
culty, to abandon the attempt.   When the pelvis is so con-
tracted as to make it just practicable to introduce the forceps
or lever, that part of the head which is above the pubis some-
times projects a little over it, so that we cannot pass the blade
until we press backward  a little, with  the finger, on that part  tf
which we can reach.  All attempts to overcome the resistance
by force, every trial which gives much  pain, must be re-
probated.  But, on the other hand, as long as his conduct is
gentle and prudent, the young practitioner must  not  be de-
terred  because the patient complains,  for the uterine pains
are often excited by his  attempt;  or  some women, from
timidity, complain when no unusual irritation is given to the
parts.   Slow, persevering, careful trials, must be made; and
I beg, as he values the life of a  human being, and his own
peace of mind, that he do not desist, and have recourse to
the crotchet in cases at all doubtful, until it has been well
ascertained that neither the lever nor forcq>s could be used.
   The instrument being joined,  we pull  it downward, and
move it a little, to ascertain  that it is well  applied.  We
then begin  to extract, taking  advantage  of the first pain. 
92
If the pains still continue, we pull the instrument downward,
and, at  the  same  time, move the  handle a  little  forward,
toward the pubis;  and then, after halting a second, move it
slowly back again, still pulling down.  We must not  carry
the instrument  rapidly  or strongly forward  or backward,
against the pubis or perinseum, but the  chief direction of
our force should be downward, in the direction of the axis of
the brim.  The motion of  the  pendulum kind is intended to
facilitate this, but, if performed with a free, rapid, and forci-
ble swing, the soft parts must be bruised, and  great pain oc-
casioned.  The operation of extracting is  not to be carried
on rapidly,  or without  intermission; on the contrary, we
must be  circumspect,  and  imitate the steps of nature, [and
hence  in general  we  should  only act  during a pain.]   We
must act and cease to act alternately, and examine, as we go
on, the progress we are making, and also ascertain that the
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.(d)
  (<f) We are obliged here again, unwillingly, to dissent from the respecta-
ble authority of our author.  The forceps, even in face cases, will rarely shp
if properly applied.  It is generally owing to improper application,  not
having first accurately ascertained the 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 he 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
 feces 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, ao
 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 fatus being dead in utero, and yet these were delusive
for, by the forceps, the woman was dehvered of a living child, although 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 the integuments open
first, it is owing, I apprehend, to  sloughing from pressure and injury. A
very distinct case of spontaneous bursting of the cranium may be found in J.
Hamilton's Cases, p. 17. 
95
   But although it  be thus laid  down as a general rule, that
the pelvis, wliich 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
two4
   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 dcinand-

  * 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.
  ■(■ 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.
  t 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 child in utero was capable of sensa-
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 noros 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 pelvis; 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 he 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. h.                         o 
§8
 oceiput, 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 tlfereforc 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  vertebra 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 haye 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 pelvic
measures only an inch and two thirds. 
100
   The head  being 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, which  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 2
 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 child,
 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 die cluld,
but this is a very uncertain and precarious practice.
   (g) The reader is referred to a case of premature labour artificially induced,
where the child  Uved for some time after delivery, related by the Editor in
the 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
 which are subjoined some observations on this method of practice by S. Mer-
 riman, M. D. Physician-Accoucheur to the  Middlesex Hospital, &c. &c."
 Medico-chirurgical Transactions, Lond. 1812, Vol. III. p. 123, and seq.
   Dr. M. concludes, that  •' In  the grca'f r number of instances, indeed, the 
105
                       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 csesarean 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 either be dead born, or will be born with so little life as to expire
in a few hours; but in many cases the child has been preserved.  Thus out
of 47 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 child 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 likewise 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.   Where, and only
where, it can be ascertained, that the head placed in 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 pelvis which will  not permit, by any means, an ordinary
sized foetus 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, VH. 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,(/t) 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 he 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 suc-
cess in performing the Cesarean operation, prefer making the incision in the
linea alba.  Cooper agrees in recommending this mode. Vide Diet, of Sur-
gery: Dorsey's Edition, 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; and 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.  Adhesive
 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, with  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 full time, 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 Traits d'Accouchemens. Tom. 3. p. 20, &, seq. & J. B. De Mangeon,
De Ossium pubis Synchondrotomia, Parisiis, 1811.
  * Vide case by Mr. Welchman, in London Med. Jour, for 1790, p. 46. 
107
the 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 child.
                      CHAP. VIII.

                  Of Complicated Labour.

 ORDER 1.  LABOUR COMPLICATED WITH UTERINE HEMORU-
                          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 
10S
 watery fluid, tinged with blood, flows from the womb, but this
 js 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 the 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 apphed with advantage  where
labour is so little advanced.  It has also been proposed to rupture the 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; 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 deliquium,  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 are, 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. The 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 child, 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.
   Puerperal 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.(fe)  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,

  (k) 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 durir^ every case of puerpcal convulsions. 
113
 a fact to which I 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.(7)  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 o& 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. 11 p. 344.
   VOL. II.                          q, 
114
 the skull is diminished, and the convulsion mitigated.   But
 this is not all; for the patient is suffering  from 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 ;2  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  most
 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, the child speedily born, and the woman immediately became calm
1112. 
115
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-
fid internal remedy which  can be  prescribed;  but I cannot
from mv 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
 mother 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 refened 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 mentioas 4 cases, 2 of which perished.] 
116
         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  he  ruptured, by attempts rashly made to
 turn the child ;f  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. (?n)  In
 a case detailed by Dr. Douglass, (p. 50.) the head of the child
 was resting on the perineum, 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 the 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 laceration.^  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

  * A'ide Mem. of Med. Soc. Vol. II. p. 118.
  j A fatal case of this  kind is related by Mr. Dease.—One more fortunate
in Alie issue, is inserted in Mem. of Med. Soc Vol. IV. p. 253.
 • (to) Vide a case by the Editor, inserted in the New York Medical Re-
pository for 1804.  Hexade 2, Vol. 1
  i Perfect's Cases, Vol. II. p. 439.—Hamilton's Cases, p. 138. 
117
the head has partly descended into the pelvis, and the pelvis
be laree   In this case the liquor amnii is usually dischai ged
before the rupture takes place.  The most frequent cause,
however, of this accident, is a disproportion between the size
of the. head and the capacity of the pelvis, by which a portion
of the cervix uteri is pinched between the head and the pelvis,
and fixed so, that the action of the uterus is directed against
this spot, rather than the os uteri.  The woman feels very
severe pain, either in the back  or at the pubis, which during
 the action of the uterus,  augments to an extraordinary de-
 gree, and then the part gives  way.  Another way m winch
 the cervix may be lacerated, is by the linea iliopectmea being
 so sharp,* that when the uterus is pressed against it, the pai ts
 are either cut through, or so much acted on, that they are in
 a manner killed, and  give way,  having a sphacelated ap-
 pearance.   In  some cases the rectum, but much more fre-
 quently the bladder is opened.
    Now, from this view we learn, that those women are  most
 liable to rupture of the uterus, who  are  very irritable, and
  subject to cramp; or  who have the pelvis contracted, or its
  brim very sharp; or who  have the os uteri very rigid, or any
  part of the womb indurated.  Scholzius relates a case, where
  it was produced by scirrhus of the fundus; and Friedius one,
  where it was owing to a carneo-cartilaginous state of the os
  uteri.fn)  Sometimes the uterus seems to be predisposed to this
  accident, by a fall or bruise.  Reidlinus relates one instance
  of this.  Behling, Steidele, and Perfect, furnish us each with
  another.   Salmuthus considers  a thinness of the uterus as a
   predisposing cause of rupture;  and Dr. Rossf relates a case
   where it seemed to have this effect, the womb not being above
   the eighth part of an inch thick, and tearing like paper.
     We are led to anticipate  laceration,  when the patient is
   restless, and complains of very severe local pain, subject to

    * In a case of this kind, the line was on one side, as sharp as a fruit knife,
   and a cartilaginous knob projected from the symphysis. The bladder was torn.
    (n) See also a case of similar nature by Dr. M. Anthony. Eclectic Repei-
   tory, Vol. IV, p. 496.
    f Annals of Med. Vol. III. p. 277. 
118
great exacerbation, and attended with a very acute or tear-
ing sensation. The pains are violent and frequent, and usual-
ly do not produce a great effect on the os uteri, which is often
very rigid.  These symptoms are still more alarming, if the
liquor amnii have been fully evacuated.   In such cases, it is
necessary to detract blood, which relaxes the parts, and then
if the symptoms still continue, to suspend for a time, the pains
by an anodyne clyster.  When  this accident docs happen,
the woman feels something give way within her, and usually
suffers,  at that time, an increase of the pain.  The presenta-
tion disappears  more or less speedily, unless the head have
fully entered the pelvis, or the  uterus contract spasmodically
on part  of the child, as happened in Behling's patient.* The
pains go off as soon as the child passes through the rent into
the abdomen; or  if the presentation be fixed in the pelvis,
they become irregular, and gradually decline.   The passage
of the child into the abdominal  cavity is attended with a sen-
sation of strong motion of the belly, and is sometimes pro-
ductive  of convulsions.   The shape of the child can be felt
pretty distinctly through the abdominal coverings.
  The patient, after this accident,  soon  begins to vomit a
dark  coloured fluid, the countenance becomes ghastly, the
pulse small and feeble, the breathing is  oppressed, and fre-
quently  the patient cannot lie  down.   Sometimes the intes-
tine protrudes through the wound in the uterus, and has even
been strangulated in it.   These symptoms do not all appear
in every case, nor come on always with the same  rapidity.
In Dr. Ross's patient, although the child escaped through a
rent in the vagina into the cavity of the abdomen, and though
the nature of the case was ascertained,  yet no  hemorrhage,
fainting, nor bad symptoms, took place;  and the child being
delivered, the woman recovered.
  If the patient be not speedily relieved, she becomes very
restless, tosses in the bed, and vomits frequently; complains
of a pain in  the  belly, which  becomes swelled, the pulse is
rapid, the extremities become cold, and the  strength sinks.
In every case that I have seen, the intestines were chiefly
              * nailer's Disput. Tom. III. p. 477. 
119
affected, being  much  inflamed.  The interval which elapses
between the accident  and death, is various; but  generally,
whether the  patient  be  delivered  or not, she dies within
twenty-four hours, often in a much shorter time.  Steidele,
however,  relates a  case, where the  patient  lived till the
twelfth day ; Dr.  Garthshore's patient lived till the twenty-
sixth day; and in the Coll. Soc. Havn. Vol. II. p. 326, there
is the case of a woman, who, after  being delivered, lingered
for three months.(o)
   Different opinions  have been held respecting the best mode
of treatment.  Some have advised the performance  of the
cesarean operation,  some delivering per vias  naturales, and
others leaving the case to nature.  We have instances of all
these methods being  successful;  but the delivery, by turning
the child, has advantages over the  other modes, and certain-
ly ought,  with scarcely any exception, to be resorted to.
When the os uteri is dilated before the accident takes  place,
as is usually the case, and the hand can, without much diffi-
culty, be introduced, it  is to be passed through the os uteri,
and   the rent  in  the uterus,  into the abdominal cavity, in
search of the child's feet, which are to be brought down, and
the case managed in the same way as in presentation of the
feet.   When the placenta is extracted, we are to introduce
the hand again, to ascertain that  no part of the intestines
have protruded through  the wound.   This process is  always
easy, when the rent  is in the cervix uteri or the vagina.
   But when the os uteri is rigid and very little  dilated be-
fore the accident happens, and cannot he opened without ex-
treme irritation, which is, indeed, not often the case,  and is
rather a state which  may be  supposed, than actually met
with; or when the uterus is spasmodically and violently con-
tracted between the rent and the os uteri, which  may hap-
pen,  if the fundus be lacerated;  I  am inclined to join with
those, who consider attempts to deliver as adding to the dan-
ger.   These cases, if they ever occur, must do so very rare-
   (o)  Dr. Douglass's patient recovered after the delivery of the child.  Mr. *
Haden's patient also recovered, after rupture of the uterus. Vide Med. and
Chirurgical Transactions,  Vol. H. p. 184, and seq. 
                          120

 ly ; but it may happen that deformity of the pelvis prevents
 delivery.   In such circumstances, we  must either perform
 the csesarean operation, or leave the case to nature.   If we
have been called early, when the child is yet alive, and be-
fore the abdominal viscera have been much irritated by the
presence of the foetus, we are warranted to extract the child
by a small incision.4  If some  time, however, have elapsed,
then such iiritation is often given, as renders  it doubtful, if
the additional injury of the operation could be sustained.  On
the other hand, if little irritation be given, and the woman is
tolerably well, there is room to  hope, that a natural cure may
be accomplished, as in extra-uterine pregnancy; and there-
fore, as the child cannot be saved now, it may be more prudent
to trust to nature.*
  The cases which admit  most  easily of delivery, are  those
where the rent is situated in the cervix uteri or vagina; and
laceration of the vagina is less dangerous than rupture of the
uterus,6 provided the bladder be not injured.  I do not think
it necessary to make any farther remarks on the laceration of
the vagina, as distinct from that of the womb.
  When the head  is engaged in the  pelvis, and  cannot  re-
cede after the womb is torn, we have other symptoms, indi-
cating rupture of the uterus, or at least the necessity of using
instruments. The strength sinks, the pains become useless or
go off, the patient vomits,  &c.
  When, from precursory symptoms, we expect that lacera-
tion is about to take place, we  must accelerate labour either
by turning, or the  use of instruments, according to circum-
stances.  This is more necessary if the patient has formerly
had the uterus torn.

          ORDER 6. WITH SUPPRESSION OF URINE.

  Suppression of urine may take place during labour, in con-
 sequence of the head of the child being locked in the pelvis;
 or from a kind of paralytic state of the bladder, produced by
 long retention of the urine; or by  a small stone, or quantity
 of mucus, obstructing the urethra.  It produces tenderness, 
121
  and great pain, in  the  hypogastric region,  which is also
  swelled. The pain is constant, but is increased during every
  effort  of the abdominal muscles to bear down, because then
  the bladder is pressed.  It is injurious in so far as it tends to
  impair the uterine action, and it is dangerous on account of
  the risk of the distended bladder being  ruptured by the con-
  traction of the abdominal muscles,  or its giving  way  by a
  gangrenous rent  The  bad  symptoms consequent to this
  event do not always  come on instantaneously, and sometimes
  the bladder still  retains a little urine.  In a case related by
  Mr. Hey, in the fourth volume of Medical  Observations and
  Inquiries, they did not take place till the second day.   The
  patient was thirsty,  vomited,  had a frequent  desire to void
  the urine, which  she did very suddenly, but not more than a
  tea cup full at once.   The pulse was quick, the belly swelled,
  and pressure gave her pain.   She died about the eighth day,
  and the bladder was  found to be ruptured at its upper part.
   When the urine cannot be passed by  the voluntary efforts
 of the woman, aided sometimes by pressing up the head of
 the child, the catheter must be introduced.  The perforations
 of the  instrument, however,  ought to be  large, as a slimy
 tough mucus in the urethra, sometimes fills completely those
 of the ordinary size.  If the head should  be  so jammed in the
 pelvis,  as to prevent the introduction of the catheter, the wo-
 man must be delivered.(p)
   In some cases,  although no water is made for a long time,
 yet no inconvenience is felt; and when the catheter is intro-
 duced,  very little water is evacuated.  This depends upon a
 diminished  secretion;  and although, of itself, it cannot de-
 termine us to accelerate delivery, yet, should it be attended
 with other bad symptoms in  tedious labour, it may form an
 additional argument for interfering, as then the functions are
 becoming impaired, and effusion may take place into some of
 the cavities.

  (/») 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.                          K 
BOOK III.
OF THE PUERPERAL  STATE.
                       CHAP. I.

             Of the Treatment  after Delivery.

  Immediately after  the placenta is expelled, the finger
ought to be introduced into the  vagina, to ascertain that the
perinseum 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 av oided.
  Having thus simply stated what appears  to be necessary,
I must next say what ought to be avoided.  It is customary 
123
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 he voided; the
first is, when the woman has much pain in the lower belly, 
124
 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 pi'olapsus 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
uterus.* 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 the delivery of the  child, it
will be felt, if the hand be applied on the  abdomen, Uke 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 child, 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 delivery. 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 v. as 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 severe 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 hanjl into the uterus, which  excites its action,  and pre-
vents flooding.   We are 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, hut 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 maybe the conse-
quence.  I cannot therefore agree with the ingenious M. LeRoy, in the fol-
lowing directions  respecting hemorrhage after  the  birth  of the  child.
" Quand la fernme n'est pas delivr£e et qu'il survient une perte, il faut attendre
patiemment voir s'il ne se manifeste aucun symptdme 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 degorge alternativement, lorsqu'enfin la fcmme 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; alora il
faut employer des moyens propres  a redonncr du ressort & la matrice/'
Lecons, p. 57.
   VOL. IT.                                5 
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)

  (q) It appears  from a late  publication, that a novel mode of restrainin g
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 the cavity of the uterus, in the hand of the
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 the 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 other 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 gentlyin-
 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, a3 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 hand 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 pat
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, or «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-
  r
  (r) Le Roy thinks the position of the patient in hemorrhages, is worthy
of consideration; in uterine hemorrhage, the horizontal position of covu-se
must be preferred, and consequently the 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 ammoniac 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-
tiones, 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-
 ed 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 tin;
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, wiD
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 slowly
 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.  AVe  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
tincture 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 the introduction of the finger 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 purpos", 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 abdett
men when  the womb is  expelling the coagulum.   We also
eheck 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
   voe. il,                          i  " . 
136
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 back, 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 weak 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 midwifej 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 ways.  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.
  f Chapman relates a case of inversion, where the midwife pulled forcibly
at the uterus, and excited convulsions, fainting and death.  Case 29. p.  123.
  (*) 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 pam,
(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. 
140
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, and 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.
*f Case by Dr. Duffield, in Trans, of Coll. at Phil. 167.
  * Case by Dr. Albert.  Annals of Med. Vol. V. 390.
  § Vr. White's case,Med.Comment.  Vol. XX. 247. 
141
ficult, nay, sometimes impossible to reduce it, owing chiefly
to contraction of the os uteri.(f)   Dr. Denman 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*-.
sumedto be prevented.  This plan appears to  have succeedeuV.n a c^
related by Dr. Dewees, in the Philadelphia Medical Museum, Vol. V 1. p. ZV,
and seq. Case 2nd. 
143
 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 Jfter-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.
  ■\ In a case related in Recueil des Actes de la Society de Sant£, de Lyon,
the uterus was taken for a polypus, and the hgature applied.  The mistake
being discovered, it was  instantly withdrawn, but the woman died in a few
days.
  ± In one case the os uteri adhered to the neck of the  polypus, and gave
rise to appearance of inverted uterus.  Mem. of Med. Soc. Vol. V. p. 14.
  («) 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 the
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 had 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(x)  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-
cus—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 suc-
ceed, the strong infusion or tincture of hops may be tried. 
144
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, with laudanum,
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, wliich is productive of spasm in the
uterine  fibres, and sometimes of the intestines. Thi6 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. it.                         ' 
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, the  patient was much
oppressed, had foetid breath, &c. on the twelfth, an eruption 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. n. 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, we ought 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 he 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
mation 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 jthe human bowels, when given as a cure for
taenia.  If the turpentine fail,  a large dose of laudanum is to
be given in a clyster, and fomentations are 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 Epliemeral 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 week
 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 sfage has continued for some
time,  the hot one commences, and this ends in a profuse per-
spiration, wliich 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 mind
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
back 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
Cliat 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.   Aphtha?
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, which arc
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 pustules
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.
  This disease is peculiarly apt to attack those who are weak-
ened by fatigue, evacuations, or other causes: and hence wre
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 
                          157

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 
10U
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  gradually 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
are 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 articular 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.  II.                            k 
162
 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 cqme 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 docs 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, wliich 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 some-
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 shoidd be given, to allay irri-
tation, and the strength must be supported under the fever,
which  resembles hectic. 
164
                      CHAP.  XV.

               Of Peritoneal Inflammation.

  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 violence 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 appears
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 fseces.
These symptoms are more er 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  usually4
 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 arc 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 HI,
 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.  3 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 afterwards 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-
ftammation connected with the puerperal state, as under any other circum-
stances.  C. 
167
debility is  produced, cordials, of which wine is the hest,
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  scat 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 concern- 
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 first, but  presently becomes brown,
 and often aphtha 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.   The
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
 child.  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-
VOL. II.
* Glasgow.
              z 
                          170

flammatiou 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 the
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 are 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, we trust chiefly to  tonics, in
 the cure of puerperal fever; we support the strength, and re-
 gulate the state of the alvine 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 practitioner* more divided than respecting
 the treatment of puerperal fever. Prom 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, (tj)



                        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  the region  of the abdomen,
are the remedies which have succeeded best in my hands.  C.
  (y) It is most probable that the low form of fever here described, under
the name of puerperal fever, is comparatively a rare disease in the 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 the subject of fevers attacking puerperal women, he would particularly
recommend to tiie 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; Hey of Leeds, and Arm-
strong of Sunderland, on the puerperal fever wliich prevailed as an 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
eases 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. abate; but if
 may happen that they are protracted longer, and they do not
 go  off entirely for some time.  When they go off, the patienl;
 is left feeble, and the  limb stiff, weak, and  often for a time 
174
 powerless.  In the course of the cure, we frequently feel hard
 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.(a)  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 be
treated accordingly by tile remedies appropriated to that form of disease. 
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 docs 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.(a)

   (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- 
176
 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

fected limb, as well as to the limb  itself; and it is asserted, that no other
remedies beyond those necessary to keep the bowels open, are ever used.
fVide 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 the 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, which he thinks has often
produced the best effects. 
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 p»lsy.   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.
  f Active purging is very useful in this disease.   I have also known much
good to be derived from blisters to the Sacrum. C.
   VOL. II.                             X A 
178
  Hemiplegia may attack women in the puerperal state, as
well as at other times.  It proceeds from the same cause, and
requires the same treatment, as usual.   If death takes place,
blood is found extravasated in the brain.
                      CHAP. XIX.

            Of Puerperal Mania  and Phrenitis.

  All women, in the puerperal state, are more irritable, and
more easily affected, both in  body and mind, than at other
times, and some even become delirious.  The period at which
this  mental disease appears  is various,  but it is seldom if
ever sooner than the third day, often not for a fortnight, and
in some cases not for several weeks after delivery. It usual-
ly appears rather suddenly;  the patient awakening, perhaps,
terrified from a slumber, or  it seems to be  excited by some
casual alarm.   She is  sometimes extremely voluble, talking
incessantly, and generally about  one object, supposing, for
example, that her child is killed, or stolen; or, although na-
turally of  a religious  disposition, she may utter volleys  of
oaths, with great rapidity.  In other cases, she is less talk-
ative, but is anxious to rise and go abroad.  It is not, indeed,
possible to describe the  different varieties of  incoherence,
but there is oftener a tendency to  raving than melancholy.
She  always recognises  surrounding objects, and either an-
swers any question put to her, or becomes  more  exasperated
by it.  She can  by  dint of perseverence, or by proper  man-
agement, be for a time interrupted in her madness, or ren-
dered in some degree obedient.  In some instances, she rea-
sons for a little, pretty  correctly on her insane idea.   The
eye has a troubled appearance, the pulse, when there is much
nervous  irritation, or  bodily exertion, is frequent, but it is
not in general permanently so, though  it is liable to accele-
rations ; the skin is sometimes rather hot, the tongue white;
the secretion  of milk  is often, but not always, diminished,
and the  bowels are usually  costive.  In some instances the 
179
patient recovers in a few hours, in others the mania remains
for several  weeks, or even  some months;  but I believe it
never  becomes  permanent, nor does it  prove fatal,  unless
dependent  on phrenitis.   Venesection has been advised  in
this disease; but I agree with those who consider it as hurt-
ful, or at least as useless.   The best practice, I think, is to
apply leeches to the temples, open the bowels, with a smart
dose of calomel, keep the  surface gently moist, by means of
saline julap, and afterwards allay irritation with liberal doses
of camphor.  Blisters have  by some,  for whose  opinion 1
have much regard, been  considered as  useless,  or detri-
mental ;  but I am confident I have seen them do good, after
they had discharged freely.   Opium is a very doubtful re-
medy;  it oftener makes the  patient restless, than procures
sleep;  but in the wane of the disease, it  does, in some cases
agree  with the patient, and is productive of great benefit.
There is sometimes considerable difficulty in keeping  the pa-
tient in  bed, and making her  take either food or medicine.
It is therefore of great advantage to have early recourse to
the strait waistcoat, which not only commands the patient,
but tends to make her exercise  self-control.  In the progress
of the disease, attention  must be paid to the bowels, and it
must be remembered, that often the patient  voids both urine
and faeces without telling, not from being unable to retain
them,  but from inattention or perversity.  The mind is not
at first the subjectof 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  the  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
often, especially in mania, if applied in the proper condition «f 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 little 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 th? 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
en 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 1
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 the 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 the 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 has 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 faces  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 fcetid 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,  wliich 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 the  breast with a
mixture of laudanum, brandy, and hartshorn. C. 
185
fbr 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 the  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
cases, 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.                            e u 
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
month preceding parturition, had the most complete success in preventing
the excessive soreness and suffering to which the lady had 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 exti'eme anguish arising
from this variety of disease. 
187
a little, are also occasionally of service; and it is observa-
ble, that no application continues long to do good.   Frequent
changes, therefore,  are necessaiy.  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. Hartshorne 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 days. 
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
by nursing,  or if  the secretion be  very spaiing, 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  child.  Opiates are useful
at bed time, to procure sleep, and the bowels  arc to be kept
open.  Many women, after delivery, 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.

  L\ consequence  of affection of the menstrual  action, 01
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.
  Very 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 csecum 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 v.agina, 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-
ternal 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 borne 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 hgature 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.
  (d) This is rather too near the navel,  for in case of the hgature cutting
through 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  wrapping
the  child 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 giving 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 breathe, 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, in weakly 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  has 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, (e)
   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 receiver, and
given to the nurse.  Next, the soft white incrustation, which

  (c) 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 the 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 Foederis works, which
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 legal
decision is called for,  leans rather to the  side of mercy, will most probably
act so as to satisfy his own conscience, as well as the demands of enlighten-
ed justice.  See also,  Mahon Medecine legale,  Vol. II. Art. Docimasie pul-
monale, p. 436. 
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 be 
198
made, the better.  Last of all, a cloth is to be applied, to re-
ceive the faeces 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,  or perhaps 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.  If 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.(g)
 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
 gaseousflatulency,  in the primae vise 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.                         D D 
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 Congenite and Surgical Diseases.

                     § 1. HARE-LIP.

  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 after birth, 
203
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 faeces, 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 yeav.
The child was enabled to retain the feces, but the anus appeared as if it were
sunk an inch deeper than usual.  Recueil Period. Tom. I. p. 36.
  f Vide observations on this subject, by Dumas and Allan, in" the Recueil
Period. Tom. HI. p. 46, and 133, and a case in point by Duret, in Tom. IV.
p. 45. 
204
  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  priti- 
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 ui.'ess 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 and local inflammation, and not  unfrequently  convul-
sions.

                    § 4.  SPINA BIFIDA.

   Spina bifida is an imperfection of the vertebral  canal and
 the spinal marrow. The bone is deficient generally about the
 lumbar vertebra? : 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
 faces  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 first
 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 
306
 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.(/i)


                           §5.  MARKS.

   Marks and blemishes arc very frequent, and may be placed

   (h) The very ingenious Astley Cooper, in some observations published in
the Medieo-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  applied, similar in form to
that which is sometimes used for umbilical 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,  i9 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 the patient to much  constitutional irritation, but  leaves him without
rhe 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.   Nevertheless,  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. HI. p.
138, aud 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  h emorrhage  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 congeriite 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-
nethyhas  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 the  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. \bernethy, 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, upof
which their  repletion seemed to depend.   These two intentions admitted of
being readily accomplished. A many-tailed bandage of sticking piaster 
208
                 t, 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 applied 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 the 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-Ud, 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 the treatment of one species of Njcvi Ma-
terni.] 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 lingua? 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,

  (i) This is a good lest; for, if upon the insertion  of the finger into the
child's mouth it sucks it readily, division of the framum cannot be necessary
  VOL.  II.                            E F, 
210
or hooping cough; and whenever this attacks an infant, I
augur very ill.  I  have no remedy to propose.   Comparative
ease 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 Diseases
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 the 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 are 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 
211
 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;  hut 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

  (A?) A very mild and useful application in burns, particularly in those of
children, is a liniment composed of equal parts of mild ohve oil and  lime
water, well mixed together by agitation; this may be laid on with a feather,
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,th§ feather. 
212
to be daily washed 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 arc deaf.  But by
keeping the ear warm, and by scrupulous attention to clean-
liness, the discharge stops, and the hearing returns.

         § 11.  FffilTD  SECRETION FROM TIIE 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.  OPTHALMIA.

   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 tiie  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 sid- 
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, the 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 the eye-lids; these have sometimes produced the best effects. 
214
 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 in
 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 consist of two lamina,
both of which, 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 tooth  consists of  two parts, bony matter, and cortex
striatus, 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.  Wrhen 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.
   The first 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
giving 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 will 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 5
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
real 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. 
S20
                § 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 papulse are surrounded
  with  a red base.  This redness is often the most ev ident 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  papulse  are still more distinct.
  The papulse 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 papulse 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. 
SSI
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 bowels 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 papulse, 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 to
be changed.  I am very much disposed to adopt his opinion.—See also Tur-
ner on the Diseases of the Skin, p. 69. 
222
neck, which 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 papulse, 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 papulse  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 appears 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
papulse 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-
pulse 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
papulse.  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 none 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 arms, previous to the
proper eruption, or even along with it.  Dr. Underwood says,
this  eruption does not dry off like measles; but as Dr. Willan
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 papulse 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
powders. Some advise emetics, and the use of the bark; but
neither, 1 believe, are in general necessary.

               § 4.  STROPHULUS CANDIDUS.

   Strophulus candidus consists of papulse  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 papulse 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 papulse, 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  papulse  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  beat, and by drinking cold water
when heated, or other less obvious  causes.   It is frequent in
warm weather, 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 papulse,
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 a broad scurfy efflorescence,
about the elbow joint, or other flexures.  A suitable dose of
calomel is the best remedy, or, should the patient be oppressed,
ah 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 
223
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 the 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  are 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 papulse, 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 blanes 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 cohsrentibus, oleoso succo turgidis."
Plenk, 71.
   VOL. II.                           « G 
22(5
 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  when the child is  on
 the 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.  B"ut  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 giv ing
 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
 tinia remediis vix locus est: qua} Mam  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 ap-
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 j  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 aphthse, 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 w hen 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 the  following
terms.   Sunt vesiculai granis milii magnitudine ct similis, su- 
229
bito 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 papillse
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 he 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 papula;, dif- 
                            £30

 fering in colour vjery 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
 papulse, 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,
 w ith  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 top.  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,
 « quk vix furfur 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, with 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 laisse le 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 to
boil a piece of stick brimstone in water, in order to make a bath.
  f 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, wliich is  infectious,  consists of efflorescent patches of
 various sizes, covered with scurf or small scales.  The patches
 appeal* 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 \ery soon covered with scurf, through the interstices of
which the surface is seen to be red.   The shape is irregular,
 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
 the baldness  increases, as the red circle extends. Within the 
233
circle the skin is whitish and a little seurfy.  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  papulse, giving the skin a dirty
wliite 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
sometime 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 liniment, composed of sweet almonds  and hog's lard, has been
   VOL.  II.                           H H 
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
 niay 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 hcrpetica.
   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, v\Inch, when removed, are soon  replaced. Ibis 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 phlyctsense, with dark erysipelatous margins, which
 discharge sharp matter, run together, are hot and itchy, and
 seem to cat away the skin, forming an ulcer called noma.

found useful.  Sometimes heat, or other  causes,  produce a different kind of
eruption, already described under the name of lichen.
  • It' 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 \ind 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 fomentations 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. terebinthinse, &c.  If,
however,  the ulceration  be very  superficial, an  ointment,
contaiping 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, cerse  flavje, a^'i; resinsc  pin'u g ss; tere-
binth. 5ss ; ol. myrrhar, q. s. fiat ceratum.   De Morb. Cur. Tom. IV. p. 154.
__With children this must be used 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 papulse, 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 early  stage, it
is sometimes combined with strophulus. The parts are itchy,
but when they are scratched, matter does not come out by
the 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; in consequence
of which,  and the disease of the skin taking place soon after
birth, I have been 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 yellow 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 
339
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 hair.

                      § 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 pustides 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 the application of an ointment, containing
camphor and sulphur. 
240
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. picse,  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,! 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
of 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.  picse, 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.
  ■j- Dr. Underwood recommends the decoction  of tobacco, or lotio sapo-
nacea; Dr. Frank, urine;  and Mr. Barlow, the  following lotion: R.  kali.
sulph. Ziii; sap. alb. giss;  aq. calcis, ^viiss; spt. vini, ^ii. M.—Dr. Heber-
den recommends the decoction of white hellebore. 
241
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 with porrigo, it will be
useful to wash the parts with lime-water alone, or with the
addition of  a little  oxy-muriate of mercury, or with a sul-
phureous  lotion; or anoint the parts with camphorated lini-
ment, nng. acid. nitr. ung.  hyd.  nit. or sulphur  ointment,
and use the tepid bath occasionally.   Sea-bathing is of great
benefit.

                § 19. SCABS F.ROM 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 different sizes.   They generally are
 attended with  a considerable degree of inflammation,  and.
 end in suppuration.  The small abscess bursts, and a little
    vol. n.                          * l 
242
scab forms, after which the inflammation dies away.  Such
a pustule has been called ecthyma, or sometimes terininthus.
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. PETECHIA.

   Purpura,  or petechia  sine febre, is a disease not uncom-
 mon with children,  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  fseces 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  papulse, forming a  disease  described separately,
under the name of lichen lividus, 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 with 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 
244
the gums, especially near the symphysis of the jaws, become
foul, and  covered with  a  brown lymph.   An  eruption of
petechias 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 Avicenna, 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 kind
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 child born of healthy parents, with
sublivid inflammatory patches, and ichorous vesications, about the belly and
thighs; but by the use of bark, and especially the mother's milk it recovered. 
243
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  papulse,  but this appearance
presently goes off.   The treatment  is nearly the same as  in
erysipelas.   Sometimes small irregular erythematic patches,
accompanied  with cedematous  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 bugs,  &c. in those
whose skin is dehcate, are distinguished by having a small mark or speck in
the middle. 
246
 becomes livid, the strength must be carefully supported, and
 the bowels opened.  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 oxyde 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 fcetid  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 fcetid 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 shilling.  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,
ii 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-
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 cedematous look.
These  local appearances are accompanied with emaciation
and fever, and the child 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 spirit 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.  APHTHJE.

  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.  n.                        K K 
250
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 aphthse 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 the system, connected with the local
disease, as in malignant sore throat, and  many other  dis-

  * Dr. Underwood is of opinion, that fever very rarely attends aphthx, when
it appears as an original disease. 
251
eases.  It behoves us then, in forming our judgment, to 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 aphth* 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 « 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 aphthse, 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. 
252
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 ipecacuanha? 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. 
254
   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. APHTHiE ON THE TONSILS.

  Aphthae sometimes  appear  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 arc 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 papulse 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 
257
by continuance, and presently are combined with additional
symptoms of the disease.
  The genitals and anusa 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 with
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 frsenum, 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, kc.
   VOL. II.                           T.I, 
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 the 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 
259
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, (w)

                     § 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,  w henever 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  oedematous. It

  (m) Vide Alley on Hydrargyria, and Mathias on the Mercurial Disease,
alsoSpens on Erythema Mercurialein Edin. Med. and Surg. Journal, Vol. I
and 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, &c.   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.
   WThen 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 confluent small-pox.   In this case, the erup-
tive fever is more severe, 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 petechia 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 arc 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 give 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;
hut 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. II.                            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,* wliich 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 appeal's, 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 the 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 trou-

  • Inoculation, even after exposure to infection, is capable of producing ?
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 two 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.(m)   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 stiil 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
 efflorescence  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 the
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,  wliich 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 
269
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,
the  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 the 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 
270
  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, scar-
  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

to 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 which 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 which is of a fighter colour, should 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 off from the 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, hewever,  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 immodified 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 particular 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 the 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 secj 
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.(<j)

  (q) The following note is extracted from the Eclectic Repertory for July
1813.  The interesting nature of the information it contains, it is presumed,
precludes the necessity of apologizing for introducing it here.
  " The following important statement, from the annual official Reports of
the Board of Health of Philadelphia, with the accounts  of persons vacci-
nated by the society for promoting vaccination, must be peculiarly interest-.
ing and conclusive in respect to the benefits  of this invaluable discovery.
By the Reports of the  Board of Health, it appears, that there have died of
inoculated and natural small-pox, in the city of Philadelphia and its neigh-
bourhood,
         In  1807                  32 persons.
             1808                145
             1809                101
             1810                140
             1811                117
             1812                None.
          In 1809            1102"\  Persons were successfully vac-
             1810             955
             1811           1277
             1812           1255
               Total      4589J
VOL. II.                             N N
cinatcd by the Physicians of the
Society  for promoting vaccina-
tion in the  city  and neighbour-
hood of Philadelphia. 
274
                   §33.  CHICKEN-POX.

  The  chicken-pox  is  a disease, sometimes  mistaken for
small-pox; a/id atone time, and by some authors, described
along with it.  It is preceded  by eruptive fever, which con-
tinues for three days, and is marked  by languor, loss of ap-
petite, thirst,  furred tongue, pain in the head, back,  and
limbs, sometimes pain in the epigastric  region, with nausea
and  vomiting.  The pulse is quick, the  face  occasionally
flushed^ and cough  and hoarseness may attend the disease.
Convulsions also, in some  cases, occur  during the fever, or
the child has tremours when asleep, accompanied with terri-
fying dreams, or he is slightly delirious.  The eruptive fever
does not always go off when the eruption appears, but may
continue even till the third day of the eruption.   In general,
however, the symptoms are mild, and sometimes exceeding-
ly trifling.  The eruption commences on the back, or breast,
and next appears on the face and head, which is not the order
observed by the variolous eruption.  Last of all, it appears
on the extremities.  The pustules very  soon contain lymph,
and by the fifth day are covered with  scabs or crusts,  which
is earlier than happens in the variola. These drop off sooner
tlianin small-pox, and very seldom leave any cicatrix.  The
eruption is attended with very considerable itching, in conse-
quence of which the pustules are soon broken.   The pustules
are seldom or  never confluent, and Dr. Heberden never could
count more than twelve upon the face, but we sometimes meet
with many more.
  In varicella, almost every vesicle,  on  the first day, has  a
hard inflamed margin.   On the second or  third, they are full
of serum at the top; and those which are  fullest of the yel-
low  liquor,  resemble small-pox pustules of the fifth or sixth
day. On the third or fourth day, the shrivelled and wrinkled
state of the vesicles which remain entire, give a different ap-
pearance from the variolse; and on  the fifth day, the pre-
sence of scab  assists the diagnosis.  It is proper, however,
to add,  that in some cases,  I have found the pustules longer
than usual of running their course, and the disease altogether, 
275
so like small-pox, that I would have been at a loss to decide
on the nature of the disease, had  not the rest of the children
in the family had the chicken-pox at the same time in the
usual form.
  Such is the general description of this disease; but it con-
sists of some varieties, wliich have very properly been sepa-
rately described by  Dr. Willan, whose distinctions I shall re-
tain. 1st, The lenticular.  The eruption consists, on the first
day, of small red  protuberances,  not exactly circular, with a
flat shining surface, in the middle of wliich, a minute vesicle
is soon formed.   These on the second day, resemble miliary
vesicles, are about the tenth part of an inch in diameter,  and
are filled with whitish lymph.  On the third day, the extent
is the same, but the fluid is straw-coloured.  Next day, many
of the  vesicles are broken ; and those wliich are not, have
shrunk, and are puckered at their margin.  Few are entire
on the fifth day.  On the sixth day, small thin brown scabs
appear universally,  in place of the vesicles.  On the seventh
and eighth days, these turn yellow and dry, from the circum-
ference toward the centre; and  on the ninth or tenth day,
drop off, leaving red marks without pitting.  2d. The colloi-
dal.  The vesicles rise suddenly, and  have a hard inflamed
border.  On the  first day, they are acuminated, and con-
tain  a bright transparent lymph.  Next day, they are more
turgid, the lymph is straw-coloured, and they are surrounded
with more  extensive inflammation.   On  the  third day, the
vesicles have shrivelled, have inflammation round them ;  if
entire,  contain purulent matter, if they have burst, they are
covered with slight gummy scabs.  The scabs fall off in from
four to five days,  and often leave durable pits.  A fresh crop
of pustules come out on the second or third day, and runs the
same course with  the first; so that the eruptive stage in  this
specie»is six days,  and the last  formed scabs are not sepa-
rated till the  eleventh or twelfth day.   3d. The swine or
bleb-pox.  The vesicles are large and globated, but the base
is not exactly circular.  They are surrounded  with inflam-
mation, and contain transparent lymph, which on the second
day  resembles whey.  On the third  day, they subside  and 
276
shrivel, and appear yellowish, the fluid being mixed with a
little  pus.   Before  the  end  of the  fourth  day, they  are
covered with thin  blackish scabs,  which fall off in four  or
five days.
  The chicken-pox is a very mild  disease, and requires  no
other management than  keeping the bowels open, and the
surface moderately cool.   The skin may be sponged  with
cold water,  which diminishes the heat, and lessens the num-
ber of pustules, if done, during the eruptive fever; at a later
period, it abates the itching. -  1 have, especially in scrofulous
children, observed, that if the bowels were neglected  by the
parents, and the diet was full and heavy, the pustules became
much inflamed, and ended  in sloughs, which  left large and
permanent cicatrices; and in some cases, boils and abscesses
have occurred from the same cause.

                     § 34.  URTICARIA.

  Urticaria, or nettle rash, may appear either as an acute or
chronic disease.*   The first is  most .frequent  with  infants
and children.   It is preceded by languor, sickness, and fever,
on the third day of wliich, but sometimes earlier, an itchy
eruption appears,  bearing  a very exact resemblance  to  that
produced by the stinging of nettles.  It consists of irregular
patches, slightly elevated  above the  surface.  These are of
a dull white colour at the  centre,  and red toward the mar-
gins, which are sometimes hard and well defined.  The size
and shape of the patches are very various.  Generally they
are  about the  size of  a penny-piece,  but sometimes form
pretty long  stripes.  This eruption is, in some cases, attended
by  a slight turgescence of the skin, but especially of the
face and eye-lids.  The patches do not remain constantly out,
but  appear  and disappear irregularly  during the  disease,
which lasts for seven or eight days,  including  the period of
the eruptive fever.  When the eruption declines, the languor,
 stomachic symptoms, and  feverishness, go off.   The disease

  * Dr. Willan notices five different species of this disease ; but for the pre-
sent purpose,  this simple division is sufficient. 
                          277

terminates by slight exfoliation of the skin.   In infancy and
childhood, it is often dependent on dentition, or affections  of
the bowels;  and from the itching  which attends it, great
distress is produced.  The febrile urticaria is not infectious,
but iu  certain seasons it  is very prevalent; and the same
holds true with regard to the chronic species.  Chronic ur-
ticaria is more rare in infancy.  It differs from the  former,
chiefly in being  destitute of fever, and vexing the patient
at intervals for a length of time; sometimes even for years.
The patches seldom continue out, however, for above a few
hours  at  a time.  They are, like the former,  reproduced
readily by exposure to cold, and are also particularly trouble-
some after undressing to go to bed.  A. temporary eruption
of this kind, without fever,  is often consequent to eating
 particular kinds of fish, or substances which disagree with
 the stomach.   An eruption somewhat  resembling urtica-
ria, is  described by Dr. Willan, under the name of roseola
 annulata; it differs in size, and some other circumstances,
 whilst it  agrees in others.  It consists of circular patches,
 about half an inch in diameter, the margins rose-coloured,
 the centre of the usual colour of the skin.   These cover the
 body, and produce, especially at night, a  sensation of heat
 and itching.  When unattended with  fever, the eruption fades
 in the morning, and  becomes round  and  elevated at  night.
 The use of acids,  and sea-bathing will be of service.
    A gentle emetic, followed by one or two purges, gives re-
 lief in  acute urticaria.   The child should, if possible, be
 kept from scratching, so as to tear the skin; and this will be
 the easier done, if he be preserved in an uniform tempera-
  ture.  The tepid  bath sometimes  gives relief.   The chronic
  species is more obstinate, and in consequence of the abrasion
  of the skin, from  frequent scratching, it has sometimes been
  treated  as itch,  but without advantage.   The bowels are
  to be kept open by cream of tartar,  and some tonic medicine
  should be administered.  The  tepid bath daily will  also be
  proper, but sometimes, sea-bathing continued for some  months
  succeeds better.  Mercurials have been tvi-A with very little
   good effect^ 
278
                     § 35. SCARLATINA.

   Scarlatina may appear under two different forms.  In the
first, it is accompanied with  inflammatory fever, and is ge-
nerally mild; in the second, it is connected with a typhoid
fever, and is very malignant.  The first species admits of a
farther subdivision,  according to the degree of mildness; one
variety being attended with slough or ulceration of the throat;
another still milder, with little or no affection of the fauces.
This has by  some been called scarlatina simplex, to distinguish
it from the first, or scarlatina anginosa.
  The scarlatina simplex begins with a febrile attack, attend-
ed with considerable debility, chilliness, nausea, and pain  in
the belly and about the  loins and extremities.  It generally
attacks very suddenly in the afternoon or evening, the patient
having been, not an hour before, lively,  and  apparently  in
good health.  The pulse is extremely rapid, being often 140
in the minute; the trunk is very warm, and the feet cold; the
respiration frequent, irregular, and sometimes sonorous; the
eye  sunk, and the  eye-lids  turgid and red on the inside.
Sometimes,  but not often, convulsions occur early, and are  to
be considered as unfavourable.  On the next day, if not ear-
lier, an eruption appears, first on the face and neck, and very
soon, always within twenty-four hours, it is diffused over the
whole body. It consists of numerous minute specks, so close-
ly set together, that the skin appears altogether of a red co-
lour, like a boiled lobster, and it feels rough. Broad patches
also appear  on those parts which are most exposed to heat or
pressure.  The inside of the eye-lids, nostrils, cheeks, and
fauces, are of a deep red colour, and the tongue participates
in the  appearance.  The eruption is most vivid at night, and
especially on the evening of the third or fourth day.  On the
fifth day it declines,  and is wholly gone by the seventh, when
desquamation takes place.  During the  eruptive stage, the
patient is generally either restless,  or very drowsy, often
slightly delirious, and both during this stage, and the process
of desquamation, complains  much of itchiness.   Whilst the
fever lasts, the skin is extremely hot.  The contagion, in ge- 
279
neral, operates on the third or fourth day after the person
has been exposed to it.
  The scarlatina anginosa is attended with more severe symp-
toms.  It commences  with the usual symptoms of fever; and
in general, whenever these appear, or even before the  fever
commence, the throat  will be found, on inspection, to be af-
fected ; but sometimes the cynanche does  not  take  place till
the eruption come out, which is nearly about the same period
as in the former species.  Dr. Sims says, that the first marks
of disease are paleness and dejection of countenance, and that
at this time the fauces will  be found to be red.  I am very
much inclined to adopt the same opinion.  From the first,
there is a sensation of stiffness about the muscles of the jaw
and neck,  and very soon,  generally on the second day, the
throat feels as if straitened, the voice becoming hoarse, and
sometimes  a croupy cough  takes  place.  In this  case, the
breathing often becomes  sonorous, or even so obstructed that
the child is suffocated, as in cynanche trachealis.   In very
many cases, deglutition  is  performed  with difficulty, and
sometimes  the drink returns by the nose.  On examining the
mouth we find at the  first, that the tongue has a very red co-
lour, and its  papillae are evidently  elongated.  In the pro-
gress of the disease, it is often covered with a fur.   The ton-
sils are early  observed to be of a deep red colour, and very
soon whitish  streaks may be discovered.   Superficial ulce-
ration is frequent on  the second or third days, and the parts
become covered with a  white or ash-coloured substance,  or
slough, whilst the rest of the tonsil becomes of a  dark red
colour.   The  sloughs are sometimes not removed for a week
or  more,  but often are detached on the fifth or sixth day,
when the cuticular eruption declines.  The eruption, in this
variety, is the same in appearance and duration as  in the
former.  When it is slight, or disappears  suddenly, it has
been said that the event is hazardous, but this is not always
the case.   The fever is attended often with great nausea,
bilious  vomiting, restlessness, head-ache, and delirium. The
 heat is excessive, the pulse  feeble, and sometimes fluttering,
 always very rapid.  The languor and inquietude are  great, 
280
  especially when the sloughs are forming.   About a week or
  ten days after the eruption fades, anasarcous swelling  of the
  legs  may take place, and  continue  even  for two or three
  weeks.   Sometimes other parts of the body swell, or the pa-
  tient has ascites.
    Scarlatina is sometimes succeeded  by pain in the ear, fol-
  lowed by temporary deafness, and the discharge of foetid se-
  rous  fluid.  This often abates, upon  syringing the car with
  decoction of chamomile for a few days; but it may be more
  obstinate, and the child remain permanently deaf.   The ton-
  sils occasionally suppurate, after the external disease abates.
  Swelling of the parotid gland is not uncommon;  and it is
  said by various authors, when it is late of appearing, to pro-
  tract or  renew the symptoms, even the eruption itself; but
  this I have not witnessed.   Sometimes the glands of the neck
  swell and suppurate, or the  bones of the nose, after obstinate
  ulceration,  become carious.   I  have  seen  some unfortunate
  cases, where  the lips have  sloughed completely away,  and
  these ended fatally.  Even after the  patient has, to all ap-
  pearance, recovered from scarlatina, there sometimes unex-
  pectedly supervene languor, debility,  and pain of the bowels,
  frequent  pulse and loss of appetite, which symptoms termi-
  nate in dropsy. Bronchitis or pneumonic affections may also
  be produced.  In some cases, the patient becomes languid
  without fever or dropsy, but these generally do well.
•■• In the second species, or  scarlatina  maligna, the pulse is
  very small and feeble, sometimes indistinct.  The debility is
  fery great, the patient fainting on making the  smallest ex-
  ertion, and very generally he is unable to sit up in bed.   In
•  the scarlatina benigna, the tongue is  red, the eyes and eye-
  lids red,  the  throat at first red, and the skin like a  boiled
  lobster;  but in this species,  the tongue is  livid, tender,  and
  soon covered,  together with the teeth and lips, with a brown
  or black  crust, the eyes are dull, and the  inside of the eye-
  lids dark coloured, the cheeks are  livid, the throat of a dark
  red colour, with brown or blackish sloughs; there is foetid
  breath, with acrid  discharge from the nostrils.   The  inside
  of the labia pudendi of girls, and of the prepuce of boys,  has 
281
in scarlatina the same colour with the inside of the cheeks and
lips, in the scarlatina maligna, the vulva and lips are of a dark
colour, and sometimes mortify.  The eruption  is sometimes
faint, in other cases very dark and purple-coloured, and often
appears and disappears irregularly.  In the progress of this
disease, delirium, great fretfulness, or coma may come on.
The breathing is rattling, the neck seems to be full, and of a
livid colour, and the  head is bent back.  This disease some-
times proves fatal in  a few hours. It is not, however, always
alike mortal, for there are several smaller degrees of malig-
nity,  forming a gradation betwixt this and the scarlatina
anginosa.
  The first species, when properly managed, is not very dan-
gerous, but  the last is  attended  with great hazard.   The
prognosis must  be made, by attending to  the symptoms of
debility, the progress of  the affection of the throat, the ten-
dency to inflammation of the trachea, and the general cha-
racter of the epidemic.
  Drs.  Withering, Adams,  and Willan,  believe,  that  the
scarlatina does not  attack the  same person twice, though
the throat may be to a  certain degree repeatedly affected.
Although I have had many opportunities of attending to this
disease, I cannot form a  decided opinion  on this important
point;  but  I  am inclined  to  adopt the same  conclusion.
Aphthous affections of the  throat, and exudation  of lymph
from inflammation,  are  often  considered  as  belonging  to
scarlet fever,  though the eruption be absent, but the conclu-
sion  is incorrect.   Those who arc exposed to the contagion
of scarlatina, may have  sloughs in the throat, attended with
considerable debility, but a regular repetition of the scarlet
fever is certainly not a frequent occurrence.  Sometimes
other eruptive diseases, such  as a roseola infantilis have been
taken for it.
  The  scarlatina  simplex and  anginosa,  are  often so mild
diseases, as to require little medicine, but still great atten-
tion is necessary.  When there  is a considerable appearance
of  inflammation,  venesection has  been  recommended ; but
this is very seldom necessary, often hurtful, and may almost
   vol.  n.                           o o 
282
uniformly be superseded by other means.   Emetics, given
early, are often attended with advantage, and render the sub-
sequent disease milder.  But laxatives are still more useful,
and in mild cases arc the only medicines which are required.
In some epidemics, the boweb arc moved with  greater diffi-
culty than in others, and in those cases the laxative must be
stronger.   Even when there is a  tendency  to diarrhoea, if
the stools be foetid and unnatural in their  appearance, pur-
gatives are equally necessary as in the opposite state.  The
best medicine to be given at first, is calomel in a brisk dose,
which  often, even at the commencement of the disease, brings
away foetid stools.  This medicine cannot be used too early;
and  if an  emetic have been given, calomel ought rapidly to
succeed it.   After the operation of the first dose  of calomel,
the bowels must be kept open,  or  even rather loose, by the
daily use of infusion of senna with an aromatic. This is bet-
ter than repeated small doses of calomel, which often affect
the mouth considerably.  But if the stools be very foetid, the
patient oppressed, and the belly full,  a brisk purgative may
be given oftener than once in the course of the disease. Ano-
ther remedy of great importance, is affusion with cold water.
From careful  observation, and repeated trials,  I can with
confidence recommend this remedy, which by no  means pre-
vents the exhibition of purgatives at the same time.  It is of
consequence to use this early, and whenever the patient feels
steadily hot, the shivering having gone off, and the skin feels
very warm to the hand  of another person,  it is  time to put
the  patient into an empty tub and  dash  over him a large
pail-full of cold water.  By  this I have known the disease
arrested at once, the eruption never becoming vivid, and the
strength and appetite in a  few hours returning. Even where
it is not arrested, it is pleasant to observe the change it pro-
duces. The patient, from being dull, languid, and listless,
feels brisk, and disposed to talk or laugh;  the skin becomes
for a time colder, and refreshing sleep is frequently procured.
The repetition must depend  on the  degree of  heat; one ap-
plication is sometimes sufficient, but it often  is necessary the
first day to use it three times, and next day once in the morn- 
283
ing, and again in the evening.  It is seldom requisite after-
wards ; for although the disease may continue, it is mild, and
laxatives complete the cure.  If  the  affusion be not employ-
ed, we ought to  have the surface cooled frequently with a
sponge dipped in cold water.  Even an advanced state of the
disease, if the bath have  not  been previously employed, and
the skin is hot, does not  preclude  its use, though  at this
period, it is generally better to employ the sponge.   On the
contrary, it revives the patient.  These two remedies do not
only mitigate the disease, but lessen the risk of dropsical
swelling taking  place afterwards.*   Gargles are often use-
ful, when they can be  employed.  Water, acidulated pretty
sharply with muriatic acid, or mixed with capsicum vinegar,
forms a very good gargle.  Acid fruits are proper.  The
diet should be light and nourishing.   In mild cases, it is not
necessary  to give wine;  but if the debility be considerable,
small doses of wine may, toward the end of the disease,  be
administered.  Should  anasarca take place,  laxatives and
diuretics, such as digitalis, are proper.
   The scarlatina maligna is  much more dangerous, and re-
quires the most  vigorous practice.   The early use of cold
water is highly proper, and often gives a favourable turn to
the future disease.  Laxatives are likewise necessary, and so
far from  weakening the patient, if prudently  administered,
seem to increase  the  strength.   Wine should be  given,  in
such doses as do not flush the patient, or make him  hotter.
Ammonia is sometimes of benefit.  Two drachms should be
dissolved  in six ounces of water, and the solution sweetened
with  sugar.   To infants,  two tea-spoonfuls,  and to elder
children,  from a desert to  a table-spoonful  of  this solution,
may be given every  two hours, or oftener if  possible.  An
infusion of capsicum in vinegar is also  employed with ad-
vantage;  so much of it is to be added to a given quantity of

  * Dr. Hieglitz recommends in scarlatina, first, an emetic of ipecacuanha,
and then so much  Epsom  salts  as shall  procure four stools. In bad cases,
he gives four grains of calomel daily, or  rubs  in Jss of ung. hyd.  When-
ever the salivary  glands become affected, the  disease, he says, takes a
turn. 
284
 water, as renders it pungent.   This mixture may be given in
 the same doses as the solution of ammonia, and it both acts
 as a general stimulant and as a local application to the throat.
 Bark has certainly, in  many cases, been of service; but in
 general, children do not take it in such doses as to do much
 good; or they loath it or reject it by vomiting.  Even when
 taken freely, I do not think that it is a medicine that can be
 depended on, in the cynanche maligna of children.  When it
 is prescribed, it ought to be combined with ammonia or capsi-
 cum.  But in general it is better to give it in clysters made
 of beef-tea without salt.  Myrrh has  also been given, com-
 bined with vinegar; but of the effect of this, I cannot speak
 from my own observation.  Oxygenated muriatic acid  in
 doses of twelve drops to children, has been employed;  but I
 question if it produce  better effects than  water acidulated
 with sulphuric  acid, which, if the ammonia be not employed,
 makes a very proper drink.  If the patient  at an advanced
 period, be restless, and the skin dry and rough, ablution with
 tepid water  will  be useful.  As gargles, capsicum vinegar
with water, or muriatic  or nitrous acid with honey and water,
may be  employed;  but  as children often cannot,  or will not
 use gargles,  it may be  useful to throw these on  the tonsils
with a syringe.  It is also  proper to touch the sloughs and
tonsils frequently,  with a  pencil dipped in the  tincture  of
myrrh or camphorated  spirit of wine.   Fumigations, made
by pouring sulphuric acid on  nitre,  placed in a vessel in
the bed-room, have  also a good effect on the throat.   When
the sloughs are large, or the child breathes with difficulty, or
has a croupy  cough, a gentle emetic of ipecacuanha  some-
times does good, and ought to be tried.   It is to be followed,
 if the child be a  year old, by two grains of  calomel every
hour, till stools are procured.  If less than a year, one grain
may be given at a time.  Blisters have also been applied to
thf throat, but I really  cannot  say decidedly, that they do
good, and they add  greatly to the irritation of the child.   In
bad cases, there is risk of their  being followed by mortifica-
tion  of the part.  Sometimes, in the course of this disease,
apoplexy succeeded  by hemiplegia, and  inability to articulate 
285
distinctly, takes place.  Blisters should be applied to the
head, and if the patient survive, the paralytic  symptoms go
off in a few weeks.
   During the  course of the disease,  the  strength  must be
supported by nourishment, or if that cannot be swallowed, by
nutritive clysters.
   When a disease of  this kind appears  in  a family,  the
children who  are unaffected, ought, if possible, to be sent
away, and should not return for a month.  In the meantime,
the clothes should be washed, and the apartment well venti-
lated, and fumigated with  the vapour of oxygenated muriatic
acid.  This  fumigation may be  employed, even during this
disease,  for the destruction of the  contagion,  and of the
smelling matter in the  room.

                      § 36.  MEASLES.

   Measles commence with a distinct eruptive fever; on the
first and second days  of which, the patient complains of
irregular shiverings, alternating with heat, general debility,
languor, loss of appetite;  has white  tongue, thirst, pain in
the back and limbs, slight sore throat, hoarseness, with dry
cough and sneezing, weight and pain across the forehead,
giddiness, drowsiness,  frequent and irregular pulse, costive-
ness, and high-coloured urine.  On the third or fourth day,
the symptoms  become  more severe; the  eyes arc  tender,
watery,  and  appear as if inflamed,  the eye-lids are  often
swelled, the nostrils discharge thin  serum, and the patient
sneezes more frequently.  There is now often  some degree
of dyspnoea, and sometimes pain and tightness in the chest.
These febrile  symptoms  usually come  on distinctly, about
twelve or fourteen days after exposure  to infection; but  I
have  known  children seized more gradually, being  teased
with hard cough, and rendered more irritable and fretful for
many days before the eruptive fever commenced.  The erup-
tion appears  betwixt the third  and sixth  day of the fever,
but most frequently on the fourth and  it  remains for about
Ihree days.  It is first visible on the  forehead, then on the 
286
 throat, then on the face.  Next day it appears on the breast,
 and  by the evening it covers  the  trunk and extremities.
 The eruption consists at first of small red spots, apparently
 a little raised, like papulse, but without vesicular tops.  Then
 the spots extend so far as to form an oval or irregular figure,
 slightly elevated, but flat,  resembling a flea bite.  Very soon
 large patches appear, intermixed  with the distinct spots.
 These are irregular in shape, but tend to the semilunar figure;
 they are made up of clusters of  distinct spots.   In some
 cases, the eruption, though vivid, is not considerable;  and
 in this case, it consists almost equally of patches and circular
 and irregular spots, and the intervening skin is of the natural
 appearance. When the eruption is more copious, the patches
 are most numerous and extensive.   In  children under a year
 old,  the eruption is not so thick and  confluent as  in older
 subjects, and  in  many places has a  papulous appearance,
 especially on  the face and hands.  In some cases,  the erup-
 tion, though of the usual configuration,  is pale and indistinct;
 but in general, whether vivid  or not, when the finger is pass-
 ed over the surface, the skin  feels unequal, from the eleva-
 tion of the  spots  and patches.  The  colour is most vivid
 after the eruption has been out for a  day.  Sometimes the
 eruption suddenly and prematurely recedes, or never comes
 fully  out.  Both of these cases are unfavourable, the fever is
 high, and the  oppression great.  In  the regular course of
 things, the eruption on the face fades a little on the sixth day,
 and next day that on the  body becomes also paler.*  From
 this to"*the  ninth  day, the eruption is going off, and then
 the former situation of the rash is only marked by  a  slight
 discolouration.  The departure of the efflorescence is attend-
 ed with  desquamation, during which the patient complains
 much of itchiness.   The fauces in this disease, about the
 fourth day, are covered with   small red patches, which next
 day have a  scattered or  streaked appearance.   The inflam-

  • Sometimes, instead of this, the eruption becomes very dark-coloured,
 or purple, with increase of the languor and fever.  Mineral acids in this
 state are useful, and most children recover.  The danger  is greater when
petechia appear among the patches, for this marks great debility. 
287
mation of the eyes, sneezing, and hoarseness, generally de-
cline  with the eruption,  and,  towards  the end,  cpistaxis
sometimes takes  place.   The fever continues  during the
eruption, but the sickness and  nausea abate when the erup-
tion comes out, and  about the sixth day the heat and rest-
lessness go off.  A spontaneous diarrhoea often terminates the
feveri and then the  appetite returns pretty keenly.  Some-
times, especially if the disease have been severe, the measles
are followed either by an eruption of inflamed pustules* over
the body, which may ulcerate, and prove troublesome, but
more  frequently they fade, or by a vesicular herpetic-looking
eruption about the mouth, or sometimes by gangrenous af-
fections  of the lips or vulva,f  or by enlargement of the
glands of the neck, or dropsy, or a cough, somewhat resem-
bling that in hooping-cough,  or by hectic fever, continuing
for many weeks.
   Sometimes the sickness and oppression are great and per-
manent.  The  child never looks up,  but breathes  heavily,
and, owing to stuffing of the nostrils, loudly.   He coughs of-
ten, has frequent  pulse and hot skin.   He can scarcely be
roused up, even to take  a drink.  This state  arises  more
from the brain than the lungs.
   In measles, the membranes are very apt to be affected. Ge-
nerally, the membranes of the  windpipe, bronchise, fauces,
nostrils, and eye-lids, are chiefly affected, but sometimes that
of the stomach  or bowels principally suffers, producing sick-
ness, vomiting, or purging.  At other times that of the brain
is affected, producing coma.
   Rubeola, in general, is not  a fatal disease, when stimulants
are avoided.  When it proves fatal, it is  most frequently in

   • These are sometimes taken for a kind of small-pox.  They are occa-
sionally succeeded by a scabby diseasa of the skin.  The skin is inflamed
and covered with rough loose yellow scabs.
   f The measles, about nine years ago, were more prevalent than any prac-
titioner I have met with, remembers them to have ever been before. They
began about the middle of winter, and continued during the summer and
autumn.  I have had occasion, during the epidemic, to see different in-
stances of the  gangrenous affection I have mentioned.  The children all
belonged to the poor, and Uved in confined houses 
288
consequence of the pulmonic  affection, sometimes of coma,
or fever  and oppression, with  symptoms of effusion in the
brain, connected with recession, or imperfect appearance of
the eruption.
  The treatment is extremely simple, and may be briefly ex-
plained.   During the eruptive fever, the use of mild diapho-
retics, and the tepid bath, will be of advantage.   The bowels
should be kept open, but the child should not be much purged
after the first day.   If there be a considerable diarrhoea from
extraneous causes,  as dentition, or  directly connected  with
the fever, H is often found that the eruption is late of appear-
ing, and a late eruption is generally attended with some trou-
blesome symptoms, as it indicates a tendency to  affection of
some  internal membrane. A little rhubarb, given early, often
moderates this.
  If the  eruption do not come freely out, or recede prema-
turely, and the  child be sick, oppressed, and breathe high,
we must attend first of all to the bowels.  If diarrhoea exist,
and the  child be  not plethoric, a little rhubarb should be
given, and then spiritus ammonia aromaticus  with  lauda-
num,  and the child should be put in a warm bath, having a
little mustard  diffused in it;  afterwards a sinapism, follow-
ed by  a warm plaster  should be applied over the stomach,
and we determine to the surface  by giving a saline julap. If
in this  state the child  be costive, a gentle purgative should
be given,  for  the bowels may be either too torpid or too ir-
ritable.
  I have not advised the liberal  use of purgative medicines,
though these  are  found beneficial in scarlatina, because we
often  find that diarrhoea interferes with the eruption.  But
the bowels are upon a general principle to be kept regular,
or rather open;  and if the stools be foetid or  ill-coloured,
then,  even although diarrhoea exist, small doses of calomel
should be given, and afterwards, if necessary, the purging is
to be moderated by anodyne clysters.   So far as I have ob-
served, the continuance of  the diarrhoea, in  this case,  does
not mitigate the symptoms;  and if the child recover,  it is
either by the use  of medicines bringing the bowels into a 
289
better action, or it is independent of the mere evacuation pro-
duced by the diarrhoea.
  If the pneumonic symptoms be considerable,  marked by
cough, oppressed breathing, flushed cheeks, and pain in the
chest, wliich, in  young children, may  be discovered by the
effect of coughing, and if a slight motion excite coughing, a
blister should be applied to the breast, and if the symptoms
are urgent, either the lancet must be early used, or leecnes may
be applied at the top of the sternum, according to the age and
constitution of the child, and moderate doses of calomel given
to keep the bowels open.  If the cough be  frequent, without
inflammatory  symptoms,  opiates give great relief.  If the
symptoms of inflammation be such as  to require bleeding, or
to render the  propriety  of  using laudanum doubtful, then
small doses of solution of tartarite of antimony may be given
every  two hours, but not to such extent as to produce sick-
ness or vomiting.   Diarrhoea should  not be checked, unless
severe, and  it  increase debility, or produce hurtful effects.
Anodyne clysters are then the best remedies.
   Coma or drowsiness very frequently  attend the measles,
and  the child may perhaps scarcely look up  for some  days.
When the nostrils are stuffed with  mucus, the breathing,  in
this case, has  an alarming  appearance of  stertor.   Most
children recover from this state;  but as some  die evidently
from this cause, and as we have no  means  of ascertaining
the security of any individual, I hold it expedient to use means
for the removal of the coma, particularly by  giving a purge,
if the  child have not a looseness,  and shaving the  head,
and afterwards  applying either a sinapism or  a blister. When
the child is plethoric, it may also be  proper to apply leeches
 to the forehead.
   The cough which  remains  after measles,  is generally re-
 lieved by opiates. Hectic fever is often removed, by keeping
 the bowels open, giving an  anodyne at bed-time, carrying
 the child to the country, and adhering to a light diet.  Other
 symptoms are to be treated on general principles.
   When the measles are epidemic, it  is  not uncommon to find
 those who had formerly the disease, affected sometimes with
   vol,. II.                           p p 
290
 catarrh* without any eruption,  sometimes with an eruption
 preceded by little or no fever, and without any catarrh.  This
 has been very distinctly observed, during every season when
 the measles were prevalent.   Whether the eruption be of the
 nature of measles, is not easily determined, but certainly the
 external resemblance is very great, in so much that this erup-
 tion has been  called rubeola sine catarrho.  It requires no
 particular treatment, and is only noticed because it is some-
 times taken for measles, but does not prevent the patient from
 a second attack.f


                        § 37.  ROSEOLA.

   Sometimes an eruption, termed by Dr. Willan roseola,^: is
 taken for measles.  The first species, roseola sestiva, has no
 small resemblance to rubeola.   It is often preceded by chilli-
 ness, alternating with  flushes of heat,  languor,  faintncss,
 restlessness, occasionally with  delirium or convulsions.   At
 some period, betwixt  the third  and  seventh day from the
 commencement of these symptoms, the rash appears, general-
 ly on the face and neck,  and afterwards in a day or two over

  * During the epidemic six years ago, opthalmia was extremely prevalent
 amongst both young and old.
  j- Of all the eruptive diseases the measles are undoubtedly the most in-
flammatory. They therefore require to be treated by depletion.  Bleed-
ing, even pretty copiously, can rarely be dispensed with.  I speak now of
the disease as it appears in  this country.  To this remedy may also be
added occasionally purging with the neutral salts, and the  antimonial pre-
 parations  with a view not  less  of diminishing arterial action than over-
coming the stricture on the surface of the body. The whole antiphlogistic
 plan is indeed to be pursued.  If there be much local affection either in the
 lungs or head, blisters should be employed.  Change of air, especially by
 removal to the country will be found most speedily and certainly to subdue
 those distressing effects which too often follow the disease, such as diarrhoea,
 cough, &c. C.
  t This  he defines to be a rose-coloured rash, without scales or papulae,
variously figured, and not contagious.  By some former writers, this term
 is applied to a disease resembling nettle-rash.  Vide  Lory, p. 398.—The
 appearance of roseola sstiva is extremely well expressed by Dr. Willan in
his plate. 
291
all the body.  The patches are larger and more  irregular
than those of the measles,* in which the eruption consists of
spots like flea bites, and patches made up of these spots ar-
ranged sometimes in a crescentic form, and of a colour sel-
dom deeper  than bright  scarlet, often much paler.  In this
disease, however, the eruption is at first red, but in general
it soon assumes a deep roseate hue, from which Df. Willan
gives its name.  The fauces are tinged with the same colour,
and the patient feels a slight roughness in the throat.  The
eruption appears first at night, and continues vivid next day,'
with considerable itching.   On the third or fourth day, only
slight specks of a dark red colour are observable, which next
day disappear, and together with these the internal disorder.
In some instances, the skin on many parts, becomes of a
dusky colour, with an  appearance  of slight vesication, or
desquamation.  The drowsiness, sneezing, watery eyes, and
running at the nose, so common in measles, are wanting in
roseola, and  there is no  pulmonic complaint, whilst, at the
same  time, the patches are larger, and occasionally intermix-
ed on the body with an appearance  of nettle-rash.   Some-
times the  rash is only partial, appearing in patches, slightly
raised above the surface, with a dark red flush of the cheek.
This  form lasts about a week, the rash appearing and disap-
pearing occasionally ;  and usually the disappearing of the
rash is attended with nausea, faiutness, &c.  In some cases,
no fever is observable, or the progress and duration of the
eruption is more irregular than  I have described; and some-
times on the  breast or trunk, the eruption  lias a great resem-
blance to urticaria, whilst on the arm, the appearance is de-
cidedly like roseola. This disease appears to be somewhat in-
fectious. For, in particular seasons, I have observed it to be
unusually frequent, and to affect all the children of a family.
In such cases the eruption has lasted from two to four  days,
but has been attended with very little fever. The only treat-
ment which is necessary, is giving gentle laxatives, the use of

  * Sometimes young infants have an efflorescence of numerous coalescing
patches, of a strong red colour, rounded, and of the size  of a six-pence
These terminate in desquamation in less than a week. 
292
acids, and light diet.  If the eruption be suddenly repelled, the
warm bath is proper.  Should there be a marked determina-
tion to the head, brisk purgatives are proper.
  Another species, called roseola autumnalis, affects children
generally in the harvest, and consists of distinct patches, of
an oval or circular shape, which  increase to nearly about the
size of a shilling;  they are not elevated, but are of a very
dark colour, appearing, at a distance, as if a black cherry or
brambleberry had been pressed on the skin, so as to leave the
impression. The patches are not attended with fever, are
usually diffused over the arms, and disappear in about a week.
Acids may be taken internally.
  The roseola infantilis appears during dentition, or in a dis-
ordered state of the bowels.  It consists of a red efflorescence,
usually very closely set, so that the surface is almost entirely
of a red colour, as in scarlatina; but there is more appearance
of patches than in that  disease, and the other  symptoms are
wanting.   The eruption generally goes off in a  day, but it
sometimes  appears  and disappears for  several days, with
symptoms of great irritation. No particular treatment is ne-
cessary,  except what is  required on account of concomitant
circumstances.  It is sometimes preceded  or attended  by
vomiting or convulsions,  with pale face and languor.  In
such cases, a gentle emetic, the warm bath, and cordials are
proper.
                       CHAP. V.

                    Of Hydroceplialus.

  Hydrocephalus is  one of the most dangerous and insi-
dious diseases to which  children  are subject.  It sometimes
makes its attack suddenly, cutting the patient off in a few
days; sometimes more gradually, and is protracted for many
weeks or months.  It has, therefore, been  divided into the
acute and chronic; and as it may either appear as an idiopa-
thic  disease, or come on in the course of other  diseases, at 
293
first quite different, it may likewise be distinguished into the
primary and secondary.
  Acute hydrocephalus begins very like a common fever, but
there is  more  frequent  vomiting, and greater pain in the
head, especially on  one side;  whilst in  most other fevers of
children, the greatest uneasiness is generally felt in the belly,
the head  being  often unaffected.   After  the febrile symptoms
have continued for some  time, marks of oppressed brain ap-
pear, and the patient dies comatose, or convulsed.  Such is
the outline of the disease, which, however, it will be necessary
to describe a little more  minutely.  Very often the patient,
for  some time previous to the attack, is languid, peevish, and
uncomfortable, without any particular complaint.  The appe-
tite is impaired, he has frequent sick fits, or vomits bile, and
the bowels are generally very costive, though sometimes  he
purges foetid,  dark-coloured, or  green fseccs, and he com-
plains occasionally of his head. Towards evening, the face is
a little flushed, and the skin is hot, and very soon the disease
becomes formed.   In other instances, however, and these by
no means unfrequent, the disease invades more suddenly, or
with scarcely any previous indisposition.  The patient  feels
chilly, whilst his skin is hot; he complains greatly of his head,
especially at the forehead, or at one side, sometimes very much
of his neck.  He cannot  keep out of bed, his eyes are  very
sensible  to the light, and,  when examined, the  pupils are
contracted, sometimes irregularly, and the eye in some cases
is troubled, in others as  clear as usual.  Spasmodic cough
and pains in distant parts occasionally supervene.  The head-
ache is constant, and produces moaning, or the  patient lies
silent and unwilling to speak a word, or often even to take a
drink.  The stomach is very early affected,  and for some
days he vomits bile, and whatever he swallows; has no appe-
tite, and little thirst; the tongue is white, the bowels general-
ly costive, but sometimes loose,  and  the  stools  in that case
green and foetid; pain is felt in the belly, and occasionally in
other parts of the body.  The sleep is broken, and frequently
interrupted, as  if the patient had a frightful dream; he starts, 
294
 grinds his teeth, and picks his nose, which makes the disease
 sometimes pass for the consequence of worms.   The pulse in
 a few cases, in not very frequent; hut in general, especially if
 the disease be rapid, it is at first very quick, being about 120
 in the minute.  In about  eight or ten days, the pupils are
 somewhat dilated, and the patient squints a little.  In  some
 cases, the vomiting is renewed, but more frequently it is not.
 The pulse at this time often becomes slow, beating only 60
 in the minute, and being generally irregular.   The pupil is
 more dilated, and the  eye less sensible than formerly to light.
 The head-ache is usually diminished,  but the patient fre-
 quently cries out, or even screams.  In some cases, delirium
 comes on; in others,  the patient continues sensible and  in-
 telligent,  until the stupor  supervene.  More  food is  often
 taken, in this stage, than formerly.  In the course  of either
 two or three days, the pulse becomes again quicker, the pupil
 more dilated ; but still the patient may continue to see, and
 complain of the light, and  often  answers  distinctly every
 question.  Presently, however, the  symptoms  of oppressed
 brain become greater, the pulse is weak,  and gradually in-
creases to 160 in the  minute.  The eye squints, vision is at
last lost, the urine is either retained, or,  with the  freces,
passed involuntarily.  The  breathing  becomes stertorous,
 and  the patient  dies.  In the course of  this  malady, the
cheeks are  alternately flushed  and pallid; and after the
second stage,  one side is more or less paralytic, whilst the
other in many cases is convulsed; indeed  convulsions  may
 come on at any period of the disease,  even in its commence-
 ment.  The  symptoms are generally aggravated during the
 night.  When the patient  sleeps, the eye-lids are often  only
 half closed, and the eyes turned up.  He  complains  much,
 or becomes, giddy, when the head is raised.
  Hydrocephalus has  been divided into three stages, charac-
 terized by the state of the pulse and of the sensibility.  In the
 first, the pulse is frequent, and the sensibility great.   In the
 second, the  pulse becomes slow, with marks of oppressed
 brain.  In the third, it is again rapid, there is great debility 
295
and cerebral irritation.  But it is to be recollected, that these
stages are not always well defined, for sometimes the pulse
never becomes slow.
   This disease runs on generally till the twenty-first  day, if
the patient be above two years old; but if the child be younger,
it often terminates more speedily, sometimes so early as the
fourth or fifth.*
   From this account, it appears, that the symptoms, when the
patient can  describe them, are in  the first stage much the
same with those of the common fever of the adult, or many of
the febrile diseases of  children, and that upon these super- •
vene those of oppressed brain.  In  some cases, however,
water has been found in the ventricles when no symptoms in-
dicated it during life,f or when many of the usual symptoms
were absent.:}:
   Infants cannot give an  account of their sensations, and
therefore we are more  uncertain, until  the symptoms of op-
pressed brain appear.   We may, however, dread the  nature
of the disease,  when the infant has a high fever, vomiting,
with costiveness or diarrhoea, lies oppressed, and apparently
sick, with the eyes obstinately shut, dislikes the  light,  puts
the  hand frequently up to the  temples,  as if going to rub
something off the head, has starting and spasms, and awakes
suddenly as  if terrified, and sucks or drinks at first with great
rapidity.  The diagnosis, it must however be confessed,  is

  * It is not at  all uncommon in hydrocephalus at the expiration of eight or
ten days,  especially  if its progress has been rapid, for the more violent   *
symptoms to subside so as to induce a very sanguine expectation of a speedy   |
recovery.  Thisis often a most treacherous and fatal calm, as it results from   \
an effusion in the ventricles of the brain.  The vessels in this way become
relieved, and the disease is suspended.  After a short time, however, the
extraneous fluid acts as a re-exciting cause, and the  disease returns with re-
doubled force.  Under such circumstances, it is perhaps incurable. Effusions
in other cavities of the body may be taken up, but as far as we know, the
ventricles are destitute of absorbents, or if they exist, they act incompetently
in these cases.  C.
  f Vide Quin's Treatise, p. 43.
  t Dr. Rush mentions cases where there was no pain in the head, or where
itbegan like a catarrh, or wanted the strabismus, dilated pupil, sickness, anii
loss of appetite.  Med. Inq. Vol. II. p. 210. 
296
very difficult; for in disorders of the bowels, from dentitiou
and other causes, spasms, starting, drowsiness, and strabis-
mus,  may take place.*  It is perhaps  prudent, whenever
there is much  fever, with any ambiguous symptoms, to pro-
ceed as if the  patient were threatened with hydrocephalus,
more especially, as the early  use of the  remedies thus  indi-
cated will generally be  serviceable  in the complaints with
which this disease may be confounded; and if  we delay to
the last stage, to obtain a more certain  diagnosis,  we have
scarcely any hope of  doing good.   When children can give
an account of their sensations, we  may  with great justice
fear this disease, when they complain much of the head, have
vomiting, and quick pulse.
  Dissection shows that  the vessels of the brain are full of
blood, some of them very turgid,  the membranes  and brain
in some places seem inflamed, and covered with coagulable
lymph; whilst betwixt the dura mater  and the brain,f  but
still more frequently  in the ventricles of the  brain, there is
an  accumulation of water, sometimes to the extent of se-
veral ounces,  and it is generally of a very pure and trans-
parent  quality.  The abdominal  viscera are sometimes in-
flamed.
  Hydrocephalus  is produced by causes,  the  operation of
which cannot  always be detected,  but  sometimes it can be
traced to  the  sudden  removal of an eruption, or  cutaneous
discharge from the scalp, blows on the  head, &c.   A scro-
fulous constitution appears  to give predisposition to  the
disease.  The term hydrocephalus  is, perhaps, in one sense
improper, as it expresses  merely a symptom occurring in the
end of the disease, and which does  not  exist whilst  the dis-
ease is curable.  No one thinks of calling  pleurisy, empye-

  .*  A very interesting case, where strong symptoms of hydrocephalus were
produced by accumulation of the  fxces, and a speedy cure obtained by
purging with senna, is related by the late Mr. Benj. Bell.—Hamilton on Pur-
gatives,'p. 217.
  j- In this case the disease is  called hyd. externus, to distinguish it from
the species in which the water is in the ventricles, which is called hyd. in-
ternus. 
297
ma, though that  is a termination of pleurisy; it would be
apt to call  the attention of the practitioner to a different set
of indications from those  pointed out in  the inflammatory
stage.*
  The most proper treatment would seem to consist  in the
early application  of leeches to the temples, and  purging the
patient with calomel; after  which, the  bowels  are  to be
kept rather loose.  These means should always be had re-
course to on the very  first attack of the febrile state, and in
many  cases will effectually check the progress of the disease,
and prevent effusion.   But if they do not immediately give
relief, the head should be  shaved, and a blister applied.  If
the patient has a diarrhoea instead of being costive, it ought
not to be rashly checked :  but if the stools  be green,  foetid,
or contain lumps, doses of calomel should be given repeatedly.
In the second stage, mercury combined  with digitalis should
be used freely, and repeated blisters applied  to the head, so
as to keep up a discharge.   If the spasms  are very frequent,
opiates may ultimately  be employed, as they will, at least,
render the appearance less distressing to the relations.   Such
is the  nature of practice in this  disease;  but when effusion
has taken  place, it is difficult to prove that medicine has any
power over the malady.   It is only in  the very commence-
ment that we can do good.  If this  period be lost,  no  future
vigilance can regain the ground.   I do then most  earnestly
intreat my reader to  resort timeously to  the application of
leeches and smart purges, which alone  ean  subdue the mor-

  • This is a correct distinction.  The proximate cause of the disease, or
indeed the disease itself, is  an increased action of the vessels of the brain:
the  proximate effect, an effusion of water  into  the ventricles.   By con-
founding the disease with the effect,  practitioners have given very oppo-
site and contradictory reports respecting the powers of medicine in curing
it By  bleeding, purging, cupping and  blistering, we  can undoubtedly of.
ten cure the  disease itself, but, when  effusion has taken place, it.  may be
deemed generally a desperate case.  We should, therefore, endeavour, to
relieve  the blood vessels by the  most active  depletion so as to prevent ef.
fusion.  It is  now more than thirty  years since Dr. Quin pointed  out not
only the correct theory, but also the proper practice in this disease.  His va<
tuable treatise on the subject cannot be too often consulted.
   VOL. IT.                              0; 0; 
298
bid action which precedes effusion.  If from a hope that the
disease is of a less formidable nature; or from fear of giving
unnecessary alarm in a case not decidedly dangerous ; or
from the still  more inexcusable cause of inattention,  these
means be neglected, how bitter is the reflection which arises
in the mind, when symptoms of effusion appear.  We can-
not, indeed, by the most early and  vigorous  treatment  al-
ways save our patient, but we can by this conduct  always
obtain the consolation of thinking, that we have faithfully
done our duty.
  When  hydrocephalus is known to be a family disease, it
will be proper to use every mean to strengthen the constitu-
tion, such as the cold bath, light nourishing food, and strict
attention to the bowels.   If the child be plethoric, the bowels
should be kept loose, and a small issue may be inserted.  We
should be particularly careful not to heal too  suddenly any
eruption, especially about the head.   The first symptoms of
disease must be watched; and we had better  be blamed  for
using remedies too early, than  have to regret that  we em-
ployed them too late.
  The chronic hydrocephalus makes its attack  more slowly,
and runs its course with much less speed.  It seems some-
times to be gradually approaching from birth, the child being
dull, languid,  subject to frequent fits of stupor or  drowsi-
ness, and the head enlarging faster than it ought to do : or
it may even begin in utero.  In other cases, the child is  at
first tolerably healthy, and it is many years before symptoms
of the disease appear.  First of all, we observe him to be
duller than usual, with a slight degree of fever, attended with
pain in the head,  sometimes  constant but moderate, some-
times attacking like paroxysms of head-ache, attended with
sickness  and vomiting.  He is amused for a short time with
the entertainments of his age, but is soon tired, and generally
is found, after a little play, lying on a chair. The appetite is
gradually impaired, and his food is apt to sicken him, or to
be  rejected by vomiting.   The head-ache becomes more con-
stant,  and sometimes severe, often attended with giddiness,
and pain or stiffness in the neck. The skin is rather hot, the 
                          299

pulse at first is frequent and irregular, though in  some in-
stances it very early becomes unusually slow, and  continues
so for a long time.  The bowels  are  constipated,  the urine
sometimes passed with pain and  difficulty.  The eye is dull
and  languid, and  at  times the patient sees double or indis-
tinctly.  After these symptoms have continued some time, the
bones of the head enlarge greatly,  if the sutures have not unit-
ed, and the veins on  the scalp become very distinct.  The
body wastes, and the muscular powers arc more or less im-
paired.   In this state, the patient  may live many months; or
occasionally the disease seems to receive a check, and the pa-
tient lives for years with an enlarged cranium, and sometimes
in a state of idiotism.   In general, however, in a few weeks,
or at most a few months, the symptoms of compressed brain
become  more distinct.  The pupils are  dilated, the patient
squints, the limbs are paralytic  and  convulsed, the urine is
suppressed so that the catheter is  required, the pulse full and
slow, but presently it  becomes weak and fluttering, and the
patient dies comatose, with stertorous  breathing.  When the
patient can give an account of his sensations, we may early
be led to suspect some disease in the head, but in infancy we
can receive no account of the sensations.   We may discover
it, however, by the unhealthy look of  the child, the frequent
application of the hand to the head, which often  is greater
and feels heavier than usual, even before water be formed;
drowsy fits, and sometimes  convulsions; vomiting, and awak-
ing terrified from sleep;  at the same time that there seems
to be no  tendency  to  dentition.   Afterwards the size of the
head, and other symptoms, indicate  the disease  more de-
cidedly.
   There is an affection, which is liable to be confounded with
chronic hydrocephalus.  The patient  complains of his head
and neck for a length of time, has  the pain increased by exer-
cise, agitation, or reading long, and sometimes he squints.
The pain, however,  is rheumatic, follows the course of that
disease, is not constant, and shifts its  place.  The  squinting
is either habitual, and consequently accidental, with regard
to the disease, or it is caused by a temporary affection of the 
300
 muscles of the eye, and  is increased by looking long at any
 object.  The patient is easily agitated, and, at a more ad-
 vanced age, would be said to be hysterical. Laxatives, bark,
 and sea-bathing, are useful.
   On opening the head, we generally find a great quantity of
 water in the ventricles, and some  even on  the surface of the
 brain.  Sometimes the ventricles are so much enlarged, that
 the cerebrum resembles two vesicles pressing on the cerebel-
 lum.  The bones of the cranium are occasionally very thin
 and softened, sometimes very irregular on their inner surface.
 In a girl who died, after having been ill for about five months,
 I found the inside of the cranium, at the lower part, covered
 with sharp bony processes or spines.
  The practice  consists  in the application of blisters to the
 head, or the formation  of an issue on the  scalp by means of
 caustic.   The bowels are to be kept open, or at least regu-
 lar, by the use of purgative medicines; and it will be proper
 to give a course  of calomel or mercury, combined with digita-
 lis, nearly in the same doses we would use for dropsy.  By
 this plan, some children  are cured, and others have the head
 reduced in size for a time.*   These have the urine consider-
 ably lessened in quantity; and when the medicines do good,
 they increase the flow  of urine.   It has been proposed, by
 bandages and other means, to support the bones  of the head,
 and prevent distension, but of this I can say nothing from
 my own observation.
  The secondary hydrocephalus is a very frequent disease,
 and is extremely insidious.  The symptoms at first are quite
 independent of any affection of the head, and arise from den-
 tition, disorders of the bowels, or other causes.   But in the
 course of the disease so excited, especially if it be attended
 with fever, symptoms indicating a diseased  state  of the brain,
 supervene with more or less celerity.   That this should take
 place  is not  wonderful, when we consider  the remarkable

  *  In a case attended by my brother, he succeeded so far with the mercury
and digitalis, as to render the fontanelle slack, whereas, before, it was tense
and  prominent.   But whenever this slackness was produced, convulsions
came on, and the patient died. 
301
sympathy existing betwixt the brain and other organs, and
the great vascularity of the brain, as well as its delicacy in
children.  But however the fact is to be explained, its exist-
ence  is undoubted. It  is unfortunate, that the first set of
symptoms often fix the attention of the practitioner solely to
the cause which is supposed to produce them, whilst the new
disease is overlooked until all hope is at an end.  It is highly
necessary, in all diseases of children, to watch the safety of
the head;  and  whenever symptoms appear, indicating an
affection of that organ, to have recourse to the application of
leeches, blisters, and other means, which have been  pointed
out. Indeed, in all protracted diseases of children, especially
if attended  with  considerable fever, it  will be prudent to
shave the head, and apply a small blister upon it.  Calomel
purges are of great utility.
                       CHAP. VI.

                     Of Convulsions.

  Convulsions proceed from various causes during infancy.
They very  frequently  arise  from irritation in the bowels,
from dentition, or in the course of eruptive fevers.   Some-
times they  proceed from immediate affections  of the brain
itself,  and  very often they occur in hydrocephalus.  They
may be distinguished into those proceeding from a primary
affection of the brain,* and those  occasioned by sympathy
with some  other organ  in  a state of  irritation.  It is not,
however, easy to make the diagnosis in every instance; and
when convulsions continue long, whatever may have been
their origin, the brain ultimately suffers; and  if the disease
be  protracted,  the patient becomes emaciated, and  perhaps

  • An epidemic convulsion is mentioned as prevailing at one time in Paris,
affecting children under eight years of age, and young whelps ; in which
blood was constantly found effused under the cranium.  It proved fatal in
seven hours.  Recueil. Period. Tom. IX. p. 286. 
302
 paralytic,  or even  hydrocephalus may  very  early be ex-
 cited.
   We may be  assisted in our judgment, by examining the
 gums, especially if the child be about the time of life when
 teeth  appear;  by  inquiring  into  the state of the bowels,
 whether they be  loose or bound,  or the child be troubled
 with worms; by learning  if an eruption have  suddenly dis-
 appeared : or if the child have been frightened, or had heavy
 food, or too  much food, or  been sucking a woman whose
 mind had been recently agitated; or  if none of these causes
 be discovered, we should inquire if  the  child  have already
 had those febrile eruptive diseases,  which are often preceded
 by convulsions, especially small-pox.  In  at least nine cases
 out often, convulsions proceed from irritation of the bowels;
 the stools being generally  unnatural, or the digestive func-
 tions impaired.  This observation is  of much importance in
 practice, as  it points out both the  means  of prevention and
 of cure.
   Very young infants are subject to a slight degree of spasms
 called inward fits, in which the mouth is, during sleep, drawn
 into a smile; the eye-lids are not quite closed, and the eyes
 are turned  about, so as at times to discover the white; the
 breathing seems occasionally to flutter, and  the child is very
 easily startled.   These fits appear to be occasioned by wind
 in the stomach or  bowels,  for they are relieved by a  dis-
 charge of wind, and require  some  carminative, such as su-
 gar of anise, with a gentle  laxative.  They generally go off
 in a short time, but sometimes they are succeeded by vomit-
 ing or purging, or drowsiness, ending in convulsions.*

  * Dr. Armstrong was the first I  believe who  called the attention of phy-
sicians to this complaint.  He has written very elaborately upon it, and
deems it much more formidable than it is commonly represented to be.
Where it is neglected, he says, " it will degenerate into an almost constant
drowsiness, which is succeeded by a fever and  thrush, or else it terminates
in vomitings, sour curdled or green  stools, the watery gripes, and convul-
sions."  The antimonial wine given as an emetic is the  chief remedy which
he has suggested.
  Notwithstanding the preceding frightful picture, I cannot help consider-
ing " inward fits" as a very trifling sort of complaint,  too trifling, indeed, to 
303
  Some children, very early after birth, appear languid, moan,
and  pass dark-coloured faces, different from meconium, and
after it, in the usual course of  things, ought to be removed.
Presently they fall into a state, rather resembling syncope than
convulsions, and die perhaps  in forty-eight hours after they
are born.  The early use of calomel, in small doses, conjoin-
ed with some gentle aromatic, is proper.*
  Others, soon after birth,  are seized with a violent fit of
crying, and they become more  or less distinctly convulsed,
and the muscular irritation may repeatedly recur.   This is
relieved by the warm bath, gentle laxatives, and rubbing the
belly with a little laudanum.   I have sometimes thought that
this state was induced by tyeing the  cord too near the belly,
by which an  irritation  was communicated to the abdominal
viscera.  Infants of a month old,  who  are subject to severe
fits  of crying  from colic, which is  often induced  by  bad
nursing, may be suddenly carried off by a convulsion after a
violent and continued paroxysm of screaming. This state re-
quires great attention to the bowels and to diet.
   Regular convulsions  may occur at a very early period of
infancy, and  in this case attack those children who, from the
time of birth, have been subject to heavy sleep,  or  to whine
 and moan, or to violent screaming, or to start suddenly from
 their sleep, and who have twisting of the extremities while
 awake.
   Convulsions vary much  in their  degree  and  duration.
 Generally  the child is seized quickly with a spasm of the
 muscles of the arm and legs, which are agitated to  and fro,
 the fists are clenched, the body bent back,  the features dis-
 torted,  the eye-lids open, the  pupils  dilated,  and the eyes

 get a place among the diseases of infants.  That very young children often
 exhibit the symptoms described by Mr. Burns is undoubtedly true. These,
 however, will be found to proceed from uneasiness, the  consequence of an
 overloaded and distended stomach.  The mild carminatives will generally
 give relief. But if they fail, the stomach must be emptied by  a puke or
 purge.  It is better however to prevent this complaint altogether by a pro-
 per regulation of the child's diet. C.
   • At this very early  stage of life, I would prefer purging with castor oil
 to calomel. C. 
301
 either fixed in the socket or rolled about  The face is either
 pale or livid.  These convulsions may prove very suddenly
 fatal; but sometimes after the fit has lasted a minute or two,
 it goes off and does not return.  In  other cases,  it  returns
 very frequently for several days, or at uncertain intervals for
 many weeks.  In general, the longer the fits, and the shorter
 the interval, the greater is  the danger.  The occurrence of
 paralytic symptoms or emaciation, in those cases where fits
 are frequently repeated, add greatly  to the danger, and gene-
 rally indicate hydrocephalus.
   When  a child is seized with convulsions,  a very  great
 alarm prevails;  and  it is  expected, that if the practitioner
 arrive before  the child is carried off, or  has recovered from
 the fit, very prompt  and active means must  be employed.
 The flrst thing  to be done, is to order a warm bath and a
 clyster to be got ready  immediately;  and while these  are
 preparing, we inquire into  the circumstances of the case,
 and examine the gums.  If the child be at the time of teeth-
 ing, and no other cause be discovered, it will be proper to
 cut the gum freely over that part where the teeth ought, ac-
 cording to the usual  order of dentition, to appear, even al-
 though no swelling  be discovered.  Then the child is to be
 put into the warm bath, the face alone being kept above the
 water, and he is to be retained there for a few  minutes, if
 the fit do.not pass  off sooner.  In some instances the ad-
 dition of a little hartshorn or mustard  to the bath is useful.
 When the child is taken out of the  bath, a cloth is to be ap-
 plied over the stomach, or great part of the abdomen, wet
 with strong spirits, and lightly sprinkled with pepper.  A
 clyster is at the same time to be thrown up, so as to operate
 speedily; and this is to be followed by a  calomel purge, and
 the subsequent use of laxatives, to keep the  bowels  open.
 Even if the child has diarrhoea, if the  stools be  not natural
 in appearance, laxatives will be proper, according to the di-
'rections given in considering diarrhoaa.* Emetics have also

  * The propriety of giving purgatives in convulsions, when the bowels
 are costive, or the stools unnatural, is confirmed by experience, and the ef-
fects of this course in chorea. 
305
been employed during the fits; but unless we have reason to
suspect that  some indigestible or  improper substance has
been taken, they will not be so beneficial as laxatives.   But
when fits are only apprehended in dentition, from starting,
feverishness, and circumstances ascertained by former ex-
perience to precede convulsions, a gentle emetic is often of
service, and  ought to be followed by the warm  bath and
some antispasmodic,  such as asafoetida, conjoined with a
laxative if necessary.   Tincture of asafoetida, with the ad-
dition of oil of anise is a very useful remedy, or we may give
tincture of hyoscyamus with oil of anise.  When it is deemed
proper to exhibit emetics  during the fit, a few spoonfuls of a
solution of sulphate of zinc may be given in quick succession,
as operating speedily and safely: or ipecacuanha  may be
employed, and the fauces tickled with a feather, to hasten its
operation.
  If the face be flushed, or the arteries of the  neck beat
strongly, it will next be proper to apply a leech to the fore-
head, and  avoid  stimulants; but if the face be pale, a few
drops of the aromatic spirit of ammonia may be given repeat-
edly, or a  little white-wine whey may be used in place of it.
   Opium is hurtful when the face is flushed; and even when
it is pale, is only useful  when there seems to  be considera-
ble  irritation about the bowels, or from the  gums.  Oil of
rue is strongly recommended by Dr. Underwood ;  and when
the fits are repeated, it will be proper to make use. of this,
or asafoetida, castor, or other antispasmodics.  The spine
should, in  such cases, be repeatedly rubbed with some stimu-
lant embrocation, or oil  of  amber, and a blister  should  be
applied to the head, after it  has been bathed for a time with
 cold vinegar.
   When a child  has  repeated convulsions, and almost con-
 stant moaning and  bending back of the neck or spine, the
 disease is  incurable, as it proceeds from water in the head.
 It may, however, be protracted for several weeks.   Repeated
 small blisters on the head, and the daily use of calomel, may
 be tried in such  chronic cases, but at last, the only relief is
 obtained by opiates.
   VOL. II.                             R R 
306
  Trismus nascentium is not a very frequent complaint in this
country, but it is not uncommon in warm climates.   It makes
its attack within the first fortnight of life, very rarely before
the sixth day, and has been supposed by some to be connect-
ed with a costive state of the bowels, by others with the fall-
ing off of the navel string and the state of the  umbilicus.*
In some instances, the spasm is confined to the jaw, which
is rigid and closed ;  in others it extends to the neck or trunk,
which  is stiff and bent back.  The disease  is very fatal, not-
withstanding that the warm and cold bath opiates,  purga-
tives, and blisters, have been  fully tried.   The state of the
navel should be attended to, and proper dressings applied, so
as to avoid irritation.
  After the period of infancy is past, and during the time
when the second set of teeth are coming out,  convulsions are
generally of  the epileptic kind, attack suddenly, the patient
screaming out as if terrified, and then he falls down convul-
sed.  Wrhen the fit goes off, the patient becomes nearly quite
well.   These do not indicate that the patient shall be subject,
after puberty, to epilepsy.   They are  relieved by attending
to the state of the gums, removing decayed  teeth,  and cut-
ting the gum over the grinder which is coming out, but espe-
cially by kcejping  the bowels open.  01.  succini,  valerian,
sea-bathing,, and tonic  medicines have  also  been  found of
service; .asafoetida or camphor given by  the mouth, or in
clysters, have  been  useful.   Convulsions have sometimes
been caused by impure  air, and  can only, in such  cases, be
relieved "by a removal  to a purer atmosphere.  This is a
fact which it may  be of service to remember.

  * Vide a paper by Dr. Bartram, in Trans, of Coll. of Phys. at Philadelphia,
Vol. I. p. 227. 
807
                       CHAP. VII.

                  Of Chorea and Paralysis.

  The convulsions called chorea sancti viti, attack children
most frequently from the age of eight years to that of puberty.
This disease makes its approach with languor, and dislike to
the entertainments of the age; a variable and sometimes very
keen appetite, in general continued costiveness, attended usu-
ally with a hardness  and swelling of the  abdomen, especially
at the lower part,  though occasionally the belly is flabby, and
rather small,  instead of tumid.   Sometimes the bowels are
open, but the stools are not of a natural appearance.  Pre-
sently convulsive  twitches and motions of the muscles of the
face take place, and  are succeeded by more marked convul-
sive affections of the  muscles of the extremities and trunk, so
that the patient cannot sit still, nor carry a cup of tea safely
to the mouth.   These are  often almost constant; even  when
the patient is  asleep,  the limbs are in motion, and the rest is
greatly disturbed.   He does not walk steadily, and sometimes
seems to be palsied, or the motion  may be very rapid, the
head  shaking like a rattle.   The patient is sensible during
the convulsive  motion.  At a more advanced, period, the
countenance becomes vacant, the  eyes  dull, the speech  is
affected, and, in some cases, the patient cannot even swallow
without difficulty.  Emaciation takes place, and a febrile state
may be induced.
  A variety of  remedies have been tried in this disease, but
none with so much advantage  as purgative medicines, which
have been prescribed with the happiest  effect by Camper,*

  *  " Having described the nerves, I now  come to  the symptoms, which
" are easily explained  by their connection.  I will begin with tremour of the
"feet, which is common in hysterical cases.  But I ought in the first place
"to  mention, that the  dreadful  hysterical symptoms, which we daily see
" either in individual parts, or in the whole body, are altogether dependent
" upon the accumulation of acrid matter in the prima: vise ; for the intolera-
" ble foetor, the scantiness and unnatural appearance of the fxces always warn
" us of an approaching paroxysm of rigours and convulsions. 
308
Sydenham, and Hamilton.  These, if given early, and before
the disease is fully  formed, will very effectually relieve the
patient, and at this  time they only require to be gentle, and
repeated, as the state of the bowels may require. But when
the disease is confirmed, « powerful purgatives must," as Dr.
Hamilton observes,  « be given in successive doses, in such a
" manner that the latter doses may support the effect of the
" former, till the movement and expulsion of the accumulated
" matter are effected, when symptoms of returning health
" appear."  Calomel  and jalap are useful purgatives in this
disease, and Dr. Hamilton is in the habit of using aloetic pills
on the days when these are not employed, which is a useful
practice  when the patient can swallow  pills.  My own ex-
perienpe  leads me decidedly to  agree with  Dr. Hamilton in
the employment of  the aloetic pills,  two of which may be
given three times  a-day, or according to the effect they pro-
duce.  Dr. Underwood recommends aloetic and  mercurial
purges. By these  means, chorea is often cured in a fortnight,
or, in obstinate cases, within two months.   Boys are said to
be more  readily cured than girls.  If no great amendment
take place soon, we  must not on that account desist,  but con-
tinue the  purging plan for  several weeks, and generally we
succeed at last  Tonic medicines are useful adjuvants, and
in obstinate cases, we must take the  assistance of  copper,
arsenic, and the other remedies which formerly were chiefly
trusted to for the cure of convulsions. The food should be light
and nourishing, and due exercise taken  in the open air.*
  Some children are apt to awake during the night scream-
ing violently,  or in  great agitation, as if in dreadful terror.

 « Ought  not purgative  medicines, and even the most drastic ones, to be
" exhibited ? they probably might cure spurious epilepsy, chorea sancti viti,
" and other spasmodic diseases, hitherto generally deemed hopeless by medi-
" cal men.**   Camper on the Pelvis, Chapter iii. section 7.
  • I can bear testimony to the decisive and superior efficacy of active and
continued purging in chorea.  Two cases of the disease in boys,  which had
been previously treated for several months by stimulants and antispasmodics,
without the least advantage, were perfectly cured by me in a very few weeks,'
by administering every two days; a powerful purge. C 
                          309

This proceeds from a dream, but the imaginary scene con-
tinues after waking, the child, for example, insisting that
snakes are crawling along the curtains.   This is cured by a
smart purgative, given every two  days for some time, and
avoiding much supper.
  A weak, or even completely paralytic state of one of the
superior or inferior extremities may take  place, in conse-
quence of a bad state of the bowels, in which case the stools
are offensive, and the belly tumid.  This is cured  by purga-
tives and friction.   But it may also proceed from some slight
pressure of the brain,  or  medulla spinalis, though no mark
of this can be discovered locally, unless it be that often the
head is  rather larger than  usual.   Sometimes one  arm ap-
pears to be either powerless or weak for many days, and
yet otherwise the child is in health.   This yields to a purge
and friction  with oil of amber.   In other  cases, one leg is
long  weak,  and  the  child drags  it slightly.   Whimsical
practitioners  have  mistaken this for  diseased hip-joint,
though  the bone were  precisely the same with  that  on the
other side.  It goes off in course of time, and only requires
the cold bath.                               *
  It has happened that children have had a distinct attack of
apoplexy, succeeded by palsy. This requires the same treat-
ment as in adults.                            t .  .
                    CHAP. VIII.

                       Of Croup.           /'

  The croup is  divided by some writers into two species,
the inflammatory and  spasmodic; but there is perhaps no
case of croup in which spasm is not to a certain degree com-
bined, only  in some cases the  inflammatory symptoms are
more prominent than in others.   The croup begins  with
shivering and other symptoms of fever, which, when the child
is old enough, can be very well described by him;  but in in-
fancy, we discover them by thirst, restlessness, starting, hm 
310
 skin, and a tendency to vomit.  Along with these symptoms,
 but sometimes for a day or two preceding them, the child has
 a dry hoarse cough.   In some cases, the attack  is very sud-
 den, the previous indisposition being short and scarcely ob-
 servable.   The local disease  manifests itself by  a  difficulty
 of breathing, attended with a  wheezing noise;  the voice is
 shrill, the cough is a very particular sound, somewhat  re-
 sembling the barking  of a little dog; others  describe it aa
 resembling a cough sounding through a trumpet.  It is not
 uncommon for vomiting  to  attend  this cough in the early
 stage.  The pulse from the first is  frequent, the patient is
 restless and anxious, and the face flushed, the eyes often wa-
 tery and inflamed, and the mouth frequently filled with viscid
 saliva or phlegm.  Very  soon,  especially in  those cases
 where the face is much flushed, a great degree of drowsiness
 comes on, from which the  child, however,  is frequently
 aroused by the cough, and fits of suffocation, and great agi-
 tation ; for this disease has exacerbations, during which the
 heavy  sonorous breathing is exchanged  for  a  violent strug-
gle, in which the child makes a crowing  noise, and  if old
enough, starts up, and  clings  instantly to the nearest object,
 and stares most piteously.  If the disease  be more mild, the
face in this remission is sometimes pale, otherwise it is flush-
 ed, and before death  it assumes  a  blue or  purple  colour,
whilst  the lips become livid;  in the  early stage they may
be rather  pale.  If it  do not prove suddenly fatal, the face
 and lips become tumid in the progress of the disease.  Con-
vulsions sometimes succeed the cough.
  The duration of the complaint is various ; in some cases
 it proves fatal in a few  hours, in others  not for a week, but
 most frequently in a day or two.  Much depends, in this re-
 spect,  on  the  degree  of inflammation,  the  violence of the
 spasm, and the strength and constitution of the child. Some-
 times there is much more of spasm than  inflammation in the
 disease, in wliich case we have  less fever, less permanent
 dyspnoea, and less frequent cough, but the attacks  of  suffo-
 cation are not  milder.  Those cases end best, where  the
 breathing is  least sonorous, the fever most moderate,  the 
311
cough early attended with expectoration,  and the  symptoms
seem at times to become so slight as to constitute intermis-
sion.
   Dissection has always discovered, on the inside of the la-
rynx, a lymphatic incrustation, or layer of membranous-look-
ing substance, which  is  sometimes coughed up  in consider-
able portions.*  This, though it adds greatly to the danger
and distress of the patient,  is not to be considered  as the
cause of the disease ;  for it is merely an effect of inflamma-
tion, which, together with spasm, could produce all the symp-
toms without its aid.
   The most frequent cause  is the application of cold and
damp.  Infants under six months are not often seized with
this  complaint, but from  that  period to the age  of puberty
are obnoxious to it.f   They are  peculiarly liable to it  soon
after being weaned.
   From the nature of the disease, blood-letting has been with
most practitioners a favourite remedy, and, doubtless, has of
itself cured the complaint.   In such cases, however, it has
 generally been pushed too far, and been succeeded by  great
 debility, for children do not bear much evacuation of blood, j:

   * This is too general an assertion. Dissection does not always discover
a membrane in the larynx.  On the contrary, I believe, it  is very rarely
found. Though I have examined many children who have died of the croup,
I have never yet met with it.  I  have sometimes seen a collection of inf.
pacted mucus, but never any thing which resembled, in the least,  a mem-
branous organization.  That the membrane of inflammation,  howevi r, occa-
sionally exists in the trachea I cannot doubt, as it has been mentioned by
very credible writers.  C.
   ■j- Croup sometimes occurs  even among people of advanced age.  Cases
 of this kind have  been repeatedly noticed by different practitioners in  this
 country.  C.
   $ If by this observation, the idea is meant to be conveyed, that children
 compared with adults are more apt to  sink under the loss of blood, it is not
 only, I  think,  erroneous, but in its practical tendency  exceedingly mis-
 chievous. During the  growth of the body, the  fluids, and especially the
 blood, in relation to the solids are larger in quantity, as is distinctly shown
 by a variety of circumstances.  This fulness of their vessels, and the  greater
 excitability of their systems, render children peculiarly liable to inflamma-
 tory affections.  Nearly all their diseases partake in some degree  of this
 character.  It follows, therefore, that they require oftener to be bled.  M\ 
312
 In the commencement of the disease", detracting blood, espe-
cially  if followed up by an emetic, will usually  be  found  of
 great service, and ought seldom to be neglected; but it is not
 to be  trusted to alone, neither should  it be employed late
 in the  course of the disease, nor even at an early period ought
 it to be repeated, if  the symptoms do not speedily seem   to
 yield to it.    If possible, the blood  should be taken by open-
 ing a vein, which is  generally very easily done even in in-
 fants.   If this cannot be done, leeches must be applied to the
 throat, but they are not equal to venesection.
   Emetics  have been greatly recommended by some, whilst
 others have little faith in their utility.  I have sometimes ob-
 served great benefit from them, if employed very early; and

own experience, confirmed by that  of other practitioners,  has perfectly  sa-
tisfied me, that blood-letting may be used with as much safety, and decided-
ly with greater advantage in  the complaints of children,  than in those of
adults.  If too, they do not at the time bear the loss of blood better, they un-
doubtedly  recover much  sooner from its effects.  The prejudice against
bleeding in children seems to have arisen out of the too prevalent opinion,
that owing to an extreme delicacy and frailty of constitution, they cannot
bear any vigorous impression.  As a natural consequence of this opinion, the
general practice in their complaints is extremely feeble, exactly, indeed, of
that kind whieU has been facetiously described as observing a strict neutra-
lity between the patient and the disease, neither declaring for the one nor
the other.  By no narrow or partial observation, I am thoroughly persuad-
ed, that the very contrary of this opinion is true.  Children, I have remarked,
display an uncommon tenacity of life, and strength of constitution. They
often survive under circumstances which destroy  adults.  They have been
found living at the breasts of their mothers who had perished by exposure
to cold  They resist contagion better than adults, and when attacked, more
certainly recover not only from contagious diseases, but from all others, if
properly treated. They also sustain better the operation of the most active
remedies, namely, of vomiting, purging, sweating, and blistering;  and, I
may repeat, bleeding.  These superior vital energies give,  moreover, to
children very extraordinary recuperative powers.
  Children recover confessedly, more speedily from wounds, and injuries,
and surgical operations.  They likewise recruit more rapidly after being re-
duced either by disease, or by remedies.  While there is any indication of
life, however discouraging the appearances may  be, I never consider  the
case of a child in an acute disease  as altogether desperate.  But still retain-
ing some hope, I continue to administer to  the restorative principle of the
constitution.   C. 
                          313

would advise them to be given in every instance.  Even in
the advanced stage of the disease, emetics do much service,
appearing mechanically to remove the lymphatic membrane.
Decoction of seneka, and preparations of  squills, have been
used to assist the expectoration of the membrane, but they do
not equal emetics for this purpose.
  Antispasmodics  have been  trusted to, almost exclusively,
by many;  but I apprehend that  their exhibition ought to he
confined to a different disease, which  I shall immediately
notice.
  Blisters  applied to the throat are useful remedies, and
should not be neglected.  The warm bath is also of service.
   Calomel would  appear to be  a most powerful remedy in
this disease, and,  if given early, it will most frequently save
the child.  I do not, however, recommend it to the exclusion
of other remedies, with which it  is by no means incompatible.
The early detraction of the  blood, followed by an emetic,
and the subsequent use of calomel,  will afford  the greatest
hope of removing the  disease.   But I  think it my duty to
state, that in some cases no alleviation was  obtained by any
remedy but the calomel; and in others it was trusted to alone,
 and with success.  To an infant of  six months, a grain and
 a half of calomel may be given every hour, until it  purge
 freely; to  a child a year old,  two grains; and  to one of two
 years,  sometimes even four  grains are given every hour,
 until the bowels are acted on, and the child purges freely or
 vomits repeatedly. The stools are generally green in colour,
 and their discharge is usually accompanied with an allevia-
 tion of the symptoms.   When this is observed,  the dose must
 be repeated less frequently, perhaps only once in two hours
 for some time, then still seldomer, and finally abandoned.
 Should the child be greatly weakened,  either by the disease
 or the medicine, the strength must  be afterwards carefully
 supported  by  nourishment and cordials.   It is astonishing
 how great a quantity of calomel is sometimes  taken in a
 short time, without affecting  the bowels, or purging violent-
 ly afterwards.  Occasionally above  100, and often  50 or 60 
314
grains arc given in this disease.  Salivation is not produced
in children.(r)
   That excellent and  experienced practitioner, Dr. James
Hamilton, jun. to whom we are chiefly indebted for the intro-
duction of the use of calomel in croup in this country, from
the practice of Dr. Rush,* is extremely unwilling to bleed chil-
dren freely in their diseases, from its subsequent debilitating
effects; and in croup, begins at once with the calomel, after
having used the  warm bath.  He observes that  « in every
case where it was  employed previous to the occurrence of
lividness of the lips and other mortal symptoms, (amounting
now to above forty) it has completely succeeded, both in cur-
ing the disease,  and in preventing  any shock to the child's
constitution."  He  adds,  that he has now seen  two cases,
where, although the  croup was cured, the patient sunk from
weakness;  and  therefore very properly gives a  caution to
stop the calomel, whenever the symptoms begin to  yield.  The
alleviation in true croup follows the  discharge of dark green
stools, like boiled spinage; in spasmodic croup, it takes place
whenever vomiting has occurred.   When  much  debility is
produced, he, besides using  cordials, applies a blister to the
breast.  I have a high opinion of the efficacy  of calomel, but
I cannot speak by any means so strongly as Dr.  Hamilton $
for even when it was early, pointedly, and exclusively em-
ployed, and brought away green stools, I have known it fail;
and deem it my  duty  most  earnestly to  caution the reader
against trusting to it exclusively; at the same time I must add,
that I have known it procure recovery  from  very desperate
cases, even without evacuation by stool; and  when, after a

  (r) This assertion  may be considered as generally  correct, but notwith-
standing, instances have occurred of sahvation being produced in children by
mercury; and when  this is unfortunately the  case,  it is apt to be attended
with the most unpleasant symptoms, sometimes threatening gangrene, and
requiring the most assiduous care and attention of the  practitioner.
  * Mr. Burns has erroneously ascribed to Dr. Rush the credit of introduc-
ing calomel in the treatment of croup.  As far as I have been able to ascer-
tain, it was first employed in this disease about forty years ago by Dr. Kuhn
of this city, to whom the practice of physic is indebted for some of its most
valuable contributions.  C. 
315
great quantity of calomel was given and relief obtained, it
was necessary to open the bowels by clysters.  Calomel has
been combined with ipecacuanha to produce vomiting, but I
cannot satisfy myself that I have ever seen this combination
do more good than either of the medicines would have  done
singly.
   Spasmodic croup, or acute asthma, is often,  but not neces-
sarily  connected with inflammatory croup.  There is, per-
haps, no case of the latter disease which is not attended with
spasm of the muscles  of the larynx,  but there are many
cases of spasm without inflammation; yet if the spasm con-
tinue long, there is a great risk of inflammation taking
place, and  of a membrane being  formed. The spasmodic
croup attacks children chiefly, but it may also affect women,
especially about the  age of  puberty,  and harass them oc-
casionally for many  years afterwards.  It makes its attack
very suddenly,  generally at night, and sometimes for  many
 nights in succession, especially  if the child be agitated, or
 the mind of the young woman anxious respecting it.  The
 patient breathes with difficulty,  and with a wheezing sound,
 has a hard barking cough, with paroxysms of suffocation, as
 in inflammatory croup.   The extremities become  cold, the
 pulse during the struggle is frequent, but in the remission it
 is slower; and if the remission be great, it becomes natural,
 unless kept up by agitation.  There is little or no  viscid
 phlegm in the mouth, no  drowsiness, but  rather terror, and
 the eye stares  wildly during the paroxysm.  The disease is
 often suddenly relieved by sneezing, vomiting, or eructation.
 It differs, then, from the  inflammatory croup, in the sudden-
  ness of its attack, in there being little fever, but only quick-
  ness of pulse, greatly abating when the child does not strug-
  gle for breath; no drowsiness, and little phlegm about the
  mouth.   The  cough is  less shrill, and the fit often goes off
  suddenly  and  completely, either spontaneously, or by the use
  of the remedies acting quickly.  Sometimes, however, inflam-
  mation  takes  place,  and this  disease is,  in infants, very
   readily converted into true croup. 
316
   It is at times brought on  by exposure to cold, and in that
case, it  is occasionally preceded by  slight sore throat, or
hoarse cough; but oftener  the spasm comes on without any
precursory symptoms. Sometimes it is excited by dentition,
or, if the patient be older, by passions of the mind.   Not un-
frequently, a renewal of the disease is excited in those who
are subject to it, by eating a full meal in the evening.
   With regard to the treatment, I shall briefly state the re-
sult of my observation.  In young girls, venesection has uni-
formly given relief, the spasm suddenly  abating, and very
soon going entirely off, after a certain quantity of blood  has
flowed.   Topical blood-letting has not the same effect.  But
if the paroxysm should  be repeated for  many  nights, this
remedy cannot be employed on every attack, as it debilitates
and predisposes to the disease.   Emetics, such as sulphate of
zinc, have the same effect with blood-letting in general;  but
sometimes the fit, though impeded during their operation, re-
turns, and in such cases has yielded to  venesection.  Oc-
casionally the emetic  has  been very long of operating, the
stomach not being easily acted on ; and in those cases, blood-
letting has produced speedy  vomiting and  immediate  relief.
Opiates, and antispasmodics,  such  as ether, given in large
doses, have, if exhibited in the very commencement of the at-
tack, sometimes checked it,  but have not always that  effect,
and, if not given soon, are longer of procuring relief.   With
regard to the effect of calomel in croup affecting girls and
women, I  can say  nothing; for the paroxysm is so severe,
that we cannot and must not trust alone to its operation.
  A relapse  is to  be  prevented by giving purgatives, and
avoiding exposure to cold  damp air. In young girls, a course
of tonic medicines alone, or combined with asafoetida or va-
lerian, will be useful;  and when the attacks have been kept
off for some time, sea-bathing will be proper.
   With infants we generally succeed by giving instantly an
emetic, and afterwards calomel in considerable doses, so as to
produce sickness and  vomiting, or free purging.   But if the
emetic do not decidedly mitigate the disease, then, in place of 
317
trusting solely to the calomel, we premise if possible venesec-
tion. Asafoetida* has been strongly  recommended in this dis-
ease, and has sometime a very good effect.  The warm bath
is also useful.   If the child be about the period of  dentition,
the gum should be examined,  and cut if tumid.   If the dis-
ease do not  soon  yield to these  remedies, there  is ground to
suppose  that  it  will be  converted into the  other  species of
croup;  but this affects the prognosis  rather than  the treat-
ment.!

  • Dr. Millar has given an ounce of this gum to  a  child of eighteen
months old in forty-eight hours, and almost  as much at  the same time in
form of clyster.  His formula is as follows; R. C. asafoctidx, Jii, Spt. Min-
dereri, ?i, Aq. puleg. ?iii M. s. a.  A table spoonful of this is to be given
every half hour.  Vide Observations on Asthma, p. 43.
  f The  practice  recommended by Mr. Burns is nearly the  same as that
which prevails in this country.  Though the distinction of inflammatory and
spasmodic croup is undoubtedly well founded, yet I am not aware,  that it
leads to any practical difference.  My mode of treating this disease is as fol-
lows.  I begin by  endeavouring to puke the child very  freely, and for this
purpose I commonly employ the tartarized  antimony, given at short inter-
vals, as being one of the most certain and powerful  of the emetics.  At the
same time I direct the child to be put into the warm bath  for ten or fifteen
minutes.   This is a useful remedy.  It rarely fails to promote the operation
of the emetic, and will, indeed, alone sometimes cure the disease.  If, how-
ever, the emetic does not operate, or if after its operation, the anticipated
effect be not realized, 1 then bleed copiously,  and repeat the bath and the
emetic.  The attack must be extremely obstinate  if it do not now yield.
Nevertheless, it will occasionally continue with little or no abatement.  Un-
der these circumstances, I resort to topical bleeding either by leeches, or by
cups, and afterwards, if necessary, apply a blister, or sinapism of mustard to
the throat; extending from ear to ear.  If the preceding remedies fail,  or
the symptoms be so alarmingly violent as to demand immediate relief,  I bleed
ad deliquium  animi.  When pushed to this extent, I may  almost say that
blood-letting in these cases is invariably successful.  I learnt this practice
from two of the most distinguished physicians  of our country, who seem to
have employed it nearly about the same time. I allude to Dr. Belville of
Trenton, and  Dr. Dick of Alexandria.  After the  force of the disease is
 broken,  which is shown by the alleviation of the hoarseness, and of the diffi-
cult respiration, and above all by the restoration of the natural susceptibility
 of the system to the action of medicine, I administer calomel, not in small
 and repeated doses as is more generally advised, but in  the largest possible
 dose, in order that it may speedily and most actively purge.  In this partica- 
318
   Soiine children are subject  to slight wheezing, continuing
for a day or two, with  intermissions, and accompanied with
a hoairse cough, but without  fever.   Emetics, laxatives, and
a  large burgundy pitch plaster, applied to the back, remove
the disease.
   Infants during dentition are subject to sudden  attacks of
spasm  about the windpipe, producing  a  temporary feeling
of suffocation with  a crowing sound,  but there is no hoarse
cough.  It is apt to take place suddenly at  night, or  when
crying.  It is relieved  by rubbing the throat well with ano-
dyne balsam, or laudanum, and giving a combination of tinc-
ture  of asafoetida  and of hyoscyamus.   The warm bath is
also useful.   The gum  should be cut.
                          CHAP IX.

                      Of Hooping-Cough.

   The hooping-cough often begins like  a common cold, the
 child coughing frequently, and having more  or less fever.

Iar stage of the disease, a thorough opening of the bowels carries off the
lingering symptoms, obviates a relapse, and confirms the convalescence.
But if cough, or hoarseness, with tightness of the chest and deficient expec-
toration remain, I employ the decoction of the polygala senega as an expecto-
rant. It is in extinguishing the remains of croup that it displays, I think, its
best properties.  Doubtless, however, it may be used at an earlier period of
the disease with advantage as an emetic. But  still I prefer the emetic tar-
tar.  I have recently heard that croup has been very successfully treated by
a watery solution of corrosive sublimate, by large quantities of melted lard
or ohve oil given internally, and by common mustard in the state  in which
it is used at our tables.   Of the latter, a tea-spoonful is given to a child, to
be repeated if required.  Its operation in spasmodic croup especially, is re-
presented to be most decisively useful.  I have  not tried, nor am I disposed
to try any one of these remedies.  They each come to me, however, recom-
mended by very respectable authority.  With the  remedies already known
to me I rest satisfied.  These in my practice have rendered croup the most
curable of all the violent infantile diseases.  C. 
319
In some cases the fever is slight, going off in the course of a
week,  in  others very severe  and long continued, attended
with great oppression or  sickness, and  want of appetite.
The cough generally comes on  very abruptly, and is some-
times early attended with that sonorous spasmodic  inspira-
tion, denominated hooping, in  other cases,  not for a consi-
derable time, and this is considered as a favourable circum-
stance, but it is not always so,  for in young children, death
may take place,  although  the  disease  never  fully form.
The fits are generally most frequent, and most severe during
the night.  When the cough becomes formed, the paroxysm
consists of a number of short  expirations, closely following
each other, so as to produce a feeling of suffocation, relieved
at last for an instant, by a violent, full, and crowing inspira-
tion;  then in general the  cough or spasmodic expirations
recommence, and the paroxysm, consisting of these two parts
continues until a quantity of phlegm is coughed up or vomited,
alone, or with the contents of the stomach, and this ends the
attack.   The  expirations sound like a common cough, but
are more rapid, and frequently repeated as in violent laugh-
ing.  Sometimes the sound is lower, or the cough resembles
the chattering of  a monkey, quickly repeated.   These pa-
roxysms vary in frequency and duration.  Sometimes they
are slight; at other times, and especially during the night,
they are attended with a most  painful sensation, and appear-
ance of suffocation,  the  face  becoming turgid and  purple,
the sweat breaking,  and  blood gushing  from the  nose or
other parts.   The  extremities become cold  during  the fit,
and the whole frame is  much agitated.  But even severe as
the paroxysms are,  if the disease be not attended with fever,
the patient seems quite  well after the fit,  and begins to eat
with a renewed appetite.  A fit of crying will at times, even
after the  disease  has been apparently removed, excite tiie
cough.   The features often remain swelled for a considerable
time.
   Hooping-cough is very dangerous for infants, as they often
die suddenly in a  fit of suffocation; elder children escape
more safely, though even they are sometimes carried off, tit** 
320
fever continuing, or anasarca coming on, with exhaustion.
Sometimes the lungs become diseased, and hectic fever takes
place, or peripneumony is produced, or the lungs become
cedematous.  Convulsions may also occur and carry off the
child.
  Many remedies have been employed in this disease, which
it will be proper  to divide  into those intended to  abate  the
fever, and those  given to relieve the cough.  Venesection has
for the first of these purposes been  recommended; but it is
very rarely requisite, and only when the patient is plethoric,
and we apprehend that some vessel may burst in  the  lungs
from the violence of the cough, or when there are  symptoms
of inflammation.  Leeches may in these circumstances be ap-
plied to the chest.   The most generally useful remedies are
laxatives and the saline  julap,  which often in a few days
moderate the fever  greatly.  The tepid bath is useful, and,
if there be much irritation and restlessness, hyoscyamus
sometimes does good.
  For the  relief of the cough, nothing  is so beneficial as
emetics.  These have been  given in nauseating doses,  so as
to make vomiting be readily excited by  the cough; but, in
general, a full dose of ipecacuanha will be as effectual, and is
less distressing.   At first, the emetic  should be  frequently
repeated, especially to infants, perhaps  once a-day, or once
in two days, according to circumstances; and this degree of
frequency is by  no means  injurious.   Antimony  has been
highly  praised  by  many,  but it is more apt  to weaken the
stomach, and in  very young children it  sometimes produces
violent effects.   Stimulating substances, such  as a combina-
tion of soap, camphor, and oil of turpentine;  or juice of gar-
lic, or oil of amber, or of thyme, &c. rubbed over the spine,
or the thorax and the stomach, have a good effect; and similar
applications to the  soles of  the feet have certainly in some
cases done much good.  Antispasmodics, such as asafoetida,
ol. succini,  musk, &c. have been recommended, and in some
cases are  successful.  Opiates are  also of  service.  Dr.
Willan says, that he found  the watery infusion of opium
more useful than  any other narcotic.  When the  disease is 
381
protracted,  cicuta  has been recommended, but  it does not
seem  to  have any  advantage over opiu n, or hyoscy&mus.
It has also been applied externally.  The most effectual re-
medy, however, is change of air, which often has a marked
effect  on  the disease in a few hours.  When the patient be-
comes restless, and coughs more, it should again be changed.
The diet ought to be light.  If there be fixed  pain in the
chest, difficulty of breathing, and fever indicating inflamma-
tion, either venesection or leeches, according to the age and
circumstances of the child, will be  absolutely necessary; but
our evacuation must be prudently conducted.  Blisters, and
digitalis in such cases are useful.  Pain produced merely by
the violence of the cough, remitting or going at times en-
tirely off, and generally seated about the upper part of the
sternum, is relieved by those means which relieve the cough.
  When the paroxysms have been very  severe,  the  breath-
ing oppressed, the cheeks livid,  and the pulse  very weak,
some children have been saved  by  the application of leeches
to the chest, blisters, and small  doses of the compound powder
of ipecacuanha.
  When  the  patient is threatened with hectic, or becomes
emaciated and weak, nothing is of so much benefit as  coun-
try air and milk diet, at the same time that  we  keep the
bowels open.  Blisters  should be applied to the  breast,  if
there be fixed  pain  or dyspnoea.  If there be anasarcous
swelling, the digitalis, conjoined with cordials, will be useful.
   Convulsions sometimes are excited by the fits, or occur at
the same time with them, and immediately suspend the cough.
They are very  alarming, and may suddenly carry off the
infant, especially if he be very  young.  The child  should in-
 stantly be put into a warm  bath,  which  is to be repeated  as
 often as  the convulsions come on.  The bowels  should  be
 opened,  the head shaved and blistered.   If the fits be repeat-
ed, and if the child be plethoric, leeches ought to be applied to
 the temples.  The air ought also  to be,  if possible, immedi-
 ately changed.   In some cases, tincture of hyoscyamus given
 in a  mixture, or clysters containing camphor, seem to allay
   VOL. II.                        t T 
322
the tendency to spasm ; and in every instance, it is proper to
rub the back and belly with anodyne balsam.
  If the cough return after it has gone off for a time, a gentle
emetic is the best remedy.*   A sudden change of  weather
from  warm to cold, is very apt to renew the cough.  If the
face or lips remain swelled, gentle laxatives are proper.
   During the continuance of the disease,  the diet must be
light,  but nourishing, if the patient be weak: but more spar-
ing at first if he be on the other hand plethoric, and inclined
to inflammation.  Toward the conclusion of the disease, bark
and tonics are useful to re-establish the health.
  There is a cough very like hooping-cough, and which gives
rise sometimes to the groundless  fear that the child  is going
to take that disease; or on the other hand, if somewhat pro-
longed,  it may pass for hooping-cough; and afterwards, the
child being exposed to infection, takes the disease, and is said
to have  had it twice.   This  kind of  cough has  less  of the
suffocating appearance than the hooping-cough; the expira-

  • Like  most other contagious diseases, the hooping-cough  will run its
course in spite of all our exertions to cure it. We can, indeed, do little more
than mitigate the more violent symptoms. Among the best of the palliative
remedies is a watery solution of asafoetida.  Where the  cough is attended,
as is sometimes the case, with convulsions, the sulphate of zinc may be given
with advantage.  A combination of the salt of tartar and cochineal, said to
have been originally suggested by Dr. Pearson of London, has lately become
a very popular remedy in this city.   This, however, is not the prescription
of Dr. Pearson.   His is as follows:
                    R. Carbon, sod: gr. iii.
                      Vin. ipecac, gtt. v.
                      Tinct. theb. gtt. i.
                      Aq. font. Zj.
To be given to a child a year old every three hours.  I have tried both the
alkalies but with little success.  I am sure that the above mixture derives its
efficacy, if it have any, from the laudanum and ipecacuanha which it contains.
The tincture of cantharides united  with the  decoction of bark, and elixir
paregoric has been highly extolled by Dr. Lettsom.  I have  no  experience
with it Emetics, on the whole, I think are our best means in this disease.
They should be given in the first stage of it, and be repeated at least once
a-day whilst the violent symptoms continue. Bleeding and blisters are occa-
sionally useful.   C. 
323
tions are fewer, and do not follow each other so quickly, and
the inspiration is not performed so rapidly, and with the dis-
tinct hooping sound.   It sometimes  succeeds measles, or ap-
pears as a kind of influenza.  It is  cured by an emetic and
anodynes.
                       CHAP.  X.

Of Catarrh, Bronchitis, Inflammation of the Pleura and of the
                         Stomach.

  Infants are subject, as in after life, to catarrh, either com-
mon or epidemic.   It is attended with fever and inquietude,
redness of the cheeks, watery discharge from the eyes and
nostrils, disposition to sleep, frequent, and sometimes irregu-
lar pulse, panting and shortness  of  breathing, with frequent
cough, which, however, is not severe.   It generally goes off
within a week, by the use of gentle purges,  blisters, anti-
monials, and, if the fever be considerable, leeches applied to
the breast.   A hoarse barking cough, is cured by an emetic,
and wearing flannel round the throat.*
   Bronchitis is far from being an uncommon disease of in-
fants.   It  sometimes takes place very early after birth; in
other instances not for several weeks.   It begins with cough
and pretty copious secretion of mucus  or  phlegm, which,
however, the child will not allow to come out of  the mouth,
but swallows.  The cough is frequent, but not uniformly so,
coming on in paroxysms.   It is  of  stifled sound, and some-
what hoarse, or occasionally even shrill, from slight inflam-
mation at the top  of the windpipe. The breathing is oppress-
ed or rattling, but not permanently so. Vomiting  is also
not an  uncommon attendant, the epigastrium is distended,
the stools are  generally bad, the face is pale, and the child

  * Blood-letting, and that too pretty profusely, is very often required to
cure the catarrh of children, in this country. As it appears here, it is gene-
rally a highly inflammatory disease.  C. 
                          324

sick and oppressed.   He takes the breast, but  dislikes  all
meat.  Presently, if death be not produced by the accumula-
tion of phlegm, the secretion becomes more of a purulent ap-
pearance.  The respiration is more oppressed, and the noisy
breathing is more frequent.   The hand3,  but especially the
feet, swell a little, whilst the body becomes emaciated.  The
cheeks are occasionally flushed in the evening, and the pulse,
which was always frequent, becomes still more so, and irre-
gular.   The fits of  coughing are severe, and attended with
appearance of  suffocation, and  at  last the child dies.  On
opening the body  we  find the ramifications of  the trachea
filled with purulent-looking matter, and in some parts there
is an approach towards the  formation of tubercles.  The
lungs are sometimes paler than usual, in other instances more
solid.                            •
  This is a very  obstinate disease, but it does not prove very
rapidly fatal.   In the  commencement it resembles common
catarrh, and requires the same treatment, purgatives, vene-
section  and a  blister.  In the  advanced stage, and under
various circumstances, I have tried  emetics, blisters, calomel,
and  expectorants, but  without  decided  benefit.  Blisters,
with calomel, combined with ipecacuanha, to act both  on the
bowels and also as an expectorant, together with a removal
to the  country, appear to constitute the best practice.  I
think it right to  mention, that though the pectoral disease
may be  slight,  yet  by the sickening  effect of a purgative,
especially castor oil, great panting, paleness, and other ap-
pearances of  danger, have been produced,  which have  all
gone off  after having the bowels opened freely by a clyster,
which brought off the purgative.
  Inflammation of the pleura is more  frequent with children
than many suppose.   The skin is very hot, the face flushed,
the pulse quick, the breathing short and oppressed ; there is
a cough,  aggravated  by crying, motion,  and by laying the
child down in bed.  He is likewise more disposed to cough,
and is more uneasy on the one side than the other.  If not re-
lieved soon, the breathing becomes laborious, the extremities
cold, the cough stifling, with rattling in the throat and stu- 
325
por; or  the pulse becomes irregular and  intermittent, the
extremities swell, the countenance  is  sallow or dark-colour-
ed, the breathing difficult with  short cough, and frothy ex-
pectoration, which oozes from the mouth.  On inspecting the
chest, the inflammation is sometimes found to have terminat-
ed in hydrothorax,  oftener in  adhesions.  This disease re-
quires venesection, or the early  application  of leeches to the
sternum, according to the age and constitution of the child;
the use of blisters, calomel, purges, and the tepid bath.  An-
timonials and digitalis are also  sometimes  of service.*   In
the last stage, diuretics are proper, especially a combination
of squills and digitalis, whilst the strength is to be supported
by the breast-milk, or light diet.f
   This disease sometimes terminates in  abscess and  puru-
lent spitting, with  hectic; but much more frequently, the pul-
monary  consumption  of infants and children begins, as in
adults, more slowly, is marked  by a  short  dry cough, flush-
ings of  the face,  frequent small  pulse,  difficult breathing,
wasting,  and  nocturnal  sweats.(s)   The  expectoration  is

  * This disease is to be treated exactly as pleurisy  in the adult. If the
attack be violent, the child will probably  require to be bled two or three
times. Blisters should not be apphed till the  disease is somewhat reduced.
Previously, they always do injury.  The pulse here, will be one of our best
guides. C.
  f The decoction of the senega snake root is ah admirable remedy in this
stage of the disease. C.
  (*) It may be proper here to observe, that the infantile cough above de-
scribed by our author, is often dependent on a scrofulous diathesis of the
system; this is very fully illustrated and explained by Dr. Parrish, in an in-
teresting paper, inserted in the Eclectic Repertory  for January, 1812, en-
titled, " An Account of the Appearances on Dissection of several scrofulous
subjects, with a few observations on the connexion  between, scrofula  and
phthisis pulmonalis."  Dr. Parrish  has denominated the disease scrofula in-
terna, and has found by an accurate examination after death, that not only
the abdominal viscera and the lungs are occasionally  affected with scrofula,
but that even " the heart itself is subjected to this destructive inalady."  In
these cases he supposes that a metastasis, or a translation of scrofula from
the  external  to the internal parts  may take  place, and that by endeavour-
ing  to produce a reverse effect, the internal  disease may be palliated or
 cured.
   From the decided effects produced by the discharge from blisters on each 
326
 generally swallowed, but sometimes *it is ejected, or  it  is
 vomited up, and is found to be purulent. There is seldom any
 cure for this state;  all  that can be done is to send the child
 to the country, apply small blisters to the breast, keep the
 bowels in a proper  state,  give a  mixture containing opium
 and digitalis, and support the strength  with suitable nourish-
 ment.  If the expectoration be only phlegm, then, although
 all the other symptoms be present, there is considerable hope
 of saving the child.   But  if it be purulent,  and the parents
 are consumptive, the danger is  much  greater.  This state,
 however, does not in general succeed pleurisy. It is general-
 ly induced more slowly, by tubercles, accompanied with en-
 largement of the bronchial glands.*
   Inflammation of  the  stomach  is not a common  disease  of
 infancy, nor is it discovered without considerable  attention.
 There  is  great fever, frequent  vomiting, the  mildest  fluid
 being rejected soon  after it is swallowed, the throat is first
 inflamed, and then covered with aphthae, which spread to the
 mouth.  The child cries much.   The region of the stomach
 is full and very tender to the touch. The bowels are general-
 ly loose.   If the  child  be old  enough  to describe his sensa-
 tions, he complains of heat or burning about the stomach and
 throat;  if younger, he directs the hand frequently to the

side of the thorax, in checking the progress of the cough, dyspnoea, &c.  he
thinks it would be eligible at the very commencement of the disease, to en-
deavour to produce tumefaction and suppuration in the glands about the
neck and on the thorax, near the axilla, where external scrofula is generally
seated. " Would this attempt, he asks, to excite disease in these parts
which [if the expression is allowable] external scrofula chooses for its seat,
be more irrational than the application of sinapisms to the lower extremities
in irregular or retrocedent gout >"  Hence, he seems inclined to think, that
the use of setons and issues, have fallen too much into  disuse.  We would
recommend to the student, the attentive perusal of this paper, as justice can-
not be done to  it in the short and imperfect abstract of a hasty note.
  * Although it is not exactly connected with my present subject, I may
mention, that sometimes  the bronchial cells are much enlarged, the child
has cough and difficult breathing.  The air escapes, and passes from the
root of the lungs to the  mediastinum, insinuating itself betwixt its layers,
and thence to  the neck, where it produces emphysema.  Punctures ought
immediately to be made. 
327
stomach and breast.  There is sometimes,  from the first, a
cough and short breathing, but the constant vomiting shows
the disease to be in the stomach.   It is not easy to say what
causes this, for it cannot always be traced to acrid or stimu-
lating substances swallowed.  It  is proper immediately  to
bleed or apply leeches to the pit of the stomach, according to
the age and strength of the child ;  then a blister is to be ap-
plied, and stools are to be  procured by  calomel.   Fomenta-
tions and the warm bath  are also useful.   M. Saillant re-
commends the  juice of lettuce,* to be  given in spoonfuls
every hour, but I do not know any advantage this can have
over mucilage and opiates.  The disease is uncommon, but
when it does  occur,  is apt to be  mistaken for a  disordered
state of the stomach and bowels, producing aphtha.f
   There is another state of the stomach, which, from the soft-
ness of the texture, is apt, after death, to be confounded with
gangrene.  There  are, however, no marks  of inflammation ;
but the stomach seems as if it had become so soft by macera-
tion, that it gives way  on  being handled. This state is some-
times confined to one part of the stomachy sometimes it ex-
tends even to the small intestines,  and more than one child in
the same family have died of this disease.   It is not easily
discovered before death, for its most prominent  symptoms,
namely, purging, with griping pains, occur in other diseases
of the bowels,   It is, however, very early attended with cold-

   • The juice of lettuce is a very powerful anodyne.   By inspissation an ex-
cellent opium may be procured from it. If it be useful in the  above disease,
it is probably owing to its anodyne property. C.
   | In all cases of this affection, except very slight ones, bleeding is indis-
pensible.  Inflammation in any portion of the alimentary canal runs very
speedily to gangrene, which can only be avoided by a pretty free use of the
lancet. The pulse here, as in many instances, is a very fallacious guide.  We
are not to expect to find it much altered.  In general, it is lower and more
feeble than in health, and this too in proportion to the violence and extent
of the inflammation.  C.
   t Dr. Armstrong mentions a case of this kind, where the  upper part of
the stomach was thus diseased,  but the pylorus sound.  The stomach was
distended with food, but the intestines were very empty, which might b"
 owing to diminished power of contraction in the stom^-l 
328
ness of the face and extremities, and  the countenance  is
shrunk and anxious.   It affects the intestines oftener than
the stomach.  This state of the stomach cannot always be
attributed to the effect of the gastric juice. When the stomach
is acted on by this solvent after death, we find that it is very
soft, some of it in a state of semi-solution, the inner surface
being dissolved  and some of it actually removed, so as  to
make a hole.  When  the preparation is put into spirits, and
held between the eye and the light, the flocculent appearance
of the inner surface is distinct, and numerous globules are
seen within the peritoneal coat, which are probably the glands
undissolved.
                      CHAP. XI.

                      Of Vomiting.

  Vomiting is very seldom an idiopathic disease of chil-
dren. Many puke their milk after sucking freely, especially
if  shaken or dandled.  This is not to be  counted a disease,
for all children vomit more or less under these circumstances.
A fit of frequent and repeated vomiting,  soon after sucking
or drinking, if unattended  with  other  symptoms, and the
egesta are of natural appearance, may be supposed to depend
on irritability  of the stomach, wliich can  be cured, by ap-
plying to the stomach a cloth dipped in spirits, and slightly
dusted with pepper, or an  anodyne plaster.   Sometimes a
spoonful or two of white-wine whey settles the stomach.  If,
however, the egesta be sour or ill-smelled, and the milk very
firmly curdled like cheese, and the child is sick, it is proba-
ble that more of that caseous substance remains, and a gen-
tle puke of ipecacuanha will give relief.  On the other hand,
should the egesta be green and bilious, gentle doses of calo-
mel will be serviceable, especially after an emetic.  The sick-
ness which sometimes precedes vomiting, especially if it be
<aused by bile, is  accompanied with great oppression, pant- 
329
ing, deadly paleness, and an appearance altogether as if the
child were going to expire.   The relief given in this state,
by vomiting, is great and sudden.
  Vomiting, connected with purging or febrile disease, is to
be considered merely  as symptomatic.  It is, however, de-
sirable to restrain it, which is done by  giving small doses of
saline julap, and removing the primary disease.   Sometimes
the oesophagus is  found  ruptured in children, and the con-
tents of the stomach poured into the thorax.  This probably
happens from spasm taking place at the upper part of the oeso-
phagus, whilst the stomach is rejecting its contents.
                      CHAP. XII.

                      Of Diarrhoea.
                              *
  When we  consider the great extent of intestinal surface,
its delicacy, and the intimate connection which exists betwixt
the bowels and other organs, we shall not be surprised at the
powerful and important effects produced on the system at
large, by disorder of the alimentary canal.
  In attending to diarrhoea, we must examine the structure
of the intestine, and the purposes it is destined to perform.
The bowel itself consists of muscular fibres, of glandular ap-
paratus, of nerves and blood-vessels, and of a system of lacteal
vessels, which probably do more than absorb, assisting also,
by glandular action, in the formation of chyle, which does
not perhaps  exist in a perfect state in the contents of the
bowels.  Now, although these different parts tend to consti-
tute  one organ, yet they are not so blended in action, that
all must be alike affected when the organ is deranged.  All
may be disordered, but one sooner, and to a greater degree,
than the rest.  The  fibres may be excited to inordinate ac-
tion, producing rapid  contraction, and speedy expulsion of
the contents; and this may, or may not be accompanied with
spasms and great pain.  The exhalents may be greatly af-
  voi..  it.                           r v 
330
fected, producing  copious discharge of intestinal secretion,
which  may  be watery, mucous, slimy,  or, when the vessels
are  abraded or open, tinged w ith  blood.   The absorbents
may have their action impeded,  and the chyle is not duly ab-
sorbed.  The injury of one of these systems of organization
not only affects the rest, but this intestinal disease influences
parts immediately  connected with the intestines, such as the
stomach, liver, pancreas, he.   This leads us to consider the
contents of the bowels.  If the food be good, and the stomach
digest properly, the chyme is good and natural. But if the
food be bad, or in exuberant quantity, or the power of the
stomach be impaired, the chyme is not properly formed, and
the food is found in the intestines not thoroughly changed or
digested; perhaps little altered in  its appearance.   If the
bowels have the same torpor with the stomach, it is  retained,
and forms accumulations, ending in great mischief.   If the
bowels  be  irritable, as in  diarrhoea, it is generally passed
speedily.  The egesta from the stomach arc naturally mixed
with the bile, pancreatic juice,  and intestinal secretion;  and
the colour of the compound is yellow or yellow with a brown
tinge; and during its passage downwards, a certain quantity
of gas, possessing  a peculiar smell, is extricated.*  In young
infants, however, when they are properly suckled, the stools
are somewhat different from their state at  a  more  advanced
period. They are of a yellow colour, are something like cus-
tard, or are  curdy, and have by no means the offensive smell
they afterwards possess.   If the stools have a very curdy ap-
pearance, or are too  liquid, or green or dark-coloured, or ill-
smelled, they are  unnatural.   The  changes effected in the
passage of the chyme are not merely chemical, but dependent
on animal action; for the contents of the stomach, mixed
with the fluids found  in the intestines, and exposed to the
same degree of heat, will not form natural-looking faces, but
the substances will simply assume the acetous or putrefactive

  * Both the smell and the colour of the faeces are found to depend greatly
on the bile. When the bile is  obstructed, the stools are clay-coloured or
pale, and have not the feculent smell. 
                            331

fermentation.  If the powers of the stomach and intestines
be impaired, then this fermentation goes on to a great degree
in the stomach and bowels, much gas is extricated,* inflation
is produced, and the aliment becomes sour or putrid.   If too
much bile be added, the faeces are green, sometimes dark-co-
loured.   This redundancy of bile may be produced by causes
acting immediately on the liver, at least not through  the in-
terposition of the intestines, and the bile comes even to be a
source of irritation to the bowels, and excites diarrhoea ; or
the affection of the bowels  may  influence the liver, and ex-
cite it to a greater secretion.  Some children are more bilious
than others, and are subject to fits of paleness, sickness, and
bilious vomiting.   The pancreatic juice and intestinal secre-
tion,  when not changed in quality, but only increased in quan-
tity,  are  probably not, like the bile, a source  of irritation,
but only the produce of it.  But these discharges, sometimes
mixed with bile, sometimes  with blood effused from  a small
vessel, may accumulate, together with the egesta of the sto-
mach, and  form a  black, pitchy-looking substance,! which
sooner or later produces  very bad effects. In  other instances,
these form a more watery substance, which is passed off with
griping, and purging of stools like moss water.
   The colour of stools in diarrhoea varies  according to the
violence of the disease.   In slight cases, where the action of
the bowels is only  increased  in degree,  but not altered in
kind, and the stomach is not injured, the faeces are of a yel-
low colour,  but thin, owing to the increased discharge, and
have not run into fermentation.  When in  children the di-
gestive faculty is somewhat impaired, and the aliment is im-
proper,  fermentation goes  on  more strongly,  and the faeces
   * Vauquelin has ascertained, that the  stools are always more or less acid.
When exposed to the air, they become more acid, and soon afterwards  ex-
hale ammonia, which they do till destroyed.  The greatest part of the  gas
extricated in the bowels consists of carbonic acid, with carbonated and sul-
phurated hydrogen, more or less foetid.  In indigestion, the greatest part of
the gas is inflammable.   Fourcroy's System, &c. Tom. X. p. 75.
  | The decomposition of bile by acids, wliich combine with its  soda, fur-
nishes a precipitate, which is  thick, viscid, very bitter, and inflammable.
This is probably the origin of pitchy-looking stools in some cases, though
in others they may proceed from effused blood. 
332
contain more acid than  usual, which, although the bile  be
not increased in quantity, may give them a green colour,*
and the intestines are distended with air. Very green stools,
however, imply  a redundancy  of  bile, and the darker the
shade of green the greater is the quantity of bile.   When the
irritation is great and universal, the stools are very watery,
and of a dark green colour; or if the irritation be still greater,
they are brown; and in either case, if the child  be on the
breast, portions of coagulated  milk are found swimming in
the fluid;  if not, we  have either bits of any solid food taken
by the child, or  small masses of dark-coloured faeces which
had  been accumulated in the bowels.   When the digestive
faculty is almost gone, the stools consist of the aliment mixed
with bile.   Thus, if the child be drinking milk and water,
or be not weaned, the stools consist of green, watery fluid,
with clots of milk, streaked with bile.  When the irritation
is greatest  at some  particular part of the intestines, it is
not unusual for these  appearances to alternate  with dis-
charge of slime and blood, as we see in intus-susception.
When the secretion of  bile is diminished, the stools  have a
cineritious appearance;  but this state is not often met with in
diarrhoea.   Sometimes,  when  the  liver is affected, or the
bowels much diseased, the faeces may, among other changes,
put on the appearance of pale yolk of egg, or are almost like
pus.
  Diarrhoea may be injurious  in  different  ways.   The in-
creased peristaltic motion of so great a tract of sensible mus-
cular substance, must, like  other great  muscular  exertions,
weaken the bowels,  and thus the whole body  which sympa-
thizes  with it.  Great  debility is often rapidly excited  by
affections of the  intestinal fibres, though there  has  been little
evacuation.   Diarrhoea likewise injures the system, by the
irritation  and great  secretion  wliich often accompanies  it;
add to this the diminution of the powers of digestion, and the

  * All acids decompose bile, and in general produce a green precipitate.
Either an unusual quantity of bile, or of acid in the bowels of children, will
produce green stools; and stools which are  not at first green, often become
soin a short time after they are passed. 
333
obstacle  afforded to the absorption of the  due quantity of
chyle, together  with the derangement which other parts of
the system  may suffer, and the disease thus excited, such as
convulsions, anasarca, &c.
  On inspecting the bowels after death, they are very seldom
found in  a state  of  inflammation, but either greatly inflated
and relaxed, or  with more or fewer intus-suscepted portions.
In one case, no fewer than  47 intro-susceptions were found
in the same  body.   On examining these portions, the valvulse
conniventes  are found to be  rather  more  prominent than
usual,  but the parts are  not inflamed.  Invagination of the
intestine is the most frequent cause of fatal diarrhoea, not
less than 50 cases having occurred to my brother in the course
of his dissections.   Intus-susceptio  may be produced sud-
denly, in consequence of spasm, and may  occasion great
pain, with purging; or it may be caused by acrid purgatives,
or those  which  produce  much griping, as senna tea, made
by boiling the leaves; or  it  may  take place in  diarrhoea
when attended with considerable irritation, and it adds to the
violence  of the disease.  It is sometimes accompanied with  a
diseased state of the glands.   In this case there  may be  a
swelling of the external glands, and there is often a tendency
to cough.   There may be a double intus-susception, and the
tumour so formed may lodge in the pelvis and fill it.   Inflam-
mation is very far  from being a necessary attendant on this
state, it is even uncommon.
   The diagnostic of intus-susceptio is very obscure,  and
whatever may be said to the contrary, I believe we have no
certain mark by which to judge. It has been discovered, when
no previous  circumstances led to a supposition of its existence.
But in general  there is considerable pain, and  marks of
local irritation;  such as slimy stools, with or without blood;
sometimes  a little  frothy slime is passed, sometimes a sub-
stance like  rotten eggs, and at times the contents of the in-
testines  are vomited.  It is  attended  with stretchings and
cryings, as  in colic, with occasional  attacks of great paleness,
like syncope; the belly is tender to the touch, and sometimes
in infants the pulse is slower than ordinary.   When the dis- 
334
ease continues long, the  emaciation is very great, the face
resembling the bones, with merely a skin covering them,
whilst the eyes are sunk.  On the extremities, the skin is lax,
and seems much too wide for the bone and muscles.   Some-
times the intus-suscepted  portion is thrown off, and passes by
the rectum.
  Dissection likewise shows, that a diseased state of the liver
not unfrequently accompanies diarrhoea, and this may be  a
cause of purging  oftener than is supposed.  It is to be sus-
pected, when the biliary secretion is  most  affected and the
region of the liver is fuller than usual, when there is cough,
frequent fits of sickness, and vomiting or purging  of bile.
It is most effectually remedied by small doses of calomel.
  In some cases,  the intestines become very soft, white, or
almost diaphanous, and easily torn, and contain a substance
somewhat like purulent matter, or thin custard.
  Diarrhoea.appears under various circumstances,  not only
with regard to the nature of the stools, but their frequency,
the pain which attends them, the duration  of the complaint,
and the effect on other parts.  In some cases the stools are
extremely frequent and uniformly so.   In  others, the dejec-
tions  come  in paroxysms,  being worse either through the
night or through the day.   Some children are gently grip-
ed ; others are sick,  oppressed, and  do not cry, but moan.
In severe cases, the stomach is  very irritable,  rejecting the
food; but it is not equally so in every stage of the disease,
though the stools  may be the same in frequency.  The ap-
petite is more  or less impaired,  and in bad cases the aliment
quickly passes off, and every time the child  drinks it is ex-
cited to purge. The  mouth, in obstinate bowel complaints,
generally becomes aphthous, and the anus excoriated or ten-
der, and it is not uncommon for the feet to swell.  Some-
times the child is flushed  at certain times of the day, or the
face is uniformly  pale, and the skin waxy in appearance. In
general, if the disease be severe, a considerable degree of
fever attends it, and a continued fever in this  disease is al-
ways unfavourable.  The stools may come away with much
noise from  wind, or may be passed as  in  health.   When 
335
there is great irritation, they are either squirted out forcibly,
or come  in small quantity, with much pressing.  Diarrhoea
sometimes proves fatal in 48 hours, but it may be protracted
for several  weeks, as is often the case when intus-susceptio
has taken place.  In  such protracted cases, the emaciation
is prodigious, the face is lank, the eyes sunk, and the ex-
pression anxious; the strength gradually sinks, the eyes be-
come covered with a  glossy crust, the extremities  cold, the
respiration heaving, and the child dies completely exhausted.
  Diarrhoea may be excited by a  variety of causes; such as
too much food, or sudden change of the kind of aliment, and
hence it is  often caused by weaning a delicate child.  At-
tempts to bring up children altogether on spoon meat, some
injurious quality of  the nurse's  milk,  improper diet after
weaning, the irritation of ill-digested food,  redundancy of
bile,  previous costiveness, dentition,  the application  of cold
to the surface, or a morbid state of the bowels connected with
general debility, produced either  by bad air or natural deli-
cacy of constitution',  are causes of diarrhoea. Those children
suffer most who are feeble, puny, or  delicate.
   As diarrhoea is a frequent cause of death, we cannot be too
attentive to its treatment, nor too early in the use of reme-
dies, especially as we find, that if it  be neglected in its com-
mencement, it is apt to end in a very obstinate or incurable
state.  On this account I have been led to consider this dis-
ease very carefully,  and shall briefly mention  the  treatment
I  have  found most  effectual.  When the stools are natural in
colour, but more liquid than usual, the frequency moderate,
the continuance short, and no fever is present, it will be use-
ful to give small doses of rhubarb, conjoined with an aromatic,
taking care, however,  that these do not  end in producing
the opposite extreme, or costiveness.  In many  cases, the
disease will subside of itself; but  if it do not abate spontane-
ously, or by the use  of small doses of rhubarb, then it comes
to be considered, how far it is proper to check the inordinate
 action of the fibres of the intestines.  This is readily done by
 an anodyne clyster,   But if the diarrhoea have been excited
 by improper food, or redundancy of food, or if it he  attend- 
336
 ed with acute fever, and especially if the child  be plethoric,
 it will be useful to give some mild laxative, such as magnesia
 and rhubarb, or an emulsion containing castor oil,  or small
 doses of calomel.  The tepid bath is also beneficial.  If there
 be oppression, with fever or sickness, a gentle emetic will be
 a proper prelude to the laxatives.  Afterwards, if the disease
 continue, and there be marks of much irritation  of the fibres,
 anodyne clysters will be of signal service.
   If the diarrhoea come on quickly, and the stools are from
 the first green or  morbid, and the stomach  be  irritable, or
 its functions impaired, we should examine the gums, and cut
 them if the child be getting teeth.  This removes or lessens
 a source of irritation.   But whether the disease be produced
 by teething,  by change of food  consequent  to  weaning, or
 other causes, great attention is  necessary.   If  the child be
 sick and oppressed, a few grains of ipecacuanha will be  pro-
 per; and afterwards small doses of calomel,* or some other
 laxativef  should  be  given  morning and evening.    These
 carry off the morbid feculent matter, and excite a better ac-
 tion of the bowels.  The calomel is  usually a most  effectual
 remedy, and it may be given even to infants  a few days  old.
 To them a quarter or half a grain,  rubbed  up with  sugar
 is a proper dose, and may be given  morning and  evening.
 To older children  we give a grain.   If laxatives  do not in-
 crease the debility and pain, and if they render  the  stools
 more natural  in appearance, they do  good, and may be con-
 tinued  in  decreasing quantity, till  they are  abandoned  al-
 together.  But if they  merely increase  the frequency of the
 dejections, without greatly  altering their quality, the  stools

  * That excellent practitioner, Dr. Clarke of Dublin, has strongly advised
half a grain of calomel to be given every night, or every second night to in-
fants when troubled with green  stools and griping; observing, that in the
course of a week or two, the stools become natural, and that it is rarely ne-
cessary to give more than  from 4 to 5 grains altogether.  Mem. of Irish
Acad. Vol. VI.
  f Cold drawn  castor oil may be given in the following form: R. 01.
Ricini, jiii;  Mannx, ^ss; Spt. amnion.  Arora.  zi; Aq. Cassix, ^ss; aq.
Font. 5iss. fiat emulsio. Of this a tea-spoonful may  be given as often as
necessary. 
337
continuing watery, ill-coloured, and offensive, and the strength
and appetite sinking,  we can expect no good by continuing
them, and must restrain the purging by repeated anodyne
clysters, taking care that we do not delay their use too long.
When the secretion is copious,  and the stools frequent,  and
perhaps squirted out with  great irritation, the strength  will
sink very rapidly, and a few hours may decide the  fate of
the child.  In such circumstances, it  is necessary, even al-
though  the contents  of  the bowels be morbid, to  moderate
the fibrous and secretory action, by anodyne clysters.  Af-
terwards the  morbid matter is expelled,  or can be removed
by gentle laxatives.   Opiates given by the mouth have often
a bad effect on  the  child, and  never are equal in bene-
fit to clysters.  Cretaceous  substances, joined with  aro-
matics, are useful when there  appears  to be  a redundancy
of acid; but  astringent medicines,  such  as kino or catechu,
though they  sometimes  seem in slight cases to be of  service,
yet in more  obstinate diseases fail, unless  they be combined
with opium, and then the benefit is perhaps more to be
ascribed to that drug than to their effect; or if given in great
quantity, they may perhaps excite to invagination of the in-
testines.  In obstinate cases,  small doses of calomel given
 morning and evening with the use of anodyne clysters at the
 same time, to keep the purging within  due  bounds, are of
 more service than any other remedies, and will save a great
 number of children; I can speak  of this practice with confi-
 dence.  Dr. Armstrong,  however, when the stools are liquid
 or  watery,  sometimes colourless or  brownish, or  streaked
 with blood,  and of very offensive smell, advises antimonial
 vomits, repeated every six or eight hours, till  the stools
 change their appearance.   But this remedy operates severe-
 ly, and may induce no small degree of debility.  If the plan
 be  rejected, he advises  a solution of Epsom salts, with a
 small  quantity of laudanum.  Dr. Underwood,  in  this dis-
 ease, prescribes emetics, then  warm purges,  and afterwards
 small doses of ipecacuanha, with  absorbents and  aromatics.
    Dr. Cheyne,  in obstinate and prolonged  purging, which,
vol,. II.                           x x 
338
from frequently occurring about the time of weaning, he calls
atrophia ablactatorum, strongly advises small and repeated
doses of mercury, as the most effectual remedy.
   When there is  much fever, the use of the tepid bath morn-
ing and evening, and small doses of saline julap, or compound
powder of ipecacuanha, and clothing the  child in flannel, will
be of great benefit.
   In every case,  external applications have, I think, a claim
to be employed.  These consist of friction with anodyne bal-
sam, or camphorated oil of  turpentine, or the application of
an anodyne plaster,* to the whole abdomen, which is better.
Small blisters  in succession, applied to  the belly  are highly
useful.  It is also proper to bandage the belly pretty firmly,
but by no means  tightly, with flannel.
   During  the  whole course  of the  disease, it  is proper to
support the strength with  light nourishment, such as  beef
tea, arrow-foot jelly, toasted flour boiled with milk, &c.; or
if the child be not weaned, it is sometimes of service, in con-
tinued or repeated attacks of diarrhoea, to change the nurse.
The strength should be supported by  small quantities of
white-wine whey, given frequently.  If the  child, as is fre-
quently the case,  will not take nourishment, then clysters of
beef tea, or arrow-root  are to be employed, mixed with a few
drops of laudanum.   These are of signal service, and ought
to be early and  carefully  employed till the child can take
food into the stomach.
   When the mouth becomes aphthous, it may be washed
with a little syrup, sharpened with muriatic  acid; or borax
may be employed, along with the proper internal  remedies;
and when  these  restore the bowels  to  a healthy state, the
mouth becomes cleaner.  The appearance and disappearance
of the aphthae  generally  mark  the fluctuation  of the bowel
complaint.  The  excoriations which appear about the anus

  » Such as the following: R. Saponis,  2ji; Empl. Lytharg. Zvi; Ext. Ci-
cuta, zii» 01- n»entQ-  P^P- 5SS • Fiat empl.  Or R. Empl. resinos,  Jvi,  Pulv.
opii Zi, Camph. zii; 01. Jumper, zss; Fiat empl. Or if there be much
spasm, we may use  the Empl. asafcetidje, Pharm. Edin. with tiie addition
of opium. 
339
require to be bathed with solution of sulphate of zinc, and
call for great tenderness in administering clysters.
  When the feet become swelled, and the urine diminished
in quantity, some diuretic must be added to the other means.
The best is the spiritus etheris nitrosi.
  If the  child become drowsy, or have a tendency to coma,
much benefit will be derived from shaving the head, and ap-
plying a small blister to the  scalp.  Affections of other or-
gans,  supervening  on  bowel complaints,  must  be treated
promptly on general principles.
   It will thus appear, that the practice in diarrhoea is chiefly
 confined to the following points :
   First,  To  remove  every exciting  cause,  scarifying the
 gums in dentition, rectifying the action  of the liver when it
 is deranged, and regulating the diet when the quality of the
 food may be supposed to have disordered the bowels.
   Second, To lessen sickness and oppression of the stomach
 by  a gentle emetic ;  but  particularly  to remove irritating
 faces, and excite a better action of the intestinal surface, by
 small doses of calomel in prolonged cases, or by a dose of
 rhubarb and magnesia in recent cases of purging.  The cir-
  cumstances under which the administration of laxatives is
  beneficial or injurious, have been already pointed out.
    Third, To restrain  inordinate peristaltic motion, and ex-
  cessive secretion, by anodyne clysters and external applica-
  tions, neither of which are incompatible with the occasional
  use of calomel.
    Fourth, To remove  or allay  coincident or consecutive
  symptoms by appropriate remedies.
     Fifth, To support  the strength from the first by suitable
  nourishment and cordials; and whenever the stomach cannot
  receive or retain food, to give nutritive clysters. 
340
                      CHAP.  XIII.

                      Of Costiveness.

   Costiveness is natural to some  children,—acquired by
others.   In the  former case, it often happens, that the mo-
ther is of the same habit, and in these circumstances, we find
that less detriment accrues than in the other; yet even here
it is necessary to prevent the costiveness from increasing, as
it may excite not only colic, but more serious diseases, such
as convulsions, or diseases in  the bowels.  Some children,
of a very irritable habit, have the rectum spasmodically af-
fected at times, on passing the  faeces, which may be follow-
ed by a convulsion.  This being frequently repeated,  the
child becomes afraid to go to stool, and  retains the faeces as
long as  possible, which  induces a costive state.  Sometimes
the terror  is so great, that the child  can only be made to
pass the faeces when half asleep.
  In hereditary costiveness, it  is difficult, if not impossible,
to induce a regular state of the  bowels;  and perhaps in some
cases, this,  if it could  be done, would, seeing that it is not
natural  to the constitution, be injurious to the child.  But
we must beware,  lest, by  indulgence, this  habit increase.
Whenever  the child  is pale and puny, or dull, and does not
thrive, there is risk of convulsions or some severe disease be-
ing induced. At a more advanced period of childhood chorea
may be produced.   Acquired  costiveness may be overcome
by medicine, and encouraging regular attempts to procure a
stool.   A  variety of means have been employed in .hese
cases, such  as suppositories, magnesia,  and other laxatives.
The best remedy for changing the state of the bowels seems
to be calomel, which may be given  in a suitable dose, even
to an infant, for a day or two in  succession, and then omit-
ted ; employing in the interim a little manna alone, or com-
bined with castor oil, and sometimes magnesia may be sub-
stituted for a change.   In  more  obstinate cases, infusion of
senna,  or  two or three grains of aloes may  be given.  A 
341
quarter of a grain of ipecacuanha, mixed  with sugar, may
also be tried.   It is also proper to change the nurse, or alter
the diet of the child, giving barley-meal porridge, veal soup,
ale-berry.(i)
                       CHAP. XIV.

                          Of Colic.

   Colic is a frequent complaint with  children, especially
 when they are  costive.  It is often produced by too much
 food, exposure to cold, irregularities in the diet of the nurse,
 or some bad quality of her milk.   It  makes its  attack sud-
 denly, and is known by violent screaming, induced without
 any  warning, and accompanied with hardness of the abdomi-
 nal muscles, kicking, and  drawing up of the legs, and often
 suppression of urine.   These symptoms are soon removed by
 a clyster or suppository,  which brings away both faeces  and
 wind.  The warm bath,  fomentations,  and  friction on the
 belly with anodyne balsam or laudanum, will be serviceable;
 and  if the pain continue,  two or three drops of tincture of
* opium, or a rather larger dose  of tincture of hyoscyamus,
 with oil of anise, may be  given.*  When the child is costive,
 a laxative is to be exhibited after the anodyne.
   If a child be subject to  repeated attacks  of colic, a few
 drops  of tincture of asafoetida are useful, and we  must al-
 ways take care to prevent the long continuance of pain, as it
 may end either in visceral inflammation or convulsions.

   (0  Or rye mush and molasses,  which is easily procured in every family,
 and may answer the purpose better than any of the enumerated articles.
   * The anodyne mineral liquor of Hoffman,  is an excellent medicine in
 these affections.  C. 
342
                      CHAP. XV.

                      Of Peritonitis.

  Peritoneal inflammation, or enteritis, is not an uncom-
mon complaint with children.   It begins with violent pain in
the belly like colic, but is more constant and continued, and
is accompanied with a considerable degree of fever, costive-
ness, and  tenderness  in the  belly.  If this disease do not
prove speedily fatal, and if on the other hand, it be not per-
fectly removed, the child remains long ill, perhaps for some
weeks, and the nature of the complaint may for a length of
time be mistaken.  There is constant fever, but it is subject
to exacerbation in the evening. There is increasing emacia-
tion, and occasional attacks of pain in the belly. The stools
are usually obstructed, and when they are  procured, they
are slimy, bloody, ill-coloured, or scybalous.  On examining
the belly externally, induration may sometimes be discovered.
The appetite is lost, the thirst is considerable, the pulse be-
comes more frequent and feeble, the debility increases, and
the extremities become cold,  and  in  this exhausted  state,
the  child sometimes lies for many  hours before dissolution.
On inspecting the abdomen, the bowels are found adhering,
or forming knots, and sometimes the liver partakes of the
disease.
   In younger infants, the consequences of peritoneal inflam-
mation, when it does not prove rapidly fatal, or excite con-
vulsions, arc obstinate slimy purging, vomiting, and increas-
ing emaciation.
   In young infants, we cannot carry  evacuation far.  But
whenever there is a prolonged attack of colic,  we  may ap-
prehend a severe disease, and must use the warm hath, clys-
ters to open the bowels immediately, and then an opiate clys-
ter to allay morbid sensibility; a small blister should be ap-
plied to the belly, and if the symptoms be very urgent, this
may be preceded by leeches, though these are rarely in infants
required.  In elder children, the attack is often brought on 
343
by cold, or by eating indigestible substances, as for instance,
nuts.   No time is to be lost in opening the bowels by clysters
and laxatives, and in detracting blood from a vein.  Fo-
mentations and blisters are useful.  If these means be neglect-
ed, or do not succeed, there is little hope afterwards of saving
the patient, unless the bowels adhere to the abdominal mus-
cles and an abscess takes place, which  is indeed very rare.
In the usual state  produced by this disease,  we have little in
our power, except to regulate the  state of the bowels, apply
small  blisters, and support the  strength.   When abscess
has taken  place  near the  pelvis,  or about the rectum, the
child  cries much on going to stool,  seems afraid to pass the
faeces, and may  at the  time be seized  with spasm or con-
vulsions.  The faeces are very offensive,  and occasionally
purulent matter is discharged.  In such cases I have found
magnesia  useful  as a laxative,  and hyoscyamus with oil of
anise of great benefit as an anodyne.  If the  appetite be not
lost there is  hope of a cure, and I have known desperate cases
recover.
                      CHAP. XVI.

                      Of Marasmus.

  Connected with, and generally dependent on, a morbid
state of the bowels, is the marasmus, or wasting of children.
This  disease is preceded and accompanied by costiveness,
sometimes alternated with a diarrhoea, in which the stools are
foetid, or unnatural in  appearance.  It begins with lassitude
and debility, loss of appetite or depraved appetite, fcetid breath
and fcetid stools, tumid belly, pale leucophlegmatic counte-
nance, with swelling of the upper lip.  Presently fever super-
venes, the countenance  becomes at times  flushed, and the
skin hot and dry, with frequent pulse, thirst,  restlessness,
picking of the nose, and disturbed sleep, in which the patient
grinds his teeth and starts. The debility gradually increases,
and  if relief be not procured, death,  preceded by great 
344
emaciation, takes place.   This disease is most frequent with
those who are fed on improper food, or eat many raw roots,
or much unripe fruit; or those who have the digestive faculty
impaired by confinement, bad air, or neglect of the bowels.
It very often is considered as produced by worms; but these,
although they may often exist in the bowels, are by no means
essential to  the disease.
  This disease may, in the  commencement, and before the
appearance  of fever, be arrested by a course of  active purges,
given at proper intervals; at the same time that we give light
nourishing diet, and inculcate the necessity of exercise in the
open air.  In the febrile stage, the cure is more difficult, but
is to be accomplished on a similar principle, by attending to
the state of  the bowels.  For this purpose, purgatives must
be frequently repeated, especially calomel; and here it is ne-
cessary to remark, that the stools are not always hard; they
are often fluid, but generally foetid,  and dark  in the colour,
or appear to contain indigested food. A course of purgatives,
however, by degrees procures discharge  of faeces of natural
appearance.  Whilst this course  is conducting, the  strength
is to  be supported by  proper  diet,  and the prudent use
of wine.  The power  of  the  stomach may be increased by
chalybeates  or other  tonics,  provided these  are  not nau-
seated  by the  patient.   After recovery has taken place, we
must, by very gentle laxatives, preserve an open state of the
bowels, which will prevent a relapse. Sea-bathing is likewise
of advantage.
  The state of the bowels which gives  rise  to  marasmus,
sometimes produces speedily more acute  symptoms.  These
constitute a  very frequent species of fever,  which  we shall
afterwards consider. 
345
                      CHAP. XVII.

                   Of Tabes Mesenterica.

  Tabes mesenterica, or hectic from disease of the mesen-
teric glands, is a very frequent disease.   It is not often met
with before the time of weaning, nor after puberty, seldom
after the age of eight  or ten years.  The disease consists in
enlargement of the mesenteric glands,* which are sometimes
universally affected, but are especially enlarged into a hard
mass about the root of the mesentery.  These tend slowly to
the formation of a cheesy substance, but death may take place
before that process be  accomplished.  The commencement
of the disease is slow and  obscure;  the patient complains of
little or no pain, but  is  subject to an irregular state of the
bowels ; is either costive, or passes dark loose faeces;  is un-
healthy in his appearance,  and liable to occasional attacks of
fever.   The urine is white  or turbid.   The appetite is not
much  diminished, and  digestion  goes  on;  but  the  belly is
hard,  and somewhat tumid.  The child  is more fretful than
usual, and sometimes, especially if  very young, is troubled
 with vomiting.  This is the  incipient stage, and resembles
 very much that of marasmus, proceeding from affection of the
 bowels, independent of diseased glands.   As the disease ad-
 vances, the body wastes away, the face is pale, and  the fea-
 tures  become sharp,  the  abdomen gradually enlarges more,
 and the patient complains of lancinating pains, of short dura-
 tion however, within the belly, or near the back.  The stools
 are now sometimes bound, but oftener loose, frothy, and mix-
 ed with bile; occasionally the patient has diarrhoea, with vo-
 miting. The fever, which  at first is obscure  and intermitting,

   • This state is sometimes accompanied with swelling of the thymus gland,
 and the lymphatic glands  of the neck.  Swelling  of the thymus gland, by
 pressing on the trachea and oesophagus, produces difficulty of breathing and
 of swallowing, and sometimes suffocation.  By pressing on the subclavian
 vein it obstructs the passage of the chyle,  and may thus excite disease in
 the mesenteric glands.  Blisters applied to the top of the sternum sometimes
 do good.
VOL. II.
Y T 
346
becomes more acute  and distinct,  with exacerbation  in  the
evening,  attended  with restlessness and acceleration of  the
pulse, which rises to 120 strokes in a minute, or even more.
The patient is listless, and his mind becomes gradually inac-
tive, though he does not lose hopes of recovery.   The  tongue
is generally clean, but sometimes  covered with a white or
brown crust,  especially in the middle;  and in an advanced
stage, the whole mouth  and throat become aphthous.  The
thirst is trifling, but the  appetite  is usually impaired, and a
short cough supervenes.  As the disease proceeds, the ema-
ciation of the body increases, the  eyes  are sunk and  glossy,
the nose sharp, and apparently elongated, the face sallow, but
the lips are sometimes florid, and the cheeks flushed at night.
The abdomen is hard, and sounds  like  a drum when struck
upon, or if not very tense, knots may sometimes be felt within
it.* The urine is lessened in quantity, and it often deposits
a white or lateritious sediment, the feet swell, and  during
sleep, the forehead, scalp, and sometimes the breast, are cover-
ed with a profuse sweat, whilst the rest of the  skin  is hard
and dry.  The progress of this  disease is not always alike
rapid.  In some cases, the patient lives for a year or two in
bad health; but in general,  after hectic has appeared, a few
months, sometimes weeks, cut him off.
  In the commencement of  this disease, the steady  and re-
peated use of mild purges of calomel, conjoined with some
light bitter infusion, decoction of bark,  tonic medicines,  and.
gentle  friction over the belly continued  for a considerable
length  of time, morning and evening,  would  appear to  be
of more service than any other plan of treatment.   It  has
been proposed to give calomel in small doses, as a mercurial;
but it does not appear to have great  efficacy, and is  chiefly
of  use, in so far as it acts as a gentle purgative.  Copious
evacuations  in this  disease are not  required.   It  is suffi-
cient that the bowels be brought into, and kept in a regular
state, which,  in the incipient stage, at  least, sometimes re-

  * Sometimes a hard tumour may be felt within the belly, pretty early in
the disease.  It is often felt in the right side, near the origiu of the colon. 
34?
quires pretty strong doses.   But in the  confirmed and  ad-
vanced stage, stools are easily obtained; and from the loose
state of the bowels which often prevails, it comes to be  a
question, how far laxatives are proper.  Upon this important
subject, I  observe, that  these  medicines  ought not to be
severe, but gentle, and given frequently,  provided they have
the effect of diminishing the tumour of the belly,  making the
stools more natural, and do  not impair  the strength.  The
lax stools  which take place in  this  disease spontaneously,
never abate the tumefaction ; but a gentle course  of laxatives
•ften does, and this is a most favourable  effect.   Farther,  if
the paroxysms of fever be severe, and early in their appear-
ance, we find it  necessary to use purgatives more freely than
in opposite circumstances;  evacuation by stool being in such
cases advantageous.  In the confirmed and advanced stage,
it is sufficient that such a dose of calomel be given  every
night, or every  second or third night, as shall keep the bow-
els open if disposed to be costive, or, if loose, make the stools
more natural  in their appearance than they would be with-
out the administration of medicine.   We  must, however,
take care, that the mercury do not excite much effect on the
constitution, lest debility  be increased; it  is therefore pru-
dent, sometimes to combine the calomel  with rhubarb, or to
employ a little castor oil  emulsion.  Along with this plan,
we may, in every stage of the disease, derive advantage from
the use of tonic medicines, such as bitters  and chalybeates,
especially in the form of mineral waters.   But the last are to
be used cautiously, if there be marks of inflammation existing
in the glands; and in such cases, some  light bitter infusion
is preferable to chalybeates. In such  circumstances, the
laxatives are to be used more freely, the tepid bath is to be
employed, and the belly rubbed freely with anodyne balsam.
Gentle  exercise in the open air is of great service, and it  is
useful in the early part of the disease to reside near the sea;
but if the glands seem to  be in a state of inflammation, dis-
covered by shooting pains with  fever, the  patient must not
bathe;  and indeed, at all times, the utility and safety of the
 cold bath seem  to be doubtful, except when the disease is so 
348
far removed, that we  have chiefly to contend with debility.
The warm bath is more  generally useful.  The diet should
be light and  nutritious, but all stimulating and  indigestible
substances must be avoided.  If an inflammatory state exist,
milk in different forms, soft-boiled eggs, and vegetables, are
proper.  If no inflammation  be present, some  animal  food
will be of service; nay, as in other scrofulous affections, a
very considerable proportion of animal diet is sometimes
beneficial, in preventing the tumour from inflaming and form-
ing a cheesy  substance, or in  giving a favourable turn to the
action, when the  acute state  of inflammation has abated, in
those cases where it is met with, for it is by no means an
universal occurrence.
  In the latter end of the disease, little can  be  done except
palliating symptoms,  and supporting  the strength by soups
and a  little wine. Diarrhoea should be restrained by  ano-
dyne clysters.
  Cicuta, burnt  sponge,  and  some other medicines,  have
been advised in this disease, but I cannot say that they have
been employed with advantage.   Electricity is sometimes of
service.
                     CHAP.  XVIII.

                       Of Worms.

  Worms exist in the bowels,  perhaps, of every child,* but
especially in those whose bowels are debilitated by bad man-
agement, or by acute disease; and  hence, in the end of dis-
ease, or after recovering from such illness, worms are often
expelled, both by children and adults.  Worms are  of dif-
ferent kinds, but  infants  are  chiefly infested with lumbrici
and ascarides, the taenia being  rarely met with until children
are four or five  years old.   We also sometimes meet with
some uncommon species of worm, which are ejected by vomit-

 • Worms rarely appear in the bowels, till after the child is weaned. 
349
ing, and some lususes have been passed by stool;  thus, for
instance,  I have seen a worm about three inches long, hav-
ing  two large flat  heads, with two bodies, separated for a
little, and then united in a common trunk, ending in a taper-
ing tail.  Insects of different kinds may also be introduced
accidentally into the stomach and bowels, and live there for
some time.
  Ascarides generally occupy the  rectum,  producing much
itching in that part, so that sleep is  often  prevented.  The
irritation causes indigestion and pain in the belly, with pick-
ing of the nose and white face, a variable appetite, and some-
times a desire for indigestible  substances.   The worms are
discovered in  the stools  like small white threads,  and occa-
sionally they  creep  out from  the rectum.  The stools are
often slimy or mucous.  This kind of worms is removed by
injections of  aloes mixed with  water, or  any strong bitter
infusion containing salt in solution,(«) or  the common tur-
pentine injection; lime-water  and olive oil also  sometimes
destroy them, but cannot be  depended on.   Calomel purges
are  proper likewise; and any  disordered state of the ali-
mentary canal, which exists, is to be treated on  general
principles.
  The  ascaris  lumbricoides  is  often from six to ten inches
long.   In  its general  appearance  it resembles  the  earth
worm, but differs from it, in  having, besides other  distinc-
tions, a longitudinal line on each  side, whereas  the*«arth
worm has three lines on the upper surface.  It dies soon af-
ter its expulsion, but when alive, it moves  like an eel, and
does not shorten the body like a worm. Dr. Hooper, in the
5th vol. of the Mem.  of Med. Soc. has a valuable paper on
intestinal worms.  Lumbrici may exist in every part of the
alimentary canal, and frequently are ejected by vomiting, as
well as by stool.  The symptoms are those of intestinal ir~

  (u) Dr. Kuhn of Philadelphia, whose expeiience has been very extensive,
and whose correct and discriminating judgment is unquestioned, says he has
found no article  so useful in  the destruction of ascarides, as injections of
a solution of common salt. Vide Barton's Edit, of Cullen's Mat.  Med. Vol. If. 
350
ritation,* pains in the belly, frequent attacks of diarrhteai
variable, and often voracious appetite, the child sometimes
becoming  hungry almost immediately after  having  ate
heartily, foetid  breath, pale complexion, tumour of the lips,
with  livid circle round  the eyes,  swelling of the belly  at
night, and disturbed sleep, the child occasionally awaking in
a great terror, and being liable to starting and  grinding of
the teeth.  When awake,  he picks his nose, is plagued with
temporary head-ache, sometimes has a dry cough, with slow
fever, or convulsive affections.  I have  already pointed out
several diseases proceeding from disorder of the bowels, and
these may arise from worms, in as much as they are capable
of irritating  the bowels, or injuring their action, or increas-
ing such a debilitated state, as may have predisposed to their
accumulation.   A variety of anthelmintics  have been ad-
vised ; for an account of which, I refer to the  writers on the
Materia Medica.   Sulphur, tansy, aloes,  spigelia marylan-
dica,  dolichos pruriens, the goeffrea, worm  seed, tin powder,
filings of steel, &c. have at all times  a  good  effect;  but in
general, calomel purges  given repeatedly and  liberally, pro-
vided the constitution  of the patient will bear them,  will be
found very effectual; or these may  be alternated with saline
purgatives,  oil  of turpentine, or suitable doses of aloes or
jalap.   In obstinate cases, much benefit will  be derived, by
giving  a  regular course  of purgatives so as to keep up a
constant but  gentle effect  on the bowels.  After the worms
are expelled, a  bitter  infusion, or chalybeate water, will
be useful to strengthen the bowels, or these may even be em-
ployed whilst we are using the purgatives.
  The trichuris, or long thread worm,  is  about two  inches
long,  and two-thirds of this form a  tail like a hair.   The
body is about the 16th of an inch thick, and the worm is white

  * Hence it is  not easy to say  that worms are the cause of a child's com-
plaint, for other morbid affections of the bowels produce the same symptoms.
A course of purging removes these symptoms, without bringing away any
worms; although the slimy appearance of the stools is attributed to the
worms being dissolved. 
351
like the ascaris.   It is found in the rectum, and also higher
up, even in the ilium.
  The tsenia consists of many flat  jointed  portions,  and is
divided into the T. Solium, where the orifices are placed on
the margins of the joints, and the T. Lata, where they are
found in the surface.  The usual symptoms  are produced.
The best remedies are smart purges of calomel, alternating
with  doses of oil of turpentine  proportioned to the age;  a
desert spoonful may be given to a child of four years of age.(#)
The taenia is more difficult to be removed than other worms.
                      CHAP. XIX.

                        Of Jaundice.

  The jaundice of infants is a disease attended with great
danger, especially if it appear very soon after birth, and the
stools evince a deficiency of bile;  for we have then reason to
apprehend some incurable state of the biliary apparatus.  I
conceive that there are two species of this disease, which are
very opposite in their nature.   In the first, there is an ob-
stacle  to the passage of  the bile into the intestine, the child
is costive, and the  meconium is paler than usual, and after
it is removed, the stools become light-coloured; the skin, very
early  after birth,  becomes of a deep yellow colour, which
extends to the eyes.   The child sucks very little, has occa-
sionally  a difficulty  in  swallowing, is languid,  becomes
emaciated, moans  much, is troubled  with  flatulence,  some-
times  with cough  and  phlegm  in the trachea, or vomiting,
convulsions, colic,  and fever, occasionally supervene.  In
some cases, the liver is felt enlarged, and the hypochondrium
is tumid.   The  water is very high-coloured.   This disease

  (x) Oil of turpentine has been given to infants in smaller doses, measured
by drops, for the other species of worms with success.  It may certainly be
considered as a powerful anthelmintic.  The reader is referred to other
cases illustrating its effects in the expulsion of taenia, to Eclectic Repertory,
Vol. I. and to M'.dico-Chirurgical Transactions, Vol.  U 
352
often proves fatal in a week, but it has been known to con-
tinue in variable degrees of violence for a considerable time,
and at last to  disappear, though such children continue long
delicate.  With regard to the cause of this disease, we  find,
that sometimes it consists in obstruction of the hepatic duct,
or ductus communis, either by thickening of the coats, or
pressure,  in consequence of enlargement of some part in the
vicinity of the duct; or it may consist in imperforation of the
duct.  Sometimes it proceeds from temporary obstruction of
the duct, owing to viscidity of the bile.   Now some of these
cases are irremoveable, others are  not; but as we cannot
a priori say what the  cause may be, in any particular in-
stance, we must use the means of cure in every case.   The
most likely remedies for removing this disease,  are gentle
emetics, given very early and followed by the exhibition of
half a grain of calomel, morning and evening, till the bowels
are acted on;  or we may give this medicine even three times
a-day, in  some cases;  but we must be cautious not to induce
much purging, or push  the mercury far, lest we bring on fits.
  The second species differs from the first, in the stools be-
ing  dark-coloured or  green, showing  that  there is no ob-
struction, or at least no permanent obstruction, to the pas-
sage of the bile.*   Like  the first species it appears  soon
after birth,  and  is  accompanied  with  great oppression,
moaning, colic, and convulsive  affections.  It is attended
with much danger, and frequently  carries off the infant in a
few days.  The early use of calomel would appear to be the
most proper practice, and the strength must  be supported in
all those cases by the breast milk, given with the spoon, if the
child wont suck, and small doses of white-wine whey.
  Jaundice, appearing  at a considerable time after birth, does
not  require a  separate consideration here, nor is it a very
common occurrence.

  • It is in this species alone that the opinion can be admitted, that infantile
jaundice depends  on absorption of bile from the intestines. 
353
                       CHAP. XX.

                    Of Diseased Liver.

  Enlargement and inflammation of the liver are not un-
common in infancy and childhood, but the first is most com-
mon in infancy.  It is productive of vomiting,  oppressed
breathing, cough, fever, and sometimes purging.  The liver
can be felt enlarged, and extending lower down, or more to
the left side than it ought to  do, which will distinguish  this
complaint from inflammation of the lungs, which is also not
so frequently attended with  vomiting.* 1 cannot say much
that will be satisfactory respecting the treatment.  Mercu-
rial friction is chiefly to be relied on.f
  Hepatitis in infancy is  marked with the symptoms attend-
ing enlargement of the liver; but there is  more fever,  and
sometimes pain, when the liver is pressed on.   The disease
often begins with symptoms of disordered  stomach, and colic
pain.   Fever comes on, accompanied with cough, which is
sometimes soon succeeded by jaundice.  The stools are often
like yolk of egg, or, if there be obstruction to the passage of
the bile, they are clay-coloured, and the urine red, with much
sediment.   On inspecting the body of infants who have died
of this disease, the surface of the liver, sometimes only its
convex surface, is often found of a deep red  colour, with an
exudation of white lymph, exactly resembling the  cuticle of
a blistered part.  Betwixt the liver and diaphragm, we  find
white flaky fluid, something  like pus, and similar matter is
often found  among the bowels, mixed with  pieces of fatty-
looking lymph.  The liver is not "necessarily enlarged,  nor

  * On examining the liver, it is sometimes found soft, and not much altered
in structure, sometimes hard, and almost cartilaginous, with the pori biliari,
hardened and obstructed, so that secretion of bile does not take place, and
the gall bladder becomes shrivelled.  This state cannot be attended with
jaundice.
  j- Active mercurial purges I have found useful in this stage of the disease,
after which, small doses of calomel should be given morning and evening for
some weeks.  If there be pain, leeches should be applied  to the side.  C.
  VOL. II.                            z z 
354
 its substance affected.  The stomach and bowels are not in-
 flamed,  but  sometimes have  a white blanched appearance,
 and contain a fluid like thin custard.  The bile is not changed
 in its colour.   In some instances of chronic inflammation,
 the liver is somewhat enlarged, of a dark  colour, and the
 veins turgid.  Blisters, laxatives, and  a gentle course of
 mercury are the principal means of cure.  In older children
 we find hepatitis to commence either acutely or slowly. When
 it begins acutely, the child probably after a surfeit, or some
 irregularity of diet, or exposure to cold,  complains of severe
 pains in  the upper part of the belly, like colic, accompanied
 with sickness and vomiting;  and either attended,  or  soon
 succeeded by fever,  short cough, and pain,  sometimes  dull,
 sometimes sharp in the right side, and occasionally affecting
 the shoulder.   Jaundice also,  not unfrequently, is produced
 and lasts for a few days.   There is  thirst, no appetite, but
 the child feels  continually as if he had ate too much, is sub-
ject to fits of  squeamishness,  and complains when the  liver
 is pressed.  If the remedies do not check  the disease, the
liver enlarges,  and its region is full; abscess is formed, at-
tended with irregular chilliness, hectic symptoms, and much
pink-coloured sediment in the urine.   In  a few weeks, some-
times in  a shorter period,  the  patient is  sensible of a smell
like rotten eggs, which he thinks comes from the stomach ;
then a little fcetid  matter  is coughed up, which is followed
by copious expectoration; or he ejects pus as if he vomited
it from the stomach.   The cough and spitting, with hectic
symptoms continue long, but at last decline and go off.
   In the early stage,  blood-letting, if instantly resorted to,
may be of service, but not if delayed.  Blisters are always
proper.  The bowels should be freely opened,  and afterwards
a gentle  course of mercury  employed.  In the suppurating
stage, mercury should not be used, but the strength  is to be
supported by proper  diet.   In the expectorating stage, the
same plan is necessary, with the use of tonics, such as chaly-
beates joined  with myrrh, and occasionally opiates.  A
speedy removal to  the country, if the weather is  mild, is
advantageous.  Sometimes the  abscess bursts into the  sto- 
355
mach or intestines, adhesion previously taking place; or, I
have known it burst into  the general cavity of the abdo-
men, and the matter  accumulate there, forming a tumour
like ascites, bursting at last by the navel, which inflamed; or
it has been drawn off with a trocar, and recovery has been
accomplished.
  The more slow or chronic species may be excited by a tor-
pid state of the whole chylopoetic viscera,  consequent to ne-
glected bowels, or other causes ; or it may occur after some
other disease, such as  peripneumony, scarlatina, &c.  The
child has fits of sickness, vomits bile in the morning, and
loses his appetite ; or if he has a strong desire for particular
kinds of food, or feels very h ingry at times, he either can-
not eat when he receives  food,  or is instantly filled.   The
 strength diminishes, the bowels are torpid,  and the stools
 white, in some cases bilious, or dark and offensive;  mothers
 there is a constant dry cough,  and inclination to  hawk  or
 spit, the pulse  is  frequent, the  upper part of the belly be-
 comes swelled at night, but there is little or no pain in the
 region of the liver; if any be felt, it is rather referred to the
 bowels.  By and  bye considerable pain, like  colic,  is telt
  near the stomach, especially at night, and that part of the
  belly is then swelled, but towards morning it subsides.   On
  examination, however, the hypochondriac region is felt fell,
  and the liver  can be perceived  extending towards the lett
  side, and pain, and  sometimes sickness,  are  produced by
  pressure.  The urine is high-coloured, the feet swell at night,
  and the face has a slight hectic flush.  Ifthe disease be  not
  checked, it goes on to suppuration, producing distinct hectic
  fever, terminating in death, ifthe matter be not discharged;
  or, it may be,  irritation proves fatal, even without suppura-
  tion.   Repeated blisters,  laxatives, and  mercurial inunction
  are the remedies, with diuretics, if there be dropsical symp-

    °Tne spleen is frequently enlarged, and sometimes contains
  tubercles.  I   do not know any  other diagnostic symptom,
   than the  belly being tumid  and hard in the  region  of the
   spleen ; frequently a cough attends this state.  Mercurial lax- 
356
atives, and blisters,  are the best remedies, but most cases I
have met with have  proved fatal.*
                     CHAP. XXI.

                         Of Fever.

  Fever is a frequent disease in infancy and childhood, but
it is generally symptomatic, or produced by some local irri-
tation.  Typhus fever is extremely  rare in  infancy,  but it
sometimes is communicated to children a few years old.   It
is known by our evidently tracing the channel of infection.^
The child at first is languid, pale, chilly,  and debilitated,
the appetite is lost, the  head becomes  painful,  the skin hot,
the tongue foul, the eye dull, or suffused, and the pulse very
quick:  and if a favourable crisis be not  procured, great op-
pression, succeeded  by  stupor, precedes  death.    In  the
course of the disease, the bowels are generally bound,  the
stools foetid, and the urine thick.  It  requires the early use
of emetics in the cold stage, succeeded  by saline julap.  If
the  hot stage, however,  be fully established,  and the heat
considerable, the affusion will be of advantage, succeeded by
calomel purges and saline julap, with  light diet, and the use
of ripe fruit.  A free circulation of air is of essential benefit.
The skin, in  the course of the disease, especially among the
poor, should be sponged daily with tepid water, and the bed-
clothes, if possible; changed frequently.  If the head be very
painful in the first- stage, the  application of  leeches to the
forehead and the  use  of laxatives will be useful.   If pain
continue, or stupor, or constant drowsiness  supervene, blis-

  • I pursue here the same mode of treatment as in enlargement of the fiver.
Exercise, and especially swinging, is useful. Compression of the abdomen
by a flannel bandage is also beneficial.  C.
  t Many of the fevers of children, not at all originating in contagion, soon
run into the typhus form.  This, therefore,  can hardly be considered as a
diagnostic.  C. 
357
ters will be proper.  The strength, in the  latter end of  the
disease,  is to be  supported  by the prudent use of wine.
Cough in general requires blisters to the breast, with squill
vinegar.
   The most frequent fever, however, excluding those accom-
panied  with eruptions,  is the fever  from irritation, which,
although it may proceed from various causes, is essentially
the same in  its nature, and  the indications of cure.   It  has
of late years been described under the name of the infantile
remittent fever, though  the  fever so  described belongs to
childhood,  rather than infancy.  It will be  useful to divide
the fever, at present to be considered, into that variety which
occurs in early infancy, and that which takes place in child-
 hood.  With regard to the description of  the first variety
it is very similar to the early stage of hydrocephalus, but the
remissions  are  more distinct in the morning, and the exacer-
bations  greater in the evening.   The pulse is  very quick,*
the skin hot, the mouth warmer than  usual.  The child is
 at first fretful,  restless, costive, and inclined to vomit;  then
 he becomes more oppressed, and in  some  cases has slight
 cough, with increased secretion  of  phlegm  in  the trachea;
 perhaps, he does not for hours lift his eyes, till the remission
 comes,  when he looks up, and attends to the objects present-
 ed to him for a short time.   He sucks in general freely, and
 sometimes bites the nipple, and very often aphthae appear in
 the mouth.  The bowels are irregular, but whether the stools
 be frequent or seldom, they are generally green or brown,
 and offensive.  The urine is usually high-coloured and scanty,
 and sometimes the feet swell a little,  and  very often become
  cold.   If the disease prove fatal, it is generally attended, in
 the end, with symptoms of effusion  into the ventricles of the
 brain, or the infant is exhausted gradually by the continuance
 of the  fever,  or more  quickly by  the accession of obstinate
  diarrhoea.  A favourable change takes place, sometimes  about
  the fifth day, sometimes  later,  the  child  looking up  for a

    * In the early stage of hydrocephalus, the  pulse is more irregular, and
  often beats alternately quick and slow, for two or three pulsations, 
35S
longer space of time than formerly, and seeming more free
from sickness.  After this,  the symptoms subside, and the
strength is gradually restored.  It is very common to find,
that at this time,  one  or more teeth have made their ap-
pearance.  In many cases, the fever may proceed from af-
fection of the bowels; but frequently it is caused by denti-
tion, the irritation in the jaw operating  either alone, or in
connexion with a morbid state of  the bowels.   In this kind
of fever, the gums  should be carefully inspected, and, if ne-
cessary,  cut.  Small doses of calomel should be given morn-
ing and evening, mixed with magnesia, to prevent costive-
ness, or to  evacuate irritating faeces. A few drops of tincture
of hyoscyamus, with a saline julap, may be given occasional-
ly to abate irritation.  The tepid bath  should  be employed
once a-day, when the  exacerbation takes place,  and the
strength supported by the breast  milk or beef tea.  Ifthe
child be  plethoric, a leech should be early applied on the
forehead; and if a favourable crisis do not soon take place,
the head ought to be blistered.  In some cases, although the
acute symptoms go off,  the  child does not recover, but  re-
mains fretful, languid, and emaciated. The eyes are suffused,
the feet swell,  and the  stools  are not regular  nor  natural.
In some instances, tumours of the mesenteric glands seem to
be excited.
  The remittent fever of older children is met with from the
age of two or ten or twelve  years, and is generally found to
be produced, either speedily after eating some improper sub-
stances which have not  been immediately removed from the
stomach or bowels, or gradually by the induction of a costive
state, or  the accumulation of irritating faeces in the bowels.
In the first case,  the  fever  attacks suddenly, sometimes
through the day, but generally at night, and the child is sick,
pale, very restless  extremely hot, disturbed in the sleep, and
thirsty.  Sometimes he  vomits, or complains of head-ache,
or pain in  the belly.   The tongue is at this time tolerably
clean, but next day it becomes furred, and the fits of vomit-
ing  or sickness are pretty  frequent.  They are generally
preceded by head-ache, which goes off or abates after throw- 
359
ing up. If this disease be attacked immediately with an eme-
tic, followed in the morning with a smart purge, the  health
is soon restored; but if the remedies be delayed till the next
day, I have generally found,  that although the emetic, with
purging, mitigate the disease, it does not arrest it speedily,
but notwithstanding the regular use of laxatives with diapho-
retics, it continues for several days. Emetics and purgatives,
in this disease, generally bring  off some  half-digested sub-
stance, such as almonds, orange peel, &c.  It is astonishing
how torpid the bowels sometimes are, large doses of medicine,
either producing no effect, or lying for  some time inactive
in the stomach, they are then vomited.  In such cases, strong
clysters are proper to assist the physic.
  In the second case,* the attack is often more gradual,  the
child being  for several days  somewhat feverish and unwell.
The pulse is frequent, and, in the course of the day, he  has
several attacks of feverishness, during which he is dull, and
disposed to sleep or lie down  ; but these do not last very long,
and in the interval he seems  tolerably well, but is easily  put
out of temper, and complains when lifted or touched, though
he be not hurt.   The appetite is not steady,  he has little
thirst, and the tongue is clean.  The bowels  are  sometimes
very  open,  but  oftener bound.  These  symptoms  appear-
more or less distinctly for about a week, though  sometimes
not so long.  Then an acute paroxysm of fever takes place,
preceded by shivering, and attended generally by vomiting.
The pulse becomes much more  frequent, sometimes 140 in a
minute.  The cheeks are flushed, and  the  patient is very
drowsy, but complains of  little pain in  the head, or indeed
any where,  except occasionally in the belly, which may at
times be very severely pained, or if  he complain of head-
ache, it is evidently from  his stomach, for it is followed by-
sickness or vomiting. The fever does not continue alike se-
vere during the whole of the day ; it remits a little, but not
at very regular hours.   The exacerbation which usually oc-
curs in the afternoon, is generally accompanied with drow-

  * This is commonly called a worm fever, although worms are not necessu-
rily passed in this disease. 
360
siness.  Very soon after the attack of fever, the tongue be-
comes covered with a white or brown coat, and both the sto-
mach and the bowels seem to be extremely torpid.'  The ap-
petite, indeed, is  soon almost totally lost, or the food which
is taken is not digested.  The bowels are generally, but not
always costive;  and the stools  are foetid,  dark-coloured,
sometimes  like pitch, or thin and olive-coloured, or green
and curdy-looking, or clay-coloured, indicating a deficiency
of bile.  This last state sometimes alternates with too  co-
pious secretion of bile.   There is a great desire to pick the
nose and lips; and ifthe child be not watched, sometimes an
ulcer is thus produced upon the lips or angle of the mouth.
  The face is  flushed during the exacerbation; but,  except
at this time, it is pale.  The eyes are dull and white; though
sometimes, in the course of the disease, they arc unusually
clear.  Generally, delirium occurs in the advanced stage of
the disease, and in some cases it is difficult to keep the child
in bed.  From this state, however, he can usually be recalled
for a few minutes, and will then answer questions 'distinctly.
If the debility be considerable, the countenance becomes  va-
cant, the child picks at the bed-clothes, and though he does
not speak much, makes a constant inarticulate noise. In some
instances, convulsions have taken place; but these are rare,
and are chiefly met with in young children.   Sometimes the
stools are passed in bed, without any intimation being given.
This disease runs on for a week or two, or even for several
weeks, and may  at last destroy the patient by debility; an
event which will take place earlier, if the  proper remedies
are not employed, than if they  be, even although  they may
ultimately fail.   In general, success attends their use.   Tu-
mefaction of the belly, with great and constant fever, are very
unfavourable.
  In mild,  but protracted cases of this fever, the patient per-
haps is confined to bed only part of the day, and becomes
cheerful in the afternoon.  The stools for a day or two im-
prove, and then become  very offensive; the appetite returns
soon, but the fever, emaciation, tumour of the belly, and other
symptoms, may continue for several weeks. 
361
  This  fever bears a very considerable resemblance to hy-
drocephalus.  But in hydrocephalus there is a more frequent
vomiting, and as often a tossing of the hands above the head
as picking of the nose or lips.  There is pain of the head,
which is wanting, or if it occur early, it is, in  this fever, in
paroxysms connected with  sickness, or  affection of the sto-
mach. There is screaming and strabismus, and often a more
constant delirium, from which the patient cannot be roused,
after it  has continued for  some time;  and convulsions are
accompanied with great injury of the mental faculties. There
is in general, in  this fever, more complete remission  of the
symptoms at  some time  of  the day than in water  in the
head, the pulse  not only  being  slower, but the child more
lively and easier.  The stools are more foetid  and  darker
than in hydrocephalus, in which they are often  thin and
bilious, and sometimes glossy.  The pulse  in hydrocephalus
is more irregular, and, in the second stage, usually becomes
slow and intermittent.  It must, however, be acknowledged,
that, in some instances, it is very difficult to make the diag-
nosis, especially if we have not  attended the child from the
first.  I have had the happiness of seeing children recovered
from situations apparently desperate,  when there was every
reason   to fear that the  disease was  water  in the  head,
though the result proved the contrary.  Fortunately, in all
such ambiguous cases, the exact diagnosis would be of more
consequence in determining the prognosis than the  treat-
ment.  For, in  these circumstances, the application of blisters
to the head, the use of laxatives, and supporting the strength,
are the means  to be chiefly resorted to in both diseases.
   It appears to me, that this disease proceeds  at first from a
 deranged state of the stomach and intestines, which very soon
 is communicated to the liver and lacteal system, but perhaps
 still more early affects the action of the nervous and vascular
 systems.  The treatment in this view, will consist in employ-
 ing such means as excite brisker action of the  stomach and
 bowels, such as purgatives,  and improve  the nature of the
 action, altering the morbid into more natural action, as mer-
 curials and afterwards tonics.  At the same time, that these
    VOL. IT.                            3 A 
362
remedies are directed to the original cause, it  is proper to   »
employ such other means as the particular state of the ner-
vous and  vascular systems may require, especially such as
operate on  sensation  and secretion, as heat, cold, blisters,
opiates, diaphoretics.
  It is generally proper to begin the treatment of this  dis-
ease, on its first attack, with an emetic, which is  to be fol-
lowed with a purgative.   In some  cases, the usual  dose of
the purgative will prove effectual; but oftener a much larger
quantity must be given. We cannot a priori say what quantity
may be necessary to procure stools.  Usually, it is greatly be-
yond what any one who has not seen much of  this disease
would expect.  Senna tea answers the purpose very well; or
if the child can swallow pills, the aloetic pills stay well on the
stomach, and, if given in sufficient number,  act excellently
on the bowels.   Clysters are of great benefit.  It is useful to
purge the bowels freely at first; but after this, it is not pro-
per to give so much medicine as will operate briskly.*   It is
requisite, however, to give regularly such doses as shall keep
the bowels open, and support their action.  When  the stools
are  loose, purgatives are still  proper, in prudent doses, to
evacuate them; for they are not natural in their  appearance,
and injure the action  of the  intestines.  Suitable doses of
calomel, or castor oil emulsion, or infusion of senna, or aloetic
pills,  will presently bring the stools into  a more  natural
state.  This is a very important part of our practice, but not
the whole of it, for we know well, that removing the cause of
fever does not always  remove the  fever itself.   We should,
therefore, besides using laxatives early, and continuing their
exhibition during  the  disease, as long as these  bring away
offensive  stools,  and do  not increase the frequency of the
pulse or debility, have  recourse, in the commencement of the
fever, to the use of the sponge,  with cold water to moderate
the beat.   This is to  be repeated oftener or seldomer, ac-

  * Dr. Pemberton judiciously remarks, that if strong purges are given, the
intestines are apt to become distended with air, and the patient is destroyed
with tympanites.  Practical Treatise, &c. p. 165.  It is worthy of remark,
that dissection often discovers nothing but great inflation of the intestines. 
363
cording to the benefit it produces.   Afterwards we  employ
saline julap, with a little antimonial wine, and, in  the  more
advanced stage  support the strength with regular and cau-
tiously-proportioned doses of wine.  Such, the wine excepted,
is the practice during the  first two or three days of the
fever. Afterwards, we ought to give calomel combined with
antimonium calcaroo-phosphoratum, in such  doses, as both
to act on the bowels,  and likewise to produce an alterative,
or slightly mercurial  effect. It is, however, surprising how
difficult  it is to  affect young people in this way, or produce
any tenderness of the gums.  Along with this medicine, we
may also employ occasionally other purgatives, and  foment
the belly when it is pained or much distended.  Opium and
hyoscyamus frequently allay irritation, and accelerate re-
covery, by procuring sleep. Anodyne clysters are useful  in
this respect, and also for abating griping or abdominal pain.
Pain in the side, if not abated by rubbing with anodyne bal-
sam, requires a  small blister.   Delirium  is sometimes, but
not always,  mitigated  by blistering the  head; but this  is
uniformly proper when there is considerable delirium, or any
pain in the head.  Shaving the head, and merely washing it
with vinegar, has also a good  effect.   The  diet should  be
light, but it  is not proper to force the patient to eat.   In the
progress of the disease, infusion of bark or other tonics are
sometimes beneficial,  and ought always to be tried.   When
the disease is protracted, it is sometimes of advantage to in-
termit the use of purgatives, and employ only clysters, and  at
the same time begin the use of  steel.  Under this plan, the
bowels though formerly not moved by strong medicine, act
more regularly, and recovery goes on fast.  As this happens
in the progress of protracted cases, it is probable that some-
times the purgative and mercurial medicines  are pushed too
far, and  keep up an undue irritation.  Great attention should
be paid to cleanliness and ventilation, and, when  convales-
cent,  a removal to the country is highly useful. 
 
APPENDIX.
  AS our author has not so fully illustrated  the  mechanism
of labour, as was desirable, in the  different  presentations of
the  vertex, and as an accurate and precise knowledge of the
position of the head is necessary, preparatory to the proper
application of and action with the forceps or vectis, we have
thought it best to add the description of the passage of the
head through the straits  and cavity of the  pelvis in the six
different positions of the vertex, as  minutely laid down and
detailed by Baudelocque and Gardien.   To these authors we
must therefore  acknowledge  our obligations for the pages
that follow; and we  are persuaded,  that to  the  student
and young practitioner of midwifery,  they will not be su-
perfluous, but on the contrary, will deserve  the most serious
attention, as a compass to guide him in his  course through,
what would otherwise  prove, a  wilderness of doubt and un-
certainty.
  We  have also added a table from the last edition of Bau-
delocque's art des accouchemens, which shows  the  comparative
frequency  of the  different presentations, [at least in Paris]
and of those  difficult and preternatural cases  which perempto-
rily require  the assistance of  art, either  by means of the
hand alone, or by the aid of instruments.
  It has already been explained, that the vertex or crown of
the head, the presentation of wliich constitutes the first order
of natural labours, is recognised by the presence of a round,
solid tumor, of greater  or lesser size, upon which we can trace
several sutures and fontanelles.
   But even  when the vertex presents, the sutures and fon-
tanelles do not always answer to the same point; which has
induced practitioners  of midwifery to distinguish the dif-
fe rent  positions of the  vertex, according to the manner in 
366
APPENDIX.
which this part presents at the superior strait, and which we
determine by the relative situation of the fontanelles, and the
direction of the  sutures.
   Although there is no point of the pelvis to which the pos-
terior fontanelle, which we should always take for our guide,
may not correspond, we may nevertheless confine the num-
ber of positions  to six principal ones.  Indeed, a sufficiently
accurate idea might be  given of  natural parturition, by de-
scribing a lesser number of positions.  But it becomes ne-
cessary to admit them as above enumerated, to explain fully
those cases, where  the  intervention and aid of art becomes
necessary.   For properly  to apply the forceps, and  to act
with them  advantageously, the accurate knowledge of these
different relations  of the foetal head with the pelvis, as well
as its progress through the different stages of the labour, un-
til delivered, is supposed to be well understood.
  More clearly  to comprehend this part of our subject, we
may consider the circumference of  the pelvis as divided into
two  segments, or  semi-cumferences, one  anterior  and the
other posterior.   In the three first positions, [which have
already been briefly enumerated  in a note to Chapter  1st of
the 2nd Book, and  which we shall presently more fully ex-
plain]  the  posterior fontanelle  answers to one, of what we
may venture to term the cardinal  points of the anterior semi-
circumference ;  in  the three last, the same posterior fonta-
nelle answers to  one of the diametrically opposite points of
the posterior semi-circumference.
  If we observe  the direction that the head pursues in each
of these positions, when it  is expelled  by the efforts of na-
ture alone, we shall find, that in each of them, it offers some
peculiarities, which it is of importance to understand.  The
mechanism of these different species of labour,  ought to be
studied with the greater  attention, as it is this knowledge,
which  is to guide  the practitioner in all his operations, in
those cases of labour, where malposition of the head  occurs.
Vide Chap. IV. Book II.
  First Position. In this position, the posterior fontanelle
answers to the  left acetabulum.  The back of the infant is 
APPENDIX.
367
situated towards the anterior  and left lateral portion of the
uterus and pelvis.  The face and  the breast  answering to
their posterior and  right lateral  portions.  The feet and
breech are towards the fundus uteri.
  At the commencement of labour, it is frequently only the
middle portion of the  sagittal suture  which presents at the
centre of the  superior  strait.-  Whilst both the fontanelles
remain as yet out of the reach of the Anger in' the common
examination; we cannot, therefore, at this periodf, accurately
determine the precise position of  the head.   For although
we may ascertain that the sagittal suture is directed from
the left acetabulum to the right sacro-iliac symphysis, we
are as yet ignorant whether the posterior fontanelle is  situ-
ated in the anterior or posterior  segment of the pelvis, and
of consequence, whether the vertex presents in the  first or
the fourth position.   The same  difficulty  presents  in dis-
criminating  between   the 2nd and the 5th position, and be-
tween the 3d and the 6th, whilst we  can merely  reach the
sagittal suture.
  In the  first period of labour, it is commonly one of the pa-
rietal bones  which presents.  As the labour advances, the
middle portion of the sagittal suture retires from the centre
of the pelvis, to give place to one of the fontanelles; and it is
the posterior fontanelle that most frequently presents.
  When the  waters have been discharged, the first contrac-
tions of the uterus tend, in the natural progress of labour, to
bend the head upon the breast.  Whilst this is taking place,
the posterior fontanelle approaches nearer and nearer to the
centre of the pelvis.  The head thus bent,  continues to pro-
gress through the cavity, by passing from before backwards,
in order to  accommodate itself to the axis of the superior
strait.  It continues to descend, until checked by the sacrum,
the coccyx, and the  perinaeum.
  Whilst the head descends into  the cavity of  the pelvis
in a diagonal  direction, one of the parietal protuberances
passes before the left sacro-iliac symphysis, and the other be-
hind the  right acetabulum.
   In this position, it  is  the  right  parietal bone  which an- 
368
APPENDIX.
swers to the arch of the pubis.  One of the branches of the
lambdoidal suture answers to the left limb of the pubis, and
the other branch is directed  towards the left ischiatic notch.
This has been often mistaken for  the sagittal suture, and in
consequence of its direction, which is from before backwards,
it has been supposed that the head had already performed
its movement of rotation, by  which the posterior fontanelle
is ultimately brought under the arch of the pubis.
  The head having arrived at the bottom of the pelvis, can-
not any longer follow its first direction, because it is check-
ed by the sacrum and coccyx. The contractions of the uterus
continuing to act upon it, force the occiput, as it were, to re-
volve from behind  forwards  upon  the inclined  plane, which
the left side of the pelvis offers, in order to advance towards
the symphysis of the  pubis; whilst, at the same time,  the
face turns into the hollow of the sacrum, as it were revolving
from before backwards upon the  inclined plane,  which the
other side of the pelvis presents.   If the fingers  are placed
upon the posterior fontanelle, whilst the head retains its la-
teral position, it may sometimes be perceived to perform this
movement on its axis during a strong pain.
  Whilst the occiput approaches the arch of the pubis, the
trunk  remains without motion in the uterus.   This pivot-
like motion of the  occiput,  depends solely  upon the twist-
ing of the neck. This rotation being performed, the posterior
fontanelle is situated towards the  centre  of  the arch of the
pubis,  and the anterior towards  the sacrum.  The sagittal
suture is parallel to the great diameter of the inferior strait.
The branches of the lambdoidal suture answer to each side of
the pelvis.
  The chin, which, until this period, had remained constantly
applied to the breast, begins to recede from  it.  The occiput
dilates  the external parts, and engages under the  arch  of
the pubis, under which it revolves, in rising and approaching
towards the abdomen of the  mother.  Whilst the occiput thus
progresses, the nape of the neck,  which may be considered
as the centre of motion, revolves under the inferior edge of
the arch of the pubis.  In this motion, the occiput passes over 
APPENDIX.
369
but a small space, whilst the chin,  in describing a curve,
progresses from the sacrum to the inferior commissure of the
labia. The expulsive forces bear upon the forehead and upon
the face, during this  period of labour, and oblige the chin to
recede from the breast.   The neck is sufficiently long to al-
low the head to be delivered without the trunk's advancing.
If the head in its passage does not accommodate itself to this
curve line, above described, but descends  directly in the di-
rection of the axis of the superior strait, every effort bears
upon the perinseum, which is then in  danger of rupturing in
its centre.   If  we do not succeed in obliging the head to fol-
low the direction above described, by applying pressure from
behind forwards, and from  the perinseum upwards, the only
means which remains to prevent the laceration of this part,
is to apply the  forceps, in order to direct the head forward,
and thus oblige the chin to recede from the breast.
   Scarcely is the head delivered,  when the face turns towards
the right  thigh of the woman, to which it answered in the
 commencement of labour; for it only turns into the hollow
 of the sacrum,  in consequence of the twisting of the neck, and
 resumes its first position, as  soon  as the neck is restored to
 its former situation.
   When the  head  is completely delivered,  the  shoulders,
 which had entered the superior strait diagonally, as well as
 the head,  turn one towards the pubis, and the  other towards
 the sacrum.  The left shoulder, which is towards the sacrum,
 approaches the vulva, and begins to be engaged there, whilst
 the right shoulder remains applied behind the symphysis of
 the pubis, until the other appears externally; which indi-
 cates, that when it is proper  to assist in extricating  the
 shoulders, we  should act principally upon  that which is placed
 posteriorly.
    Such is the progress of nature in this species of parturi-
 tion,  as every one may convince himself, if he will  trace it
 step by step,  through the course of the labour.  And  in  ob-
 serving it, he  will be able to distinguish three different move-
 ments.  In the first period, the head bends itself towards the
 breast, and progresses through  the cavity of the pelvis.  In
    VOL. II.                            3 B 
370
APPENDIX.
the second it performs a motion, which  brings  its long dia-
meter in the direction of pubis and sacrum. In the third, the
chin quits the breast, and the occiput turns  backwards, in
disengaging itself from under the pubis.
  The head ought to present its greatest diameters to the
greatest  diameters of the straits; but as it regards the su-
perior strait, it does  not present as  is commonly  supposed,
its smallest diameter to the smallest of that strait. Its small-
est  diameter  is directed from one sacro-iliac symphysis, to
the opposite  acetabulum.  The portion  of the head which
passes between the pubis and the sacrum, is still narrower
than that which is termed its small diameter.
  This species of labour would always be the most advanta-
geous, ifthe laws of nature were invariably carried into effect,
but in proportion as nature varies from the line  that has been
delineated, the labour becomes  more  and more difficult, and
often indeed impossible, without the aid of art.
  Second Position.  In this position  the posterior fontanelle
is placed behind  the  right acetabulum, and the anterior is
situated before the left sacro-iliac symphysis, so that the back
of the child answers to the anterior and right lateral portion
of the uterus, and of the pelvis; whilst  the face,  the breast,
and the knees,  are situated towards  their posterior and left
lateral portions.
  The mechanism of labour in this position, is perfectly simi-
lar  to  that of the preceding.  As in that, if the expulsive
forces are directed in such a manner, as to apply the chin of
the infant more  and more to the breast,  the  occiput pro-
gresses during the first period through the depth of the cavity.
In the second period, the occiput slides from behind for-
wards upon the inclined plane,  which  is presented by the
right side of the pelvis, in  order to place itself  under the
arch of the pubis; whilst at  the same time,  the  face  turns
into the hollow of the sacrum.   In the third period, the ex-
pulsive forces oblige the chin to recede from the breast; the
occiput dilates the  vulva as it turns upwards towards the
pubis.  This movement of the occiput is but inconsiderable;
it does nothing but turn itself, whilst the nape of the neck 
APPENDIX.
371
revolves under the superior part of the arch.  In order that
this revolving of the head  backwards, which facilitates its
expulsion may take place, it is necessary that the face should
pass over a curve which measures  in extent the whole length
of the sacrum, to the anterior edge of the perinseum.
   As soon as the head  is delivered, the face turns towards
the left  thigh, to which  it  primarily answered.   The left
shoulder turns  towards the pubis, and the right towards the
sacrum.  This latter alone advances until it appears at the
vulva.
   The relative proportions of the diameters of the child, with
those of the pelvis, are really the same in  this position as in
the former.  The occiput  and the face have  not  a larger
space to traverse to  arrive, the one at the symphysis pubis,
and the other in the hollow of the sacrum, in  the  position
where the posterior fontanelle is situated  towards the right
acetabulum, than in that where it is placed behind the left.
Hence it would appear, that one of these  positions  ought to
be as favourable as the other to the expulsion  of the child.
But there are,  notwithstanding, greater difficulties experien-
ced in  that where the  occiput is to the right; because the
rectum, which is placed on the left side of the  sacrum, pre-
vents the forehead from turning so readily into the hollow of
that bone.
   Practitioners have supposed  that it  more frequently hap-
pens in this position, than in the preceding, that the  direc-
tion of the expulsive powers, instead of advancing the occi-
put, as in the natural order, tends to throw  it back upon the
shoulders.  What truth there is in this  supposition, we shall
not here stop to investigate.
   Tldrd Position.   In this position the posterior fontanelle is
behind  the symphysis  pubis, and the anterior before the
projection of the sacrum.   The back of the infant is towards
the anterior, and its abdomen towards the posterior portion
of the uterus.  For a long time this was  considered as the
most common and the most advantageous position, but both
of these suppositions are incorrect; for  experience on the
contrary proves, that it is very rare;  so much so indeed, 
372
APPENDIX.
that many practitioners who have never met with it, have ab-
solutely called its  existence in question.   Those  who  have
imagined that the occiput constantly answered to  the pubis
from the commencement of labour, have only thought so, be-
cause they observed it disengage itself in this direction from the
inferior strait.   A regular examination through  the whole
process, would have taught them, that although the occiput is
expelled from under the pubis, it nevertheless enters the supe-
rior strait  diagonally.   When the occiput  passes through
the superior strait directly behind the  symphysis pubis, the
long diameter of the head is opposed to the small diameter of
this strait.   The difficulty  which is experienced by the  head
in its passage must be greater, as the friction must be  more
considerable.  If no obliquity exists, parturition may never-
theless be accomplished with a sufficient degree of ease  ; be-
cause in a well formed pelvis, the short diameter of the strait
is four inches, and the long diameter of the head is no great-
er.  If the  head  engages favourably, it only presents  its
height, or its perpendicular diameter, because the chin  rises
towards the breast of the infant, which facilitates  the expul-
sion of the head.
   There are but two periods to be taken notice of in the pro-
gress of this species of labour ; the face remains towards the
perinaeum for some time after the delivery  of the head; it
does not turn to one or  other of the thighs, until after the
shoulders, which had  entered the superior strait diagonally,
have presented at  the  inferior strait, one being towards the
pubis,  and the other towards the sacrum; but they turn  in-
differently to one or the other part of the pelvis, because the
head has not been obliged  to perform  the  pivot-like motion.
Of course,  it is not in our  power previously to designate,
which shoulder will turn towards the pubis.
   Fourth Position. In this  position, the anterior fontanelle
is behind the left  acetabulum, and the posterior  before  the
right sacro-iliac symphysis, and the course of the sagittal su-
ture is obliquely,  from the former to the latter point.   The
back of the infant is  to the right  posterior  portion,  and its
breast, &c. towards the left anterior portion of the uterus. 
APPENDIX.                  37S
  Although at the commencement of labour, the  posterior
fontanelle is placed towards the right sacro-iliac symphysis,
the face does not always come out under the arch of the pu-
bis.  We sometimes observe, that the occiput approaches the
right acetabulum, in proportion as the head advances in the
pelvis.  When this spontaneous conversion of the fourth to
the second position takes place, it is to  be considered as ex-
tremely favourable  for the patient.  From  hence  an infer-
ence has been drawn,  that when the practitioner meets with
this position, he ought, at the commencement of labour, to fa-
cilitate its progress, and lessen the sufferings of the female,
when the face is turned towards the symphysis of the pubis,
by making an  effort  to disengage it  from  that  part, and
bring the occiput, during the pains, rather forward towards
the pubis, than towards the sacrum.  Ifthe membranes have
not been ruptured, it is impossible to touch the head  during
the existence of a pain.  This  conversion cannot be accom-
plished without risk, except we act at the instant of the dis-
charge of the waters.  When nature spontaneously produces
this conversion in the fourth and fifth  positions, the same
change  of relative situation takes place in the  trunk.  We
ought not, therefore,  to attempt producing it by art, unless
the child is sufficiently moveable, to permit the trunk to un-
dergo  the same  changes in situation as the occiput; unless
this were the case, the  neck would suffer a twisting, which
would amount to the third of a circle.   It may be  important
to recollect the possibility  of this conversion, in those cases
in  wliich we  are obliged to apply the  forceps, because the
mode of proceeding will be different if that has taken place.
We should,  therefore, before  applying the forceps, endea-
vour to ascertain  whether  or no  the  face  is  towards the
pubis.
   If the  change of position, of which we have  just spoken,
has not taken place, the delivery of the head becomes more
difficult, because, in the second  period, the face turns to-
wards the symphysis of the pubis.  This part is disengaged
with more difficulty from  under the arch of the pubis, than
the occiput; for the  arch has less breadth in  its superior 
374
APPENDIX.
part, than the forehead and the face of the infant. The form
of the occiput, on the contrary, accommodates itself very
well to the arch of the pubis,  under which it  turns,  whilst
the face disengages itself behind.
   If in this position, the  contractions of the  uterus are di-
rected in such a manner, as to bear upon the  occiput, it de-
scends into the  pelvis, passing before  the right sacro-iliac
symphysis.  Wrhen the head reaches the sacrum, it can no
longer follow  its first direction.  The  contractions of  the
uterus oblige it to perform  a pivot-like motion, which turns
the occiput into the hollow of the sacrum, descending along
the inclined plane  of the  right side; whilst at  the same
time, the forehead places itself under the pubis, sliding along
the inclined plane, which the left side of the pelvis offers.  At
the end of this second period,  the anterior fontanelle is situ-
ated behind the pubis, and the posterior towards the sacrum.
   In the last period, the forehead cannot engage under the
arch of the pubis,  as the occiput does in the three preceding
positions; it is obliged to ascend behind the  symphysis, to
the internal surface  of which it remains  applied, whilst the
posterior fantanelle passes over the length of the sacrum, the
coccyx and the perinaeum to arrive  at  the bottom of the vul-
va.  At this moment the edge of the perinseum  is consider-
ably stretched, and runs a greater risk of laceration than in
the preceding positions.  The perinaeum not being capable of
remaining stationary upon the inclined plane which  the occi-
put offers, retires suddenly towards the base of the neck of
the infant.
   The posterior edge of the perinaeum becomes then  the
point of  support, or  axis, upon which the nape  of the neck
revolves, whilst the  occiput  turns  backwards towards  the
anus of the woman.   In proportion as the head turns back-
wards upon the perinaeum, the face disengages from under
the pubis.  We observe successively appear the forehead, the
orbits, the nose, the  mouth and the chin.  As soon as the
chin appears externally, the face turns towards the left thigh,
to which it primarily answered.  The left shoulder presents
afterwards towards the pubis,  and the right towards the sa- 
APPENDIX.
375
crum.   That  which is posterior, disengages the first,  the
other remaining stationary at that time.
  Fifth Position.  In this position the  anterior fontanelle is
behind the right acetabulum, and the posterior before the left
sacro-iliac symphysis. The back of the infant is towards the
left and posterior part of the uterus, its breast and abdomen
is towards the right and anterior part.  It is not unfrequent-
ly the case, that the efforts of nature alone  are competent to
convert this position into the first, the occiput gradually ap-
proaching towards the left acetabulum, in proportion as it de-
scends into the pelvis.  All the observations that have been
made on the preceding position, with  respect to attempting,
by the aid of  art, what  nature  herself sometimes performs,
are equally applicable to this position.
  The relations of the dimensions of the head of the child
with those of the pelvis,  are absolutely the same in this posi-
tion, as in the preceding;  the  face turns  equally upwards.
Hence the mechanism of this species of labour, is in every
respect similar to that of the preceding position.  If every
thing is in the natural order, the occiput descends into the
pelvis, passing before the left sacro-iliac symphysis.  In the
second period it turns towards the sacrum,  at the same time
that the forehead turns towards the symphysis pubis.  The
presence of the rectum on the left side of the pelvis, renders
this rotation more difficult,  by  preventing  the occiput from
turning freely into the hollow of the sacrum.  This position
is one of those, in which it is most essential to evacuate the
rectum by  an  enema.  As soon as the face is disengaged from
under  the pubis,  it turns  to the right  groin.  The right
shoulder is afterwards directed  towards  the pubis, and the
left towards the sacrum.  The latter alone  advances until it
appears at the vulva.
  Sixth  Position.  In this position the anterior fontanelle is
behind the pubis.  The sagittal suture  is parallel to  the
smallest diameter of the superior strait. The occiput and the
back of the infant is towards the sacrum.
  This position is the least favourable of all those wliich the
occiput can take.  Not only does the head present its length 
376
APPENDIX.
to the smallest diameter of the superior strait, but also the
face is anterior, as it regards the pelvis, as in  the two pre-
ceding positions. Happily it  is the most rare  of all.   The
rounded form of the  head, with difficulty permits it to remain
fixed duping labour against the projection of the sacrum, so
that even supposing it should answer to this part  of  the sa-
erum at the commencement of the labour, it would soon turn
to one of its sides, which would be better accommodated to its
figure.  When we happen to see the face disengage  itself
from under the pubis towards  the  end of labour, we  are not
thence to suppose, that the head engaged in that way in the
superior strait.  Although in the two preceding positions, the
head traverses this strait in a diagonal situation, the face,
which in the first period, was placed toward  one or other of
the acetabula, turns by a pivot-like motion towards the  arch
of the pubis, from under which it is delivered.
   Wre can distinguish but two periods in this position. If
the expulsive forces of the uterus act upon the occiput as oc-
curs in the natural  order, it progresses through the pelvis
before the  sacrum.   Whilst the forehead is applied  against
the internal surface of the symphysis of the pubis, the occi-
put, which ought to be delivered first,  considerably distends
the perinaeum, passing over a curve line which  extends from
the hollow of the sacrum to the lower edge of the vulva.  At
this instant the perinaeum retires backwards,  and  passes un-
der the nape of the neck, which revolves above it, whilst the
occiput turns backwards towards the anus of the woman. As
soon as the occiput begins to turn backwards,  the different
parts of the face, which until then had been retained in the
interior of the pelvis, successively disengage themselves from
under the pubis, in the order which has already been point-
ed out.
   When the chin appears externally, the face remains some-
times stationary: afterwards it turns towards one  of the wo-
man's groins, but only at the same instant that one of the
shoulders presents towards the pubis,  and the other towards
the sacrum. This position, also, is one of those  in which it is
allowable to be ignorant which of the shoulders  may present 
APPENDIX.                   377
towards  the pubis; for it is uncertain which; and when the
change of position is procured by the aid of art, it is indif-
ferent which we bring there.
  These divisions of the presentations of the vertex or crown
of the head, originated as we believe, with the experienced
Baudelocque, and on this subject he very judiciously observes,
that the head  may without  doubt present at the superior
strait, in a manner  different from those described.  The
posterior fontanelle, which as we  have before observed, we
should always take for our guide, may sometimes correspond
to the intermediate spaces between these six points; so that
we might perhaps distinguish six other positions, which might
be again subdivided  into  as  many more.  This distinction,
he remarks, would not  only be useless  and superfluous, but
might confuse the ideas.  There  is not in fact any of these
middle positions, which may not be referred to one of the six
first; and each of them ought, therefore, properly to be de-
signated by the  name  of  that to which it approaches the
nearest,  as the mechanism  of delivery in it  is  exactly the
same.
  These intermediate positions, therefore, ought to be refer-
red to the three first, as often as the posterior fontanelle an-
swers to any point of the anterior semi-circumference of the
pelvis; because  that fontanelle turns gradually towards the
symphysis of the pubis, under which the occiput is ultimate-
ly situated.
  The head, continues  Baudelocque,' sometimes follows  this
direction, even though  the fontanelle  in  question, be placed
opposite one of the sacro-iliac symphyses at  the commence-
ment of labour: but when it  is more backward, and answers
to some point in the posterior third  of the superior  strait,
all those positions ought to  be referred  to the three  latter,
that is to say, to the fourth,  fifth or sixth; because the occi-
put constantly turns in descending, towards the sacrum, and
the forehead under the pubis.
VOL. II.
3C 
 
Jl TABLE of the various Presentations at the period of Parturition which indispensably require that the Child be turned and delivered by the Feet.
[According to Baubeiocq.uje.
   S3 £
  ■*-> <u

  .■§ s
•a © t«
w T. «> !
 a> o3 o <
_J2 o-ua !
 The fore part of the ~]
Neck, or the Throat,  I
pug

Sh CD


S °
«^
£3
u
    presenting
  to the Os Uteri.
    The Breast
    presenting
      at the
     Os Uteri.
   The Abdomen
    presenting
      at the
     Os Uteri.
The fore part  of the
      Thighs
   and the Pelvis,
or the Sexual Parts,
    presenting
  at the Os Uteri.'
     Of which
     there are
       IV
j positions, viz,
"1    Of which
 !    there are
 r     iv
J positions, viz
-|    Of which
     there are
 >     IV.
J positions, viz

     Of which
     there are
       IV
  positions, viz.
|§ g
-§ ^<g

 ED .i-t W
 The Back of the   1   Of which
      Neck         L   there are
    presenting      |      IV
  at the Os Uteri.   J positions,  viz.
    The Back      "]   Of which
    presenting      !   there are
      at the         f     IV
     Os Uteri.      J positions,  viz.
The Lumbar Region^   Of which
    presenting      t   there are
      to the         |      IV
     Os Uteri.      J positions,  viz
eg

O


 o
Sec

 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.
1
   Of which
   there are
     IV
positions,  viz
J
   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.
 ^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.
"l 3d.  The Neck  and Head resting on the left Ilium; and the Abdomen  on the right Ilium.
, i_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.
, L4th.  The Breast resting on the right Ilium;  the Thighs and Knees on the left.     -
 "1st.  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.                                           5
  2d.  The Knees  over the anterior brim of the Pelvis; the .Breast and Face to the  posterior portion of the?
         Uterus.                                                                                         $
  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.   .  -
 1 3d.  The Occiput to the left Ilium; the Back to the right Ilium.     -       -      -
, L4th-  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.
 j 3d.  The Occiput on the left Ilium; the Lumbar Region on the right Ilium.
 tjlth.  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.      -       -      -  i|   -
.l_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 5 towards the Pubes  when the left.                   5
 I 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.                   $
  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 whjeH  the left Shoulder or i-
         Arm presents.                                                                                   J
  2d.  The side of the Neck over the Sacrum, and the Side over the  Pubes.  The Breastjtowards the right Ilium ?
         when the right Shoulder presents,  and vice versa.                                                 $
  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.              y
  4th.  The Ne^k and Head on the right Ilium; the Side and Hip on the left Ilium.   The Breast to the fore part >
         of the j Uterus when the right Shoulder and Arm presents, and vice versa.                            $
  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.                                                                     5
  2d.  The Axilla over the Sacrum; the Hip over the Pubes. The Breast towards the right Ilium when the right >
         Side  presents, and vice versa.                                                                     $
i 3d.  The Axilla on the left Ilium;  the Hip on the right Ilium.   The Breast towards the back part of the Uterus ?
         when the right Side presents, and vice versa.                                                       3
  4th.  The Axilla on the right Ilium; the Hip  on the left Ilium.  The Breast towards thej fore part  of the Uterus
         whenihe right Side presents, and vice versa.
  1st.  The Thfehs 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.
"1 3d.  The Thighs 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
         anterior part of the Uterus when the right Hip presents, and vice versa-
The Breast towards the ?

The Breast towards the ?
  Mte.—It is to be observed that Baudeloque, and the French practitioners generally, in preternatural Labours, or where the operation of Turning* ov the application of the Forceps becomes
Coccix and Perinseum may be free, the Thighs and Legs half extended, the Feet resting on Two Chairs placed properly, or supported by Assistants.
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 face 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 right 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. ji
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.
                                          i
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 light 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 ifthe left Side presents.

The right hand to be introduced ifthe right Side presents; the left hand ifthe left Side presents.

The right hand—if right Side----the left hanjd if left Side.        '        %

The right hand to be'introduced when the rigft 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.

necessary, place the Woman in a Supine Position, yjith the Breech brought to the Edge or Foot of the Bed, so that the 
* 
 
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                                      TABLE OF CASES OF LABOUR,

Which occurred at VHospice de la Maternite in Paris, from the 10th December 1797, to the 31st July, 1806, inclusively.
Infants born
12,751.
               Women, delivered    -     -     -     12,605.
   One hundred and forty-two of these women had twins.  Two only had triplets.
   Of these 12,751 infants, one hundred and eighteen were born before the admission of their mothers into the Hospital, or with such haste,
that there was no time to ascertain the part which presented, or the real position.
   Many of this number were not beyond the term of four or five months; and some from five to six, which reduces the number to 12,633, of
those in whom could be accurately ascertained the part which presented to the orifice of the uterus, in the course of the labour and delivery,
and the position of the particular part.


                                 The Regions which presented, the number of Times, and their Positions.
The crown of the head or vertex
The breech or the thighs
The feet......
The knees......
The face......
The belly......
The occipital region .   .
The back......
The loins......
The right side of the head
The left side of the head
The right shoulder .  .   .
The left shoulder . .   .
The right side of the thorax
The left side  .   .  .
The right hip ....
The left hip  ...  .
Number
  of
 times.
12,183
1st. Position.
10,003
2nd. Position.
2,113
3rd. Position.
4th. Position.
40
5th. Position.
22
6th. Position.
 Positions
    not
ascertained.
But four positions of all the other regions are admitted to exist.
198
147
  o
 42
  3
  1
 1
 4
20
18
 2
 1
12,633
118
 85
  1
  1
  1
  1
  1
  1
  0
  2
  0
  1
  0
  0
  1
  0

213
 71
 58
  0
  0
  0
  0
  0
  1
  0
  0
  0
  0
  0
  0
  0
  0

130
 3
 3
 1
22
 1
 0
 2
 0
 0
 1
 7
 9
 0
 0
 1
 1

51
, > ) . L .	. . 6 . 1 . . 0 . . . 17 . . 0 . . . 0 . . . 0 . . . 0 . . 0 . . 1 . . . 13 . . . 8 . . 1 . . . 0 . . . 0 .	•	• • •	1 2 1 1 1 1 1
L	48			8
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►'As 
379
Comparative statement of the Labours which were accomplish-
  ed by Nature alone, 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
                    Tn 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
  MiHg__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.
2,799	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 l'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. VI. p. 230.
  Lempriere  says, " Women in this country,  (Morocco,) suffer but little
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, &e. Vol.
II. 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.
II. 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 hves 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. 
3X2
   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.  Vide 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. Asalini  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
 feeling 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 the 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 hself can make us certain, and these can 
383
not be discovered for some time.  Fcetor of the discharge is not a test of
this.  Vide Mauriceau, obs. 281.  When a woman bears a child  which lias
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. Jt 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 fxces in the rectum.

                              CHAP. VH.
   NOTE 1, p. 105.—I believe few will dispute, that the  precise deformity
requiring the cesarean 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
behef that he could accorophsh 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 the best advice he can
 procure, to perform the cesarean 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. vin.
    NOTE 1, p. 114.—Dr. Bland is rather against delivery,  and for trusting to
 nature. Dr. Garthshore, Jour. VIU. 359, says, more women have recovered
 of this, who were not dehvered, than of those who were violently delivered.—
 Dr. Dcnman concludes, that women, in the beginning of labour, ought not to
 be delivered, H. 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. 
<*84
  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," delivery 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 intgstines were inflamed. See also, Crantz,
de Utero Rupto, p. 22; and Dr. Cathral's case in Med. Facts, Vol. VIII. 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 Phys. 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.  XLl. p. 696.  In Dr. Sym's
patient, the process for expelling the child by  abscess was in a favourable
train, when by imprudent exertion fatal inflammation was excited.  Med.
Facts, Vol. VIII. p. 150.  Bartholin also gives cases.  Le Dran  relates an in-
stance, where the uterus was ruptured on the 23d of April.  On the 13th of
May the placenta was expelled; on the 16th a tumour appeared at the linea
alba, wliich was opened, and a child extracted; the woman recovered.  Obs.
Tom. II. ob. 92.
   NOTE 6. p. 120.—In a case communicated to Dr. Hunter, the forceps were
pushed tlirough the cervix uteri,  and the intervening  portion between the
laceration, and the os uteri was  afterwards cut.   The labour was finished
naturally, and  the woman recovered.  Med. Jour. Vol. VIII. p. 368.  Dr.
 Douglass relates the successful case of Mr. Manning, in his Observations, p.
 6.   Dr. A. Hamilton gives a fortunate case, where delivery 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.
 VI. in which he remarks, that laceration near the vulva is easily cured; at 
385
the upper lateral part of the vagina, it is dangerous; and at the anterior and
posterior part, near the bladder and rectum, it is generaUy 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, the 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 the arm of the child.
                            BOOK  HI.

                             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, H. 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 little 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. XLl. p. 40.  A
 case of successful extirpation is inserted in the  same work for August 1786.
 Wrisberg 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 Society 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 delivered  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 dehvery, the womb
   VOL. TT.                                 * D 
386
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 lip
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 ligaments.—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 delivery, 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; ifthe 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 ^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 not bleed
unless there be pain in the hypogastrium, accompanied with violent stitches,
and a resisting pulse.   Even then he bleeds sparingly.
  M. Douket 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 little 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 Allan, and others, recommend carbonate of potash, in doses often
or fifteen grains.
   M. Vigarous joins with those who consider this as not a fever sui generis,
 but one varying according to circumstances.  It frequently begins, he says,
before dehvery, but becomes formed about the third  day after it.  He has
five different species.  1st, The gastrobiUous, proceeding from accumulation
of bile during pregnancy.  The essential symptom of this species is intense
pain in the hypogastrium. He advises first ipecacuanha, which 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,  aphthx, vomiting,  fetid  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
 nituita   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
 Tufl symptom of pain in  the belly, and subsidence of the breasts   He
 " es vomil and afterwards three or four grains of ipecacuanha every tiiree
 Tours   If he uses purgatives, he conjoins them with tonics  4th. With
 Phytic  affection,  or inflammation of  the  womb  attended with  great
 Zight 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 a3 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 followed 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 the external ap-
plication to the belly 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 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 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 tiie puerperal, as well as the pregnant state, although the woman be  well.

                             CHAP. XVII.

  NOTE, p. 173.—In some instances, the patient has been sensible of the
pain, which expelled the  child,  rushing  violently down the  leg.   After a
short time  it has abated, but  about the usual period this disease has ap-
peared.

                             CHAP. XXI.

  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 off 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 the appetite,nursing must be abandoned. 
389
  Pain in the side, or in the abdomen,  which is sometimes produced  by
nursing, is often relieved by friction, warm plasters, and an invigorating plan.
General weakness require tonics, wliich 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 its
 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 aphthx; livid, ulcerating, and scabbing pustules;  chancres
 on the genitals, and about the anus; excrescences;  peehng 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  the 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 him.
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 syphilis 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, w ho  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 will 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 blisters,
 which  are only confluent from their vicinity, but are distinct at the edges,
 where they are more distant,  we may, although 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 little 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 will 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  the air.
 Popular View, p. 63, et seq. 
INDEX,
  CO* The letter n. after the number of the page, indicates thai the article referred
to is contained in a note.

                               A

ABERNETHY, his  mode of treating congenite marks, vol. li.
      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
Amenorrhea, 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
Aphtha 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, u. p. 378
 Bandage to be applied after delivery, ii. p. 122
 Bathing, cold, when proper for infants, u. p. 198 
393
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 lever, 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 diseases 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, aress 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.  pi 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. S21
____________puerperal, ii. p. 109—venesection recommended in,
ii. 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,tbid.
—emetics not  useful, ibid.—camphor recommended by Hamilton,
ii. p. 115                                    .iv-
Cold, the application of,  recommended  in uterine hemorrhage, ii.
        p. 129
 Cold bathing, when proper for infants, u. p. 198
 Cooper, Astley, his mode of treating spina bifida, u. p. 20b, n.
 Corpus luteum, appearance of, after miscarriage, n. p. 191
 Cord, umbilical, presentation of, ii. p.  58
 ----- umbilical, how to be tied, ii. p. 192
 Coagula, retention of in uterus, and expulsion, n. p. 135^
 Contraction of uterus,  how produced in flooding, u. p. lo.
 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, u. p. 151
 Crinones, a species of pustule, ii. p. 242
 Crotchet, of cases requiring the, n. 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, u. p. 2iy
  Cynanche trachealis, ii. p. 309
  _.     — treatment, ii. p. 311

                              D

  Dandriff or Pityriasis  of children, ii. p. 238
  Death, sudden, from uterine hemorrhage, n. p. 14&
  Decidua, membrana, i. p. 164
  Deformity of pelvis from rickets, i. p. £*
  _________from malacosteon, i. p- 31
  ,________from exostosis and tumours, l. p. 3o
  Delivery, treatment after, ii. p. J22
                                          3 E
     VOL. II. 
894
INDE3C
 Delivery, apeedy, when proper in puerperal couvulsions, ii. p. 114
            & seq.
 ■---------recent, signs 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 in 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
 T~---------------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
 Dyspnoea 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.
Enclavement or locked-head, ii. p. 83-4
Enemata, stimulating, proper in puerperal  convulsions, ii. p. 113
Ententis  of infants, u. 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  n. 
INDEX.
399
Evolution, spontaneous of foetus, ii. p. 51
Excrescences of the labia, i. p. 51
Extra-uterine pregnancy, i. p. 168
-----------------------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, l. p. 258
 .--------treatment proper in, vide hemorrhage, 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.  192 
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 it
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 with  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. 136
         ■     -----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
Hematemosis, effect oi 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 delivery,
        ii.p. 127«.
-----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, ii.  p. 311
Hour-glass contraction of uterus, ii. p. 131
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, 34f!
-------------.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 
398
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. 333
Invagination ofintestines, frequent cause of diarrhoea, ii. p. 333
Itch, or scabies, ii. p. 230
-----dry, of children, ii. p. 236

                               J
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. US

                               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              v
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 hemorrliage, ii. p.
       ISO n. 
INDEX.
399
Leg, swelled, or phlegmatia dolens, ii. p. 172
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 diarrhoea, ii. p* 334
Lichen, ii. p. 223
-------liviaus, ii. p. 243
Locked head, ii. p. 83-4
Lochia, profuse, from rising too soon after delivery, 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
 Mammse, 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 diet 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, u.p. 59 
400
I.NDEX.
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, fcetid  secretion from, ii. p. 212
Noma, or gangrene of the check, &c. in infants, ii. p. 249
Nymphse, diseases of, i. p. 54

                             0

Obliquity  of pelvis, i. p. 9
(Edema of labia, i p. 53
.-------effect of pregnancy, i. p. 53
(Esophagus, rupture of, ii. p. 328
Oleum terebinthinee, 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, Ceesarean, 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
-------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. 1, 2, 3, & seq.
Paralysis [puerperarum], ii. p.  177
---------of children, ii. p. 309
Parrish, Dr. on scrofula interna, ii. p. 325 n 
         W                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
Petechise, 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. 27S, 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
,________portion of, remaining keeps up flooding, ii. p. 135
 _____-----------how to be treated, ibid.
 ________rashness in extracting, occasions inversion of uterus, \t.
             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
 -----------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 
*  40&                       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, i. 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. 113 & seq.
  Purpura, or petechise sine febre, ii. p. 242
  Pubis symphysis, description of, i. p. 7
  -----envision 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
  ------sestiva, ii. p. 290
  -------autumjtialis, 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, n.

                                S
  Sacrum, os, description of, i. p. 5
  Sacro-iliac junction, i. p. 8
Jr 

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 n.
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, n. 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. 2f 3
 Spleen enlarged in  infants, ii. p. 355
 Stomach and duodenum, spasms of, i. p. 184
 ________to be watched in uterine hemorrhage, u. 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, n. p. 194
 Strophulus intertinctus, ii. p. 220
 ---------albidus, id.  p. 221
   i         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 scalp, 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
Teetn, 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, aphthse 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  tenia, 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.
405
                              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
   i     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
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, id. 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,  u.
          p. 128                                   ..
Uteri, prolapsus, from rising too soon after parturition, u. 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. 13b
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 n.
 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. n. 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. 365 & seq
 Vomiting, effect of pregnancy, i. p. 181                        H*
 ---------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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