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NATIONAL LIBRARY OF MEDICINE
Washington
Founded 1836
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U. S. Department of Health, Education, and Welfare
Public Health Service
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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 AMERICAN, FROM THE SECOND 10NDON EDITION,
MUCH ENLARGED.
WITH IMPROVEMENTS AND NOTES,
BY THOMAS C. JAMES, M. D.
PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF PENNSYLVANIA.
VOL. II.
PHILADELPHIA :
PUBLISHED BY JOHNSON AND WARNER, EDWARD PARKER, KIMBER AND
CONRAD, MOSES THOMAS, REDWOOD FISHER, ANTHONY FINLEY,
MATHEW CAREY, BENJAMIN AND THOMAS KITE.
Joseph Rakestraw, Printer.
"1813.
DISTRICT OF PENNSYLVANIA, TO WIT:
Be 3 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
Caroy, 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 Proprietors,
in the words following, to wit:
" T/te Principles of Midwifery ; including the diseases of Women and Children. By
"John Bums, Lecturer on Midtvifery,and Member of the faculty of Physicians and
" Surgeons, Glasgotv. Tlte third American, from the second London Edition, much
"enlarged. With Improvements and Notes, by Thomas C.James, M. D. Professor
"of Midtvifery in the University of Pennsylvania."
In Conformity to the Act of the Congress of the United States, intituled," An Art
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 men-
tioned."—And also to the Act, entitled, u An Act supplementary to an Act, entitled
" 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 extending the Benefits thereof to the Arts of designing, engraving,
and etching historical and other Prints."
D. CALDWELL,
Clerk of the District of Pennsylvania.
CONTENTS.
CHAPTER V.
Of Tedious Labotir. Page.
Order 1. From imperfection or irregularity of mus-
cular action - - 1
Order 2. From some mechanical impediment - 11
CHAPTER VI.
Of Instrumental Labours.
Order 1. Of cases admitting the application of the
forceps or lever - - -16
Order 2. Of cases requiring the crotchet - 29
CHAPTER VII.
Of Impracticable Labour, - 37
CHAPTER VIII.
Complicated Labour.
Order 1. Labour Complicated with uterine hemorr-
hage - 43
Order 2. With hemorrhage from other organs 44
Order 3. With syncope 45
Order 4. With convulsions - - 45
Order 5. With rupture of the uterus - 51
Order 6. With suppression of urine 56
BOOK III.
Of the Puerperal State.
CHAPTER h
Of the Treatment after delivery - 56
CHAPTER II.
Of Uterine Hemorrhage - 61
IV
CHAPTER 111.
Of Inversion of the Uterus - Page 73
CHAPTER IV.
Of After-Pains - 77
CHAPTER V.
Of Hysteralgia and Suppression of the Lochia 79
CHAPTER VI.
Of Retention of Part of the Placenta - 81
CHAPTER VII.
Of Strangury - - 83
CHAPTER VIII.
Of Pneumonia - - 84
CHAPTER IX.
Of Spasmodic and Nervous Diseases 84
CHAPTER X.
Of Ephemeral Fever, or Weed 86
CHAPTER XI.
Of the Milk Fever - - 89
CHAPTER XII.
Of Miliary Fever - - 90
CHAPTER XIII.
Of Intestinal Fever - 92
CHAPTER XIV.
Of Inflammation of the Uterus - 94
CHAPTER XV.
Of Peritoneal Inflammation - 98
CHAPTER XVI.
Of Puerperal Fever - 101
CHAPTER XVII.
Of Swelled Leg - - 106
CHAPTER XVIII.
Of Paralysis - Page 110
CHAPTER XIX.
Of Puerperal Mania and Phrenitis 111
CHAPTER XX.
Of Bronchocele - * 114
CHAPTER XXI.
Of Diarrhoza - - 115
CHAPTER XXII.
Of Inflammation of the. Mamma, and Excoriation of the
Nipples - - 116
CHAPTER XXIII.
Of the Signs that a Woman has been recently Delivered 121
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 - 124
Section 2. Of cleanliness, dress, and tempe-
rature - - - - - 128
Section 3. Of diet - - - - 130
CHAPTER II.
Of Conginite and Surgical Diseases.
Section 1. Hare-lip - - - 134
Section 2. Imperforated anus, urethra, &c, 135
\ I
Section 3. Umbilical hernia - Page 1 Mi
Section 4. Spina bifida - - - 137
Section 5. Marks - - a 38
Section 6. Swelling of the scalp - - 139
Section 7. Distortion of the feet - - 140
Section 8. Tongue-tied - - 140
Section 9. Malformed heart - - 141
Section 10. Swelling of the breasts, hydrocele,
excoriation, &c. - - - lil
Section 11. Foetid secretion from the nose 143
Section 12. Ophthalmy - - - 144
Section 13. Spongoid disease of the eye - 14i
Section 14. Scrophula - - 145
Section 15. Rickets - - - lio"
CHAPTER III.
Of Dentition - - 147
CHAPTER IV.
Of Cutaneous Diseases. ,
Section 1. Strophulus intertinctus * - 151
Section 2. Strophulus albidus - - 153
Section 3. Strophulus oonfiertus - „N 153
Section 4. Strophulus candidus - . 155'
Section 5. Lichen - . ^55
Section 6. Intertrigo - ... ^55
Section 7. Crusta lactea - - . 157
Section 8. Anomalous eruptions, and general
remarks on the remedies - _ 15S
Section 9. Pompholyx, pemphigus, and pock-
eruption - - _ . mg
Section 10. Miliary eruption - ±60
Section 11. Prurigo - . _ ^6^
Section 12. Itch - . . 162
Section 13. Herpes - ... ^63
Section 14. Ichthyosis - f - 167
Section 15. Psoriasis - - - 168
YI1
Section 16. Impetigo - . j>agt 169
Section 17. Pityriasis - 170
Section 18. Porrigo 170
Section 19. Scabs from vermin 172
Section 20. Boils and pustules 173
Section 21. Petechias 174
Section 22. Erysipelas and erythema 175
Section 23. Excoriation behind the ears 177
Section 24. Ulceration of the gums - ■« 178
Section 25. Erosion of the cheek 179
Section 26. Aphthae - 181
Section 27. Aphthae on the tonsils 185
Section 28. Excoriation of the tongue, lips, &c. 186
Section 29. Syphilis 186
Section 30. Skin-bound 190
Section 31. Small-pox ... 192
Section 32. Cow-pox ... 199
Section 33. Chicken-pox 205
Section 3 k Urticaria 207
Section 35. Scarlatina 209
Section 36. Measles ... 216
Section 37. Roseola - - 221
CHAPTER V.
Of Hydrocephalus - - 223
CHAPTER VI.
Of Convulsions - - 232
CHAPTER VII.
Of Chorea. - - 238
CHAPTER VIII.
Of Croup - - 240
CHAPTER IX.
Of Hooping Cough - - 249
CHAPTER X.
OfVMarrh - 253
viu
CHAPTER XI.
Bronchitis, Inflammation of the Pleura:, and of the
Stomach - PageZBB
CHAPTER XII.
Of Vomiting - - 258
CHAPTER XIII.
Of Diarrhoea - - 259
CHAPTER XIV.
Of Costiveness - - 270
CHAPTER XV.
Of Cholic - - 271
CHAPTER XVI.
Of Peritonitis - - 272
CHAPTER XVII.
Of Marasmus - 273
CHAPTER XVUI.
Of Tabes Mesenterica - 274
CHAPTER XIX.
Of Worms - 278
CHAPTER XX.
Of Jaundice - - 281
CHAPTER XXI.
Of Diseased Liver - 282
CHAPTER XXII.
Of Fevers - 286
APPENDIX - 295
TABLE - - 309
NOTES - 313
INDEX - - 325
THE
PRINCIPLES
OF
MIDWIFERY.
CHAP. V.
Of Tedious Labour.
ORDER 1. PROM IMPERFECTION OR IRREGULARITY OP MUS-
CULAR ACTION.
If the expulsive force of the uterus be diminished, or the
resistance to the passage of the child be encreased, the la-
bour must be protracted beyond the usual time, or a more
than ordinary 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
power of the uterus is worn out before the head of the child
have fully entered into the pubis, or come into a situation to
be expelled.
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 debi-
VOL. II. A
2
lity 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,
however, 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 la-
bour is sometimes equally tedious, but, in most cases, the
delay principally takes place in one of the stages, generally
in the first, if the cause exist chiefly in the uterus'. If, how-
ever, it proceed from general debility, we often find, that
if the first stage be tedious, the powers are thereby so ex-
hausted, that the second can with difficulty be accomplished.
Hence, although consumptive patients often have a rapid
delivery, yet if the first stage be slow, the head frequently
cannot be expeljed without assistance. It is not always easy
lo 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 distended 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 com-
bined with a dull leucophlegmatic habit, or with a constitu-
tion 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 be-
come peevish or desponding, and to press with injudicious
impatience 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 pa-
tient with that gentleness and compassionate encouragement,
which humanity and refinement of manners will dictate, 19
steadily to do his'duty, being neither swayed by her fears
3
nnd intreaties, 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 excit-
ing 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
eool, 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,
rather than by wine and cordials. But, whilst in cases where
the 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 uterine
hemorrhage, the os uteri, even where there is no effective
labour, and scarcely any pain, is not merely dilatable, but is
actually dilated. In this instance, however, tHe benefit of
evacuation cannot be derived, for the discharge injures and
impairs the whole power of the uterus, and in proportion, as
the os uteri is extended, the quantity of the blood which
flows is increased; besides, the evacuation usually begins be-
a
fore 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 it
we can do this without impairing the power of the womb, we
have certainly a powerful mean of accelerating labour; vene-
section does this in certain cases. It can do no good, but
much harm in cases of exhaustion, or in cases where the re-
sistance is afforded by a contracted pelvis, and all other cir-
cumstances are right. But in cases where the parts, through
which the child must pass, are rigid or dry, or hot and ten-
der, or where the pains are great but irregular und ineffi-
cient, or the membranes have given way prematurely, 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 expe-
rience 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 impru-
dently employed, may do much mischief. In cases of exhaus-
tion, for instance, it must be dangerous; and in every consti-
tution, 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 pati-
ent prolonged exertion and exhaustion. In natural labour it
is neither necessary nor proper; in labour not greatly pro-
tracted, 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 re-
cruited.
If the woman he fatigued or debilitated, and the pulse
weaker than in lingering labour, we shall derive advantage
from the use of a smart clyster, followed by twenty drops of
laudanum, or a proportional quantity in an injection. This
does not suspend the pains, but rather excites them. A simi-
lar stimulus is sometimes given by a gentle purge, but this,
is more slow and uncertain in its effects.
5
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
obstacle, 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.
There is another state in which the pains are weak, or
remit, 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 are
proper, and they must even here be given prudently, lest
they produce a febrile state. It is also useful 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, pro-
jecting, 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 close-
ly 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 pain sharp and ineffective, and the
water discharged 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 unea-
siness in the back, lasting for nearly a minute after the pain,
(j
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 accomplished, naturally or artificially, the action be-
comes 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 rigors. 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
advantageous 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-
tion for inflammatory affections afterwards.
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 succeed-
*&fwy 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 labour,
where the process is going on with a regularity and expedi-
tion, 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 lingers on the mar-
gin of the os uteri, which is next the pubis, and gently as-
sist it, during the pains, to slip over the vertex.
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 hemor-
rhage do not take place after delivery, or that it be prompt-
ly stopped.
If the head rest long on the perinaeum in tedious labour,
the pains having little effect in protruding it, especially if
the first stage have been lingering, it conies to be a question,
whether we shall deliver the woman. This case is different
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 headach, 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. Breeds tables it would appear, that, in the Dublin hos-
8
pital, of 172 women in labour of their child, 102 were from
1-0 to 50 hours in labour; .U from 30 to iO; 2i from 70 to
80; and 12 from 90 to 100; 121 children were alivo. Of 91,
who-had born 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 introduc-
ed. It is not necessary that the practitioner remain constant-
ly with the patient. It will have a better effect upon her, if
he see her at proper intervals; whilst he is thus prevented
himself from being so fatigued, as he otherwise would be,
and is therefore better able to discharge his duty with firm-
ness and judgment.
The second general cause of tedious labour is, irregular
action of the uterine fibres. After the child is born, the ute-
rus sometimes contracts like a sand-glass, and retains the
placenta. 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 lit-
tle effect on the os uteri, or in forcing down the child. 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. 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. Opiates I have tried, but I cannot speak with
confidence of their effects, and prefer opening the membrane
if the presentation be good, and the os uteri lax; this I have
9
found very successful. But if the os uteri be rigid or undi-
lated, and especially if the presentation be not determined,
they must be kept entire, until the os uteri will permit of
turning, should the position of the child require it. 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"
generally the spasm returns, and the placenta may be long
retained, or hemorrhage produced.
A frequent cause of tedious labour, is a state of over-action^
or unproductive action in the first stage, by which the powers
of the uterus are exhausted, and the subsequent process is
rendered very slow. This exhaustion may also be produced
by the contiuuance 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 pro-
cess in general. It may be produced by irregular action of
the fibres, or by premature rupture of the membranes. In
the second case, the pains arc lingering, short, and usually
weak. I have already considered the remedies for those
states; blood-letting, clysters, gentle dilatation of the os ute-
ri, &c. and have here only to observe, that the exhaustion of
the uterus, and consequently an additional prolongation of
the labour, is to be prevented either by suspending the pains
for a time, or by rendering themmore effective; and upon
thi6 subject, I refer to what I have already said in the begin-
ning of this chapter. Unproductive action ought never to be
allowed to continue so long as materially to impair the power
of the womb. If we cannot safely render 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 recognized by
its usual symptoms, and may be produced by the injudicious
use of stimulants, heated rooms, irritation of the parts, &c.
It is to be allayed by opening the bowels, keeping the pati-
ent cool in bed, and giving some saline julap; at the same
'VOX. u. J»
10
time that the mind is to be tranquilizcd. If these means da
not abate the heat, frequency of pulse, &c. and render the
pains more effective, it will generally be proper to detract
blood, especially if tlte head or chest be pained. When local
inflammation accompanies fever, it is commonly of the pleura
or peritoneum, and is preceded by dullness and shivering.
The first is discovered by pain in the thorax, cough, and
dyspnoea; the second by pain in the belly, gradually increas-
ing and becoming constant; pressure increases it, and in
some time the patient cannot lie down, but breathes with dif-
ficulty, or is greatly oppressed, and vomits. Tlie 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 threatening of these symptoms, blood
should be freely detracted, the bowels opened, and a gentle
perspiration excited. If the inflammatory symptoms increase.
and the labour is protracted, we must deliver the woman.*
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
process 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 in-
creasing, by supporting the head or the uterus with two fin-
• I have observed, generally, that women in labour bear well the loss of
blood. Bleeding, undoubtedly, when used judiciously, facilitates the expul-
sion of the child, and secures a more speedy recovery, or " getting up." It
moreover, obviates the train of unpleasant consequences to which women
are liable from the tendency in their systems to inflammation at the time.
As a remedy to suspend uterine action with a view of turning the child,
bkeding is never to be neglected, provided the woman is not exhausted.
But when it does not produce that effect, which will often happen, then the
opium in a large dose may be resorted to with advantage. It is correct prac-
tice, however, ip most cases to let bleeding precede the anodyne. C
11
gei*s, during the continuance of a pain; at the same time thai
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 neglecting
these precautions, the uterus lias protruded beyond the exter-
nal parts. In this case, no time is to be lost in attempting
the reduction, which will be rendered easier by cautiously
pulling back the perinaeum*. If this cannot he done, the os
uteri, if lax and yielding, must be gently further dilated, the
membranes ruptured, the child turned, and the uterus re-
placedf. The os uteri has been cut, 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 in-
verted like a prolapsus ani. A soft eloth, dipped in oil, should
be placed on the part, and pressure made with the hand.
Griesinan cut the inverted vagina on a probe, but this opera-
tion can rarely be required. If the womb prolapse before la-
bour, as happened to Roederer's patient, we must manage
the case as a simple prolapsus. She had severe pains, al-
though 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 com-
pletely ossified, or the pelvis smaller than usual. In such
cases, which are to be discovered by careful examination, it
is evident 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 uni-
formly so; the head is long of descending into the pelvis, it
rests long on the perinseum, the pains are frequent, severe,
• Vide Mem. of Med. Soc. Vol. I. p. 213.
t Vide Portal's 10th Obs.; and Ducreux's case, in a paper by Sabatier, in
Mem. de l'Acad. de Chir. Tome III. p. 368. See also a case by Saxtorpfo,
[Also Fabricius's case, in Haller's Disputatloni Chirurgic*, Vol. III.]
43
and often very forcing, but the woman says they arc doing up
good. Now this state requires much patience and discretion.
The bowels should he opened with a laxative; the urine re-
gularly expelled: the strength preserved by quietness, avoid-
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 pro-
cure 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 case 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 irri-
tate thein, 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 as soon as pos-
sible.
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
powerfully 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
membranes, the difficulty is always increased. When it ex-
ists in the os uteri, that part is very long of dilating $ the
effect of the pains, for a long time, is ratlier 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 pro-
jecting like the os uteri in the eighth month of pregnancy.
In this case, the first stage is very slow, lasting sometimes
fvvo or three days; and the second is likewise tedious. The
whole process takes up, perhaps, four days or more. When
the rigidity exists chiefly or partly in the external parts,
they are found to he at first dry, tight, and firm. By degrees,
they become moister and more relaxed; but they may still
13
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 time in a kneeling or erect posture. Some methods
have been proposed for abating the rigidity; such as baths,
fomentations, and oily applications; or digitalis and sicken-
ing medicines given internally; but these have no good ef-
fects, and some of them do harm.* Blood-letting has been
employed in such cases. Dr. Rush informs ine, 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 away before the
parts relaxed. In determining on the use of blood-letting, we
must attend to the state and habit of the patient. Debilitated
womenf, and those who are exhausted by fatigue, especially
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 coun-
try, bear blood-letting better, and derive more benefit from
it. In them it is especially proper, if any degree of fever at-
tend the labour, and in all cases when the parts are rigid, if
* These remedies are mostly inefficient or injurious. The inarm bath is
productive of no advantage, and is apt to detach the placenta, occasioning
thereby dangerous hemorrhages. But I confess, my objections to it aris»
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 undoubtedly tie 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 tittcc 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.
t Dr. Dewees bleeds even delicate women, and those who are disposed to
faint on being bled, but takes a smaller quantity from then;*
11
the patient be not previously reduced, or very delicate,,
blood should be detracted pro viribus. If, however, the state
of the patient forbid this, an opiate clyster may be substi-
tuted.
In some cases, the os uteri or external parts, instead of
being rigid, are tumid, and apparently oedematous.* In these
the labour is often protracted for several hours, especially
when the os uteri is affeeted. In tedious labour, the os uteri
sometimes becomes swelled, as if blood were effused into its
interstices. This requires venesection.
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 ne-
cessary to make an incision into the os uteri, to make it di-
latef. It is also possible for the os uteri to be closed in con-
sequence of inflammation, so that it has been necessary to
make an artificial opening:}:.
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 be cut.
Excrescences proceeding from the os uteri, an enlarged
ovarium remaining in the pelvis, or tumours(a) attached to
* Where oedema exists, of course it would be useless to bleed. C
f A case of this kind occurred to Dr. Simsonof St. Andrews, and another
to a practitioner in America.
| Vide Case by Campardon, in Recueil Period. Tom. XII. p. 277.
(a) A very interesting paper by H. Park,Esq. of Liverpool, entitled " Ob-
servations on Tumours within the pelvis, occasioning difficult parturition,"
is to be met with in the second Vol. of the Medical and Chirurgical Trans-
actions; 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 child has been expelled with but little dif-
ficulty, and without injury.
Id
the ligaments, or a stone in the bladder, may all obviously
retard the labour, some of them so much as to require instru-
ments. A stone in the bladder ought either to be pushed up
beyond the head, or extracted.
A small vagina may require a longtime 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.
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 frequent-
ly, by the cord being twisted round the neck, the labour
may be retarded, particularly 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 have 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.(J) It often
remains long in a position, which we would expect to be ca-
pable of very quick delivery. By patience, the labour will be
safely terminated; but it may often be accelerated, by keep-
ing the person for some time in an erect posture, or on her
knees. After 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
(o) This retraction of the head during the recession of a pain, is more fre-
quently owing to the rigidity or re-action of the external parts; and may of.
ten be obviated, if necessary, by venesection. We believe it is rareiy owing
X9 Ae cause here assigned for it by our author.
16
the double ligature; but this is rarely necessary, for the
child may be born, even although the cord remain about the
ncck.(c)
Preternatural strength of the membranes has been consi-
dered as a cause of tedious labour, and Ave have accordingly
been desired to tear them. This is, however, very seldom the
case. When they remain long tense, it is oftencr from spasm
of the uterus than from firmness of structure.
CHAP. VI.
Of Instrumental Labours.
ORDER 1. OF CASES ADMITTING THE APPLICATION OF THE
FORCEPS OR 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 supervene, 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 occurrence, nor
(c) 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.
17
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 de-
stroy 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, arc safer for the mother, and
more favourable to the child, than the application of artificial
force. Wc should, therefore, lay it down as a general rule,
that when the deformity 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 mea-
sure, in its short diameter, only three inches and a half, then
wc must have a painful and difficult labour, because, as the
head measures as much in its lateral extent, it must be com-
pressed 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 the 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 ute-
rus, and other causes. Besides, it is difficult, if not impossi?
ble, to determine, with minute precision, the dimensions of
flie pelvis in the living subject; and they are apt to vary*
voj.. n. c
18
according as the soft parts within the pchis are more or less
swelled. AVe shall find it better to judge by the progress
which the head lias 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
would be so great as to prevent their success. It has there-
fore 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 perineum, 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, indeed,
been proposed to increase the length of the forceps, so as to
operate with them, whilst the greatest part of the head re-
mained above the brim of the pelvis; but the practice is
dangerous and difficult, in proportion to the height of the
head. The lever maybe applied, and safely acted with, when
only a third part of the head has entered the pelvis, and con-
sequently before the forceps can be advantageously employ-
ed.^) Nevertheless, necessity, and not choice, leads us to the
use of the lever in that situation. Hemorrhage or convul-
sions may require it; but in cases of simple contraction of
the pelvis, unattended with these symptoms, the lever ought
not to be applied until we have fully ascertained that the
(rf) 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 mal positions
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 sufficient-
ly low to admit the forceps."
For a full view of the Question with respect to the comparative advan-
tage 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.
19
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 decrease. I must,
however, remind the reader, that the pains may very early
become suspended, even in natural labour for hours, with-
out 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; hut if the
pelvis be a little contracted, he must be careful to ascertain
that the cessation really has proceeded from previous exer-
tion, and not from a temporary cause. When the action flags,
and there is no appearance of the fibres recruiting 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 ac-
complish. 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 tumified, the presenta-
tion sometimes distorted, and the bones may be felt making
an acute angle with each other. When the pelvis is contract-
ed 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 protuberances1 ap-
proaching nearer together, so that, in some instances, the
transverse diameter from the one protuberance 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 di-
minished. Children have been brought to me, where, either
from the application of instruments, or the action of the ute-
rus, the bones have been separated, and the one parietal
bone forced completely beneath the other. From gradual
swelling of the integuments, the head sometimes appears to
so
aihance when the bones are really stationary. Now, when
the head is stationary, and especially if the pains have de-
clined, there is great danger in longer delay, for it is some-
times difficult, if not impossible, to have the bladder emptied;
and such injury may be done to the urethra, bladder, and
rectum, as to cause sloughing.
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
arrested for a long time, either by a slighter deformity at
the brim than that which produces locked head, or by some
contraction of the outlet, or undue projeetion 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 ad-
vance a little during a pain, and recede when it goes off.
Belay, in this case, is not attended with the same risk of in-
jury to the contents of the pelvis; 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
cannot be expected from the powers of nature. It is necessa-
ry carefully to distinguish betwixt the paragompilosis or lock-
ed head, and the case of arrest, 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 per-
haps spoken too indifferently on this subject. Dr. Osborn ob-
serves, 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 principle, if fully acted on, must often be attend-
ed with dangerous consequences; and even if restricted to
cases of arrest, I must consider it as by far too strongly ex-
pressed,
SI
When 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 ex-
hausted, the cervix 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 mine is long retained, and can-
not 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 danger-
ous symptom appears, we are warranted in trusting still to
nature. But when they flag, and the head, after a severe or
tedious labour, remains 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 tender-
ness and swelling, require to be employed, although the pel-
vis be not exceedingly deformed. Delay produces inflam-
mation, ending in gangrene. Some, amongst whom is M.
Baudelocque, advise, 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 " lock-
ed" 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 Ion- 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 pe-
culiarly 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 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 re-
sult of a labour 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 apparent, and the time, of their application draws near-
er, it will be proper to prepare the mind of the relations for
what may be necessary, if the delivery be not naturally ac-
complished. With regard to the patient herself, we must pro-
ceed according to her disposition. If she be from wliat we
have already learned, strongly prepossessed against inter-
ference, it will be necessary to give such prudent hints, and
such explanations of the practice as relating toothers, 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 necessary, nothing ought to be said till ve-
ry near the time, as the anticipation of evil is often as dis-
tressing 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 ehild were of a disproportionate
size, it was the practice before the forceps were discover-
ed, 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
S3
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
employed. To avoid turning, fillets were used by some; but
no material improvement was made in practice, until the dis-
covery of the forceps and the lever, one or other of which
was1 used first in Britain, by Mr. Chamberlain, about the
middle of the seventeenth century. Others afterwards em-
ployed 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, whe-
ther 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 be more advantageous, unless we use long forceps. The
chief superiority, then, of the lever is, that it can be used
earlier than the common forceps; for when the head has
come low down, either instrument may be employed, with
success and safety, by a practitioner accustomed to the ap-
plication, 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 operator, 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 pro-
perly applied, he cannot fail in accomplishing the delivery ;
but although the lever be applied, he may, if embarassed,
go wrong, and press too much on the soft parts. It has been
said, that it is more difficult to introduce the forceps than the
24
lever, for there arc two blades in the one case, but only one
in the other. Wc know, however, that the chief 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 certain-
ly very safely with either instrument; nor do I consider it
at all as a point of honour, that he should uniformly confine
himself to one in preference to the other; for cases may oc-
cur in which particular circumstances may incline him 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.
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 pla-
ced on her left side, in the usual posture ; and we then, with
the fore finger of the right hand, feel for that car 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 introduc-
tion and operation, close to the head of the child, lest the
bladder or rectum be injured. The second is, that the con-
cavity of the instrument be kept in contact with the curva-
ture of the head, by which it will be much more easily intro-
duced 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
• This process is very indistinct in the foetus, but the direction may still be,
retained, as it refers to a well known spot.
26
is placed, ami pass the instrument in that course. In the,
usual position, the blade will be placed behind the symphysis
pubis, or perhaps a little obliquely, and the handle will be
directed 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 wc 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
suddenly, 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 tractor, than a lever. With the left hand placed
upon the shank of the blade, wc 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 instrument 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 bo
made during the continuance of a pain; for every practi-
tioner knows, that the co-operation of pains adds prodigious-
ly 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 instru-
ment, 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, without any farther assist-
VOL. II. D
2(5
-hcc, finish the deliver}-. We must be careful of the pert*
n.Tum.
When the forceps are used at first, instead of the lever,
wc must, in like manner, take the ear for our guide, passing
♦ he first blade over that side of the head which lies to the pu-
bis*. With the finger of one hand wc feel for the ear next the
pubis, whilst with the other hand wc 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 mo-
tion, until it slip between the head and the pubis. It is then
to be moved on till wc suppose its point to be applied over the
chin. In this way, the blade follows a line drawn from the
vertex to the chin, crossing over 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 arc 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
• 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 axjs of the superior strait. They are also very
conveniently portable, which is no trivial advantage, as it regards practi-
tioners in the country.
Dimensions of Haighton's forceps, as now made by C.Eberle, Surgeon's In-
strument-maker, Philadelphia.
Inches.
The whole length.................11$
Blade from the angle of the joint............6|
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...........X$
Do. of do. at its centre............2\
po. pf do. near the handles..........2f}
27
surface must be kept in close contact with the head, as it
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 oi
the axis of the brim of the pelvis, and when the instrument
is locked, the handles arc inclined backward. 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 ope-
rating. It is apparently unnecessary 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 ehild 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 for-
ceps or lever, that part of the head which is above the pubi*
sometimes projects a little over it, so that wceannot pass the
blade until we press backward a little, with tho finger, on
that part which we can reach. All attempts to overcome the
resistance by force, every trial which gives much pain, must
be reprobated. But, on the other hand, as long as his con-
duct is gentle and prudent, the young practitioner must not
he deterred 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 forceps could be usedj
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. If the.
'jjains still continue, wc pull the instrument downward, and,
28
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. Wc must not carry the in-
strument 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 forcible swing,
the soft parts must be bruised, and great pain occasioned.
The operation of extracting is not to be carried on rapidly,
or without intermission; on the contrary, wo must be cir-
cumspect, and imitate the steps of nature.(/) Wc must act
and cease to act alternately, and examine, as we go on, the
progress we are making, and also ascertain that the instru-
ment is still properly adapted to the head. The head being
made to descend, the face begins to turn into the hollow of
the sacrum, and, in the same degree, the handles must move
i"ound on their axis; and when the face is thrown fully into
i.he hollow, the handles must be turned more forward and up-
ward, being placed in the axis of the outlet. The pendulum
kind of motion must now be very little, and is to bo 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
lie placed directly over the cars. If the lever be used, its
[>oint will rest on, or near, one of the mastoid processes. If
rhe 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 Jieing less apt to slip, is preferable.(g)
{J") And hence, in general, we should only act during a pain.
(^)We are obliged here again, unwillingly, to dissent from the respectable
authority of our author. The forceps, even in face cases, will rarely slip if
properly applied. It is generally owing to improper application, not having
:lrst accurately ascertained the precise position of the head, that we hear
-owplauus. of the forceps not keeping a firm hold.
29
If the forceps or lever be injudiciously introduced, the
bladder or uterus may be perforated; or if the head be al-
lowed to remain too long jammed in the pelvis, some of the
soft parts may slough. The under and posterior part of the
bladder is apt to slough off, leaving the woman incapable of
retaining her urine, [which is discharged per vaginam.] This
is best prevented, by being extremely 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 necessary, the catheter. The
parts ought also to be kept very clean, and may be frequent-
ly bathed with decoction of chamomile flowers.(/i)
onnER 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
h only two inches and a half. It has even been stated, by
high authority, that if the dimensions were « certainly un-
der three inches, a living child could [not be born;" but al-
though this opinion be too frequently correct, yet, like all
other general rules, it has exceptions, depending on the ori-
ginal size and peculiar constitution of the child, together with
the pliability of the cranium, on the particular shape of the
pelvis, and the force and activity of the uterus, as well as
the general strength of the woman. There have been in-
stances, 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 be-
ing, under the same conformation, accomplished with the
(4) The rectum likewise, where it passes over or near the projection of
the sacrum, may, by the long continued pressure of the head, have its life
destroyed, and sloughing take place into the vagina, through which the
faeces will be discharged. These deplorable effects sometimes follow casts
of impaction, or the locked head, where instruments.have not beexi used.
30
lever*'. We are not warranted, therefore, to open the bead,
merely because wc estimate that the pelvis docs not, in its
conjugate diameter, measure fully three inches; but because
we have ascertained by a sufficient trial, that the uterine ac-
tion cannot force down the head, and that the vectis cannot
be applied 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
without 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, ae-
cording as, in our estimation, the dimensions diminish from
three inches to two inches and a half. In such extreme defor-
mity as this, we have no reason to expect that the head can
pass, unless it burstf, or be artificially opened; and there-
fore 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 decid-
ed marks of the foetus being dead in utero, and yet these were delusive, for
by the forceps, the woman was delivered of a living child, although the pel-
vis measured only about three inches. L'Art. des Accouch. $ 1898.—Cases
in point may also be seen in Dr. Alexander Hamilton's Letters, p. 94, 102
113.—-Similar instances have come within my own knowledge.
t So far as I can judge, the sutures yield sooner than the scalp, and the
brain is effusai, or pushed out like a bag. When the integuments open first,
it is owing, I apprehend, to sloughing from pressure and injury. A very dis-
tinct case of spontaneous bursting of the cranjom may be found in Dr. J.
Hamilton's Cases, p. 17.
SI
But although it be thus laid down as a general rule, that
the pelvis, which measures three inches in its conjugate dia-
meter, may admit a living child to pass, either by the appli-
cation of the vectis or forceps, or still more rarely by the
efforts of the womb, yet it is nevertheless true, that some-
times 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 hy-
drocephalic state of the 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 deli very j.
The parts may also be so tender, as to render even a com-
mon examination painful, and to prevent the application of
the vectis or its effective action, in a case merely equivocal.
Alarming convulsions may likewise induce us to perforate
the head In a case of deformity, where it is perhaps possible
that the vectis 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, has met with such a case. At one peri-
od, however, the crotchet was employed in cases of convul-
sions, where the vectis or forceps would now be used.
By the rash and unwarrantable use of the crotchet, living
children have been drawn through the pelvis with the skull
opened, and have survived in this shocking state for a day
or two:}:.
To prevent all risk of bringing a living mutilated child to
the world, and to avoid, at the same time, killing or giving
pain to the child§, * ven in those cases which clearly demand-
• I have seen a cranium so enlarged with water, that when it was inflat-
ed after delivery, so as to resume its former size, it measured twenty-two
inches in circumference.
t Baudelocque l'Art. des Accouch. § 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.
J Vide Mauriceau, obs. 584—La Motte, case CXC—Hamilton's Letters,
p. 153.—Peu 1% Pratique, p. 346.—Crantz de Re Instrument, &c } 38.
i It has been disputed, whether the child in utero was capable of sensa*
tloa, but both facts and reasoning are in favour of its sensibility.
3U!
ed the use of the perforator, some have delated operating
until the child appeared to have been destroyed by the ex-
pulsive efforts or other causes, and have therefore been anxi-
ous to ascertain the signs by which the death of the child
might be known2. It was still more desirable to know these,
at a time when the forceps were undiscovered. But the signs
arc generally extremely equivocal, nor is this much to be
regretted, for wc 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 one hand on the head of the child, and with
I he other hand convey the perforator to the spot on which
the finger rests. The instrument, being carried cautiously
along the finger as a director, can neither injure the vagina
nor os uteri, and in general no difficulty is met with in this
part of the operation. Sometimes, however, in very great
deformity, the os uteri is placed so obliquely, that it must
previously be gently brought into the most favourable, that
is, the widest part of the pelvis; and afterwards, the perfo-
rator, being placed on the head, must have its handle in the
axis of the brini, 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
mi the bone,(i) through which it, directly, or after a momen-
tary 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
eranium have entered the pelvis, the perforation can be made
without any assistance; but if the whole ofthe head be above
the brim, it may be necessary to have it kept steady, by
(i) 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.
m
pressure 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, except;
in very urgent cases, is to be left for some hours to repose*
or to the operation of natural pains. Dr. Osborn, in his ela-
borate 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 whore
there is any possibility of avoiding the perforation, it ought
not to be attempted till the event has proved the necessity.
The general principle ofthe second direction is just, where
the first has been acted on, and the strength is good, and n«
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 wThcre 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 introduced
through the aperture of the cranium, and fixed upon the pe-
trous bone, or such projection of the sphenoid bone, or occi-
put, as seems to afford a firm fixture. We then pull gently,
VOL. II. k
31
t«lr> the hold ofthe instrument; and this being found se-
cure, wc proceed to extract in the direction of the axis ot the
brim, by steady, cautious, and repeated efforts, exerting,
however, as much strength as maybe necessary to overcome
the difficulty. In doing this, we must always keep a hand,
or some ofthe 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 feci the
instrument slipping or tearing the bone, and have warning
before it conies away. We should, in extracting, 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 sometime 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 squa-
mous bones come easily away, and the frontal bones sepa-
rate from the face, bringing their orbit ary 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 crot-
chet can be used. I have carefully measured these parts,
placed in different 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 ex-
ceed an inch and an half. It is therefore of great advantage,
to convert the case into a face presentation, with the root of
the nose directed to the pubis. The size of the crotchet,
which ought to be passed over the root of the nose, and fixed
on the sphenoid bone, must, however, be added, to this mea-
surement, I never have yet been so unfortunate as to meet
with what may be considered as the smallest pelvis, admit-
35
ting of delivery per vias naturales ;* but I would conclude,
that whenever the pelvis, with the soft parts, measures fully
an inch and three quartersf, or, if the head be unusually
small, the child not being at the full time, an inch and an
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 quar-
ters, if the head be small or very soft; and the operation will
be easv, as we extend the diameter of the pelvis beyond
what may be considered as the minimum. It is scarcely ne-
cessary 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 it.
In this manner of operating, the face is drawn down first,
and the back part of the occipital bone is thrown flat upon
the neck like a tippet. If we reverse this procedure, and
bring the occiput first, and the face last, fixing the instru-
ment in the foramen magnum, then, as we have the chin
thrown down on the throat, we must have both the neck and
face passing at once, or a body equal to two inches and three
quarters. If on the other hand, we fix the instrument on the
petrous bone, which is certainly preferable to the foramen
magnum, and bring the head sideways, we must have both
that bone and the vertebrae passsing 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 conies 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 necessary
to have recourse to the cesarean operation, has occured in this city since the
year 1775, when Mr. Whyte performed the latter operation.
f M. Baudelocque considers the crotchet as inadmissible, when the pelvis
measures only an inch and two thirds
So
The head being brought down and delivered, we then fix
n 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, wc 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 inay end in the destruction
of some ofthe 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 neglected, 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 trouble-
some consequence. If the patient be not affected with mala-
costeon, 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 proposed3; 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 ofthe seventh month, does
not measure more than two inches and a half in its lateral
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 expell-
ed alive, and very seldom, even after a severe labour, dead,
through a pelvis whose dimensions are not above two inches
and an half; and lastly, we have many instances, where chil-
dren born in the seventh month have lived to old age. When-
ever, then, we have by former experience ascertained be-
yond a doubt, that the head, at the full time, must be perfo-
rated, it is no longer a matter of choice, whether, in succeed-
ing pregnancies, premature labour ought to be induced. It
is certainly easier for the mother than the application of the
crotchet, and no man can say that it is worse for the child*.
• It has been proposed, by low diet, to restrain the growth of the child but
Ihis is a very uncertain and precarious practice.
87
All the principles of morality, as well as of science, just if) 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 ofthe 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 singu-
lar, where the bones gradually yield, and become so distor-
ted, as at last to prevent even the crotchet from being used.
Now, granting a succession of pregnancies to take place in
this situation, it follows as a rule of conduct, that if the de-
formity 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 exciting abor-
tion, destroy many children to save one woman? This ob-
jection is more specious than solid. Those who make it would
not, in all probability, scruple to employ the crotchet frequent-
ly $ 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 proper; but it is no less
evident, that when they are pregnant we must relieve
tliem.(j)
CHAP. VII.
Of Impracticable Labour,
I) Vide a case by the Editor, inserted in the New York Medical Reposi-
tory for 1804. Hexade 2. Vol. I.
$ Perfect's Cases, Vol. II. p. 439.—Hamilton's Cases, p. 138.
53
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 iu the back or at the pubis, which, during the action
ofthe uterus, augments to an extraordinary degree, and then
the part gives way. Another way in which the cervix may
be lacerated, is by the linea iliopectinea being so sharp*,
that when the uterus is pressed against it, the parts arc
cither cut through, or so much acted on, that they are in a
manner killed, and give way, having a sphacelated appear-
ance. In some cases the rectum, but much more frequently
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 ofthe fundus; and Friedius one,
where it was owing to a carneo-cartilaginous state of the os
uteri. 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 w ith
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
great exacerbation, and attended with a very acute or tear-
ing sensation. The pains are both violent and frequent, and
usually do not produce a great effect on the os uteri, which
is often very rigid. These symptoms are still more alarm-
ing, 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
• 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.
t Annals of Med. Vol. IU. p. 277-
;>i
(he pain* by an anodyne clyster. When this accident docs hap-
pen the woman feels something give w ay within her, and usu-
ally suffers, at that time, an increase of the pain. The presen-
tation disappears more or less speedily, unless the head have
fully entered the pelvis, or the -uterus contract spasmodically
on part ofthe child, as happened in Behling's patient*. The
pains go off as soon as the child passes through the rent in-
to the abdomen; or if the presentation be fixed in the pelvis,
they become irregular, and gradually decline. The passage
ofthe 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 intestine
protrudes through the wound in the uterus, and has e\en
been strangulated in it. These symptoms do not all appeal'
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 pain in the belly, which becomes swelled, the pulse is ra-
pid, the extremities become cold, and the strength sinks. In
every case that I have seen, the intestines were chiefly affec-
ted, being much inflamed. The interval which elapses be-
tween 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
• Haller's Disput. Tom. III. p. 477.
55
is the case of a woman, who, after being delivered, lingered
for three months.
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. Wc have instances of all
these methods being successful; but the delivery, by turning
the child, has advantages over the other modes, and cer-
tainly 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 dif-
ficulty 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, wc 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 be 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-
ly ; but it may happen that deformity ofthe 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 before the
abdominal viscera have been much irritated by the presence
of the foetus, we are warranted to extract the child by a
small incision4. If some time, however, have clasped, then
such irritation is often given, as renders it doubtful, if the
additional injury ofthe operation could be sustained. On the
other hand, if little irritation be given, and the woman is to-
56
lerably 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 pru-
dent to trust to nature5.
The cases which admit most easily of delivery, arc 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*, provided the bladder be not injured. I do not
think it necessary to make ady farther remarks on the la-
ceration ofthe vagina, as distinct from that ofthe 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, kv.
When, from precursory symptoms, we expect that lace-
ration is about to take place, we must accelerate labour cither
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 G. WITH SUPPRESSION OF ITUINE.
Suppression of urine may take place during labour, in
consequence of the head of the child being locked in the
pelvis ; or from a kind of paralytic state of the bladder, pro-
duced by long retention of the urine ; or by a small stone, or
quantity of mucus, obstructing the urethra. It produces ten-
derness, and great pain, in the hypogastric region, which is
also swelled. The pain is constant, but is increased during
every effort ofthe 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 ofthe risk of the distended bladder being ruptured
by the contraction 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 Ob-
57
servations and Inquiries, they did not take place till the se-
cond 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 rup-
tured at its upper part.
When the urine cannot be passed by the voluntary ef-
forts 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 com-
pletely those of the ordinary size. If the head should be so
jammed in the pelvis, as to prevent the introduction ofthe
catheter, the woman must be delivered.(q')
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.
(q) An interesting case of this nature, is related by Dr.Merriman, in Edin-
burgh Med. & Phys. Journal for 1810, and in Ecletic Repertory, Vol. I. p.
269, &seq.
VOl. II.
H
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 tho 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, but this is not essential.
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 dry nap-
kin 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 bandage be felt agreebly
tight, that there be no considerable hemorrhage, and that the
after pains are not coming on severely. 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 avoid-
ed.
Having thus simply stated what appears to be necessary,
I must next say what ought to be avoided. It is customary
with many nurses, to shift the patient completely, and, for
59
this purpose, to raise her to an erect posture. Now this prac-
tice may not always be followed byr 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 syn-
cope may be produced. The pretext for this is generally to
make the woman comfortable; and, indeed, if the eloaths be
wet with perspiration or discharge, there may be some in-
ducement to shift her. But this ought to be done slowly, with-
out raising her, and if she have been fatigued, not until she
have rested for a little. Another bad practice is, the admi-
nistration of stimulants, such as brandy, wine, or cordial
waters. I do not deny, that these, in certain cases of exhaus-
tion, are salutary; but I certainly maintain, that generally
they are both unnecessary and hurtful, tending to prevent
sleep, to promote hemorrhage, and excite fever. 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 perspira-
tion. This is apt to produce debility, and many hysterical
affections, as well as a troublesome species of fever, winch it
is often difficult to remove. U also renders the woman very
susceptible of cold, and a shivering fit is very readily excit-
ed. Lastly, gossiping and noise of every kind, is hurtful, by
preventing rest, occasioning head-ach 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 oft-
en be voided if the uterus be gently raised a little with the
finger, or the catheter may be introduced. There are two
states in which we are very solicitous that the urine be void-
ed : the first is, when the woman has much pain in the low-
60
cr belly, with a desire to void urine; the second is, after
severe or instrumental 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 alto-
gether within a month, and often in a shorter time. This is
called the lochial discharge. During this time, it is neces-
sary that the vagina and external parts be daily washed
with tepid milk and water.
During the latter end of gestation, milk is generally se-
creted in a small quantity in the breasts, and sometimes it
even runs from the nipples. After delivery the secretion in-
creases, and about the third day the breasts will be found
considerably distended. Many women, indeed, complain at
this time of much tension and uneasiness, and there is usual-
ly 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
before 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 ofthe 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
61
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 re-
turned 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 allowed to be dressed, and sit a little; but even in
the best recovery, 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 rising too soon, and making exertion, a prolapsus uteri
may be occasioned, and still more frequently the lochia arc
rendered profuse, and the strength impaired.
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-
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, will 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
62
checks the motion, or coagula stop the mouths, of the ves-
sels.
It is evident that the eausc of flooding is the torpor of the
uterus*. The fibres may become inactive, or have their
tonic contraction impaired immediately after the pain which
expels the child. This will more especially happen if the
woman 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 profuse,
and produces the usual effects of hemorrhage on the system,
and these effects are greater and more speedy than those
which follow from hemorrhage Wfore delivery, for the loss
is instant and extensive. The first gush indeed docs not pro-
duce 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
childf.
• When the uterus contracts properly after the delivery of the child, it will
be felt, if the hand be applied on the abdomen, like a hard and strong mass:
but when torpid, it is not so distinctly felt, for it is softer, being destitute 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 death
may proceed from an organic affection ofthe heart, such as ossification of frz
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 per-
fect rest must be observed after delivery. Should there be any inequality in the
size of the two ventricles, the right being larger, for instance, than the left,
then any cause capable of hurrying the circulation, may make both sides con-
tract to their utmost; the consequence of which is, that all the blood in the
right side is thrown out, but it cannot be received into the left: rupture of the
pulmonary vessels must take place, and I have known many instances where
the patient was immediately suffocated.
63
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 re-
spiration 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 site 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 diffi-
culty, and quickly expires. The danger of flooding is uni-
versally known, and the consternation excited by it, is in
many cases great: One exclaims the patient is dead, another
she is dying, 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, inclo-
sing the placenta above it, whilst the rest of the fibres be-
come relaxed. This has not inaptly been called the hour-
glass uterus.
From this view it is evident, that flooding is to be pre-
vented by preserving the action of the uterus, and avoiding
whatever can increase the force of the circulation. A power-
ful means of keeping up the action of the womb, consists in
preventing it from emptying itself too suddenly. It too fre-
quently happens, when the child is instantaneously expel-
led by a single contraction, being in a manner projected
from the uterus, or when the body is speedily pulled ont,
whenever the head is born, that hemorrhage takes place;
and, in a majority of instances, the uterus contracts on
the placenta like an hour glass. Delivery then is not to be
64
hurried, the steps of expulsion 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 con-
duct; 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 sup-
porting 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
lessoning 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 ofthe
child. Some women, no doubt, are peculiarly subject to this
accident. 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 in-
stances whenever the child is born, we ought to introduce
the hand into the uterus, which excites its action, and pre-
vents flooding. We are not to meddle with the placenta, or
endeavour to extract it, our object is to excite the contraction
of the womb, and make it in due time expel the secundines.
This gives little pain, and may be attended with most im-
portant consequences to the future health or comfort of our
patient. I need scarcely, I think, add, that in every case,
more especially in those where the labour has been tedious,
or the woman has been subject to hemorrhage, we ought not
to leave the bed-side, but should examine frequently, to as-
certain 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 o
65
the uterus, upon which alone wc 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 into
the cavity ofthe uterus.
The retention of the placenta is not in general the cause
ofthe hemorrhage, but a joint effect, together with it, ofthe
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 instant-
ly away; or to endeavour to deliver the placenta by pulling
forcibly at the umbilical cord. By the first practice, 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 ofthe hand, to
excite the uterus to separate it; or, if it be already detach-
ed, and lying loose in the cavity of tho womb, wc move the
hand gently to stimulate the uterus, but neither withdraw it,
nor extract the placenta, until wc feel the womb contracting.
* Itis not my intention to advise immediate interference, although the dis-
charge be a little more than usual; but whenever it is considerable, or is af-
fecting the pulse, or producing other perceptible effects on the system, we
ought not to delay. It is a fatal error to wait until dangerous symptoms ap.
pear ; many weeks of suffering, perhaps death itself may be the consequence.
I cannot therefore agree with the ingenious M. Le Roy, in the following
directions respecting hemorrhage after the birth of the child. "Quand la fem-
me n'est pas delivree & qu'il survient une perte, il faut attendre patiemment
voir s'il ne se manifeste aucunsympt6me alarmant parceque cette perte cesse
quelquefois d'elle-meme. Mais quand les symptomes sont alarmans & qu'on
craint pour la vie de la femme, lorsque lamatrice s'engorge & se degorge al-
ternativement, lorsqu'enfin la femme se plaint d'eblouissemens dans les yeux
de tintemens d'oreilles; que les yeux, &c deviennent convulsifs; que le pouls
devienttrop petit; que les extremite's sont froides; le visage d'une paleur
mortelle ; que le sang traverse le lit; qu'on entend dans le ventre des grouil-
lemens qui annoncent la resolution des forces vitales; alors il faut employer
des moyens propres * redonner dn ressort a la matrice." Lecons, p- 57.
vox. ir> i
60
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 topi-
cal remedy. Cloths dipped in cold water should be laid sud-
denly upon the belly, or cold water may be thrown upon it.
In obstinate cases it has been found useful to project it for-
cibly with a syringe, or to throw it up into the uterus itself.
If we have not a syringe at hand, we may in desperate cases
dip a sponge or a piece of cloth in cold water, and carry it
in the hollow of the band up to the fundus uteri. Nay, ice it-
self 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.(r)
In those cases where the uterus is spasmodically contract-
ed, we must slowly and cautiously dilate the stricture, so as
to get the hand into the upper cyst of the uterus; and, in
doing so, we shall be greatly assisted by applying cold wa-
ter to the abdomen, or dashing water smartly on it from a
cloth. 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-
(r) It appears from a late publication, that a novel mode of restraining ute-
rine hemorrhage, (taking place after parturition,) has been attended with suc-
cess, 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 ofthe uterus, in the hand ofthe 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 com-
posed, 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 ad-
mixture or dilution ; and acts immediately on the internal surface of the ute*
rus. M. Evrat advises, that in withdrawing the hand, the remainder of the
lemon should be left in the uterus, supposing that it will excite the regular tonic
contraction of the uterine fibres, and thus prevent any return ofthe hemorrhage.
The uterus, when it contracts completely, will expel the compressed lemon, as
happened in a case related in the, work alluded to.
67
ger in being deliberate. It is too much the practice with
some midwives, to trust more to their fingers than to the con-
traction 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 separate
it arc sometimes necessary ; but these should be so cautious-
ly and deliberately made, as not to lacerate the placenta.
The fingers should be very slowly and gently insinuated be-
twixt the uterus and the placenta, so as to overcome the ad-
hesion, which is seldom extensive. I have known the placen-
ta retained for four days, by an adhesion not larger than a
shilling. This case proved fatal by loss of blood, which con-
tinued to take place, I understand, in variable quantity du-
ring 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 irrepara-
bly sunk. In those cases where great weakness has'been
produced, we must not only endeavour to excite the uterine
contraction in order to prevent farther 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 ab-
domen, gentle pressure is to be made by the hand on the re-
gion of the uterus, and the whole belly firmly supported with
a bandage, provided that can be applied without moving
the patient much. But as every exertion is dangerous, mo-
tion must be avoided ; and upon no account is the patient
to be shifted or disturbed for some time. By imprudent at-
tempts to raise the patient, or " to make her more comfort-
able," she has sometimes suddenly expired.(s)
(*) Le Roy thinks the position ofthe patient in hemorrhages, is worthy
of consideration; in uterine hemorrhage, the horizontal position of course
must be preferred, and consequently the feet should be more elevated than
the head.
68
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-
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
rill the patient was out of danger. Nor does this practice,
against which I was at first prejudiced from theory, ever pre-
vent the contraction of the uterus, or produce afterwards
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 frequently as to load the stomach, which produces
sickness 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 af-
ter 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. So-
lid opium is the most effectual remedy against repeated vo-
miting. 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
69
the same in every case, for some women faint from slighter
causes than others. La Motte relates one case where the pa-
tient fainted no less than twenty times in the course ofthe
night. She is to be preserved in a state of the most perfect
rest, the face is to be smartly sprinkled with cold water, a
little wine or brandy, or spiritus ammoniac aromaticus given
after the opiate rouses 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
these awful circumstances, be carefully watched; and that,
if the expression be allowed, wc 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 in-
tervals, give whatever may be necessary to the patient, with-
out 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 ofthe 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 re-
mains 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
• Even some modern writers have an opinion, that sleep is directly in-
jurious. " Somnus ejusmodi hemonrhagias recrudescere facit." Stoll. Prelec-
tiones, Vol.ii. p. 400.
70
when it is confined in the uterus, it is only known by its ef-
fects ; the pulse sinks, the countenance becomes pale, the
strength departs, and a fainting fit precedes the fatal catas-
trophe.
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, wc 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
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 hemorr-
hage, 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 unimpreg-
* When the abdomen has been bandaged too tightly, the parts within are
injured. The patient is restless and uneasy ; the pulse is frequent; she com-
plains of pain about the uterus; and numbness in the thighs. Sometimes the
lochia are obstructed; sometimes, on the contrary, pretty copious hemorr-
hage is produced. Relief is obtained by slackening the bandage; by giving
an anodyne; and, if there be no hemorrhage, by fomenting the belly.
f This, at first, is owing to muscular contraction; afterwards, absorption
forms part of the process. But if these operations shall be interrupted, or in-
jured, then the vessels, which are still large, not being duly supported, will
be very apt to pour out blood.
71
nated 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, distin-
guished from them. We have, however, less of tho 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.
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 vi-
gour of the woman. This has been called monorrhagia 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
produced 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 succeed
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
7-2
I need not attempt to prove, that the only security consists
in uterine contraction. This is to be excited by the appli-
cation of cold, and by the introduction ofthe hand, not sim-
ply to extract the coagula, but to stimulate the uterus, and
rather make it expel them. Should this be tedious, it may
be assisted by the injection of cold water into the womb.
We must also proceed with opiates, cordials and nourish-
ment 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 may be renewed, and the woman be lost be-
fore we can sec 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 cither in our examin-
ations or attempts to extract, lest wc inflame the womb. It
is more advisable to plug the vagina, and even the os uteri,
so as to confine the blood, and excite the uterine contraction.
We may also inject some cold and astringent fluid for the
same purpose, or throw a full stream of cold water into the
uterus, from a large syringe, by way of washing out the por-
tion of placenta, if it have become nearly detached. A gen-
tle emetic sometimes promotes the expulsion. The bowels
are to be kept open, and the strength supported by mild and
nourishing 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.
73
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 astrin-
gent fluids into the womb—by the exhibition of a gentle
emetic—and byr throwing cold water from a syringe upon
the abdomen when the womb is expelling the coagulum.
We also check the hemorrhage, and save blood, by the
prompt application of the plug, and diminish the action of
the vessels themselves, by allaying or removing every irri-
tation ; by avoiding the frequent use of stimulants, or at-
tempts to fill the vessels too quickly. The feeling of sink-
ing, sickness, tendency to syncope, &c. arc to be obviated by
the means already 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
breathing. 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 dipped in cold vinegar, to the back, does good.
CHAP. III.
Of Inversion ofthe Uterus.
Inversion of the uterus implies, that the inside is turned
out, and down into the vagina. It may take place in dif-
ferent 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 alto-
von. IT. K
71
gethcr, or chiefly within the \agina, and the fundus only
protrudes to a certain degree through the os uteri, forming
a firm substance, something like a child's head1. When the
uterus is inverted, the woman feels great pain, generally
accompanied with a bearing-down effort, by which a partial
inversion is sometimes rendered complete. The pain is ob-
stinate and severe, the woman feels very weak, the counte-
nance is pale, the pulse feeble, and often imperceptible, a
hemorrhage very generally attends the accident, and often
is most profuse. But it is worthy of notice, that complete
inversion sometimes is not accompanied with hemorrhage*,
whilst a very partial inversion may be attended with a fatal
discharge. Fainting, and convulsions, are not unfrequent
attendants, although the hemorrhage have been trifling.
Inversion, in a great majority of instances, depends upon
the midwifef endeavouring to extract the placenta, by pull-
ing the cord(£). Sometimes the uterus is directly pulled down,
and the placenta still adheres; in other cases, it is separat-
ed. 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.
• This was the case, in the instance related by Dr. Hamilton, Med. Com.
Vol. XVI. p. 315.—In the case by Mr. Brown, the hemorrhage was consider-
able. Annals of Med. Vol. II. p. 277.
t 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 ofthe child, until the woman complains of pain,
(which generally indicates the contraction ofthe 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.
75
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 distention of the bladder; or af-
ter severe pains and expulsive efforts, the patient may get
the better ofthe immediate injury, the uterus may diminish
to its natural size, by slow degrees, and give little incon-
venience2 ; or it may discharge foetid matter, and give rise
to frequent debilitating hemorrhage ; or hectic comes on,
and the patient sinks in a miserable manner.
If inversion be discovered early, the uterus may be re-
placed. If it have protruded out of the vagina, it is, first
of all, to be returned within it; if it have not, wc proceed
directly to endeavour to return it within the os uteri, by
cautiously grasping 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-invert 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 com-
pressing the tumour, we sometimes bring on violent bearing-
down pains. These are occasionally attended with increase,
or renewal, of flooding. 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
feltf. Occasionally, after the reduction, when the patient
is seeming to do well, she is seized with a fit and dies:}:. Or
she may remain long weak, and have swelled feet§.
* In a case related in Memoirs of Med. Soc. Vol. V. 202, the placenta was
allowed to remain five days after reduction, but this is a hazardous practice-
Perfect, case 71, brought it away after four hours.
t Case by Dr. Duffield, in Trans, of Coll. at Phil. 167.
\ Case by Dr. Albert. Annals of Med. Vol- V. 390.
Mr. White's case, Med. Comment. Vol. XX. 247-
76
If inversion have not been discovered early, it is more
difficult, nay, sometimes impossible to reduce it, owing chief-
ly to contraction of the os uteri.(») Dr. Dcnman 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 vio-
lent efforts to reduce the uterus, as these may excite convul-
sions, &c. We must in every instance alleviate urgent symp-
toms, such as syncope, retention of urine, or inflammation,
by suitable means. I may further observe, that when a pa-
tient, 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
examination 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. Examination is ofthe utmost consequence.
When the uterus cannot be replaced, wc 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, al-
lay 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 Motto's 385th case. If
inflammation come on, we must prescribe blood-letting, laxa-
tives, &c. In this way, the uterus contracts to its natural
size, and the woman menstruates as usual, but generally
(a) In cases of partial inversion, where it has been found impracticable to
reduce the uterus, it has been advised to grasp the portion which h*s passed
through the os uteri firmly with the hand, and render the inversion complete,
by bringing the whole ofthe uterus into the vagina, and keeping it there. By
this means, the danger of strangulation from the stricture occasioned by the
contraction of the os uteri on the body of that viscus, is presumed to be pre-
vented. This plan appears to have succeeded in a case related by Dr. Dewees
in the Philadelphia Medical Museum, Vol. VI. p. 20, & seq. Case 2nd.
77
the health is delicate. Sometimes the uterus becomes scirrh-
ous, 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 re-
peatedly successful3, and is performed by applying a liga-
ture high up, and cutting off the tumour below. But it must
also be remembered, that in some cases where the inverted
uterus has been either intentionally extirpated, or mistaken
for a polypusf, 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 polypus^. The history will likewise assist in the diag-
nosis.
CHAP. IV.
Of After-pains.
Few women proceed through the early part of the puer-
peral state, without feeling attacks of pain in the belly,
which are called after-pains. These are generally least se-
vere after a first labour. They proceed from the contraction
of the uterus in an irregular manner, excited by the pre-
• Schmucker's Surgical Essays, art. xvii.—A case is given in Med. Jour.
VI. 367, where appearance of gangrene, from strangulation, took place. The
womb was scarified, and the swelling quickly disappeared. The patient re-
covered.
f In a case related in Reoueil des Actes de la Societe de Sante, de Lyon,
the uterus was taken for a polypus, and the ligature applied. The mistake
being discovered, it was instantly withdrawn, but the woman died in a few
days.
\ In one case, 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.
78
sence of coagula, or other causes, and each severe pain ia
generally followed 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 ap-
plies 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 obstructed, the patient has no shivering nor
vomiting, the milk is secreted, and the pulse is seldom fre-
quent. When the pulse is frequent, then we must always be
on our guard; for if this be the case before the accession of
the milk-fever, the patient is not out of danger, and if any
other bad symptom appear, we must be prompt in our prac-
tice. After-pains may also be caused by flatulence and cos-
tiveness, which we know by the usual symptoms; but a
combination of this state with uterine after-pains, is often
attended with a frequency ofthe pulse, and may give rise to
a fear that inflammation is about to come on but other symp-
toms are absent. Uterine after-pains are relieved by opi-'
ates and fomentations.(x) When the bowels are also affect-
ed, a laxative is useful, and this is always proper when the
pulse is frequent. A severe constant pain in the hypogas-
tric 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
a young practitioner may mistake spasmodic affections or
cholic 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,
(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 ex-
perienced 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 succeed,
the strong infusion or tincture of hops may be tried.
79
and the patient is troubled with flatulence. It requires lax-
atives, antispasmodics, anodyne clysters, and friction with
camphorated spirits. Blood drawn in this disease, after it
has continued for some hours, even when the woman is not
in childbed, is sizy; and it is always so in the puerperal as
well as the pregnant state, although the woman be well.
It is necessary to attend carefully to the duration and situ-
ation of pain after delivery, and to the symptoms connected
with it. For it may proceed from inflammation of the vis-
cera ; or in some cases it is felt near the groin, and may be
the forerunner of swelled leg ; or about the hip, ending in a
kind of rheumatic lameness; or in consequence ofthe appli-
cation 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
uharp, like a stitch. It is relieved by friction, with lauda-
num, 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, espe-
cially ofthe 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 recommended. I have formerly noticed those pains in
the limbs which may succeed the use ofthe crotchet.
CHAP. V.
Of Hysteralgia.
By hysteralgia, I understand uterine pain not proceeding
from inflammation. It comes on within three or four days
after delivery, and attacks in general very snddenly. Per-
80
haps 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. Af-
ter some hours, the severity abates, and presently by proper
means the health is restored.
As the lochial discharge is usually obstructed, this ob-
struction has been considered as the cause of the pain and
other symptoms; but it is merely an effect, and sometimes
does not exist. The cause appears to consist in a deranged
state of action in the uterus, which is productive of spasm of
the uterine fibres, and sometimes of the intestines. This is
more apt to occur after a severe or tedious, than after an
easy labour, but it may occur in any case, especially if ex-
posed to cold. The symptoms will vary a little in severity
and in appearance, according as the uterus alone is affected,
or as spasm ofthe bowels is combined with the uterine pain.
It is distinguished from inflammation by the sudden nature of
the attack, the absence of shivering in general, the pain be-
coming speedily more severe than it does at the same period
of inflammation; and frequently it greatly remits, or goes al-
most entirely away for a short time. It is possible, however,
for this state, especially if it be neglected, to excite inflam-
mation, 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 clyster to
open the bowels. Then the belly is to be fomented, and if
speedy relief be not obtained by these means, an anodyne
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, laxa-
tives are useful, and a blister must be applied to the pained
part of the belly to prevent inflammation.
Si
CHAP. VI.
Of Retention of part ofthe Placenta.
If either the whole, or a considerable portion ofthe pla-
centa, be left in utcro for some time, the patient is exposed
to great danger. Hemorrhage is not the only risk, for in
many cases, severe head-ach, 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,
having been retained for a length of time, has been expelled,
before these symptoms have become urgent; but they have
afterward gradually increased, and carried off the patient.*
Sometimes the symptoms run so high, or the portions of
the 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 perspirations, 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 weeksf. Sometimes no
hemorrhage takes place during the whole course ofthe dis-
ease; but occasionally, repeated hemorrhages do occur, ad-
• 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 oppress-
ed, had foetid breath, &c. on the twelfth, an eruption appeared, and she died on
the twenty-second.
f 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 medicine,
she had weak quick pulse, hiccup, and subsultas 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'.
VOX.. II. T,
82
ding greatly to the debility ofthe 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.un-
der the disease. I am aware, that some have attributed these
symptoms not to the placenta, but to concomitant circum-
stances, such as injury done with the hand in endeavouring
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 utcro*. They continue as
long as it remains, and they usually cease when it is expel-
led.
It may be proper to examine, with the finger introduced
into the os uteri, whether any portion of the placenta can be
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 suc-
ceed. 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
dilated, and sometimes it yields very easily, or is not at all
contracted. If, however, it be rigid and unyielding, we must
* Similar symptoms have been produced by the head of the child being left in
atero. Perfect, Vol. II. p. 80.
83
not use violence ; but this condition is rarely conjoined with
retention ofthe entire placenta.
When a portion of the placenta is retained, we may derive
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 sy-
ringe with a long pipe may be employed.
Sometimes natural or artificial vomiting assists the ex-
pulsion.
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. Vo-
miting 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.
CHAP. VII.
Of Strangury.
After severe labour, the neck of the bladder and urethra
are sometimes extremely sensible ; and the whole ofthe vul-
va is tender, and of a deep red colour. This is productive
of very distressing strangury, which is occasionally accom-
panied with a considerable degree of fever. It is long of being
removed, but yields at last to a course of gentle laxatives,
opiates, and fomentations. Anodyne clysters are of ser-
vice.
84
CHAP. VI11.
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 phth-
isis, that disease is exceedingly apt to be rapidly induced
after delivery.
Pleurisy requires on the first attack copious blood-letting,
laxatives, and blisters, which arc never to be omitted. If the
early stage has passed over, the use of the lancet is doubtful,
and it is better to trust to digitalis given freelyr, and the ap-
plication of blisters. Laxatives arc also not to be neglected.
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
sometimes has a sense of suffocation; she has also a knock-
ing within 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 lan-
guid. Sometimes it is succeeded by a profuse perspiration;
and should the fits be frequently repeated, the temperature
is variable during the intervals, and the stomach is filled
with gas. This is often a very obstinate, but it is not a dan-
gerous disease, unless it proceed from uterine disease, mark-
ed by pain and swelling of the belly. It is to be relieved by
giving, during the paroxysm, a liberal dose of ether and lau-
85
danum; and during the intervals, antispasmodics, laxatives,
and tonics are to be employed. As soon as possible, the pa-
tient should remove to the country.
Colic, cramp ofthe stomach, hysteric fits, hiccup, syncope,
anddyspntra, are to be treated upon general principles. They
are most readily removed by full doses of opium, and other
antispasmodics, and clearing out the bowels with purgatives.
There is a species of dyspnoea, that depends upon exer-
tion of the muscles of respiration during labour, or distention
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 lit-
tle the compress round the belly, and giving thirty drops of
laudanum. When the diaphragm is affected, the uneasiness
is usually greatest during inspiration; and there is often a
pain in the side, or in the back, or about the pit of the sto-
mach, which may be very severe. It is attended, sometimes,
with a sense of stuffing in the breast; in other cases, with
an acute feeling of suffocation, or very sharp pains across
the lower part of the thorax, with deadly paleness, and the
pulse is extremely rapid. A very large dose of laudanum,
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, inflammation
comes on more slowly, and is often preceded by a shivering
fit, there is more cough, and the pulse at first is not so fre-
quent, 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 disease
86
is the induction of inflammation, if the irritation be not soon
removed. The best remedy is a large dose of laudanum giv-
en 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 sa-
line 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 immedi-
ate exhibition of at least sixty, perhaps a hundred drops of
laudanum, with a drachm of sulphuric ether, or two drachnis
of spiritus ammonise aromaticus ; a sinapism is also to be ap-
plied 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.
CHAP. X.
Of Ephemeral fever or weed.
The increased irritability of the system, as well as the
delicacy 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
nervous system, others from local affection of the heart, the
bowels, or the uterus. The first of these symptomatic fevers,
is generally pretty easily recognised by the sensibility ofthe
breasts; the others, particularly that connected with the
state of the womb, are often more ambiguous, the local symp-
toms being in many cases insiduous.
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, men-
87
lal 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 af-
ter delivery. It may be excited by exposure to cold, irregu-
larities 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 exposure to
cold. When the cold stage has continued for some time, the
hot one commences, and this ends in a profuse perspiration,
which either carries off the fever completely, or procures a
great remission ofthe symptoms. The head is usually pained,
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 degree of frequency. The
thirst is considerable, the stomach generally filled with fla-
tus, and the belly bound. The mind often is weakened, /md
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 eold 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 dis-
ease is not combined with any local injury, it is less danger-
ous than most fevers occurring in child-bed : but if it re-
88
cur 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 xevy sud-
denly in the course of this ailment; the breasts arc peculiar-
ly liable to become 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
parturition, 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
ephemeral 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
dullness ; or, if the patient be sick, and have a foul tongue,
a gentle emetic of ipecacuanha will be useful. Having has-
tened on the hot stage, we lessen very cautiously the num-
ber of the bed-clothes, and give saline julap with diluents,
to bring on the sweating stage. When this is done, wc air
careful not to encourage perspiration too much, which in-
creases the w eakness, 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 re-
curs 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 patient is to be cautiously
shifted, the clothes being previously warmed. After the fit,
if the patient is exhausted, a little wine may be given. Iu
the whole paroxysm, we must watch against the sudden ap-
plication 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 dullness is felt. It is of great consequence
89
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 sup-
ported 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 re-
collected, 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, beginning
like weed, but altogether arising from the state of the womb,
or other organs. The distinction is important, that no time
be lost in combating the disease; which in the one case does
not at first exist, in the other, is present ab origine. 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 ascertain it satisfac-
torily.
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
VOL. II. m
90
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 delive-
ry, 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, langour,
sometimes amounting to syncope, and frequency of pulse, with
heat of the skin. There is also a sense of pricking 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 days. Previous to
the eruption, the patient feels very much oppressed, and has
a great weight about the chest; the spirits are low, and a
sour smelled perspiration takes place in a profuse degree.
The eyes are occasionally dull and watery, or inflamed, and
the patient has ringing in the ears. The tongue is foul, and
its edge red as in scarlatina. Aphthae sometimes appear in
the throat. The lochial discharge is diminished or suppres-
sed. Before the eruption is seen, the skin feels rough like
the cutis anserina. Presently a number of small red pus-
tules appear like millet seeds, which are felt with the finger
to be prominent. In a few hours, small vesicles form on
their tops, containing a fluid, first straw coloured, and then
white or yellow. In two or three days small scabs form,
which fall off like scales. The pustules are generally dis-
tinct, but sometimes they form clusters. They appear first
• We should lay it down as a general rule, with but few exceptions, that
a cathartic should be given to the parturient female, on the third day after
delivery.
91
about the forehead, neck, and breast, and then spread to the
trunk and extremities, but very rarely affect the face. Dif-
ferent crops of pustules may come out in the same fever.
Burserius, and others, divide the postules into several va-
rieties; 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
weakened by fatigue, evacuations, or other causes; and
hence we can easily explain, why women in child-bed should
be subject to it.
Some have considered the eruption as altogether depend-
ent on the perspiration. Others consider it, as in many ca-
ses, idiopathic; and both, perhaps, at times are right. We
can only consider the disease as idiopathic, when the erup-
tion mitigates the symptoms, when the fever goes off as the
pustules arrive at maturity, and there is no other puerperal
disease present, acting as an exciting cause. It does not ap-
pear 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 accom-
panies the milk-fever, or the weed, when the perspiration is
injudiciously encouraged; and this is by far the most fre-
quent form, under which the febris miliaris appears. It
never alleviates the symptoms. It may also accompany fe-
vers connected with a morbid state of the peritoneum or
brain, which generally prove fatal; death being preceded by
vomiting of dark coloured fluid. Women, much reduced,
have also partial miliary eruptions, generally of the white
kind, without fever, which require no particular treat-
ment.
Whether the miliary fever he 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 les-
93
sening the quantity of bed-clothes, or making the bed-room
cooler. The rest of the treatment consists chiefly in re-
moving irritation from the intestines by the use of laxatives,
and supporting 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
encouraged. The linen should be frequently changed. When
the eruption suddenly recedes, we have been advised to re-
new the perspiration, apply blisters, and give musk and cor-
dials, especially when convulsions are threatened. This dan-
gerous retrocession, however, I have not met with, and ap-
prehend that it very rarely occurs. In consequence of the
improved mode of treating puerperal females, the febris
miliaris is now comparatively a rare disease.
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 sometime in existence, makes
its appearance suddenly. The same holds true with regard
to women in child-bed, who, either from previous torpor or
costiveness of the bow els 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 ap-
petite,—is thirsty,—has a white slimy tongue,—is sick,—
and occasionally vomits phlegm or bile, and is troubled with
93
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 throb-
bing, often of confusion, but seldom of continued pain in the
head. She has no fixed pain, nor any tumour in the belly,
but complains 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 ne-
cessarily obstructed, nor docs the secretion of milk, in many
instances, suffer for many 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 in-
jury ofthe functions of the womb, may supervene, and are
marked first by pains, and afterwards by tumefaction of the
lower part of the belly, and pain in making water, or on
passing the faces. 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
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
suitable 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 cos-
tive, 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 pre-
vention of re-accumulation. The diet must be very light,
such as beef tea, calves feet jelly, arrow root. &c. and if
94
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 Madeira wine may be given, as is found to im-
part a comfortable feeling, without inducing heat or restless-
ness. When the tongue becomes clean, small doses of Colombo,
or other bitters will be useful. If there be much nervous ir-
ritation or palpitation, or tendency to delirium, the campho-
rated julap is proper.
CHAP. XIV.
Of Inflammation ofthe Uterus.
Inflammation ofthe 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
disposed to admit; but it will, nevertheless, be useful to de-
scribe 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 skin becomes warm, and between the cold and
the establishment ofthe 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 con-
tinues, 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 ex-
tend a little to one side, or toward the groin. Sometimes
there is pain in the back, but frequently there is none, un-
less when the patient 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 dis-
charge gradually diminishes, but does not of necessity stop, *
95
and the milk sometimes continues plentiful. There is consid-
erable 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 ra-
ther 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
fseces dark, slimy, or foetid. Sometimes there is a degree of
strangury. In the course of a fortnight, the pulse becomes
slower, the appetite gradually returns, and these circum-
stances are preceded or accompanied with a slight dis-
charge of blood from the womb, or of purulent 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 completely to the treat-
ment; 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 continues 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 dis-
tinguish 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 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 men-
ses is discharged, and then she is almost instantly 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, if early employed, is useful, but
most cases recover without the use of the lancet, merely by
cuticular and intestinal evacuation.
The more serious and extensive inflammation of the ute-
rus, may be excited in consequence of rude management, or
other causes. The disease usually begins about the third or
9(1
fifth day al'icr delivery, but it may take place at a later pe-
riod. It is pointed out hy a pain in the lower part of the
belly, which gradually increases in violence, and continues
without intermission, though it is subject to occasional ag-
gravations. The uterine region is very painful when it is
pressed, and it is a little swelled. There is, however, no ge-
neral swelling of the abdomen with tension, unless the peri-
toneum have become affected. But the parietes are rather
slack, and we can feel distinctly the uterus through them,to
be bard and enlarged, and it is very sensible. There is also
pain felt in the back, which shoots to the groins; and there
is usually a difficulty in voiding the urine, or a complete sup-
pression, or distressing 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 temperature increased. The lochial discharge is
very early suppressed, 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-ach, is often sick, and vomits bilious or
dark coloured fluid. The pulse very early becomes frequent,
and somewhat hard, 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 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
pains abate, the pulse come down, and the lochia and secre-
tion of milk return, we consider the patient as having the
prospect of a speedy cure. But in many other cases the dis-
ease is more obstinate, the fever continues, the pulse be-
comes more frequent, but is full for a day or two, after which,
it becomes small, the tongue is redder, but dry, the pain does
97
not abate, and in some days shiverings take placM, and the
pain becomes of the throbbing kind. The face is pale, un-
less 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 blad-
der or rectum, but oftenest from the rectum. The hectic
symptoms continue for many weeks, and mayat 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 general-
ly be found, that suppuration has taken place. Pus is con-
tained often in the ovaria and tubes, and sinuses of the uter-
us. Mortification is an extremely rare termination. This is
a fact, of which my dissections convince me, and it is far-
ther confirmed by the opinion of Dr. Clarke. Little or no
serous effusion takes place into the abdomen.
This disease calls for the early use ofthe lancet, which is
the principal remedy ; and the quantity of blood which we
take away, and the repetition of the evacuation, must depend
on the constitution ofthe 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 ascertain-
ed by throbbing pains, &c. In this case the lancet is hurtful.
Mild laxatives are also highly proper. Fomentations, sina-
pisms, and embrocations, arc 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 some-
times anodyne clysters give relief. In the suppurative stage,
wc must keep the bowels open, give light nourishment, ap-
ply 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
VOX. II. •*
98
by pressure. The lower part of the belly is, after a little.
swelled and uneasy. Fever attends this disease, and some-
limes 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 wc employ fo-
mentations and blisters. If neglected, the disease may end
in suppuration, or in a painful swelling, at the ring of the
oblique muscle, which lasts a long time. This is sometimes
removed by issues. Anodynes should be given, to allay ir-
ritation, and the strength must be supported under the fever.
which resembles hectic.
CHAP. XV.
Of Peritoneal Iiiflammation.
The peritoneal lining of the abdomen, or the covering of
the intestines, may be inflamed alone; or this disease mav
be combined with inflammation of the uterus.
Peritoneal inflammation may be caused by violence dur-
ing delivery, or the application of cold, or the injudicious
use of stimulants. It may not come on for three weeks after
delivery, but it usually commences 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 vomiting, and
is marked by pain in the belly, which sometimes is very uni-
versal ; 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 frequent,
small, and sharp, the skin hot, the tongue white and dry,
the patient thirsty; she vomits frequently, and the milk
and lochia are obstructed. Very soon, the belly becomes as
large as before delivery, and is often so tender, that the
weight of the bed-clothes can scarcely be endured; the pa-
99
tient also feels much pain when she turns. The respiration
becomes difficult, and sometimes a cough comes on, which
aggravates the distress. The bowels are either costive, or
the patient purges bilious or dark coloured faeces. These
symptoms are more or less acute, according to the extern
to which the peritoneum is affected. They are, at first,
milder, and are more protracted, in those cases where the
inflammation begins in the uterus; and in such the pain is of-
ten not very great, nor very extensive, for some time. If the
disease is to prove fatal, the swelling and tension ofthe bel-
ly increase, so that the abdomen becomes round and promi-
nent, the vomiting continues, the pulse becomes veryr fre-
quent and irregular, the fauces are aphthous, the extremi-
ties cold, and the pain usually ceases rather suddenly, The
patient has unrefreshing slumber, and sometimes has deli-
rium mite. The disease may be protraeted for eight or ten
days, or even longer. If the patient is to recover, the swell-
ing 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 externally. Dr. Gordon, in his treatise on puerperal
fever, relates three cases of this kind. In one of these, the
matter was discharged 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 considera-
ble 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 decid-
edly on debility, produced by great hemorrhage, &c. wc
100
ought to open the bowels freely, and give a diaphoretic. Wc
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
open a vein, and use purgatives. I know that many are un-
willing to bleed women in the puerperal state, and the con-
dition of the pulse may seem to young practitioners to for-
bid it. But in cases of peritoneal inflammation, not connec-
ted with typhoid fever, I must strongly urge the necessity
of blood-letting, at a very early period ; and the evacuation
is to be repeated or not, according to its effects, and the con-
stitution ofthe patient*. If she have borne it ill, and is not re-
lieved, when it is used first, I apprehend that the ease has not
been simple peritoneal inflammation, but is puerperal fever.
If she bear it well, and the pulse become slower and fuller, and
the pain abate, we are encouraged to repeat it. I wish to im-
press on the mind ofthe student in the most earnest manner,
the fatal consequence of neglecting blood-letting in this dis-
ease. How many women fall a sacrifice to the timidity or in-
attention 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 perito-
nitis ; but the error is safer than the contrary extreme, for
of two evils debility is more easily removed, than inflamma-
tion. After the lancet has been freely used, if pain continue,
leeches, or the scarificator may be applied to the most pain-
ful part. The bowels are to be opened freely with calomel, or
some other purgative; and in an advanced stage of the dis-
ease, after effusion 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 inflam-
mation, or promote absorption, after effusion has taken place;
but I have not found it useful. After effusion has taken place,
and debility is produced, cordials, of which wine is the best,
should be given, and anodyne clysters are to be adminis-
tered.
* This is correct practice. Bleeding may be as safely employed in inflamma-
tion connected with the puerperal state, as under any other circumstances. C.
101
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 ofthe abdomen, but it is
not unbearable ; the belly is tender, the pulse frequent, the
thirst urgent, and often the mind is affected as in hysteria ;
or a train of hysterical symptoms supervenes, which may
lead off the attention from the seat of the disease. It re-
quires at first blood-letting, and then the frequent use of lax-
atives, 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 shiv-
ering is perceived, and varies considerably in degree, being
either slight or pretty severe. The first symptoms, indepen-
dant of the shivering, are frequency of pulse, and pain in
the head, particularly over the eye-brows, and at the same
time, or very soon afterwards, pain is felt in the belly. This
is at first slight, but it presently increases; and in some in-
stances, the abdomen is so tender, that even the weight of
the bed-clothes is productive of distress. A general fulness,
or swelling of the belly, then comes on, and it usually increa-
ses pretty rapidly, and may proceed so far as to make the
patient nearly as large as she was before delivery; and in
such cases, the breathing becomes very much oppressed: in-
deed, in every instance, the respiration is more or less affec-
ted ; the free action of the abdominal muscles, which are
concerned 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 eye
is without animation, and the lips and angles of the eyes are
white. The whole features indicate exhaustion or great de-
bility. Vomiting occasionally occurs at the very commence-
102
mcnt, 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 fe-
ver, the fluid thrown up is dark coloured, and frequently foe-
tid. This is a symptom, which, so far as I have observed, al-
ways, if it do not proceed from a morbid structure, indicates
in whatever disease it occurs, an entire loss of tone of that
organ. But to proceed with the history : There is great de-
jection of mind, langour with general debility ofthe muscu-
lar fibres, and the patient lies chiefly on her back; or there
is so much listlessness, that she sometimes makes little com-
plaint. 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 aphtlue 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 peritoneal inflammation, but it soon becomes feeble.
The thirst is not always great, at least the patient is often
careless about drink. The bowels are often at first bound;
but afterwards, especially about the third day, they usually
become 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 eases, I have met with pleuritic symp-
toms. As the disease advances, the pulse becomes more fre-
quent and weaker, or tremulous. In bad cases, the swelling
of the belly increases rapidly, but the pain does not always
keep 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
103
about the fifth day of the disease, but in some cases not un-
til the fourteenth; in others so early as the second dayr.
This fever attacks generally on the second or third day
after delivery, but it has occurred even 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.
Theomenttim and peritoneum are inflamed, but perhaps very
slightly, and gangrene is unusual. The uterus is not more
affected than the intestines. In some cases, the thoracic
viscera are affected in a similar way.
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 contagious 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 absorption of putrid
matter. The disease appears to depend on inflammation of
the peritoneum, conjoined with the operation of some de-
bilitating poison, probably, in most cases, more or less con-
tagious.
It is important to distinguish this disease from simple per-
itonitis, 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-
ach; less heat ofthe skin, less thirst, and less flushing ofthe
face. In the peritoneal inflammation, the pain in the belly
usually increases rapidly after it begins, and the swelling in-
creases along with it. Pressure gives very great pain. The
fever is inflammatory. Inflammation of the uterus has its
proper symptoms.
* G!asg»v
101
This disease is dangerous, in proportion to the malignancy
ofthe 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 difference of opinion,
which partly depends on giving the name of puerperal fever
to different disorders1. I am sorry that I find it much easier
to say, what remedies have failed, than what havudonc good.
I have stated, that in peritoneal inflammation, blood-letting
and laxatives arc the principal remedies; but in this disease
blood-letting seldom does good, and often is hurtful, lam con-
vinced, that if it is to be used at all, it must be very early, and
ihat it ought^ not to be pushed far. If the symptoms of depres-
sion 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, approaching to peritonitis,
and we are called early, a vein may be opened; but if the
pulse speedily become small, or the patient feel faintish, wc
must not continue the evacuation, and are upon no account
to repeat it merely because the blood is buffy. Wiiether we
bleed or not, it will be proper to begin the use of the bark,
giving it as liberally as the stomach will bear, or administer-
ing it in the form of a clyster. Opiates, given freely, have
the effect of abating irritation and pain, and of restraining
immoderate diarrhoea, should that come on. Diarrhoea should
not be allowed to continue long, and is always to be restrain-
ed, unless it evidently give relief, and the faeces be very
foetid. In this case, diluents should be employed. If there be
tenesmus, anodyne clysters should be given. If there be not,
emollient clysters often give temporary relief. Should the
bowels be costive, which is seldom the case indeed, a gentle
laxative is to-be given, which ought to be ofthe saline kind,
and will likely bring away dark coloured foetid stools. If the
bowels have been formerly very open, but the diarrhoea have
stopped naturally, or by the use of opiates, a gentle laxative
or clyster should be given, if more than a day pass without
105
a stool, as the accumulation of morbid faecal matter is equally
hurtful with much purging. 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 relief be obtained from natural vomiting,
which most practitioners admit, I do not see that artificial
vomiting can be useful, nor does experience support the
practice. Fomentations, and anodyne frictions, sometimes
abate the pain in the abdomen. The repeated application of
blisters 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 sup-
ported 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. Emetics and antimonials, I am afraid, do more harm
in general than good. Upon the whole, we trust chiefly to
tonics, in the cure of the puerperal fever; we support the
strength, and regulate the state of the alvine discharge, pre-
venting accumulation of morbid faeces on the one hand, and
restraining immoderate evacuation on the other.* Most
authors have laid 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 shew, 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 cor-
• On no subject, perhaps, are practitioners more divided than respect-
jng the treatment of puerperal fever. From different views of the nature of
the disease, two modes of practice have indeed been deduced almost diame-
trically opposite. Whatever maybe the propriety ofthe plan, recommended
by Mr. Burns, as applicable to puerperal fever in Europe, it would, undoubt-
edly, 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.
VOL. II. O
106
dials. Peritonitis is much more frequent than puerperal
fever.(jy)
CHAP. XVII.
Of Swelled Leg.
Tub 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 fort-
night after delivery, sometimes later, sometimes a little ear-
lier, the patient complains of pain in the lower belly, increa-
sed 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
and pain are now felt in one of the groins, near the passage
ofthe round ligament, or the exit ofthe tendon ofthe 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 sarto-
rius muscle, and is most acute in the course of that muscle;
it also darts down to the heel. Within twenty-four hours af-
ter 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,
(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 the student, the attentive perusal of the excellent essays of Dr.
John Clarke, on the Inflammatory and Febrile diseases of lying-in women.
107
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 pulse is very frequent, being often 1*0 in the minute,
and generally is small and feeble, but sharp; the tongue is
white and moist, the countenance has a pale chlorotic ap-
pearance, 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. The urine is .mud-
dy ; the lochial discharge sometimes stops, or becomes foe-
tid, in other cases is not at all affected. The nights are spent
without 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 va-
gina 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 usu-
al size. Generally in ten days, sometimes in even two- or
three, the febrile symptoms, swelling, &c. abate; but it may
happen that they are protracted longer, and they do not go
off entirely for some time. When they go off, the patient is
left feeble, and the limb stiff, weak, and often for a time pow-
erless. 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 thein not at all affected.
If the skin be punctured, no serum is effused, at least not
in the same wray as in anasarca, and the swelling is not in-
creased in a depending posture.
In some cases, the disease begins like rheumatism affecting
the back and hip joint.(») Then the upper part of the thigh
(a) It is an opinion entertained by some respectable and experienced prac-
titioners, that this disease is in fact, a variety of rheumatism, and is to be man-
aged on the general plan of treatment that is found to be successful in rheu-
108
becomes painful and swelled, and next the calf of the leg suf-
fers ; sometimes the limb at first feels colder than the other.
In one or two instances, suppuration has taken place : mor-
tification has also happened.
It is always a length of time before the patient recover,
for the swelling does not go soon entirely away, and tin-
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.
This is not generally a fatal disease, but it is tedious, and
is often accompanied with hectic symptoms. Death, how-
ever, may be caused by suppuration or gangrene ; or by ex-
haustion, proceeding from the violence of the constitutional
disease ; or from exertion made by the patient, which has
sometimes proved suddenly fatal.
The production of this disease does not seem to depend on
(he 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. It has
succeeded an abortion, or suppression of urine. I am inclin-
ed to consider the cause to be a morbid state of the parts
within the pelvis, which sometimes produces merely a stiff-
ness and swelling at the passage of the round ligament. Pin
zos and Levret consider the disease as proceeding from a
depot ofthe milk. Most modern writers attribute it to an af-
fection, of the lymphatics, which are ruptured, or have their
circulation interrupted by swelling of the inguinal glands.
Dr. Hull considers the disease as an inflammatory affection,
matic fever. After the inflammatory stage is over, it is by them considered
^s running into the chronic state of rheumatism, and to be treated according*
\y by the remedies appropriated to that form of disease.
109
suddenly succeeded by effusion. I refer, for a view of the
different opinions, to his Treatise on Phlegmatia Dolens.
The disease seems to depend partly on inflammation, and
partly on nervous irritation ; and the cure consists in lessen-
ing 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 shoidd immediately open the bowels with a purgative.
A small blister should then be applied to the groin, and after-
wards cloths, wet with tepid solution of acetate of lead, or
with warm vinegar.(a) These means may prevent the swel-
ling, or render it milder. If the disease have already taken
place in the limb, fomentations, and gentle friction, with ano-
dyne balsam, or camphorated oil, will be useful. The bow-
els 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 endeayour to remove the swell-
ing, and restore the tone of the part, by friction with cam-
phorated 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 applied to the
(a) It is the practice at one ofthe best regulated lying-in hospitals in Lon-
don, to apply flannel, well soaked in hot vinegar, to the groin of the affected
limb, as well as to the limb itself; and it is asserted, that no other remedies be-
yond those necessary to keep the bowels open, are ever used. [Vide Vol. V.
of Lond. Med. and Phys. Journal.] The editor can, from experience, add
his testimony in favour of the beneficial effects of this treatment.
Dr. John Clarke, recommends laying the whole leg affected, in a soft poul-
tice, 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 together,
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 failing 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-
110
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, sulphu-
ric 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, with small
doses of calomel, are useful. If the uterine discharge be
foetid, it is proper to inject tepid water, or infusion of chamo-
mile flowers 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 support-
ing the strength. I cannot, however, agree with those who,
in the very outset ofthe 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
* I have met with but two cases of this strange affection, which I treat.
ed, very successfully, by copions bleeding, by very active purging, and by
blisters applied to the groin, and extending up the abdomen. In these ca-
ses 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 excit-
ing salivation. C.
Ill
■x few weeks. Friction, the shower-bath, tonics, and gentle
exercise on crutches, are the means of cure. The bowels
are also to be kept open.
After a severe or instrumental delivery, the woman may
complain of excessive pain about the loins and back, attend-
ed with lameness, or even palsy. This is sometimes a very
tedious complaint, but usually it is at last removed. The te-
pid bath, with anodyne embrocations, relieve the pam ; and
at a more advanced period, sea bathing is proper.*
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 usu-
ally appears rather suddenly ; the patient awakening, per-
haps, 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„suppos-
ing, for example, that her child is killed, or stolen ; or, al-
though naturally of a religious disposition, she may utter
volleys of oaths, with great rapidity. In other cases, she is
less talkative, but is anxious to rise and go abroad. It is
not, indeed, possible to describe the different varieties of in-
coherence, but there is oftener a tendency to raving than
melancholy. She always recognises surrounding objects, and
• Active purging is very useful in this disease. I have also known much
good to be derived from blisters to the sacrum. C
112
either answers any question put to her, or becomes more ex-
asperated by it. She can by dint of perseverance, or by pro-
per management, be for a time interrupted in her madness,
or rendered in some degree obedient. In some instances, she
reasons for a little, pretty correctly on her insane idea. The
eye has a troubled appearance, the pulse when there is mueli
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 tongc white ;
the secretion of milk is often, but not always diminished, and
the bowels arc usually costive. In some instances the 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 depen-
dent on phrenitis. Blood-letting has been advised in this
disease ; but I agree with those who consider it as hurtful,
or at least as useless. The best practice, I think, is to open
the bowels, keep the surface gently moist, by means of sa-
line julap, and allay irritation with liberal doses of hyoscya-
mus and camphor. Blisters have by some, for whose opi-
nion I have much regard, been considered as useless, or de-
trimental ; but I am confident I have seen them do good, af-
ter they have discharged freely. Opium is a very doubtful
remedy ; it oftener makes the patient restless, than procures
sleep ; but in the wane ofthe disease, it does in some cases
agree with the patient. The mind is to be managed with
prudence and attention, and the patient kept as much as
possible from exerting herself.*
* 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 of the system,
which is after the excitement is a little reduced by previous blood-letting, the
fast of our anodynes. C
113
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 remov-
ed, 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.
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 country as soon as possi-
ble. 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 coverings of the brain usually appears
still earlier than delirium, from irritation. It may be caused
by determination of blood to the head, or preternatural irri-
tability 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 appears within the second or third
day after parturition. The pulse continues frequent from
the time of delivery; and after the attack, rises perhaps
above 120 in the minute; the patient does not sleep, but is
watchful, and has intolerance of light; she soon complains
of confusion, rather than pain in the head; hears very
acutely, and speaks in a hurried manner, but when ques-
tioned early, often says she is quite well. Then furious deli-
rium comes on ; she pays no regard to, or at least does not
seem to recognise objects around her, and cannot be made
to answer any questions, or understand any argument of
persuasion. She usually hurries from one subject to another;
vol. n. ]•
114
the eyes move rapidly, arc sparkling and wild, and very
sensible to the light. The lochia are not suppressed, nor are
the bowels bound, but the secretion of milk ceases. In three
or four days, the patient sinks into a low comatose state,
the extremities become cold, the breathing laborious, and
sometimes convulsions precede death. This disease requires
the prompt and early use ofthe antiphlogistic treatment, gen-
eral and local blood-letting, the use of purgatives, and the
application of a blister to the scalp. The inflammatory symp-
toms being subdued, the delirium abates, or goes off, by the
use of remedies 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 ex-
posure to cold. In other cases, the woman feels during la-
hour, as if something had given way about the throat. It
may remain long in an indolent and stationary state, being
productive either of no material inconvenience, or only of a
slight difficulty of swallowing. In other instances, it aug-
ments in size, and becomes dangerous from its pressure on
the neighbouring parts; or it inflames, forms a large ab-
scess, and bursts. Enlargement of the left lobe is more dan-
gerous than that of the right.*
• 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 ofthe Alps. The goi-
tre, with this miserable race of people, is commonly, if not always, attended
with idiotism. In the lower animals, if the gland be removed, a train of ner-
vous affections will speedily follow, and finally fatuity, or a total extinction of
mind. This has been proved by a series of experiments made, as I have un-
derstood, by the celebrated Mr. Cooper of London. As soon as I heard of these
115
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 inde-
pendent of gestation, it has been proposed to extirpate the
tumour, or to tie the arteries going to it. If there be a tenden-
cy to suppuration, it ought to be encouraged, and treated on
general principles.
CHAP. XXI.
Of Diarrhoea.
If the patient have been eostivc before delivery, large
masses of fseccs may come down afterwards, producing vio-
lent pains in the belly, piles, tenesmus, or uterine hemorr-
hage ; or the same cause may excite diarrhoea with the pas-
sage of scybal». Both states require the use of gentle laxa-
tives. Diarrhoea may also occur without previous costive-
ness ; the stools are then foetid or bilious. In this case the diet
is to be strictly regulated; gentle laxatives are to be first
given to evacuate the offensive matter, and then opiates are
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 circulation in cases of undue
determination of blood to the head. 1 was assisted to this inference by the re-
collection 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 reg-
ular 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 enlargement or total extirpation of the
gland.
With respect to the production of puerperal bronchocele we have an obvious
explanation. During parturition, and particularly if it be laborious, there is
very frequently an afflux of blood to the head, and, as may be observed, a con-
siderable distention of the thyroid gland. By this distention, which occasion-
ally 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 quan-
tity of blood, which necessarily nourishes a morbid growth ofthe part. C
116
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 JVipples.
Inflammation ofthe mamma may take place at any pe-
riod 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, cal-
led 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 af-
fect 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 ab-
scess forms, and the integuments burst, we may have matter
alone discharged, or there may be a slough of considerable
magnitude found w ithin the abscess. This proceeds from the
destruction of one or more of the glands, which if the inflam-
mation run high, do not suppurate but die. Usually, there
is a considerable degree of fever attending the complaint,
and the pain is often severe, especially when the breast i9
extensively affected. It is a very difficult thing to prevent
this inflammation from ending in suppuration. It is to he at-
tempted, 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
• I know of nothing so good in these cases, as bathing the breast with a
mixture of laudanum, brandy, and hartshorn. C
117
be only a little diffused fulness with some degree of pain,
gentle friction with warm oil is useful. If the breast be
distended 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 ac-
cumulation in the vessels. The breast is also to be care-
fully 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 open-
ing of sufficient size, provided there be no appearance of the
abscess bursting soon of its own accord. This prevents insin-
uation of matter in the cellular substance of the breast. If
the puncture be followed by a troublesome oozing of blood
from the wound, dry lint and compression must be used. In
one instance, I knew the hemorrhage prove fatal. After the
abscess bursts, or is opened, there is for some time a dis-
charge of purulent matter, which frequently is mixed with
milk; then the surrounding hardness gradually abates. The
poultice may be continued for several days, as it promotes
the absorption of the indurated substance; but if it fret the
surface, and encourage a kind of phagedenic erosion, it is
to be exchanged for mild dressings. A little fine lint is to
be applied on the aperture, but not so firmly as to confine
the matter; and over this, a cloth spread with spermaceti
ointment; great attention is to be paid to the evacuation of
the matter, and the prevention 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 tho management be negligent, or the constitution bad,
it sometimes happens, that extensive suppuration, or numer-
ous abscesses take place. The breast becoming altogether
considerably diseased, and the discharge is very foetid. In
118
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. Sinuses must be laid open from the bottom, or
counter openings must be made, and the sores dressed accord-
ing to the general rules of surgery. Even although there is
not much ulceration or any appearance of scrophulous indu-
ration, the strength may, from an extensive abscess, or pro-
tracted sore, be much diminished, and hectic induced, which
is to be removed by the means commonly employed, or al-
ready pointed out.
Sometimes, although the abscess heals readily, and have
been small, an induration remains, which either it 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
renders a relapse easy. It is therefore proper to invigorate
the system, and defend the breast for some weeks more care-
fully than usual from cold. When a relapse takes place, es-
pecially 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 schirrous 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 pains increase, becomes throb-
bing, the skin red, and, finally, the abscess bursts. . This
state requires the application of warm poultices and hot fo-
mentations.
119
Excoriation of the nipple is a very frequent affection, and
often excites that disease wc 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 nip-
ple. When the child sucks, the pain is severe, and some-
times a considerable quantity of blood flows from the part.
In some instances, an aphthous state of the child's mouth ex-
cites this affection; in others, excoriation of the nipple af-
fects the child. A variety of remedies have been employed.
Spirituous, saline, and astringent lotions have been used
previous to delivery, with a 'view of rendering the parts
more insensible; 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 fre-
quently. Solutions'of sulphate of aluminc, acetate of lead,
sulphate of copper, nitrate of silver, &c. in such strength as
just to smart a little, are also occasionally of service; and it is
observable, that no application continues long to do good.
Frequent changes, therefore, are necessary. The nipple
should always be bathed with milk and water before apply-
ing 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 melt-
ed marrow, with or without vegetable additions, form po-
pular applications. Stimulating ointments, such as ung. hyd.
nit. diluted with axunge, are sometimes of service ; or the
parts may be touched with burnt alum.
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
(A) In one instance which has been related to me by a respectable physician
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 perhaps appear an un-
pleasant preventive, yet is certainly worthy of the attention of those who have
often experienced the extreme anguish arising from this variety of disease.
ISO
child suck through a teat fixed on a metallic nipple, that the
irritation of its tongue or mouth might be removed. 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 ofthe
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 nurs-
ing. 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, some-
times remedies this defect. A deficiency of retentive power,
so that the milk runs constantly out, Is another disqualifica-
tion, and it is not easy to find a remedy. When the milk dis-
agrees with the child, having some bad quality, wc are also
under the necessity of employing another nurse. If the mo-
ther be very delicate, or be consumptive, or affected with
obstinate melancholy, or have her eyes much inflamed, or
the sight injured by nursing, or if the secretion be very
sparing, she must give up nursing. Some delicate women
suffer so much from nursing, that chlorotic, or phthisical
symptoms are induced. In this case, she must take off the
child. Opiates are useful at bed-time, to procure sleep, and
the bowels are to be kept open. Many women, after deliv-
ery, are subject to disorders of the alimentary canal, espe-
cially 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, &e. may
also occur in the puerperal state, and prevent nursing. The
ordinary methods of cure are to be employed.
121
When a woman weans a child, or from the first, does no;t
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. XXII.
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
lochial discharge. The uterus is enlarged, and has neither
the shape ofthe gravid nor unimpregnated uterus; the cer-
vix is indistinct, and the os uteri is nearly circular, and will
admit two or more fingers. The abdomen is prominent, and
the integuments relaxed, wrinkled, and eovered with light
coloured broken streaks. The breasts are enlarged, have
the areola very distinct, and contain milk; but it is possible
for this secretion 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
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 reply, 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 enlarged to the same degree as in the end of
vol ii. q
132
pregnancy, and when the mass is oxpelled, as it is soft, the
perineum cannot be injured. If then it can in a criminal ease
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 born a child. Other circumstan-
ces may also concur in confirming the opinion of the practi-
tioner; 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 anato-
mists, 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
coagula 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 ofthe 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.
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
123
not yet assumed the same order as usual, but the, distended
caecum is often more prominent than the rest.
It is a month at least, before the uterus returns to its un-
impregnated state.
We know that the wroman has had a recent miscarriage,
by the state ofthe breasts, the sanguineous discharge from
the vagina, the size of the uterus, and the softness and dila-
tation of its mouth. If the woman die, the womb is found en-
larged, its surface covered with the decidua, or mater-
nal portion of the placenta. The vessels are enlarged, the
tubes and ligaments very vascular; the calyx ofthe 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 born 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 appearances during life, or after death, which oc-
cur from a miscarriage, may also arise from the expulsion of
hydatids, which usually are produced by the destruction of
an ovum, in which case, even a distinct corpus lutenm may
be discovered.
1;84
BOOK IV.
Of the Management and Diseases of Children.
CHAP. I.
Ofthe Management of Children.
i 1. OF THE SEPARATION OF THE CHILO, AM) THE TREAT-
MENT OF STILL-noRV CHILIIREN.
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 vigor-
ously, then it may be safely separated from the mother*.
This is done, by tying the navel-string about half an inch
from the navel ;(c) another ligature is applied an inch nearer
the placenta, 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
applying a ligature has been denied by different practition-
* Dr. Denman, from observing that some children, after they had begun to
breathe, had respiration checked, and died after the cord was tied, advises,
that the ligature should never be applied till the pulsation cease. But when
the child is vigorous and cries lustily, there is no occasion for delaying so
long; nor have I ever known any bad effect result from this practice. It has
been supposed, that as long as pulsation continued, the function of respira-
tion was imperfect; but it is not so: the pulsation depends more on the con-
tinuance of the vitality or action of the placenta, than on the state of the
lungs.
(c) This is rather too near the navel, for in case ofthe ligature 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 be-
tween the former one, and the abdomen of the child. It is best therefore to apply
the ligature, in a general way, at about three ringers breadth from the navel; this
leaves sufficient space for the application of another ligature if necessary.
125
ers; but it has sometimes been found, that when the iigatur*
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,
therefore, it behoves us always, unless this mark be pre-
sent, to use means for preserving the child, by which some
have been saved, after being laid aside as dead. Children
may be horn apparently dead, in consequence of the head
having remained long in the pelvis, or having been squeez-
ed in a deformed pelvis ; or owing to the cord having been
compressed, either during the process_of turning and deliver-
ing a child, or from its having descended before the pre-
senting part ofthe child, or being so situated during labour,
as to be compressed by the uterus. Some children die.owinjr
to the head being born, covered with the membranes, some
time before the body. This is the consequence of inattention,
for, if the membranes be removed from the face, there is no
risk ofthe 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 pres-
sure on the brain; or to a state of insensibility and feeble-
ness, 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 respiration.
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 i> purple, from the blood not having been sir-
126
terialised, and we have no mark of distinction till respira-
tion 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 se-
cond case, respiration, after it begins, continues longer op-
pressed, 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 estab-
lished, 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 be-
ing 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 lancet or scissars, one of the umbilical arteries,
from which blood spouts in a small stream ; and, in a short
time thereafter, 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 bottom. But the most effectual remedy is inflat-
ing the lungs, by blowing either through the barrel of a quill,
or applying 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
127
pulsation have stopped in the cord, and the child do not re-
cover, the cord is to be divided, for connection with the pla-
centa 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 probably 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 produce 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 oppres-
sed, 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 opi-
nion. If the lungs be solid and sink in water, the child cer-
tainly has not breathed; and although respiration may, from
the first, be prevented by the midwife, it cannot by the mo-
i her. 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.
128
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 re-
cently born, the lungs swim in water, and their air-cells uni-
versally 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 corrob-
orating 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 exculpa-
tory cvidcnce.(d)
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 invest-
ing 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
()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 ot
bastard children; by the late William Hunter, M. D. &c. Medical Observa-
tions and Inquiries, by a Society of Physicians in London. Vol. VI. p. 266 k
seq." As also, to those chapters of Mahon's and Foedere's 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-
monaire, p. 436.
129
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 rea-
son to suspect that the mother has had gonorrhoea or chan-
cre, 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 na-
vel string, and retain this by means of a bandage brought
round the belly. It is alleged, that it is necessary to pre-
vent umbilical hernia; but hernia does not take place be-
cause the child is not bandaged, but because the umbilicus
is unusually wide; and in those countries where no com-
press is used, hernia is not a frequent complaint. A light
bandage produces pain, difficulty of breathing, and other
deleterious effects. 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
ami 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 cot-
ton 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 consists of a short shift and a wrapper of fine flan-
nel, which is better for a week or two than the separate
pieces of dress employed by many, and which add to the
time and trouble of shifting the ehild. All children cry when
shifted and dressed, therefore the shorter and simpler that
^OR. IT. R
130
the process can be made, the better. Last of all, a cloth is to
be applied, to receive the faeces or urine, and this is to be
removed the moment it is soiled. By attention, a child may
Very early be taught to give indication when he wishes to
void the urine or fseces, and can then be held over a pot or
bason. It is proper to encourage the child to use these at
regular intervals. Children should have their bottom and
thighs washed and wiped dry, always after soiling them-
selves. The whole body ought likewise to be regularly wash-
ed, morning and evening, with a sponge and water, at first
rather tepid, but soon brought to be cold, at least of the tem-
perature that cold water has in summer. But although this
is a general practice, yet some children do not agree Avith 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 perhaps, 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 surface. The child in utcro is placed in a temperature
of about 96 or 98 degrees; but its power of generating heat
is probably 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 avoided on the one hand, and exposure to cold on the
other. The apartment should be well ventilated, but the in-
fant ought not to be exposed to the open air, for nearly a
month in wrinter, as it is apt to produce convulsions, or ca-
tarrh, 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 per-
haps be questioned, especially if the mother be able to suckle
at the usual time. A little milk and water is at all events
131
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 manna may be given with much advantage(e); but
generally the milk which is first secreted, called collostruin,
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 yellow tinge on the skin which is called the gum.
This is sometimes attended with a drowsy state. If it re-
quire anyr medicine 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'eniploy another nurse1, or bring the child up on the spoon.
If the latter mode is to be adopted, it is necessary to deter-
mine 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 speeies is best fitted for the
young of that species; and we know that there is a great di-
versity both in the flavour, and proportion ofthe 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
women, the goat, the cow; and then the ass and the mare.
(e) 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
children 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.
132
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 ofthe sheep, the goat,
the cow, the ass, the mare, in the order in which they stand;
and it is little in that of women. Sugar again is most abun-
dant in the milk ofthe marc and women, 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 be-
comes sour by exposure to air, and does not pass either to
the vinous or putrefactive fermentations. Acids do not coag-
ulate human milk.
From these remarks it follows, that if a child is not suck-
led, the best food will be milk, resembling that of women,
and the nearest is asses; but as this cannot always be procur-
ed, we must change that of cows, so as to diminish the pro-
portion of curd, and increase that of sugar and cream ; which
is done by adding an equal quantity of water, or sometimes
of new made whey, a sixth part of fresh cream, and a little
sugar.(/) This is to be mixed just as it is required, for by
standing it acquires bad properties. It is not to be given
with the spoon, but the child is to suck it of a proper heat
out of a tea-pot which is made for the purpose, and which has
a piece of soft cloth tied over the perforated mouth. This
diet may be occasionally alternated with a little weak veal
or beef soup. Panado, made with crumb of bread, is not pro-
per ; and food made with unbaked flour is still worse. In
the third month, we may, besides the milk and water, and
light soup, give occasionally a little spoon-meat, such as pa-
nado made with the crust of fine bread, and a little salt,
which is better than sugar, care being taken to break down
(/) Or a very good substitute may be found in the combination of equal
parts of barley-water, and fresh cow's milk sweetened with the best refined
loaf-sugar. And here we may mention, that brown sugar should never be
used in the food of infants, as it readily runs on into fermentation, generating
gaseous flatulency, in the prima vix and often producing great uneasiness
and colicky pains. When the child is habitually costive, the food may be
p weetened with manna instead of sugar.
133
the lumps completely. 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, wc ascer-
tain 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 appearance. If this condition of the bowels can-
not be corrected by medicines, the child in all probability
will be lost, if a nurse be not procured; convulsions, or di-
arrhoea will carry him off.
When a child is brought up on the breast, there is no oc-
casion, if the supply be abundant, to give him any other
nourishment for three or four months. After this time, how-
ever, it will be proper to give a little food of the kinds men-
tioned above, and the proportion ought to be gradually in-
creased, 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 long-
er it is delayed the better does the child thrive, provided the
milk be good. At all times, delicate, should be nursed longer
than robust, children; and, if possible, weaning should not be
made to interfere with the developement of teeth, nor be at-
tempted in the prospect of, or soon after the cure of, any de-
bilitating disease. If the mother's health permit, children
may be suckled from nine to twelve months. After the child
is weaned, the diet must be carefully attended to, and should
• It is also of advantage, that when a child is brought up on the breast, he
be not applied at all hours indiscriminately; and no child should be allowed
to suck whilst the nurse is asleep, as he is apt to surfeit himself.
lil
consist of light soup, eggs, bread, and milk. In Ireland, po-
tatoes form a principal part of the diet. In Scotland, oat-meal
porridge 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 ani-
mal 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 sea-
son 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 pri-
vations and hardships, are not improved thereby. .Cleanli-
ness 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 proportioned 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 pla-
ced 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 per-
mit, 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 acci-
dent during birth. I can here only make a few short re-
marks on some of the most frequent and important imper-
fections. The first I shall notice, is the hare-lip, which may
exist in different degrees, and be accompanied with a vacan-
133
cy in the palate. Sometimes an operation has been performed
soon after birth, 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 mean time, the child must be brought
up on the spoon, unless the defect be so trifling, as to per-
mit the child to suck a large nipple.
§ 2. IMPERFORATED ANUS, URETHRA, &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 soiled
with faces, we may be sure that the rectum is pervious. A
blunt probe, cautiously introduced, will also ascertain the
state of the gut. Sometimes the anus is covered with a thin
membrane only. In othei^cases, a great part of the rectum
is w anting, or it terminates in the bladder of the male, or va-
gina 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 in-
testine 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 employ-
ed, to keep the aperture from closing*. But if it be not
readjly found, we are not to prosecute the dissection far-
ther, but must form an artificial anus, by making an inci-
sion at the lower part of the left iliac region, sufficiently
large to allow the colon to be brought out, opened, and tht
extremity retained to the woundf.
• In a case operated on by M. Cervenon, where the incision was obliged
Lo be carried an inch high, it was necessary to use a bougie for a year. The
child was enabled to retain the fxces, but the anus appeared as if it were
sunk an inch deeper than usual- Kecueil Period. Tom. I. p. 36.
t Vide Observations on this subject, by Dumas and Allan, in the Recueil
Period. Tom. HI p. 46 and 123; and a case in point by Duret, ;r< Tom. IV
p 45.
136
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 he pervious to a certain
extent. But if it be altogether wanting, relief in the mean
time must be obtained, by puncturing the bladder. Reten-
tion of urine, not dependent on malformation, is readily re-
moved, by introducing a probe into the bladder. Deviations
in the structure ofthe vagina and hymen have already been
considered.
Imperforated meatus auditorius is very rare, and can sel-
dom be remedied, except there be merely a membrane
stretched across the canal. Adhesion of the eye-lid is often
complicated with a defect in the eye-ball itself; but when
this is not the case, an operation will be ad\ iseable.
§ 0. UMHLLICYL HERMA.
Sometimes the umbilicus is peculiarly large, and hernia
takes place soon after birth, but still more frequently^ be-
twixt the second and fourth month. Two modes of treat-
ment may be adopted. The first is compression, carefully
maintained, which should be always tried. This, in some in-
stances, produces a radical cure; the umbilical opening con-
tracting, which it never does in adults. The second mode is,
reducing the intestine, and tying the sac with a single or
double ligature. 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 ofthe cord. Tliis may be complicated
with an imperfect or transparent state of part ofthe abdom-
inal parietes ; but whether it be or not, the child generally
dies within forty-eight hours. The abdomen is too small to
receive back the intestine quickly; and even although it
could be reduced, the child, if we may judge from experi-
ence, has no great probability of existing. In one case, Mr.
Hey found the tumour burst during labour. Other species
of hernia arc to be treated on general principles. By the
137
use of a bandage made with an easy spring, children, when
they are some months old, may have hernia cured.
§ 1. SPINA BIFIDA.
Spina bifida is an imperfection of the vertebral canal and
Ihc 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 in-
ferior part of the body. This is a fatal disease, and death is
generally preceded by inflammation or gangrene of the tu-
mour. In some instances, the sac is open at the time of
birth.
The object, in this case, is to preserve the tumour entire
as long as possible, for the child dies soon after it bursts.
Astringent lotions are commonly employed. Ointments, conr
taining preparations of lead, are also used.(g)
(g) The very ingenious Astley Cooper, in some observations published in
the Medico Chirurgical Transactions, Vol. II. has recommended two modes
©f 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 plaister 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 plaister 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 openirig
from the spine, and stop the disease altogether. This is done by puncturing
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, &G. is
VOL. II. S
138
§ 5. MARK*.
Marks and blemishes are very frequent, and may be
-placed on any part of the body. They arc of two kinds:
First, simple discoloured patches, generally of a red colour,
and not elevated. These are not dangerous, but rarely ad-
mit of cure. Second, elevated discoloured marks, which are
of a purple hue, and very vascular. These are apt to increase,
and at last bursting, a fatal hemorrhage may take place.
They may be seated on the face, or in the lip, eye-lid, &c.
or on the spine, resembling spina bifida, but are more solid
or spongy, and the bone is not deficient. These ought to
be extirpated, as soon as they begin in the smallest degree
to increase. Small marks have occasionally been removed
by raising the skin with a blister, and then applying mild
escharotics.*
then to be applied, and the operation of puncturing is to be repeated as of-
ten as the fluid re-collects.
The first mode Mr. Cooper observes, is attended with no risk. The truss
forms an artificial vertebra, when the natural is defective, a buttress which
supports the part, and prevents the increase ofthe 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
the apprehension, of the future return of the disease. It may also be ob-
served, that this mode does not prevent the subsequent attempt at the palli-
ative treatment, if the radical should not be successful. 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.
438. & seq.
* These congenite deformities have hitherto been considered as incura-
ble. This is true with regard to many cases; but there are others which
may undoubtedly be relieved. They seem to consist, as has been very in-
geniously suggested by Mr. J. Bell, in an aneurismal enlargement of the
vessels of the part. Adopting this suggestion, the celebrated Mr. Aber-
nethy has deduced a very plausible mode of treating these affections. There
can be no doubt, he says, " that the repletion, distension, and consequent
enlargement of the dilated vessels, depend upon a kind of inflammatory ac-
tion of the surrounding arteries ; for if that be wanting, the mark ceases
to enlarge, and if present, it increases in size in proportion to the degree
139
§ 6. SWELLING OF THE SCALr.
Children may, especially after tedious labour, be born
with a circumscribed swelling on the head. This seems to
contain 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.
By applying cloths dipped in brandy, the effused fluid is
soon absorbed.
•f 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 Hospit-
al, says Mr. Abernethy, with this unnatural enlargement of vessels, distri-
buted every where, beneath the fore-arm, from the wrist to the elbow ; m
a short time it had swollen to that degree, that the circumference of the af-
fected fore-arra was twice the size ofthe otter, the vessels being large and
contorted.
The skin was of a dusky hue, and had not its natural smoothness ot sur-
face. The heat of this fore-arm was much greater than that ofthe correspond-
ing sound one. Pressure forced the blood out ofthe vessels, and temporarily
diminished the bulk of the limb, and made it of a paler colour. The effect of
the following treatment, which it appeared to Mr. Abernethy, right to in-
stitute, was tried. First, He was desirous of ascertaining whether a per-
manent and equable pressure would not prevent the distention, and conse-
quent enlargement of the turgid vessels ; secondly, whether reducing the
temperature of the limb would not diminish the inflammatory action, upon
which their repletion seemed to depend. These two intentions admitted of
being readily accomplished. A many-tailed bandage of sticking plaster
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 tempera-
ture. The success of these measures exceeded the most sanguine expecta-
tions. The size of the limb gradually diminished, and its temperature be-
came natural. After six months, the bandages were removed, which it was
not necessary to continue any longer. The limb was in some degree wast-
ed 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
IK)
§ 7. DISTORTION OF THE FI.I.T.
Distortions of the feet are not uncommon. They are cal-
led vari, when the foot is turned inwards ; valgi, when out-
wards. These and similar deviations arc to be cured by
pressure, applied with proper bandages adapted to the na-
ture of the case. They must operate constantly, but gradu-
ally, and ought to be applied as earlyr as possible.
§ 8. TONGUE-TIED.
When the frenum linguse is too short, or attached far for-
ward, the child can neither suck well, nor speak distinctly.
It is very rare in its occurrence. I have not seen two chil-
dren where it was really necessary to perform any operation ;
for in all the rest, the child sucked the finger,(/i) or a good
nipple very readily. The operation consists in dividing to a
upper eye-lid, so as to keep it permanently closed. The clustered vessels al-
so 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 evi-
dently impossible ; but the abstraction of heat, and consequent diminution
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 medical
treatment was discontinued, and no appearance of this unnatural structure
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 ofthe Head, and on
Miscellaneous Subjects. [Art. on the treatment of one species of Nsevi Ma-
terni.] page 140, Dobson's Edition.
(h) This is a good test; for, if upon the insertion of the finger iato the
child's mouth it sucks it readily, division ofthe frsnum cannot be necessary.
141
sufficient extent the frenum, with a pair of blunt pointed
seissars. If the artery be imprudently cut, the hemorrhage
is to be checked by compression or cautery.
§ 9. MALEQRMED 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
consisting 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 mOreorless difficult, and he is subject to attacks
of asthma, or a kind of suffocating cough, like that in perip-
neumonia, or hooping cough; and whenever this attacks an
infant, I augur very ill. I have no remedy to propose. Com-
parative ease may be obtained, by keeping the child as qui-
et as possible, avoiding a loaded stomach, or costive state of
the bowels. For an account of the different kinds of malfor-
mation, I refer to my brother's Work on Diseases of the
Heart.
§ 10. SWELLING OF THE BREASTS, HYDROCELE, &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 in-
flammation come on from rude treatment, saturnine lotions
must be employed.
Hydrocele generally goes off, by applying compresses dipt
in solution of muriate of ammonia. A puncture is rarely ne-
cessary. Phymosis requires astringent lotions. Discharges
of bloody or serous fluid from the vagina or urethra, are ea-
sily cured by ablution. Prolapsus aniisto be cured, by keep-
ing the bowels open, using the cold bath, and returning the
143
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 he
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 arc
scalded or burned, it is of the utmost importance to prevent
a mark, and nothing does so more effectually than the instant
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
matter which might fret it.
If vesications have formed, they arc 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.(i)
In more extensive and severe burns, oil of turpentine alone,
or mixed with unguentum resinosum, forms the best dress-
ing for some time, and then the sore is to be covered with
powdered chalk, which is to be continued till it heals. It re-
(i) A very mild and useful application in burns, particularly in those of
children, is a liniment composed of equal parts of mild olive oil and lime
water, well mixed together byagitation; 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 the feather.
143
presses fungus, and forms an artificial scab. In all cases,
pain is to be allayed by opiates, and the bowels arc to be
kept open.
Ear-ache is a very frequent and painful disease of child-
ren. It is discovered, if the child be old enough, by his com-
plaining of his car; but if he is too young to do this, it may
be suspected, by his being seized writh a sudden and severe
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. No-
thing 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 discharge suc-
ceed this disease, and the child is deaf, the ear is to be daily
washed out with milk and water byr means of a syringe.
Small blisters may be applied behind the ear, and the consti-
tution is to be invigorated. The bowels in particular are to
be kept regular. Many children have occasional discharges
of matter from their ears, upon catching cold, without much
pain, and at that time, they are deaf. But by keeping the
ear warm, and by scrupulous attention to cleanliness, the
discharge stops, and the hearing returns.
§ 11. FCETID SECRETION FROM THE NOSE.
The mucous secretion of the nostril is sometimes exceed-
ingly foetid, so that it is disagreeble to come near the child.
The mucus dries, and comes away in thin pieces. Astrin-
gent injections, stimulating liniments, and a variety of local
applications, as well as internal remedies, such as tonics,
mercury, &c. have been tried. These have not always how-
ever, a good effect. At the age of puberty, the foe tor some-
times spontaneously ceases.
Fcetid discharge from the «ars 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
in
very obstinate. Great attention is to be paid to cleanliness,
and to the state of the constitution.
§ 12. OPHTHALMY.
Infants are subject to inflammation of the eye, which is
most frequently of the kind called purulent ophthalmy. This
begins with redness of the eye-lids, which soon swell so
much as to prevent their being opened. Then a copious and
constant discharge of thick yellow matter takes place. This
is found also spread over the eye. If the disease continue,
ulceration of the eye, or a speck on the cornea, is produced,
or the eye itself may burst. In bad cases, the eye-lids arc
also turned out, especially when the child cries. Both eyes
are generally affected. This disease is cured sooner by as-
tringent applications, than by other treatment. A solution of
sulphate 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 arrne-
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 dram ofthe solution is to be added to an
ounce of water. When the eye-lids are turned out, he advi-
ses a poultice to be applied, made with equal parts of curd,
formed by adding alum to milk, and lard or aider ointment.
The bowels are to be kept open.(/e)
§ 13. SPOXGOID DISEASE OF THE EYE.
Children are subject to spongoid disease ofthe 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-
•
(£) 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.
145
eept 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 tu-
mid, and the countenance sallow, and sometimes swelled.
When the scrofulous constitution is not strongly marked,
the person may pass through life without any inconvenience.
But when it exists in force, different parts of the body are
apt, without any evident cause, to have their action derange
ed; their structure is changed, and then inflammation Slow-
ly takes place. The glands are most frequently affected, but
the joints or viscera may also sutler. 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, wre advise whatever can strengthen the
system, 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 exer-
cise in the open air, great attention to cleanliness, an open
state of the bowels, and good nourishing diet, with a small
proportion 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 inter-
vals, pledgits dipped in a solution of cerussa acetata. 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,
VOL. II. T
146
cicuta, bark, and great variety of medicines, have been ad-
vised, 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 arc to be managed chiefly
by issues.
§ 13. RICKETS.
The disease called rickets is characterised 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
shape, and the breast protrudes. The bones of the pelvis
approach 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 arc impaired,
the bowels are bound, or foetid stools are passed. The
pulse is weak and frequent. The teeth arc late of appear-
ing, and are not good. The mind is often prematurely ad-
vanced. This disease may prove fatal, by ending in water
in the head, convulsions, or hectic fever; but it often is cured
sponstaneously, or with assistance. It usually attacks be-
twixt 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, general friction over the body, chalybeate medicines,
and warm clothing.
147
CHAP. III.
Of Dentition.
The formation of the teeth is begun long before the foe-
tus leaves the uterus. It is carried on slowly, and is not
completed for several months after birth. The parts con-
cerned in this process, are the jaw, the gum, and the soft ru-
diments of the tooth itself. The jaw, at first, has only a
channel running along its surface ,• but this afterwards is
divided by transverse 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 vascular, and assumes nearly the size and
shape which the body of the tooth is to have when ossifica-
tion has commenced. The tooth consists of two parts, bony
matter, and cortex striatus, or chrystallized enamel, covering
the bone. The 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 the birth the shell is
considerably advanced. Soon after the process begins, the
inner surface of the sac deposits a soft earthy substance,
which crystallizes and forms enamel. When ossification is
advanced so far as to form the shell of the body ofthe tooth,
the lower part becomes 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 protrudes in two divisions. As ossification ad-
vances on the root, the body rises in the socket, and the sac
rises with it; but in proportion as the enamel is crystallized,
148
the sac becomes less vascular and thinner, and at last is ab-
sorbed; 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 ab-
sorbed, 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 arc shed, to
give place to others more durable and more numerous, as
the jaws are longer in the adult. The permanent teeth be-
gin 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 lodg-
ed 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 arc 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.
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 low-
er jaw, and next those ofthe 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 be-
low the gums, At this time, the two first permanent grind.
149
ers appear at the back part of the jaw, and the middle in-
cisors ofthe lower jaw loosen and drop out; and byr degrees,
all the milk teeth give place to others which are larger, strong-
er, and better adapted to the increased size of the jaws. In
this curious process, which strongly displays the wisdom of
God, we arc early taught the perishable nature of our frame.
But it is also a pleasing reflection, that dissolution is suc-
ceeded by a state of greater perfection.
Many children cut their teeth with great ease and regu-
larity, but some suffer considerably. It is usual for the child
to have some irritation of the mouth during dentition. The
gums are hot and itchyr, 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 se-
cretion of saliva 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 advances 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 grind-
ers and cuspidati are 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 dentition; we have three indications to attend
to. First, to allay local irritation. Second, to alleviate ur-
gent or symptomatic complaints. Third, to support the
strength.
Theirs* is accomplished most effectually, by dividing the
gum with a lancet, completely down to the teeth, if it be
considerably advanced. Even when it is not so far advanced,
as to be near the surface, the division ofthe gum gives tem-
porary relief. Gum-sticks act something in the same fugaci-
ous manner; by enabling the child to press, or rub the gum
a little, he obtains a short relief. All children instinctively,
thrust their fingers into the mouth, and this may be permit-
1J0
ted; nor is there any riskof abad habit being induced. This
is as useful as the gifm-stickr 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.
Second, We allay general irritation, or fret-fulness, 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 exhibi-
tion 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 he 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 detrimen-
tal, is to be abated by those means, which will hereafter be
pointed out; and especially, if itbe 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 bow els
into a better state. The greatest number of children who
die during dentition, perish in consequence of obstinate or
neglected diarrhoea. Sickness, loathing at food, and ill smell-
cd breath, require a gentle emetic. Spasmodic and convul-
sive 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 gene-
ral rule must be laid down, namely, to treat them as we would
do in any other circumstance, with the additional practice of
cutting the gum. Delicate and slender children suffer chief-
ly from bowel complaints, and spasmodic affections; stout or
plethoric children, are more apt to suffer from acute fever,
with determination to the head.
151
i
Third, We support the strength directly by the breast
milk, arrow root, beef tea, or, if necessary, by clysters of veal
soup, or calves feet jelly; and indirectly by restraining im-
moderate evacuations. If the child have been recently wean-
ed, it is often of service to apply him again to the breast.
CHAP. IV.
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 characterising the
eruptions which I describe, by whatever name they may be
called, and also to point out the mode of treatment common-
ly employed.
§ 1. strophulus intertixctus.
The first eruption which I shall mention, is well known
under the name of red gum, and is described very accurate-
ly by Dr. Willan, as his first variety of strophulus, a papu-
lous eruption. The strophulus intertinctus, or red gum, con-
sists of a number of acuminated elevations of the cuticle, of
a vivid red colour, not in general confluent, and sometime^
even pretty distant from each other. The papula are sur
rounded with a red base. This redness is often the most
evident part of the eruption in very young infants, and the
disease much resembles measles. It covers a great part of
the trunk, and keeps almost entirely off the face. In the cen-
tre of the spot, we may observe a very minute elevation or
papula, with a clear top. There is no fever, nor Juis the child
152
catarrhal symptoms. The eruption comes out irregularly,
and is either more durable, more fugacious, or more partial,
than the measles. On the feet, the papula are still more dis-
tinct. The papula 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 un-
der the cuticle at the apex, giving it a glistening appear-
ance ; but they seldom discharge any fluid, and scarcely ever
form pus. This eruption appears generally on the face and
superior extremities, but sometimes it spreads universally
over the body. On the back part of the hand, the papula oc-
casionally contain 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 inconveni-
ence. It seems to be connected v, ith the state of the stomach
and bowels ; and any uneasiness the child may suffer during
the continuance of the eruption, or previous to its appear-
ance, seems referable to this source. The particular connec-
tion existing betwixt the chylopoetic viscera, and the sur-
face, I do not pretend here to explain or investigate. I hold
the fact to be established, and from no circumstances more
decidedly than these, viz. that in adults, certain kinds of
food 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 fol-
lowed by cuticular eruptions, whilst the sudden disappear-
ance of the eruption, on the other hand, is succeeded general-
ly 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, f The affection at present under consideration re-
* Sometimes a few spots of this kind may be observed on the forehead
of children at the time of birth.
f Or. 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 diposed to adopt his opinion.—See also
Turner on Diseases of the Skin, p. 69
153
quires no particular remedies. It is sufficient to avoid the
application of cold, which might suddenly repel the eruption ;
and filth, or other irritation, which might increase it, or su-
perinduce another affection. Should the stomach or bowels
be affected, or the child be oppressed, a very gentle laxa-
tive 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 gentle laxative, will be
proper.
§ 2, STROPHULUS ALBinUS.
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 con-
tained in the papula, 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 erup-
tion on the neck, which is exposed to the sun in warm wea-
ther. It has sometimes been mistaken for the itch.
§ 3. STROPHULUS COXFiiRTUS.
The strophulus confertus is a very frequent affection dur-
ing dentition, but seldom appears before that period, though
it may continue after it. It consists of papula, often sot ex-
tremely close together, forming patches, varying from the
size of a sixpence to a dollar. Such, at least, is the appear-
ance on the face and arms, to which part it is often confined,
especially to the former. But it sometimes appears on the
trunk, and there the papula are larger, flatter, and surround-
ed with more inflTutimation, than those on the face or arms,
vou. it. v
154
looking at a distance like measles. This eruption not only
varies a little, according as it appears on the trunk or ex-
tremities, but also according to the age of the child. For af-
ter the seventh mouth, wc find, especially on the arms, the
papula 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
papula may on some parts be distinct from each other,
whilst elsewhere they form clusters so close, that the red-
ness surrounding 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 papula. This eruption is sometimes preceded by sick-
ness, and, in certain circumstances, 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 confounded ; and not unfrcquently, 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 the mea-
sles ; but as Dr. Willan remarks, it often does terminate
with a slight exfoliation of the cuticle. A variety of this dis-
ease appears like red patches in 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 to-
ward the centre. By near examination, several small papu-
la 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 denomina-
ted by Dr. Willan, strophulus volaticus, and is said not to be
very common, but I think it is frequently met with. It i§
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,
155
and the use of the bark; but neither, I believe, are in gen
cral necessary.
§ 't. STROPHULUS CANMnUS.
Strophulus candidus consists of papula having a smooth
shining surface, wdiich appears of a paler colour than the
rest of the skin, and the base is not surrounded by any in-
flammation. It is described by Dr. Underwood as resembling
itch, but it is neither red nor itchy. It generally either at-
tends dentition, or succeeds some acute disease of children,
ana is justly considered as a very favourable symptom. II
is most frequently met with on the trunk of the body, the
arms, or forehead. In a few days the papula 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 bis elaborate work, to a
papulous eruption, chiefly affecting adults. It may, however,
appear also in children; and I have seen it succeed some of
their febrile diseases, as, for instance, measles. It consists of
numerous distinct papula, some of which are pale at the top,
but vcuy slightly red at the base; these are generally small
like pin heads. Others are larger and flatter, and more in-
flamed, but have always at first a clear apex, and do not end
in ulceration, but die away in slight scurf. Sometimes on the
body, there are small shining or silvery looking patches, from *
exfoliation ofthe cuticle; or the skin may peel off more ex-
tensively, as if it had been blistered. They resemble often
the papula in strophulus, but seldom form in clusters, and
have not, in general, any diffused redness connecting one
papula to another. There is, however, sometimes about the
joints or fore-arm, a considerable degree of red efflorescence,
covered with scurf. This eruption may be produced by ex-
posure to heat, and by drinking cold water when heated, or
154)
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 erup-
tion itself may last for more than a fortnight, but in a few
cases it goes off in a day or two. These papula, 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 docs it ulcerate; it is not very itchy, and if scratch-
ed 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 oppres-
sed, an emetic and saline mixture may be given. When there
is no febrile affection, it will be sufficient to keep the sur-
face clean by means ofthe tepid bath.
§ (5. 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 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 arc 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 dis-
ease changes, and the cellular substance inflames; either of
these terminations may take place, and will require the
Usual treatment.
157
§ 7. CRISTA 1ACTEA.
Urusta lactea, or milk blotch, is a scabby eruption, which
appears generally first on the cheeks or forehead, and then
extends over a considerable part of the face, and even the
scalp. This disease belongs to the achorcs, or pustules con-
taining 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 confluent, so as to form a considerable patch.* A suc-
cession of pustules may appear on the same place. They are
not in general 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 plethoric, this eruption is frequently met with on
the face, while the body is covered with papula, like prurigo
or small achores. Inflamed pustules first form on the face, con-
taining 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 particular smell, like that of a cat, Lory de-
scribes a variety of this disease, under the name of ignis
sylvestris or volaticus; and says it goes off in blisters or thin
crusts, without any inconvenience, except a degree of itch-
ing. 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
ofthe neck swell, the eruption goes off, and when they sub-
side the eruption returns. This is a disorder which is often
met with when the child is on the breast. It has been attri-
buted to the richness of the milk, and generally goes off after
• " Incipit a vesiculis numerosis cohaerentibus, oleoso succo turgidis."
Plenk 71.
lj«
one or two teeth have made their appearance*. It L- not at-
tended with any danger, scarcely with inconvenience, and
never leaves any mark or scar behind it. But having been
sometimes, at an early stage, mistaken for syphilitic blotches,
it has caused much unnecessary alarm. With respect to tin
treatment, very little is necessary, except keeping the bow-
els open, or giving purges occasionally; and if the child be
plethoric, making the diet more sparing. In general, strong
local applications are improper; but if any particular partis
very sore, a little 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 al-
so 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 recom-
mends Harrowgate 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, ex-
tends hoc in tinea remediis via- locus est, quae illam exsiccant,
cum damno admoventur.
§ 8. ANOMALOUS ERUPTIONS, &C.
During dentition, or in consequence of affections of tin
bowels, different anomalous eruptions may appear, which
arc not distinctly referable to any well defined species. Sonic-
times we find upon the arm, one, two, or three inflamed por-
tions of the skin, something like small pox, but rather lar-
ger, 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 ; it goes off
in a few days without any medicine.
* Some have considered this as scrofulous disease. Vide Stoll Prelec-
tiones.—Frank de Morb. Curand, &,c.
159
In general, it should be a rule in the treatment of erup-
tions, to wash the surface, once a-day at least, with tepid
water and keep the bowels open. In obstinate eases, prepa-
rations of sulphur, antimony, calomel, and arsenic, have
hcen employed ; but the last is too dangerous to be admit-
ted into practice. Sometimes the juice of the sium aquatic urn,
in considerable doses, or the decoction of the woods, will be
of service ; and in indolent eruptions, the tincture of cantha-
rides has been beneficial. As external applications, lemon
juice, the decoction of hellebore, or of stavesacre, infusion of
tobacco, 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 appli-
cation of cloths wet with butter milk, are employed, some-
times with benefit. Sea-bathing is frequently of service and
a bath of w arm 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 pom-
pholyx, consists of a number of vesications of different sizes,
appearing 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-
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 x
sometimes with aphtha, is more serious, and is called pem-
phigus infantilis. The vesicles, at first small, soon become
* Diluted hepatised ammonia, but especially solutions ofthe sulphuret-of
'irae or pot-ash, may be employed for this pnrposr.
160
pretty large and oval, and their contents become turgid.
They appear soon sifter birth, generally in emaciated infants,
affect botli the trunk and extremities, arc 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 ;i
week; and only those children arc saved, who were previ-
ously 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, pret-
ty 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
tincture of cantharides.
§ 10. MILIARY ERUPTION.
Sennertus describes, under tSie name of sudamina, an
eruption like millet seed, fretting the skin, and affecting
children about the neck, arms, &e. Plcnk defines it in the
following terms. Sunt ves'tcula grants milii magnitudine etfor-
m& similis, subito absquefebre erumpentes. The child should be
bathed occasionally 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 dcscrib- ".*
ed 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-ach and pain in
the baek. The tongue is of a dark red colour at the edges,
161
with the papilla 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 prick -
iug 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 pus-
tules like millet seeds. These are of a red colour, but con-
tain at the top a white lymph, and are cither diffused over
the body, or collected in patches on different parts, especial-
ly the back and breast; they may alternately appear and
disappear, and though the same pustule does not continue
long, it may be speedily replaced. They may sometimes be
combined with small red efflorescences, and generally ves-
icles 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 pur-
gative. 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-
fering in colour very little from the surrounding integuments,
When they do become red, it is in consequence of friction.
* If the, top be rubbed off, a clear lymph oozes out, which forms
a thin seab, 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 frequently
with tepid water and a little soap, or lemon juice : but if we*
•glcctcd, it requires the application of sulphur.
VOL, TI. x
163
A variety of this disease consists of minute red acumina-
ted papula, with a very small vesicle at the top, terminating
not in suppuration, but yielding, when scratched, only a lit-
tle clear serum. Sulphureous preparations give relief, and
time, with attention to cleanliness, confirms the cure. Some-
times very little itching attends this eruption, and it disap-
pears 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,
•• qua? vix furfur aliquodostendat." The itch first appears be-
twixt 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
is often the case on the back ofthe hand, and forepart ofthe
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 ab-
lution, and rubbing the parts affected with sulphur-vivum
ointmentf, which, in obstinate cases, may be rendered more
* Children, in consequence of handling mangy dogs or kittens, are some-
times aifected with an obstinate itchy eruption, which is not scabies, but may
be cured by the remedies used for the itch.
t Dr. Joseph Clarke considers it as dangerous to use sulphur ointment
with infants, lest the eruption be suddenly repelled; and advises rather to
bdil a pie.ee of stick brimstone in water, in order to make a bath.
163
effectual by the addition of powdered hellebore, or sal-am-
moniac. Rosenstcin says, that the hands are very soon clear-
ed, by wrashing them with a strong decoction of juniper ber-
ries ; 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 af-
terwards.
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 serositc.
" ct dont la cieatricc 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
Harrowgate 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.
hellebore, or corrosive sublimate, mixed with hog's lard, &c.
These often fail, and even when they do remove the eruption,
the cure is said frequently not to be permanent. Itch mayr
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.
§ 13. HERPES.
Herpes has been divided into different species. It has
been described under a variety of names, and sometimes con-
founded with lichen, or its different appearances described
under the name of impetigo. Strictly speaking, the eruption
in herpes is vesicular, the base surrounded with erysipe-
latous 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
• 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.
161 .
pustules than vesicles, and others which have neither vesi-
cle nor pustule, have been admitted as species of herpes.
Plcnk 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 consists of efflorescent patches of vari-
ous sizes, covered with scurf or small scales. The patches
appear like flat red and slightly elevated portions of the
skin, having a distant resemblance to the blanes of the small-
pox about the twentieth day of the eruption, but darker in
colour, and very soon covered with scurf, through the inter-
stices 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 arc 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 ofthe surface, but especially on the extremities
and face ; sometimes on the trunk, and about the arms. They
frequently occur on the scalp, which becomes bald at the part,
and the baldness increases, as the red circle extends. Within
the circle the skin is whitish and a little scurfy. They are
also to be met with on the soles of the feet. When the scurf
falls off, the skin below, as Pinel observes, is generally sound,
but continues discoloured for a length of time; and often
the scurf is renewed, or new patches come out in other
places. Sometimes, however, the parts become excori-
ated, and even fissures may take place, or the cuticular
lines become more distinct, without excoriation. In conse-
quence of excoriation, or from scratching, a fluid exudes,
which forms rough irregular scabs of a yellowish colour,
spattered over a pretty extensive portion of red skin, which
165
is dry, but not smooth. Sometimes in the vicinity of this, wc
may observe a thick cluster, apparently of white papula,
giving the skin a dirty white rough appearance. These, how-
ever, are vesicles, containing 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 distin-
guish this disease from syphilis. In some instances, especi-
ally in spring and summer, 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 lit-
tle scurf, and continue for some time after the scurf falls off.
This is sometimes combined with intertrigo and strophulus.
Another form, met with frequently in adults, but seldom in
children, is an universal affection of the extremities, arid
sometimes of the trunk also ; the skin being covered with
small scales, or scurfs, which arc found in considerable quan-
tity in the bed in the morning.
2d. Herpes miliaris*, or wild-fire, which, when it appears
on the lips, has been called exanthema or herpes labialis.
This consists of minute pimples, or vesicles like millet
seeds, which arc confluent, appearing in clusters, or some-
times like rings. They contain a lymph of a glutinous na-
ture, 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 fallsf off, it is apt to be renew-
ed, or still more frequently the disorder spreads in a kind
of circling direction. These rings or clusters may become
• 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 the 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 found useful. Sometimes heat, or other causes, produce a different kind
of eruption, already described under the name of lichen.
f If the scab be forcibly picked off, the part below is found raw and glos-
sy, without apparent granulation.
Hit)
very numerous, and sometimes invade pretty quickly; *o
that Lory is disposed to rank this among acute diseases. The
parts arc very generally vory itchy. This disease is not al-
ways confined to the surface, butinay also attack the throat,
In this case, the local symptoms are preceded by fever for a
day or two, and then vesicles appear on the fauces, which
are soon- followed by a herpetic eruption about the mouth,
and inside ofthe lips. The internal affection ends in slight
ulceration, the external in the formation of scabs, and the
complaint is removed in about a week. If not known, it is mis-
taken for a more malignant disease. Dr. Willan has de-
scribed this under the name of angina hcrpetica.
Another species of herpes appears on different parts of
tho body, but especially on the face. It consists of a pretty
large portion of inflamed skin, covered with different broad
thin .scales, which, when removed, are soon replaced. This
is described as being a variety of ignis sacer. It is not
so common with children, as in women, and it is very obsti-
nate.
3d. The phagedenic herpes, or herpes exedens, differs
from the former species, in ulcerating and destroying the
skin, sometimes spreading along the surface, sometimes pe-
netrating deep. It generally begins with small painful pus-
tules, or phlyctana, 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.
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*.
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,
• Frank recommends the tobacco cerate, for which he gives the following
receipt: R. succi nicotianx, cent flavee, a giii; resinse pini, ^iss; terebinth,
gas,; ol. myrrh*, q. S. fiat ceratum. De Morb. Cur. Tom. IV. p. 154.—With
children this must be used cautiously.
16.7
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, follow-
ed by gentle doses of calomel, w ill 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 re-
quired and stimulating or astringent local applications, such
as ointment of red nitrated mercury, lime-water containing
muriate of mercury, 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 applications. Calomel is useful.
The spreading herpetic ulcer generally requires strong
stimulants, such as caustic, butter of antimony, camphorat-
ed spirit of wine, resinous ointment, ol terebinthina, &e.
If, however, the ulceration be very superficial, an ointment,
containing white calx of lead, or calx of zinc, is often of
service ; and sometimes the spreading may be stopped by-
cauterizing a narrow rim of skin round the ulcer. The in-
ternal use of nitrous acid may likewise, in. this kind of her-
pes, 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 am
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.
168
§ 13. 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 arc
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 generally begin like papula, of small size, and vesi-
cular at the top. These end sometimes in scurf, oftener in
thin scales as has been described. On the back of the hand,
the vesicles 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
eruption often begins on the face or neck, and spreads to
the body and extremities. It is very obstinate, and some-
times 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 excori-
ated, and covered partly with scales and scurf, and partly
with scabs, which arc 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
i69
been seized with this disease soon after the small-pox or
chicken-pox. The appearance oh the head is nearly the
same as in pityriasis, 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 ofthe skin taking place soon after
birth, I have been consulted respecting children given out
to nurse, who were apprehended to have syphilis. Dr. Wil-
lan remarks the syphilitic appearance of this disease, but
justly observes, that all other marks are absent. The sy-
philitic form of this disease is attended with hoarseness, and
the patches are of a livid colour, with a slighter degree of
scaliness, 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
cleanliness is favourable to its production. The application
of preparations of sulphur, and ointment of nitrated mer-
cury, with the use of the tepid bath, especially made with
sea-water, daily, will often cure this disease; but in obsti-
nate cases, we must give some sudorific, such as antimo-
nials, or decoction of sarsaparilla, alone or with calomel* or
have recourse to the Harrowgate or Moffat waters, which
have great efficacy. They should be used both externally
and internally. Solutions of soap, or of alkali, or of sul-
phuret of potash, form very useful baths. Decoctions of
hellebore, or solution of muriate of ammonia or of oxy-mu-
riate of mercury are also proper as external applications.
The application of cloths wet with butter-milk, or a poul-
tice 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 disease, which consists of broad vesicles about the size of
a split pea, circular in general, but with a shelving jagged
vol. ir. t
170
margin. These arc surrounded with diffused redness, and
contain purulent looking matter. Sometimes the top is dark
coloured, as if it were filled with bloody lymph, and the mar-
gins arc of a livid red colour. Some are of an irregular shape;
and the contained fluid being very small, the general appear-
ance of the whole blotch, is livid. These vesicles are very
numerous, 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 er puckered, as if drawn to-
ward the scab. This disease is attended with itchiness, and, if
much scratched, the parts may be fretted and ulcerate. It
is occasionally attended with a rough-scaly appearance of
the palm ofthe hand. Sulphureous preparations arc 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 forehead,
the skin is covered with thick white scurf, which can be re-
moved 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 washing it
with soap and water. If neglected, ulcers may form, and the
disease be converted into the one next to be described.
§ i 8. 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 accom-
171
4
panied with an eruption on the face, and other parts of the
body, which has been taken for the itch; and indeed this dis-
ease has been called the 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 resembling, in minia-
ture, the scabs on the head. On the body there will be found
many small pustules or pimples, with a red base and lym-
phatic top; and these also appear on the face, which is sel-
dom 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 face, especially on the chin, similar to those on
the head. Many rank the crusta lactea with porrigo, and
consider both as scrofulous. It differs from the pityriasis or
dry scab, in being pustular and humid. In order to cure this
disease, it is useful to remove the hair. This has been pro-
posed to be done, by pulling it out, by means of a pitch plas-
ter; 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 apply 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 dis-
ease be more extensive and obstinate, some depillatory* may
be employed; but this is rarely required. For this purpose, a
combination of the ung. pica, 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 bladder is to be put over the scalp, to prevent the cap
from sticking. After three or four applications, the scabs,
and even the hairs, are loosened, and these are to be remo-
ved by degrees; after this new hair wiU grow, without any
scab at the bulb or root.
* Quick-lime is sometimes employed for this purpose, and enters into the
composition of many of the oriental depillatories.
17^
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 wash-
ed with a weak solution of oxy-muriate of mercury, or muri-
ate 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. pica, and ung. hyd,
nit. are employed with advantage. Sulphur ointment with
the addition of a little white precipitate of mercury, or the
weak mercurial ointment have been likewise found of ser-
vice. In some obstinate cases, caustic, or cantharides oint-
ment, 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, decoction 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 sulphureous
lotion; or anoint the parts with camphorated liniment, ung.
acid, nitr-ung. hyd. nit. or sulphur ointment, and use the
tepid bath occasionally. Sea-bathing is of great benefit.
§ 19. SCABS FROM VERMLJf.
The bloody scabs which are formed on different parts of
the head, especially in the hollow near the neck, in conse-
quence of vermin, are cured by combing and washing the
hair daily? and rubbing some mercurial preparation on the
• Dr. Underwood recommends the decoction of tobacco.or lotio sap onacea;
Dr. Frank, urine; and Mr. Barlow, the following lotion; R. kali, sulph. 3'iii;
sap. alb. 3iss; aq. calcis, gviiss; spt. vini, 3U. M.—Dr. Heberden recom-
mends the decoction of white hellebore.
173
scabs; whilst an ointment, composed of oil of bays and staves-
acre, should be rubbed over the scalp among the hair, or the
powder of staves-acre 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 sub-
stance, which suppurate very slowly. The first are properly
called pustules, and they are of different sizes. They gene-
rally are attended with a considerable degree of inflamma-
tion, and end in suppuration. The small abscess bursts, and
a little scab forms, after which the inflammation dies away.
Such a pustule has been called ecthyma, or sometimes ter-
minthus. It requires in general little treatment, except the
application of some soft ointment when the situation per-
mits it. But if the pustules be numerous, as is often the case,
after small-pox and other acute diseases, it will be ne-
cessary to use bark and the cold bath, especially sea-bath-
ing ; and the most painful and largest pustules may be hast-
ened on by a poultice. The bowels are to be kept open.
The second are a kind of tuberdes, 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 dress-
ing, and sometimes the application of precipitate accelerates
) 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
V accine 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 di-
rections for the proper mode of using the scab, or crust, by Dr. Samuel
Fowel Griffitts, Eclectic Repertory, Vol. 1. p. 362. Dr. G. has used with
success, a scab, which he had possessed for eleven months. As it appears to
be a matter of importance to the young practitioner to understand this sub-
ject well, we shall take the liberty of subjoining from the paper above al-
luded to, the most essential circumstances to be observed in the use of the
scab in vaccinating.
" The most perfect vesicles which go on \a 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 lighter colour, should be removed with a knife, and a
portion of the remaining dark, hard internal part is to be shaved off, redu-
ced 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 Oh the scratch-
ed part. No more ofthe scab mutt 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?'
vol. ir> % c
203
must be present in order to operate, have not yet been de-
termined with certainty.
Even where none of these causes exist, and when the ve-
sicle runs its course ..with distinctness, it does, though very
seldom, happen, that the constitution is not rendered unsus-
ceptible of the variolous action. It were much to be wished,
that some test could be discovered, by whieli the security
could be determined. The constitution is often manifestly
disordered during some part of the vaccine progress, and
such children are most probably secure ; but sometimes the
disorder is too slight to be discovered, and therefore this
sign is not to be relied on. We arc also assured, than even
when no constitutional disorder has taken place, the child is
secured. Other means, then, have been resorted to, in or-
der to discover if the system be affected, so as to have a
eompletc change induced by the inoculation. These arc
two in number : 1st, If a second inoculation be performed-
on the fifth or sixth day after the first, a vesiele 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 per-
formed any time after the twelfth day after the first inocu-
lation, some degree of inflammation will be induced; but if
the system have been affected, 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 constitu-
tional affection;.but sometimes, even, although the constitutiof
have been changed by the vaccine inoculation, a slight fe-
brile affection may be excited, either without any secondary
pustules, or attended by an efflorescence on the skin, of
an eruption of small hard pustules, which disappear in
about three days. It unfortunately happens* however, that
parents in general do not think it necessary to adopt any of
these means ; and inoculators, perhaps, trust too much to
their own power of discrimination, in determining how far
a vesicle is capable of producing the desired effect. Some
test is tlue more requisite as vaccination, is often performed
203
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
tubcrculated, and do not suppurate, but end in desq«amation.
I nave, however, seen a very distinct case of suppurating
^mall-pox, in a girl who, some years before, had gone through
the vaccine process in the most satisfactory manner ; of which
1 am certain, having attended her on both occasions. I d»
not, from these remarks, mean to depreciate the cow-pox;
on the contrary, it is only by ascertaining the precise power
of vaccination, that its full benefit can be derived toman-
kind : and although the warmest friends of this discovery
tnust admit, that it is not always successful, yet it has hither-
to 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 inoculation with a mixture of vario-
lous 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 tiie 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
(/») Numerons cases have of late years been undeniably adduced, of the va-
riolous virus producing its full effects twice in the same system, bo 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 ofthe Medical Society of London, Vol. IV.
The patient's face was severely pitted with the first attack, and he died near-
ly 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 se«.
204.
each other, both diseases will be communicated to the patient,
twhether the incisions be near or remote, and small-pox pus-
tules will be produced on the body; but they seldom maturate,
and the disease is generally mild. When, however, the va-
riolous inoculation is performed more than a week, as, for
instance, nine days before vaccination, 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 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 lac-
tea, herpes, &c. but it does not thence follow, that these are
the consequence of inoculation; and it is not unworthy of re-
mark, that no new cutaneous disease has been produced by
the introduction of the cow-pox.()
(7) 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 vaccina-
ted by the society for promoting vaccination, must be peculiarly interesting
and conclusive in respect to the benefits of this invaluable discovery. By
the Reports ofthe Board of Health, it appears, that there have died of in-
205
§ 33. CHICKEN-POX.
The chicken-pox is a disease, sometimes mistaken for
amall-pox; and at one 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 vom-
iting. 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
tremors when asleep, accompanied with terrifying dreams, or
he is slightly delirious. The eruptive fever does not always
go off when the eruption appeal's, but may continue even till
the third day of the eruption. In general, however, the
symptoms are mild, and sometimes exceedingly trifling. The
eruption commences on the back, or breastj 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 extremi-
ties. The pustules very soon contain Jymph, and by the
fifth day are covered with scabs or crusts, which is earlier
than happens in the variola. These drop off sooner than in
small-pox, and very seldom leave any cicatrix. The erup-
tion is attended with very considerable itching, in consequence
oculated 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
1810 955 I vaccinated by the Physicians
1811 1277 I of the Society for promoting
1812 1255 | vaccination in the city and
---- | neighbourhood of Philadel-
Total 4589J phia.
206
of which tbe pustules are soon broken. The pustules aro
seldom or never confluent, and Dr. Heberden never could
count more than twelve upon the face, but wc 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 arc full
of scrum at the top ; and those which are fullest of the yel-
low liquor, resemble sm<|l-pox pustules of the fifth or sixth
day. On the third or fourth day, the shrivelled and wrink-
led state of the vesicles which remain entire, give a different
appearance from the variola ; and on the fifth day, the pre-
sence of scab assist 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, 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, which have very properly been sepa-
rately described by Dr. Willan, whose distinctions I shall
retain. 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 which, a minute
vesicle is soon formed. These on the second day, resemble
miliary vesicles, are about the tenth part of an inch in diam-
eter, 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 which arc
not, have shrunk, and are puckered at the 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
circumference toward the centre $ and on the ninth or tenth
day, drop off, leaving red marks without pitting. 2d, The
conoidal. The vesicles rise suddenly, and have a hard inflam-
ed border. On the first day, they are accuminated, and con-
tain a bright transparent lymph. Next day, they are more
207
turgid, the lymph is straw-coloured, and they are surrounded
with more extensive inflammation. On the third day, the ve-
sicles have shrivelled, have inflammation round them ; if
entire, contain purulent matter, if they have burst, they arc
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 comes out on the second or third day, and runs
the same course with the first ; so that the eruptive stage in-
this species is six days, and the last fonmed scabs are not
separated till the eleventh or twelfth day. 3d, The swine or
bleb pox. The vesicles arc 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
shrivel, and appear yellowish, tbe fluid being mixed with a
little pus. Before the end of the fourth day, they are cover-
ed 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 loose, 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. I have, especially in scrofu-
lous children, observed, that if the bowels were neglected by
the parents, and the diet was full and heavy, the pustules
become much inflamed, and ended in sloughs, which left
large and permanent cicatrices ;■ and in some cases, boils and
abscesses have occured 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,
• Dr. Willan notices ave different species of this disease ; but for the pre -
rcnt purpose, fhis simple division is sunicietr
308
on the third day of which, but sometimes earlier, an itchy
eruption appears, bearing a xcrv 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 margins,
which are sometimes hard and well defined. The size and
shape of the patches arc 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 turgesccncc ofthe skin, but especially ofthe face and
eye-lids. The patches do not remain constantly out, but ap-
pear 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 feve.rishness, go off. The disease
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 dis-
dressis produced. The febrile urticaria is not infectious, bin
in certain seasons it is very prevalent; and the same holds
true with regard to the chronic species. Chronic urticaria
is more rare in infancy. It differs from the former, chiefly
in being destitute of fever, and vexing the patient at inter-
vals 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 troublesome 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 urticaria, 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 itcli|ug. When unattended
209
with fever, the eruption fades in the mornirig, and becomes
round and elevaterl at night. The use of acids, and sea-bath-
ing will be of service.
X gentle emetic, followed by one or twro purges, gives
relief 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 temperature.
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 treat-
ed 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 tried with very little good effect.
§ 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 j
one variety being attended with slouglror ulceration ofthe
throat; another, still milder, with little or no affection ofthe
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, at-
tended with considerable debility, chilliness, nausea, and pain
in tbe belly and about the loins and extremities. It general-
ly attacks very suddenly in the afternoon or evening, the pa-
tient 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 so-
norous ; the eye sunk, and the eye-lids turgid and red on the
inside. On the next day, if not earlier, an eruption appears,
first on the face and neck, and very .goon, always within
VOL. II. 2d
210
twenty-four hours, il is diffused over the whole body. It
consists of numerous minute specks, so closelv set together,
that the skin appears altogether of a red colour, 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 appear-
ance. The eruption is most vivid at night, and especially on
the evening of the third or fourlh day. On the fifth day it
declines, and is wholly gone by the seventh, when desqua-
mation takes place. During the eruptive stage, the patient
is generally either restless, or wry drowsy, often slightly
delirious, and both during this stage, and the process of des-
quamation, complains much of itchiness. Whilst the fever
lasts, the skin is extremely hot. The contagion, in general,
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
a,s 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 ofthe
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
colour, and its papillae are evidently elongated. In the pro-
gress of the disease, it is often covered with a fur. The ton-
311
sils arc early observed to be of a deep red colour, and very
soon, whitish streaks may be discovered. Superficial ulcera-
tion 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 for-
mer. 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, hcad-ach, and delirium. The heat
is excessive, the pulse feeble, and sometimes fluttering, al-
ways very rapid. The languor and inquietude are great,
especially when the sloughs are forming. About a week or
leu days after the eruption fades, anasarcous swelling of the
legs may take place, and continue even for two or three
weeks. Sometimes other parts ofthe 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 ftetid se-
rous fluid. This often abates, upon syringing the ear 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 tho 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 al-
212
so oe 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
very great, the patient fainting on making the smallest exer-
tion, and very generally he is unable to sit up in bed. In the
scarlatina benigna, the tongue is red, the eyes and eje-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 co-
vered, 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 co-
lour, with brown or blackish sloughs; there is a foetid breath,
with acrid discharge from the nostrils. The inside of the
labia pudendi of girls, and of the prepuce of boys, has in scar-
latina the same colour with the inside of the cheeks and lips;
in the scarlatina maligna, the vulva and lips, arc 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 tbe 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
sometimes proves fatal in a few hours. It is not, however,
always alike mortal, for there are several smaller degrees of
malignity, forming a gradation betwixt this and the scarla-
tina anginosa.
The first species, when properly managed, is not very dan-
gerous, but the last is attended with great hazard. The prog-
nosis must be made, by attending to the symptoms of debi-
lity, the progress of the affection of the throat, the tendency
to inflammation of the trachea, and the general character of
the epidemic.
Drs. Withering, Adams, and Willan, believe, that the scar-
latina does not attack the same person twice, though the
throat may be to a certain degree repeatedly affected. Al-
though I have had many opportunities of attending to this
disease, I cannot form a decided opinion on this important
218
point; but I am rather 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 are 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 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 v ery seldom necessary, often hurtful, and may almost uni-
formly be superseded by other means. Emetics, given early,
are often attended with advantage, and render the subsequent
disease milder. But laxatives are still more useful, and in
mild cases are the only medicines which are required. In
some epidemics, the bowels are moved with greater difficulty
than in others, and in those cases the laxative must be strong-
er. Even when there is a tendency to diarrhoea, if the stooU
be foetid and unnatural in their appearance, purgatives are
equally necessary as in the opposite state. The best medi-
cine to be given at first, is calomel in a brisk dose, which of-
ten, 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 suc-
ceed 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 better
than repeated small doses of calomel, which often affeet the
mouth considerably. But if the stools be very foetid, the pa-
tient 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.
Froin careful observation, and repeated trials I can with con-
fidence recommend this remedy, which by no means prevents
51*
the exhibition of purgatives at the same time. It is of con-
sequence 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 when
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 appli-
cation is sometimes sufficient, but it often is necessary the
first day to use it three times, and next day once in the morn-
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. 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 pe-
riod, 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 useful,
when they can be employed. Water, acidulated pretty sharp-
ly 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 ofthe 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
• 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 |ss of ung. hyd. When-
ever the salivary glands become affected, the disease, he says, takes a turn.
215
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 his 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 oftcner if possible. An
infusion of capsicum in vinegar is also employed with advan-
tage ; so much of it is to be added to a given quantity of
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 capsicum. Myrrh has also been given, combined 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 produces better effects than water acidulated with sul-
phuric acid, which, if tbe 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 tbe 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
^16
large, or the child breathes with difficult v, or has a croupy
cough, a gentle emetic of ipecacuanha sometimes does good
and ought to be tried. It is to be foil,', ed, if the child be a
year old, hy two grains of calomel every hour, till stools are
procured. If less than a year, one grain may be given at ;.
time. Blisters have also been applied to the throat, hut 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 mortification of the part
Sometimes, in the course of this disease, apoplexy succeeded
by hemiplegia, and inability to articulate distinctive takes
place. Bhsters should he applied to the head, and if the
patient survive, the paralytic symptoms go o-ff in a few
weeks.
When a disease of this kind appears in a family, the chil-
dren who are unaffected, ought if possible, to be sent away,
and should not return for a month. In the mean timu, the
cloaths should be washed, and the apartment well ventilat-
ed, and fumigated with the vapour of oxygenated muriatic
acid. This fumigation may be employed, even during the
disease, for the destruction of tho contagion, and of the
smelling matter in the room.
§ 06. MKASLES.
Measles commence with a distinct eruptive fever; on the
first and second days of which, the patient complains of ir-
regular 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 are 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,
217
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. It is first visible on the
forehead, then on the 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 papulae, but
without vesicular tops. Then the spots extend so far as to
form an oval or irregular figure, slightly (Jevated, but flat,
resembling a flea bite. Very soon large patches appear, in
termixed 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 con-
sists almost equally of patches and circular and irregular
^pots, 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 eruption, though of
the usual configuration, is pale and indistinct; but in gene-
ral, whether vivid or not, when the finger is passed over the
surface, the skin feels unequal, Jrom the elevation of the
spots and patches. The colour is most vivid after the erup-
tion has been out for a day. Sometimes the eruption sud-
denly and prematurely recedes, or never comes fully out.
Both of these cases are unfavourable, tlue 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
* Sometimes, instead of this, the eruption becomes very dark coloured, or
purple, with increase of the languor and fever. Mineral acids in this state
'vor. II. '> E
^1S
to the ninth day, the eruption is going off, and then the for-
mer situation of the rash is only marked by a slight disco-
louration. The departure of the efflorescence is attended
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 nc.\i
day have a scattered or streaked appearance. The inflam
mation ofthe eyes, sneezing, and hoarseness, generally de-
cline with the eruption, and towards the end, epistaxis
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 diarrhoa often terminates
the fever, and then the appetite returns pretty keenly.
Sometimes, especially if the disease have been severe, the
measles are followed either by an eruption of inflamed pus-
tules* over the body, which may ulcerate, and prove trouble-
some, but more frequently they fade, or by a vesicular hcr-
petic-looking eruption about the mouth, or sometimes by
gangrenous affections of the lips or vulvaf, or by enlarge-
ment ofthe glands ofthe neck, or dropsy or a cough, some-
what resembling that in hooping-cough, or by hectic fever,
continuing for many weeks.
Rubeola, in general, is not a fatal disease, when stimu-
lants are avoided. When it proves fatal, it is most frequent-
ly in consequence of the pulmonic affection, sometimes of
coma, or fever and oppression, with symptoms of effusion in
are useful, and most children recover. The danger is greater when petechia
appear among the patches, for this marks great debility.
• These are sometimes taken for a kind of small-pox. They are occa-
sionally succeeded by a scabby disease of the skin. The skin is inflamed
and covered with rough loose yellow scabs.
f The measles, three years ago, were more prevalent than any practitioner
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 instances of the
gangrenous affection I have mentioned. The children all belonged to the
poor, and lived in confined houses.
219
the brain, connected with recession, or imperfect appear-
ance of the eruption.
The treatment is extremely simple, and may be briefly
explained. During the eruptive fever, the use of mild dia-
phoretics, and the tepid bath, will be of advantage. The
bowels should be kept open, but the child should not be pur-
ged after the first day. If there be a considerable diarrhuea
from extraneous causes, as dentition, or directly connected
with the fever, it is often found that the eruption is late of
appearing, and a late eruption is generally attended with
some troublesome symptoms. A little rhubarb, given early,
often moderates this.
If the eruption do not come freely out, or recede pre-
maturely, 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 laudanum,
and the child should be put in a warm bath, having a little
mustard diffused in it; afterwards 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 cos-
tive, a gentle purgative should be given, for the bowels may
be either too torpid or too irritable.
I have not advised the liberal use of purgative medi-
cines, 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 afterward, if necessary,
the purging is to be moderated by anodyne clysters. So far
as I have observed, the continuance of the diarrhoea, in this
case, does not mitigate the symptoms; and if the child re-
cover, it is either by the use of medicines bringing the bow-
els into a better action, or it is independent of the mere eva-
cuation produced by the diarrhoea.
If the pneumonic symptoms he considerable, marked by
eough, oppressed breathing, flushed checks, and pain in the
220
chest, which, 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 child
be robust, or the symptoms urgent, either one or two leeches
may be applied at the top of the sternum, and moderate
doses of calomel given to keep the bowels open. If the
cough be frequent, without inflammatory symptoms, opiates
give great relief; and if there be no diarrhoea, the acetum
scillffi may likewise be given. Diarrhoea should not he
cheeked, unless severe, and it increase debility, or produce
other hurtful effects. Anodyne clysters arc the best reirie-
dies.
Coma or drowsiness very frequently attend the measles,
and the chijd may perhaps scarcely look up for some days.
When the nostrils are stutt'ed with mucus, the breathing, in
this case, has an alarming appearance of stertor. Most chil-
dren 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
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 ofthe
•During the epidemic three year* ago, ©pthalmia was extremely preva-
fent amongst both young and ©to.
22 i
nature of measles, is not easily determined, but certainly
the external resemblance is very great, in so much that thin
eruption has been called rubeola sine catarrho. It requires
no particular treatment, and is only noticed because it is
sometimes taken for measles, but does not prevent the pa-
tient from a second attack.*
§ 37. ROSEOLA.
Sometimes an eruption, termed by Dr. Willan roseola,! is
taken for measles. The first species, roseola aestiva, has no
small resemblance to rubeola. It is often preceded by chil-
ncss, alternating with flushes of heat, languor, faintness, rest-
lessness, occasionally with delirium or convulsions. At some
period, betwixt the third and seventh day from the com-
mencement of these symptoms, the rash appears, generally
first on the face and neck, and afterwards in a day or two
over all the body. The patches are larger and more irregu-
lar than those of the measles,^: in which the eruption con-
sists of spots like flea bites, and patches made up of these
spots, arranged sometimes in a crcscentic form, and of a
• Of all the eruptive diseases the measles are undoubtedly the most in-
flammatory. They therefore require to be treated by depletion. Bleeding,
even pretty copiously, can rarely be dispensed with. I speak now of the
disease at it appears in this country. To this remedy may also be added
occasionally purging with the neutral salts, and the antimonial preparations
with a view not less of diminishing arterial action than overcoming the stric-
ture 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 distress-
ing effects which too often follow the disease, such as diarrhoea, cough. &c. C
f This he defines to be a rose coloured rash, without scales or papulx, va-
riously figured, and not contagious. By some former writers,' this term is
applied to a disease resembling nettle-rash. Vide Lory, p. 398.—The ap-
pearance of roseola aestiva is extremely well expressed by Dr. Willan in his
plate.
\ Sometimes young infants have an efflorescence of numerous coalescing
patches, of a strong red colour, rounded, and of the size of a sixpence.
These terminate in desquamation in less than a week.
222
colour seldom 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 Tir.
Willan gives its name. The fauces arc 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 arc observable, which
next day disappear, and together with these the internal dis-
order. 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 tbe 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 ofthe 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, faintness, &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 has a great resem-
blance to urticaria, whilst on the arm, the appearance is de-
cidedly like roseola. This disease appears to be, in a certain
form, infectious. For, in particular seasons, I have observed
it to be unusually prevalent, and to affect all the children of
a family. In such cases, the eruption has lasted from two to
four days, and has been attended with very little fever. Tbe
only treatment which is necessary, is giving gentle laxatives,
the use of acids, and light diet. If the eruption be suddenly
repelled, the warm-bath is proper. Should there be a marked
determination 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 tbe
size of a shilling ; they are not elevated, but are of a very
283
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,
arc 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
disordered state of the bowels. It consists of a red efflores-
cence, 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 treat-
ment is necessary, except what is required on account of
concomitant circumstances. It is sometimes preceded or at-
tended by vomiting or convulsions, with pale face and lan-
guor. In such cases a gentle emetic, the warm-bath, arid
cordials are proper.
CHAP. V.
Of Hydrocephalus*
Hydrocephalus is one ofthe most dangerous and insirii
ous 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
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 bel-
ly, the beadbeiug often unaffected. After the febrile symp-
221
toms have continued for some time, marks of oppressed brain-
appear, and the patient dies comatose, or convulsed*. Such
is the outline of the disease, which, however, it will be neccs-
sary to describe a little more minutely. A''cry often the pa-
tient, for some time previous to the attack, is languid, pee
vish, and uncomfortable, without any particular complaint.
The appetite is impaired, he has frequent sick fits, or vomits
bile, and the bowels are generally very costive, though some-
times he purges foetid, dark coloured, or green fseees, and he
complains 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 sud-
denly, or with scarcely any previous indisposition. The pa
tient feels chilly, whilst the skin is hot; he, comphuns great-
ly 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 exa-
mined, 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 su-
pervene.- The hcad-ach 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 af-
fected, and for some days he vomits bile, and whatever he
swallows ; has no appetite, and little thirst; the tongue is
white, the bowels generally 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, grinds his teeth, and picks his nose,
which makes the disease sometimes pass-for the consequence
of worms. The pulse, in a few cases, is not very frequent;
but 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 be*
225
comes slow, beating only 60 in the minute, and being gene-
rally irregular. The pupil is more dilated, and the eye less
sensible than formerly to light. The head-ach is usually
diminished, but the patient frequently cries out, or even
screams. In some cases, delirium comes on; in others, the
patient continues sensible and intelligent, until the stupor
supervene. More food is often taken, in this stage, than for-
merly. 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, how-
ever, the symptoms of oppressed brain become greater, the
pulse is weak, and gradually increases to 160 in the minute.
The eye squints, vision is at last lost, the urine is either re-
tained, or passed with the faces involuntarily. The breath-
ing becomes stertorous, and the patient dies. In the eourse of
this malady, the cheeks are alternately flushed and palid; 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 com-
mencement. 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-
terised 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 debili-
ty 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 young-
er, it often terminates more speedily, sometimes so early as
the fourth or fifth day.*
• 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
VOL. II. % F
226
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 tlic adult, or many
of the febrile diseases of children, and that upon these super-
vene those of oppressed brain. In some cases, however, wa-
ter has been found in the ventricles when no symptoms indi-
cated it during life*, or when many of the usual symptoms
were absentf.
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 confess-
ed, is very difficult; for in disorders of the bowels, from
dentition and other causes, spasms, starting, drowsiness, and
strabismus, may take place.}: It is perhaps prudent, when-
ever there is much fever, with any ambiguous symptoms, to
violent symptoms to subside so as to induce a very sanguine expectation
of a speedy recovery. This is 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 dis-
ease returns with redoubled force. Under such circumstances, it is per-
haps 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.
• Vide Quin's Treatise, p. 43.
f Dr. Hush mentions cases where there was no pain in the head, or
where it began like a catarrh, or wanted the strabismus, dilated pupil,
sickness, and loss of appetite. Med. Inq. Vol. II. p. 210.
i A very interesting case, where strong symptoms of hydrocephalus were
produced by accumulation of f 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 considerable
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 stimulant
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.f
* If there be the appearance of much determination of blood to the
head, we should instantly bleed the child. We cannot, under such circum-
stances, wait for the slow depletion by leeches. Convulsions in children, if
not produced, are often kept up, undoubtedly, by fulness of the vessels of
the brain. C.
f After the bowels have been well evacuated by an active purge, which
ought not to be neglected in any case of convulsions, anodyne injections will
be very useful. They often act like a charm in quieting that peculiar irrita-
bility of the nervous system in children, which renders them so prone to
these affections. If the laudanum should fail, which it will sometimes do,
we may try injections ofthe watery solution of asafoetida, and particularly
of the strong infusion of the common hops. In those terrible cases of epilepsy
where paroxysm follows paroxysm in rapid succession, I have witnessed very
beneficial effects from injections of cold water. They will sometimes imme-
diately suspend the paroxysms. Ice, or other very cold applications to the
region of the stomach are also serviceable. Does not analogy warrant our
employing these remedies in the obstinate convulsions of children ? Placing
the child in a current of cold air will be found, I am confident, to relieve the
convulsions soener than the warm bath. C.
237
Trismus nasccntium is not a very frequent complaint in
this country, but 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
connected with a costive state of the bowels, by others with
the falling 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 convuls-
ed. When the fit goes off, the patient becomes nearly quite
well. These do not indicate that the patient shall be sub-
ject, after puberty, to epilepsy. They are relieved by at-
tending to the state of the gums, removing decayed teeth,
and cutting the gum over the grinder which is coming out,
but especially by keeping the bowels open. 01. succini, val-
erian, 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. of Philadel-
phia. Vol. I. p. 227.
23*
chap. vn.
Of Chorea.
The convulsions called chorea sancti viti, attack children
most frequently from the age of eight years to that of puber-
ty. This disease makes its approach with languor, and dis-
like to the entertainments of the age ; a variable and some-
times very keen appetite, in general continued costivcness,
attended usually with a hardness and swelling of the abdo-
men, especially at the lower part, though occasionally the
belly is flabby, and rather small, instead of tumid. Some-
times the bowels are open, but the stools arc not of natural
appearance. Presently convulsive twitches and motions of
the muscles ofthe face take place, and are succeeded by more
marked convulsive affections ofthe muscles of the extremities
and trunk, so that the patient cannot sit still, nor carry a cup
of tea safely to tbe 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. Tbe patient is sensi-
ble during the convulsive motion. At a more advanced peri-
od, the countenance becomes vacant, the eyes dull, the speech
is affected, and, in some cases, the patient cannot even swal-
low witliout difficulty. Emadation takes place, and a febrile
®tate 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*,
Sydenham, and Hamilton. These, if given early, and before
• " Having described the nerves, I now come to the symptoms, which are
** easily explained by their connection. I will begin with tremor of the feet,
•« which is common in hysterical cases. But I ought in the first place to men-
•« tion, that the dreadful hysterical symptoms, which we daily see either in
«• individual parts, or in the whole body, are altogether dependent upon the
239
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 ofthe 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 ofthe
•« former, till the movement and expulsion of the accumula-
" ted matter are effected, when symptoms of returning health
" appear." Calomel and jalap arc 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
experience 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 twTo 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 tbe purging plan for several weeks, and generally we
succeed at last. Tonic medicines are useful adjuvants. The
food should be light and nourishing, and due exercise taken
in the open air.*
" accumulation of acrid matter in the primae vise ; for the intolerable fectbr,
14 the scantiness and unnatural appearance of the faeces always warn us of an
" approaching paroxysm of rigors and convulsions.
•« Ought not purgative medicines, and even the most drastic ones, to be ex-
"hibited? they probably might cure spurious epilepsy, chorea sancti vfti,
" and other spasmodic diseases, hitherto generally deemed hopeless by tae-
" dical men." Camper on tbe Pelvis, Chapter iii. section 7.
* I can bear testimony to the decisive and superior efficacy of active and
continued putting in chorea*. Two cases ofthe 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 weekly
by admhrstering every two days, a powerful purge. C
•^10
chap. vin.
Of Croup.
The croup is divided by some writers into two species,
the inflammatory and spasmodic; but there is perhaps no cast
of croup in which spasm is not to a certain degree combined,
only in some cases the inflammatory symptoms are more pro-
minent 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 infancy.
we discover them by thirst, restlessness, starting, hot 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 sudden,
the previous indisposition being short and scarcely observa-
ble. The local disease manifests itself by a difficulty of breath-
ing, attended with a wheezing noise ; the voice is shrill, the
cough is of a very particular sound, somewhat resembling
the barking of a little dog ; others describe it as 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 watery 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 agitation ; for this disease has
exacerbations, during which the heavy sonorous breathing is
exchanged for a violent struggle, in which the child makes a
crowing noise, and if old enough, starts up, and clings instant-
ly to the nearest object, and stares most pjteously. If this
disease be more mild, tbe face in the remission is soraetim-s
pale, otherwise it is flushed, 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 sud-
341
denly fatal, the face and lips become tumid in the progress
of the disease. Convulsions 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
respect, 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 which 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 tho
breathing is least sonorous, the fever most moderate, the
cough early attended with expectoration, and the symptoms
seem at times to become so slight as to constitute intermission,
Dissection has always discovered, on tbe inside of the
larynx, a lymphatic incrustation, or layer of membranous
looking substance, which is sometimes coughed up in consi-
derable portions.* This, though it adds greatly to the dan-
ger 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.| 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,
• 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 impacted
mucus, but never any thing which resembled, in the least, a membranous
erganization. That the membrane of inflammation, however, occasionally
exists in the trachea I cannot doubt, as it has been mentioned by very credi-
ble writers. C.
f Croup sometimes occurs even among people of advanced age. Cases
sf this kind have been repeatedly noticed by different practitioners in rhi#,
country. C.
VO*. If. 2 H
2*2
has of itself cured the complaint. In such cases, however,
it has generally been pushed far. and been succeeded by
great debility, for children do not bear much evacuation of
blood*. In the commencement of the disease, detracting
blood, especially if followed up by an emetic, will usually be
* 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 mischiev-
ous. 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 exci ability
of their systems, render children peculiarly liable to inflammatory affections.
Nearly all their diseases partake in some degree of this character. It fol-
lows, therefore, that they require oftener to be bled. My own experience,
confirmed by that of other practitioners, has perfectly satisfied me, that
blood-letting may be used with as much safety, and decidedly 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 undoubtedly recover
muchsooner from its effects. The prejudice against bleeding inchildren 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 impres-
sion. As a natural consequence of this opinion, the general practice in their
complaints is extremely feeble, exactly, indeed, of that kind which has been
facetiously described as observing a strict neutrality between the patient and
the disease, neither declaring for the one nor the other. By no narrow or
partial observation, I am thoroughly pursuaded, that the very contrary of
this opinion is true. Children, I have remarked, display an uncommon te-
nacity of life, and strength of constitution. They often survive under circum-
stances 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 mote certainly recover not only from
contagious diseases, but from all others, if properly treated. They also sus-
tain belter the operation ofthe most active remedies, namely, of vomiting,
purging, sweating, and blistering; and, I may repeat, bleeding. Tht&e
superior vital energies give, moreover, to children very extraordinary recupe-
rative powers.
Children recover confessedly, more speedily from wounds, and injuries,
and surgical operations. They likewise recruit mpre 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.
2+3
found of great service ; but it ought not to be trusted to alone,
neither should it be employed late in the course of the dis-
ease, nor even at an early period ought, it to be repeated, if
the symptoms do not speedily seem to yield to it; neither is
it generally proper in any stage, if the infant be very young.
If possible, the blood should betaken by opening a vein ; but
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. 1 have sometimes ob-
served great benefit from them, if employed very early ; and
would advise them to be given in every instance. Even in
the advanced stage ofthe disease, emetics do much service,
appearing mechanically to remove the lymphatic membrane.
Decoction of seneka, and preparation 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 be
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 diild. 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 eases no alleviation was obtained by any remedy but
the calomel j 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, some-
times even four grains are given every hour, until then^g
bowels are acted on, and the child purges freely or voinits ve-
%
244
peatedly. The stools arc generally green in colour, and their
discharge is usually accompanied with an alleviation of the
symptoms. When this is observed, the dose must be repeated
less frequently, perhaps only once in two hours for sometime,
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 nourish-
ment and cordials. It is astonishing how great a quantity of
calomel is sometimes taken in a short time, without affecting
the bowels, or purging violently afterwards. Occasionally
above 100, and often 50 or 60 grains, are given in this dis-
ease. 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
children freely in their diseases, from its subsequent debilitat-
ing 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, (amount-
ing now to above forty) it has completely succeeded, both in
curing 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
Btop the calomel, whenever the symptoms begin to yield.
The alleviation in true croup follows the discharge of dark
(r) This assersion may be considered as generally correct, but notwith-
standing, instances have occurred of salivation being produced in children by
mercury; and when this is unfortunately the case, it isapt to be attended with
the most unpleasant symptoms, sometimes threatening gangrene, and requi-
ring 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
pf this ciiy, to whom the practice of physic is indebted for some of its most
valuable contributions. C
245
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 blis-
ter 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 exclu-
sively employed, 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 great quantity of calomel was giyen and re-
lief obtained, it was necessary to open the bowels by clysters.
Calomel has been combined with ipecacuanha to produce vo-
miting, 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 continue
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 occasionally for
many years afterwards. It makes its attack very suddenly,
generally at night, and sometimes for many nights in succes-
sion, 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 bark-
ing 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 it
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
246
during the paroxysm. The disease is often suddenly relieved
by sneezing, vomiting, or eructation. It differs, then, from
the inflammatory croup, in the suddenness of its attack, in
there being little fever, but only quickness of pulse, greatly
abating when the child docs not struggle for breath; no
drowsiness, and little phlegm about the mouth. The cough
is less shrill, and the fit often goes off suddenly and com-
pletely, cither spontaneously, or by the use ofthe remedies
acting quickly. Sometimes, however, inflammation takes
place, and this disease is, in infants, very readily converted
into true croup.
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 ; I>m: oftencr the spasm comes on without any
jut cursory symptoms. Sometimes it is excited by dentition,
or, if the patient be older, by passions ofthe mind. Not un-
frequently, a renewal ofthe 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
result of my observation. In young girls, venesection has
uniformly 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 re-
medy 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,
returns, and in such cases has yielded to venesection. Occa-
sionally the emetic has been very long of operating, the sto-
mach 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
attack, sometimes checked it, but have not always that ef-
fect, and, if not given soon, are longer of procuring relief.
With regard to the effect of calomel in croup affecting girls
847
and women, I can say nothing; for the paroxysm is so se-vert-,
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 asafietida or va-
lerian, will be useful; and when the attacks have been kept
off for some timo, 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 tlie eme-
tic do not decidedly mitigate the disease, then, in place of trust-
ing solely to the calomel, we premise if possible, venesection.
Asafoetida* has becu strongly recommended in this disease,
and has sometimes a very good effect. The warm hath is
also useful. If the child benbout the period of dentition, the
gum should be examined, and cut if tumid. If the disease
do not soon yield to these remedies, there is ground to sup-
pose that it will be converted into the other species of croup:
but this affects the prognosis rather than the treatment.j
• Dr. Millar has given an ounce of this gum to a child of eighteen months olJ
in forty-eight hours, and almost as much at the same time in form of clyster
His formula is as follows: R. G. asafoetida, Jii, Spt. mindereri, gi, Aq. puleg.
§iii Ms. A table-spoonful of this is to be given every half hour. Vide Obser-
vations on Asthma, p. 43.
t 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 1 commonly employ the tartarizedantimony, givenat short intervals.
as being one ofthe 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 min-
utes. This is a useful remedy. It rarely fails to promote the operation ofthe
emetic, and will, indeed, alone sometimes cure the disease. If, however, the
emetic does not operate, or if after its operation, the anticipated effect be
not realized, I then bleed copiously-, and repeat the bath and the emetic
The attack must be extremely obstinate if it do not now yield. Neverthe-
less, it will occasionally continue with little or no abatement. Under these
circumstances, I resort to topical bleeding either by leeches, or by cups, and
afterwards, if necessary, apply a blister, or sinapis of mustard to the throat,
248
Some children are subject to slight wheezing, continuing
for a day or two, with intermissions, and accompanied with
a hoarse 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 wind pipe, 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 al-
so useful. The gum should be cut.
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, 1 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 near.
ly 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 difficult 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 spee-
dily and most actively purge. In this particular stage of the disease, a tho.
rough 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 expectoration remain, I employ the de-
coction of the polygala senega as an expectorant- 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 tartar I have recently heard that
croup has been very successfully treated by a watery solution of corosive sub-
limate, by large quantities of melted lard or olive oil given internally, and by
common mustard in the state in which it is used at our tables. Ofthe latter,
a tea-spoonful is given to a child, to be repeated if required. Its operation in
spasmodic croup especially, is represented to be mest decisively useful. I have
not tried, nor am I disposed to try any one of these remedies. They each come
to me, however, recommended by very respectable authority. With the re-
medies already known to me I rest satisfied. These in my practice havo
rendered croup the most curable of all the violent infantile diseases C.
£49
CHAP. IX.
Of Hooping-Cough.
The hooping-cough often begins like a common cold, the
child coughing frequently, and having more or less fever. 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 gene-
rally comes on very abruptly, and is sometimes early attended
with that sonorous spasmodic inspiration, denominated hoop-
ping, in other eases, not for .a considerable time, and this is
considered as a favourable circumstance, but it is not always
so, for in young children, death may take place, although the
disease never fully forms. The fits are generally most fre-
quent, 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 produce a feel-
ing of suffocation, relieved at last for an instant by a violent,
full, and crowing inspiration * then in general the cough or
spasmodic expirations recommence, and the paroxysm, con-
sisting 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 fre-
quently repeated as in violent laughing. Sometimes the
sound is lower, or the cough resembles the chattering of a
monkey, quickly repeated. These paroxysms vary in fre-
quency and duration. Sometimes they are slight,* at other
times, and especially during the night, they are attended with
a most painful sensation, and appearance of suffocation, the
face becoming turgid and purple, the sweat breaking out, and
blood gushing from the nose or other parts. The extremi-
ties become cold during the fit, and the whole frame is much
agitated. But even severe as the paroxysms are, if the dis-
ease be not attended with fever, the patient seems quite well
.ifter the fit, and begins to eat with a renewed appetite. A
vol.. II. 2i
250
fit of crying will at times, even after the disease has been
apparently removed, excite the 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, the
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 be-
come oedematous. 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 wc apprehend that some vessel may burst in the lungs
from the violence ofthe cough, or when there arc symptoms
of inflammation. Leeches may in these circumstances be ap-
plied to the chest. The most generally useful remedies arc
laxatives and the saline julap, which often in a few days mo-,
derate the fever greatly. The tepid bath is useful, and, if
there be much irritation and restlessness, hyoscyamus some-
times does good.
For the relief of the cough, nothing is so beneficial as eme-
tics, 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,
op the thorax and the stomach, have a good effect; and
251
similar applications to the soles ofthe feet have certainly in
some cases done much good. Antispasmodics, such as asafoe-
tida, ol. succini, musk, &c. have been recommended, and in
some cases are successful. Opiates arc also of service. Dr.
Willan says, that he found the watery infusion of opium
more useful than any other narcotic. When the disease is
protracted, cicuta has been recommended, but it does not
seem to have any advantage over opium, or hyoscyanvis. It
has also been applied externally. The.most effectual reme-
dy, however, is change of air, which often has a marked ef-
fect on the disease in a few hours. When the patient be-
comes restless, and coughs more, it should again be chang-
ed. The diet ought to be light. If there be fixed pain in
the chest, difficulty of breathing, and fever indicating inflam-
mation, cither venesection or leeches, according to the age
and circumstances ofthe child will be necessary; but our eva-
cuation must be prudently conducted. Blisters, and digitalis
in &uch cases arc useful. Pain produced merely by the vio-
lence ofthe cough, remitting or going at times entirely off,
and generally seated about the upper part ofthe 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 ofthe compound pow-
der 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 bow-
els 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 thfc
cough. They are very alarming, and may suddenly carry
©ft' the infant, especially if it be very young. The child
should instantly be put into the warm bath, which is to be
repeated as often as the convulsions come on. Tho bowels
252
should be opened, the head shaved and blistered. If the fits
be repeated, and if the child be plethoric, leeches ought to
be applied to the temples. The air ought also to be, if possi-
ble, immediately changed. In some cases, tincture of hyos-
cyamus given in a mixture, or clysters containing camphor,
seem to allay 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 gen-
tle emetic is the best remedy.* A sudden change of wea-
ther 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 ofthe disease, bark
an! 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
• 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 pal-
liative remedies is a watery solution of asafoetida. Where the cough is at-
tended, as is sometimes the case, with convulsions, the sulphate of zinc may
be given with advantage. A combination of the salt of tartar and cochi-
neal, 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 3j.
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
253
prolonged, 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-
tions are fewer, and do not follow each other so quickly, and
the inspiration is not performed so quickly, 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.
Infants are subject, as in after life, to catarrh, either
common or epidemic. It is attended with fever and inquie-
tude, redness ofthe cheeks, watery discharge from the eyes
and nostrils, disposition to sleep, frequent, and sometimes ir-
regular pulse, panting and shortness of breathing, with fre-
quent 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.*
CHAP. XL
Of Bronchitis, Inflammation of the Pleura and of the Stomach.
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
• 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
251:
and pretty copious secretion of mucus or phlegm, which,
however, the child will not allow to conic out ofthe 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 tlie wind-pipe. The breathing is oppress-
ed or sonorous, but not permanently so. Vomiting is also
not an uncommon attendant, and the stools are generally
green and offensive : The child takes the breast pretty freely,
but dislikes all meat. Presently tbe secretion becomes more
of a purulent appearance. The respiration is more oppress-
ed, and the noisy breathing is more frequent. The hands,
but especially the feet, swell a little, whilst the body becomes
emaciated. The cheeks are occasionally flushed in the even-
ing, and the pulse, which was always frequent, becomes still
more so, and irregular. 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 tho
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. At different
stages, and under various circumstances, I have tried emet-
ics, 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, toge-
ther with a removal to the country, appear to constitute the
best practice.
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, by 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
255
cold, the cough stifling, with rattling in the throat and stu-
por; or the pulse becomes irregular and intermittent, the ex-
tremities swell, the countenance is sallow or dark coloured,
the breathing difficult, with short cough, and frothy expec-
toration, which oozes from the mouth. On inspecting the
chest, the inflammation is sometimes found to have termina-
ted 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 purulent
spitting, with hectic ; hut much more frequently, the pulmo-
nary consumption of infants and children begins, as in adults,
more slowly, is marked by a short dry cough, flushings of
the face, frequent small pulse, difficult breathing, wasting,
and nocturnal sweats.(s) The expectoration is generally swral-
• 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 applied 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 an admirable remedy in this
stage of the disease. C.
(i) It may be proper here to observe, that the infantile cough above descri-
bed by our author, is often dependent on a scrofulous diathesis of the system j
this is very fully illustrated and explained by Dr. Parrish, in an interest-
ing paper, inserted in the Eclectic Repertory for January 1812, entitled,
" An Account of the Appearances on Dissection of several scrofulous sub-
jects, with a few observations on the connexion between scrofula and phthi-
sis pulmonalis." Dr. Parrish has denominated the disease scrofula interna,
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 malady." 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 endeavouring
to produce a reverse effect, the internal disease may be palliated or cured.
25Q
lowed, 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 coun-
try, apply small blisters to the breast, keep the bowels in a
proper state, give a mixture containing opium and dig-
italis, and support the strength with suitable nourishment.
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, how-
ever, does not in general succeed pleurisy. It is generally
induced more slowly, by tubercles, accompanied with enlarge-
ment ofthe bronchia] 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 sw allowed, the throat is first
inflamed, and then covered with aphtha?, which spread to
the mouth. The child cries much. The region of the sto-
mach is full and very tender to the touch. The bowels are
From the decided effects produced by the discharge from blisters on each
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 irra-
tional 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 cannot 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 ir produces enphysema. Punctures ought immediately
to be made.
257
generally loose. If the child be old enough to describe his
sensations, he complains of heat or burning about the stomach
n nd throat; if younger, he directs the hand frequently to the
stomach and breast. There is sometimes, from the first, a
cough and short breathing, but the constant vomiting shews
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 ap-
ply leeches to the pit of the stomach, according to the age
and strength ofthe child; then a blister is to be applied, and
stools arc to be procured by calomel. Fomentations and the
warm bath are also useful. M. Saillant recommends the juice
of lettuce,* to be given in spoonfuls every hour, but I do not
know any advantage this can have over mucilage and laxa-
tives. The disease is uncommon, but when it docs occur, is
apt to be mistaken for a disordered state of the stomach and
bowels, producing aphthaef.
There is another state of the stomach, which, from the
softness ofthe texture, is apt, after death, to be confounded
with gangrene. There are, however, no marks of inflamma-
tion : but the stomach seems as if it had become so soft by
maceration, that it gives way on being handled. This state
is sometimes confined to one part of the stomachy, sometimes
it extends even to the small intestines, and more than one
child in the same family have died of this disease. It is not
* 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.
f In all cases of this affection, except very slight ones, bleeding is indis-
pensable. Inflammation in any portion of the alimentary omnal runs ver/
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 ef the inflammation. C.
4 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 *olght be
owing to diminished power of contraction in the stomach.
VOT.. IT. ^ K
25H
easily discovered before death, for its most prominent symp-
toms, namely, purging, with griping pains, occur in other
diseases ofthe bowels. It is, however, very early attended
with coldness of the face and extremities, and the counte-
nance is shrunk and anxious. It affects the intestines often
er than the stomach. This state of the stomach cannot al-
ways 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
innersurfacc being dissolved, and some of it actually removed,
so as to make a hole. When the preparation is put into spi-
rits, and held between the eye and the light, the flocculcnt
appearance of the inner surface is distinct, and numerous
globules are seen within the peritoneal coat, which arc pro
bably the glands undissolved.
CHAP. XII.
Of Vomiting.
Vomitin'u is very seldom an idiophatic 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 underthese circumstances.
A fit of frequent and repeated vomiting, soon after sucking of
drinking, if unattended with other symptoms, and the egesta
are of natural appearance, may be supposed to depend on ir-
ritability of the stomach, which can be cured, by applying
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, how-
ever, 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 gentle
puke of ipecacuanha will give relief. On the other hand,
259
should the egesta be green and bilious, gentle doses of cal-
omel will be serviceable, especially after an emetic. The
sickness which sometimes precedes vomiting, especially if it
be caused by bile, is accompanied with great oppression,
panting, 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 cesophagus 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
tesophagus, whilst the stomach is rejecting its contents,
CHAP. XIII.
Of Diarrhoea.
When wc 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, wc 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 lac-
teal 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 con-
stitute one organ, yet they are not so blended in action, that
all must be alike effected when the organ is deranged. All
may be disordered, but one sooner, and to a greater degree,
260
than tbe 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 exbalants may be greatly af-
fected, producing copious discharge of intestinal secretion,
which may be watery, mucous, slimy, or, when the vessels
are abraded or open, tinged with 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, &e. 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. Hut if tho
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 are naturally mixed
with the bile, pancrcatie 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, w hen they are properly suckled, the stools
are somewhat different from their state at a more advanced
period. They are of a yellow colour, arc 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
appearance, or are too liquid, or green or dark coloured, or
ill smelled, they arc unnatural. The changes effected in
the passage of the chyme are not merely chemical, but de-
pendant on animal action; for the contents of the stomach,
* Both the smell and the colour of the fxces 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.
261
mixed with the fluids found in the intestines, and exposed to
.the same degree of heat, will not form natural looking faeces,
but the substances will simply assume the acetous or putre-
factive fermentation. If the powers of the stomach and in-
testines be impaired, then this fermentation goes on to a
great degree in the stomach and bowels, much gas is extri-
cated,* inflation is produced, and the aliment becomes sour or
putrid. If too much bile be added, the faeces are green,
sometimes dark-coloured. This redundancy of hile may be
produced by causes acting immediately on the liver, at least
not through the interposition of the intestines, and the bile
comes then to be a source of irritation to the bowels, and ex-
• ites diarrhoea; or the affection ofthe bowels may influenc<
the liver, and excite it to a greater secretion. Some chil-
dren arc more bilious than others, arid are subject to fits of
paleness, sickness, and bilious vomiting. The pancrcatif
juice and intestinal secretion, when not changed in quality,
but ouly increased in quantity, 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 stomach, and form a black, pitchy
looking substance,f which sooner or later produces very bad
effects. In other instances, these form a more watery sub-
stance, which is passed off with griping, and purging pf 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
* 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 digestion, the greatest part of
the gas is inflammable. Fourcroy System, &c. Tom. X. p. 75.
f The decomposition of bile by acids, which combine with its soda, fur-
nishes a precipitate, wliich is thick, viscid, Very bitter, and inflammable.
This is probably the origin of pitchy looking stools in some cases, though in
athers they may proceed from effused blood.
262
kind, and the stomach is not injured, the faeces arc 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 faces
contain more acid than usual, which, although the bile be
not increased in quantity, may give them a green colour,*
and the intestines arc 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 arc 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 so-
lid food taken by the child, or small masses of dark-coloured
iaeces which had been accumulated in the bowels. When the
digestive faculty is almost gone, the stools consist of the ali-
ment 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 intes-
tines, it is not unusual for these appearances to alternate
with discharge of slime and blood, as we see in intus-suscep-
tion. 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 exertion,
weaken the bowels, and thus the whole body which sympa-
* 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
so in a short time after they are passed.
263
thizes with it. Great debility is often rapidly excited by at
fections of the intestinal fibres, though there has been little
evacuation. Diarrhoea likewise injures the system, by the
irritation and great secretion which often accompanies it;
add to this the diminution of the powers of digestion, and the
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 diseases thus excited, such as
convulsions, anasarca, &c.
On inspecting the bowels after death, they are very sel-
dom found in a state of inflammation, but either greatly in-
flated and relaxed, or with more or fewer intus-susccpted
portions. In one case, no fewer than 47 intro-susceptions
were found in the same body. On examining these por-
tions, the valvules eonniventes are found to be rather more
prominent than usual, hut the parts are not inflamed. In-
vagination of the intestine is the most frequent cause of fatal
diarrhoea, not less than 50 cases having occurred to my bro-
ther in the course of his dissections. Intus-susceptio may be
produced suddenly, in consequence of spasm, and may occa-
sion 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 di-
arrhoea, when attended with considerable irritation, and it
adds to the violence of the disease. It is sometimes accom-
panied with a diseased state of the glands. In this case there
may he a swelling of the external glands, and there is often
a tendency to cough. There may be a double intus-suscep-
tion, and the tumor so formed may lodge in the pelvis, and
fill it. Inflammation is very far from being a necessary at-
tendant 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 with-
out blood; sometimes a little frothy slime is passrd. somt-
2G4
times a substance like rotten eggs, and at times the contents
ofthe intestines are vomited. It is attended with stretchings
and eryings, 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 disease continues long, the emaciation is very great, the
face resembling the bones, with merely a skin covering them,
whilst the eyes arc sunk. On the extremities, the skin is
lax, and seems much too wide for the bone and muscles.
Sometimes the intus-suscepted portion is thrown off, and
passes by the rectum.
Dissection likewise shews, that a diseased state of the
liver not unfrequently accompanies diarrhoea, and this may
be a cause of purging oftcner than is supposed. It is to be
suspected, when the biliary secretion is most affected and
he 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 ca-
lomel.
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 arc
extremely frequent, and uniformly so. In others, the de-
jections come in paroxysms, being worse either through the
night or through the day. Some children are greatly 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. Sometimes
2$5
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 there
is great irritation, they are cither 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 cxljaust-
cd.
Diarrhoea may be pxcited 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 cqstiveness, dentition, the application of cold
to the surface, or a morbid state of the bowels connected
wjith general debility, produced either by bad air or natural
delicacy of constitution, are causes of diarrhoea. Those child-
ren 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 re-
medies, especially as we find, that if it be neglected iii its
commencement, it is apt to end in a very obstinate or in-
curable state. On this account I have been led to consider
this disease 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 useful to give small doses of rhubarb, conjoined with
an aromatic, taking care, however, that these do not end
VOL. II. 3 L
366
in producing the opposite extreme, or costiveness. In many
cases, the disease will subside of itself; but if it do not abate
spontaneously, 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 rea-
dily done by an anodyne clyster. But if the diarrhoea have
been excited by improper food, or redundancy of food, or if
it be attended 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 calomal. The tepid bath is also bene-
ficial. 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 irrita-
tion 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 produ-
ced 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
* 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
necessary to give more than from 4 to 5 grains altogether. Mem. of Irish
Acad. Vol. VI.
+ Cold drawn castor oil may be given in the following form: R. Ol. Rici-
ai, giii; Manns, ^ss; Spt. ammon. Arom. gi; Aq. Cassise 35s ; aq. Font.
3iss fiat emuisio Of this a tea spoonful may be given as often as necessary,
fi67
older children we give a grain. If laxatives do not increase
the debility and pain, and if they render the stools more nat-
ural in appearance, they do good, and may be continued in
decreasing quantity, till they are abandoned altogether.
But if they merely increase the frequency of the dejections,
without greatly altering their quality, the stools continuing
watery, ill-coloured, and offensive, and the strength and ap-
petite 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 per-
haps 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. After-
wards the morbid matter is expelled, or can be Temoved by
gentle laxatives. Opiates given by the mouth have often a
bad effect on the child, and never are equal in benefit to clys-
ters. Cretaceous substances, joined with aromatics, are use-
ful when there appears to be a redundancy of acid; but as-
tringent 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 intestines. In ob-
stinate cases, small doses of calomel given morning and even-
ing, 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, alld will save a great number of
children; I can speak of this practice with confidence. 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, re-
peated every six or eight hours, till the stools change their
appearance. But this remedy operates severely, and may
268
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 disease, prescribes
emetics, then warm purges, and afterwards small doses of
ipecacuanha, with absorbents and aromatics.
Dr. Cheyne, in obstinate and prolonged purging, which,
from frequently occuring 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 com-
pound 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
balsam, or camphorated oil of turpentine, or the application
of an anodyne plaster*, to the whole abdomen, which is bet-
ter. Small blisters in succession, applied to the belly are high-
ly useful. It is also proper to bandage the belly pretty firm-
ly, but by no means tightly, with flannel.
During the whole course of the disease, it is proper to sup-
port the strength with light nourishment, such as beef-tea,
arrow-root-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. Thege are of signal service, and
ought to be early and carefully employed till the child c£n
take food into the stomach.
• Such, as the following : R. Saponis, 31; Empl. Lyfharg. Jvi; Ext. Ci-
cuts. 3'ii; Ol. mefth pip. 3 ss; "Fiat empl. Or R. Empl. resince, gvi, Pulv.
opiizi.Camph. jju; Ol. Juniper 35s ;Ti4t empl. Or if there be much spasm,
wemay use thVE^pl.^&fffitfffx.Tharm. Edin. with' the addition of opium.
269
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 aphtha? generally mark the fluctuation of the bowel
complaint. The excoriations which appear about the anus
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 de-
ranged, 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 ofthe intestinal surface, by
small doses of calomel in prolonged cases, or by a dose pf
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 exces-
sive secretion, by anodyne clysters and external applications,
neither of'which are incompatible, with the occasional use of
calomel.
Fourth, To remove or allay coincident or consecutive
symptoms by appropriate remedies.
270
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.
CHAP. XIV.
Of Costiveness.
Cosxiviiviiss is natural to some children,—acquired br-
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 cholic, but. more serious diseases, such
as convulsions, or diseases in the bowels. Some children, of
a very irritable habit, have the rectum spasmodically affect-
ed at times, on passing the faces, which may be followed bj
a convulsion. This being frequently repeated, the child be-
comes afraid to go to stool, and retains the faces as long as
possible, which induces a costive state. Sometimes the ter-
ror 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 these 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 omitted ; em-
271
ploying in the interim a little manna alone, or combined with
castor oil, and sometimes magnesia may be substituted for
a change. In more obstinate cases, infusion of senna, or two
or three grains of aloes may be given. A 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 .(t)
CHAP. XV.
Of Cholic.
Choiic 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 faces 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 he exhibited after the anodyne.
If a child be subject to repeated attack of cholic, 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 HofTman, is an excellent medicine m these
affections. C
272
CHAP. XVI.
Of Peritonitis.
Peritoneal inflammation, or enteritis is not an uncommon
complaint with children. It begins with violent pain in the
belly like cholic, but is more constant and continued, and is
accompanied with a considerable degree of fever, costiveness,
and tenderness in the belly. If this disease do not prove
speedily fatal, and if on the other hand, it be not perfectly
removed, the child remains long ill, perhaps for some weeks,
and the nature ofthe complaint may for a length of time be
mistaken. There is constant fever, but it is subject to exacer-
bation in the evening. There is increasing emaciation, 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 #>und adhering,
or forming knots, and sometimes the liver partakes of the
disease.
In younger infants, the consequences of peritoneal iuiiaai
mation, when it does not prove rapidly fatal, or excite con-
vulsions, are 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 bath, clys-
ters to open the bowels immediately, and then an opiate cly-
ster to aliay morbid sensibility; a small Wsfcer should be
applied tothe belly, and if the symptoms be very urgent, t£is
may be preceded by leeches, though these are rarely in in-
fants required. Jn elder children, the attack is often brought
273
on by cold, or by eating indigestible substances, as for in-
stance, nuts. No time is to be lost in opening the bowels
by clysters and laxatives, and in detracting blood from a
vein. Fomentations and blisters are useful. If these means
be neglected, or do not succeed, there is little hope after-
wards of saving the patient, unless the bowels adhere to the
abdominal muscles and an abscess takes place, which is in-
deed very rare. In the usual state produced by this dis-
ease, wc have little in our power, except to regulate the
state of the bowels, apply small blisters, and support the
strength.
CHAP. XVII.
Of Marasmus.
Connected with, and generally dependent on, a mor-
bid state ofthe bowels, is the marasmus, or wasting of chil-
dren. This disease is preceded and accompanied by costive-
ness, 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,
foetid breath and foetid stools, tumid belly, pale leucopleg-
matic countenance, with swelling of the upper lip. Present-
ly fever supervenes, the countenance becomes at times flush-
ed, and the skin hot and dry, with frequent pulse, thirst,
restlessness, picking ofthe nose, and disturbed sleep, in which
the patient grinds his teeth and starts. The debility gradu-
ally increases, and if relief be not procured, death, preceded
by great emaciation, takes place. This disease is most fre-
quent with those who are fed on improper food, or eat many
raw roots, or much unripe fruit; or those who have the di-
gestive 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 bow-
els, arc by no means essential to the disease.
VOL. II. 2 M
274
This disease may, in the commencement, and before the
appearance of fever, be arrested by a course of active pur-
ges, 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 diffi-
cult, but is to be accomplished on a similar principle, by at-
tending to the state of tin bowels. For this purpose, pur-
gatives must be frequently repeated, especially calomel; and
here it is necessary to remark, that the stools are not always
hard; they arc often fluid, but generally foetid, and dark in
the colour. A course of purgatives, however, by degrees
procures discharge of faces 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 chalybcates or other tonics,
provided these arc not nauseated by the patient. After re-
covery 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.
CHAP. XVIII.
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 mesentric glands*, which are sometimes
• This state is sometimes accompanied with swelling of the thymus gland,
and the lymphatic glands of the neck. Swelling of the thymus gland, by pres-
sing on the trachea and oesophagus, produces difficulty of breathing and of swal-
275
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 faces ; 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 ofthe
bowels, independent of diseased glands. As the disease advan-
ces, the body wastes away, the face is pale, and the features
become sharp, the abdomen gradually enlarges more, and the
patient complains of lancinating pains, vof short duration how-
ever, within the belly, or near the back. The stools are now
sometimes bound, but oftener loose, frothy, and mixed with
bile; occasionally the patient has diarrhoea, with vomiting.
The fever, which at first is obscure and intermitting, boeomes
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 inactive, 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 su-
pervenes. As the disease proceeds, the emaciation of the bo-
dy increases, the eyes are sunk and glossy, the nose sharp,
and apparently elongated, the face sallow, but the lips are
lowing, and sometimes suffocation. By pressing on the subclavian vein, it ob-
structs 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.
276
sometimes florid, and the cheeks flushed at night. The ab-
domen 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, arc
covered 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 sonic
light bitter infusion, decoction of bark, tonic medicines, and
gentle frictions 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 docs 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 sufficient
that the bowels be brought into, and kept in a regular state,
which, in the incipient stage, at least, sometimes requires
pretty strong doses. But in the confirmed and advanced
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 tumor 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 often does,
and this is a most favourable effect. Farther, if the par-
oxysms of fever be severe, and early in their appearance, we
• Sometimes a hard tumor may be felt within the belly, pretty early in the dis-
case. It is often felt in the right side, near the origin of the colon.
277
find it necessary to use purgatives more freely than in op-
posite 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 bowels
open if disposed to be costive, or, if loose, to 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 con-
stitution, lest debility be increased; it is therefore prudent,
sometimes to combine the calomel with rhubarb, or to em-
ploy 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 exist-
ing in the glands; and in such cases, some light bitter infu-
sion 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 bal-
sam. 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 in-
flammation, discovered by shooting pains with fever, the
patient must not bathe; and indeed, at all times, the utility
and safety of the cold bath seems to be doubtful, except
when the disease is so 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 stimu-
lating 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 pre-
sent, 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 tumor
from inflaming and forming a cheesy substance, or in giving
a favourable turn to the action, when the acute state of in-
278
flammation has abated, in those cases where it is met with,
for it is by no means an universal occurrence.
In the latter end ofthe 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. XIX.
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 of-
ten expelled, both by children and adults. Worms are of
different kinds, but infants are chiefly infested with lumbrici
and ascarides, the tenia being rarely met with until children
are six or seven years old. We also sometimes meet with
some uncommon species of worm, which are ejected by
vomiting, and some hisuses have been passed by stool; thus,
for instance, I have seen a worm about three inches long,
having 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 tlfe stomach and bowels, and live their for
some time.
Ascarides generally occupy the rectum, producing much
ieching in that part, so that sleep is often prevented. The
irritation causes indigestion and pain in the belly, with pick-
ing ofthe nose and white face, a variable appetite, and some-
* Worms rarely appear in the bowels, till after the child is weaned.
S79
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 in-
fusion ;(w) 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 alimentary
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 earth
worm has three lines on the upper surface. It dies soon after
its expulsion, but when alive, it moves like an ecl> and docs
not shorten the body like a worm. Dr. Hooper, in the 5th
vol. of the Mem. of Med. Soc. has a valuable paper on intes-
tinal worms. Lumbrici may exist in every part of the ali-
mentary canal, and frequently are ejected by vomiting, as
well as by stool. The symptoms are those of intestinal irri-
tation,* pains in the belly, frequent attacks of diarrhoea,
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-ach, sometimes has a dry cough, with slow
fever, or convulsive affections. I have already pointed out
(u) Dr. Kuhn of Philadelphia, whose experience 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. II.
• Hence it is not easy to say that worms are the cause of a child's complaint,
for other morbid affections of the bowels produce the same symptoms. A course
of purging removes these symptoms, without bringing away any worms; al-
though the slimy appearance of the stools is oftea attributed to tbe worms be-
ing dissolved.
2*0
several diseases proceeding from disorder ofthe bowels, and
these may arise from worms, in as much as they are capable
of irritating the bowels, or injuring their action, or increasing
such a debilitated state, as may have predisposed 1o 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 gcoffrea, worm seed,* tin pow-
der, filings of steel, Ace. have at all times a good effect; but in
general, calomel purges given repeatedly and liberally, pro-
vided tbe constitution of the patient will bear them, will be
found very effectual; or these may be alternated with saline
purgatives, 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 employed whilst wc arc using
the purgatives.
The triehuris, 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
like the ascaris. It is found in the rectum, and also higher
up, even in the ilium.
The tania 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,
and the usual remedies are required ; but the tania is more
difficult to be removed than other worms.(a?)
• The oil of worm seed has recently been given with great success in cases
of worms. I am told that it is equally destructive of every species. I have, how-
ever, only used it in one case of the lumbricoides. For a child of a year old the
dose is three, or four drops twice a day. It is a remedy singularly prompt and
efficacious. After continuing the medicine for three days, it should be omitted,
and a mercurial purge is given. C.
(x) Our author has not noticed the effects ofthe oil of turpentine in expelling
taenia. This has of late years been used with considerable success in very large
doses. As much as two ounces has been given at a time to an adult; without in-
291
CHAP. XX.
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. 1
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 ex-
tends to the eyes. The child sucks very little, has occasion-
ally a difficulty in swallowing, is languid, becomes emaciated,
moans much, is troubled with flatulence, sometimes with
cough and phlegm in the trachea, or vomiting, convulsions,
cholic, 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 often proves fatal
in a week, but it has been known to continue in variable de-
grees of violence for a considerable time, and at last to disap-
pear, 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 commu-
nis, either by thickening of the coats, or pressure, in conse-
quence of enlargement of some part in the vicinity of the
duct; or it may consist in imperforation of the duct. Some-
times it proceeds from temporary obstruction in the duct,
owing to viscidity of the bile. Now some of these cases are
jury. We have heard that it has been given to infants in smaller doses, [measur-
ed by dreps,] for the other species of worms and with success. It may cer-
tainly be considered as a powerful anthelmintic. The reader is referred for
rases illustrating its effects in the expulsion of taenia, to Eclectic Repertory, Vol.
I. and to Medico-ChirurgicaJ Transactions, Vol. II.
vol. n. 2 n
2S2
i'rremoveable, others are not ; but as we cannot a priori sa\
what the cause maybe, in any particular instance, we must
use the means of cure in every case. The most likely reme-
dies for removing this disease, arc 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 wc may give this medicine even three times a day, in
some cases; but wc 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, shewing 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 af-
ter birth, and is accompanied with great oppression, moan-
ing, 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 period after birth,
does not require a separate consideration here, nor is it a
very common occurrence.
CHAP. XXI.
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
* It is in this species alone that the opinion can be admitted, that infantile
jaundice depends on absorption of bile from the intestines.
283
so frequently atttended with vomiting*. I cannot say much
that will be satisfactory respecting the treatment. Mercurial
friction is chiefly to be relied on.f
Hepatitis in infancy is marked with tbe symptoms attend-
ing enlargement of tbe 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 pas-
sage 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 lympth, 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 enlarg-
ed, nor its substance affected. The stomach and bovvels are
not inflamed, but sometimes have a white blanched appear-
ance, and contain a fluid like thin custard. The bile is not
changed in its colour. In some instances of chronic inflam-
mation, 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 chil-
dren 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, accom-
• 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.
t 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.
284
panied with sickness and vomiting; and cither attended,
or soon succeeded by fever, short tough, and pain, some-
times dull, sometimes sharp in the right side, and occasion-
ally affecting the shoulder. Jaundice also, not unfrequentlv,
is produced and lasts for a few days. There is thirst, no
appetite, but the child feels continually as if be had ate too
much, is subject to fits of squeamishness, and complains
when the liver is pressed. If the remedies do not cheek
the disease, the liver enlarges, and its region is full;
abscess is formed, attended with irregular dullness, hectic
symptoms, and much pink coloured sediment in the urine.
In a few weeks, sometimes in a shorter period, the patient
is sensible of a smell like rotten eggs, which he thinks
comes from the stomach ; then a little foetid matter is cough-
ed 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 be mild, is advanta-
geous. Sometimes the abscess bursts into the stomach or
intestines, adhesion previously taking place; or, I have
known it burst into the general cavity of the abdomen, and
the matter accumulate there, forming a tumor like ascites,
bursting at last by the navel, which is inflamed; or it has been
drawn off with a trocar, and recovery has been accom-
plished.
The more slow or chronic species may be excited by a tor-
pid state of the whole chylopatic viscera, consequent to ne-
glected bowels, or other causes; or it may occur after some
285
other disease, such as peripneumony, scarlatina, &c. The
child has fits of sickness, vomits bile in the morning, and los-
es his appetite ; or if he has a strong desire for particular
kinds of food, or feels very hungry at times, he either cannot
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; in others there is
a constant dry cough, and inclination to hawk or spit, the
pulse is frequent, the upper part of the belly becomes swel-
led 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 felt 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 full, and the liver can be
perceived extending towards the left 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. If the disease be not checked, it goes on
to suppuration, producing distinct hectic fever, terminating
in death, if the matter be not discharged ; or, it may be, ir-
ritation proves fatal, even without suppuration. Repeated
blisters, laxatives, and mercurial inunction are the remedies,
with diuretics, if there be dropsical symptoms.
The spleen is frequently enlarged, and sometimes contains
turhercles. 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
iaxatives, and blisters, are the best remedies, but most cases
I have met with have proved fatal.*
• I pursue here the same mode of treatment as in enlargement of the liver.
Exercise, and especially swinging, is useful. Compression of the abdomen by
a flannel bandage is also beneficial. C.
286
CHAP. XXII.
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 eme-
tics 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 ofthe 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 he useful. If pain continue, or
stupor, or constant drowsiness supervene, blisters will be pro-
per. The strength, in the latter end of the disease, is to be
supported by the prudent use of wine. Cough in general re-
quires blisters to the breast, with squill vinegar.
The most frequent fever, however, excluding those ac-
companied 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
* Many of the fevers of children, not at all originating in contagion, soon
ran into the typhus form. This, therefore, can hardly be considered as a diag-
nostic. C
287
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 ofthe first variety, it
is very similar to the early stage of hydrocephalus, but the
remissions are more distinct in the morning, and the exa-
cerbations 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; perliaps,
he does not for hours lift his eyes, till the remission comes,
when he looks up, and attends to the objects presented to
him for a short time. He sucks in general freely, and some-
times bites the nipple, and very often aphtha 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 con-
tinuance of the fever, or more quickly by the accession of
obstinate diarrhoea. A favourable change takes place, some-
times about the fifth day, sometimes later, the child looking
up for a 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
appearance. In many cases, the fever may proceed from
affection of the bowels; but frequently it is caused by den-
tition, the irritation in the jaw operating either alone, or in
connexion with a morbid state of the bowels. In this kind
• In the early stage of hydrocephalus, the pulse is more irregular, and often
beats alternately quick and slow, for two or three pulsation-?.
2SS
of fever, the gurus should he carefully inspected, and. if nr
cessary, cut. Small doses of calomel should be given morn-
ing and evening, mixed with magnesia, to prevent costive-
ness, or evacuate irritating faces. A few drops of tincture
of hyoscyamus, with a saline jultp. may be given occasionally
to abate irritation. The tepid bath should be employed oner
a-day, when the exacerbation takes place, and the strength
supported by the breast milk or beef-tea. If the 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 remains fret-
ful, languid, and emaciated. The eyes are suffused, the feet
swell, and the stools are not regular nor natural. In some
instances, tumor of the mesenteric glands seem to be exci-
ted.
The remittent fever of older children is met with from
the age of two to ten or twelve years, and is generally found
to be produced, either speedily after eating some improper
substances 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 faces in the
bowels. In the first case, the fever attacks suddenly, some-
times 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-ach, or pain in the belly. The tongue is at this time
tolerably clean, but next day it becomes furred, and the fits
of vomiting or sickness are pretty frequent. They are gen-
erally preceded by head-ach, which goes off or abates after
throwing up. If this disease be attacked immediately with
an emetic, 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, mitigates the disease, it does not ar-
rest it speedily, but, notwithstanding the regular use of lax-
atives with diaphoretics, it continues for several days. Erne-
289
tics and purgatives, in this disease, generally bring off some
half-digested substance, 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 arc proper to assist the phy-
sic.
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 is 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 l-i-0 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 his belly, which may at
times be very severely pained ; or if he complain of head-ach,
it is evidently from his stomach, for it is followed by sickness
or vomiting. The fever does not continue alike severe dur-
ing the whole of the day; it remits a little, but not at very
regular hours. The exacerbation which usually occurs in
the afternoon, is generally accompanied with drowsiness.
Very soon after the attack of fever, the tongue becomes
covered with a white or brown coat', and both the stomach
and the bowels seem to be extremely torpid. The appetite,
indeed, is soon almost totally lost, or the food which is ta-
ken is not digested. The bowels are generally, but not al-
• This is commonly called a worm fever, although worms are not necessari-
ly passed in this disease.
VOL II. 2 9
290
ways costive; and the stools arc foetid, dark-coloured, some-
times like pitch, or thin and olive-coloured, or green and
curdy-looking. There is a great desire to pick the nose and
lips ; and if the 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 arc 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 recal-
led for a few minutes, and will then answer questions dis-
tinctly. If the debility be considerable, the countenance be-
comes vacant, 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. Some-
times 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 al-
though they may ultimately fail. In general, success at-
tends their use. Tumefaction of the belly, with great and
constant fever, are very unfavourable.
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 ofthe mental faculties. There
is in general 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.
291
The stools are more foetid and darker in this fever than in
hydrocephalus, in which they are often thin and bilious, and
sometimes glossy. The pulse in hydrocephalus is more ir-
regular, 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 diagnosis, es-
pecially 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 rea-
son 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 wTould be of more con-
sequence in determining the prognosis than the treatment.
For, in these cirsumstances, the application of blisters to the
head, the use oflaxatives, and supporting the strength, arc
the means to be chiefly resorted to in both diseases.
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 quan-
tity may be necessary to procure stools. Usually, it is greatly
beyond 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 excel-
lently on the bowels. Clysters are also useful. It is useful
to evacuate the bowels freely at first; but after this, it is
not proper to give so much medicine as will purge briskly.*
It is requisite, however, to give regularly such doses as will
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 appear-
• 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.
292
ancc, and injure the action ofthe intestines. Suitable doses
of calomel, or castor oil emulsion, or infusion of senna, or
aloetic pills, will presently bring the stools into a more nat-
ural 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 docs not always remove the fever itself.
We should therefore, besides using laxatives early, and con-
tinuing their exhibition during the disease, as long as these
bring away offensive stools, and do not increase the fre-
quency of the pulse or debility, have recourse, in the com-
mencement of the fever, to the use of the sponge, with cold
water to moderate the heat. This is to be repeated often-
er or seldomcr, according to the benefit it produces. If the
first application gives much relief, we may even employ the
affusion of cold water prudently, immediately after the hot
stage is established, and then it may abate the fever. After-
wards we employ saline julap, with a little antimonial wine,
and, in the more advanced stage support the strength with
regular and cautiously proportioned doses of wine. Opium
and hyoscyamus frequently allay irritation, and accelerate
recovery, by procuring sleep. Anodyne clysters are useful
in this respect, and also for abating griping or abdominal
pain. This also is relieved by fomentations. Pain in the
side, if not abated by rubbing with anodyne balsam, re-
quires a small blister. Delirium is sometimes, but not al-
ways, mitigated by blistering the head ; but this is uniform-
ly 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 pro-
gress of the disease, infusion of bark or other tonics are
sometimes beneficial. Great attention should be paid to
cleanliness and ventilation, and, when convalescent, a remo-
val 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 ofthe 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 ofthe passage ofthe bead
through the straits and cavity of the pelvis in the six diffe-
rent positions of the vertex, as minutely laid down and de-
tailed 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 peremp-
torily 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 which constitutes the first
order of natural labours, is recognised by the presence of a
round, solid tumor, of greater or lesser size, upon which wc
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-
296
APPENDIX.
ferent positions of the vertex, according to the manner in
which this part presents at the superior strait, and which
we determine by the relative situation of the fontancllcs,
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 ful-
ly those cases, where the intervention and aid of art be-
comes necessary. For properly to apply the forceps, and to
act with them advantageously, the accurate knowledge of
these different relations ofthe foetal head with the pelvis, as
well as its progress through the different stages of the la-
bour, until delivered, is supposed to be well understood.
More clearly to comprehend this part of our subject, wc
may consider the circumference ofthe pelvis as divided into
two segments, or semi-circumferences, one anterior and the
other posterior. In the three first positions, [which have al-
ready 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 he
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.
APPENDIX.
297
First Position. In this position, the posterior fontanelle an-
swers to the left acetabulum. The back of the infant is situa-
ted towards the anterior and left lateral portion of the ute-
rus 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 re-
main as yet out of the reach ofthe finger in the common ex-
amination ; we cannot, therefore, at this period, 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 rightsacro-iliac symphysis, we are as
yet ignorant whether the posterior fontanelle is situated in
the anterior or posterior segment of the pelvis, and of con-
sequence, whether the vertex presents in the first or the
fourth position. The same difficulty presents in discrimina-
ting between the 2nd and the 5th position, and between 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 parietal
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 ofthe 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 ofthe superior strait.
It continues to deseend, until checked by the sacrum, the
coccix, and the perinseum.
Whilst the head descends into the cavity of the pelvis in a
diagonal direction, one of the parietal protuberances passes
vol. II. 2 P
298
APPENDIX.
before the left sacro-iliac symphysis, and the other behind
the right acetabulum.
In this position, it is the right parietal bone which an-
swers to the arch of the pubis. One of tbe 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 coccix. 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 ofthe 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 pu-
bis, and the anterior towards the sacrum. The sagittal su-
ture is parallel to the great diameter of the inferior strait.
The branches ofthe 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
APPENDIX.
299
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 ofthe pubis. In this motion, the occiput passes over
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 allow
the head to be delivered without the trunk's advancing, li
the head in its passage does not accommodate itself to this
curve line, above described, but descends directly in the di-
rection ofthe 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 perineum upwards, the only
means which remains to prevent the laceration of this part, is
to apply the forceps, irt 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
sacrum, in consequence of the twisting of the neck, and re-
sumes 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 pla-
ced posteriorly.
300
APPENDIX.
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
movements. In the first period, the head bends itself towards
the breast, and progresses through the cavity of the pelvis.
In the second, it performs a motion, which brings its long
diameter 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 ofthe head which pas-
ses 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 advan-
tageous, if the 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 dif-
ficult, 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 ia
situated before the left sacro-iliac symphysis, so that the
baek 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 sim-
ilar 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
APPENDIX.
301
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 tbe 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
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 ofthe perineum.
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
302
APPENDIX.
-boulders. What truth there is in this supposition, we shall
not here stop to investigate.
Third Position. In this position the posterior fontanelle is
behind the symphisis pubis, and the anterior before the
projection ofthe sacrum. The back of the infant is towards
the antei'ior, and its abdomen towards the posterior portion of
1 lie 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,
that many practitioners who have never met with it, have ab-
solutely called its existence in question. Those who have im-
agined that the occiput constantly answered to the pubis from
the commencement of labour, have only thought so, because
they observed it disengage itself in this direction from the in-
ferior strait. A regular examination through the whole pro-
cess, would have taught them, that although the occiput is ex-
pelled from under the pubis, it nevertheless enters the supe-
rior strait diagonally. When the occiput passes through the su-
perior strait directly behind the symphysis pubis, the long
diameter of the hpad 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 con-
siderable. If no obliquity exists, parturition may neverthe-
less be accomplished with a sufficient degree of ease ; because
in a well formed pelvis, the short diameter of the strait is four
inches, and the long diameter ofthe head is no greater. 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 expulsion 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
perinseum 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
APPENDIX. 303
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 perforin 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 ofthe 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.
Although at the commencement of labour, the posterior
fontanelle is placed towards the right saero-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 suffering 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. If the membranes have
not been ruptured, it is impossible to touch the head during
tbe existence of a pain. This conversion cannot be aceon;
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 tbe trunk to undergo 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 re-,
30± APPENDIX.
collect the possibility of this conversion, in those cases in
which we are obliged to apply the forceps, because the mode
of proceeding will be different if that has taken jdace. Wo
should, therefore, before applying the forceps, endeavour 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
towards the symphysis of the pubis. This part is disen-
gaged with more difficulty from under the arch of the pubis.
than the occiput; for the arch has less breadth in its supe-
rior part, than the forehead and the face ofthe 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 direc-
ted in such a manner, as to bear upon the occiput, it descends
into the pelvis, passing before the right sacro-iliac symphy-
sis. When the head reaches the sacrum, it can no longer
follow its first direction. The contractions ofthe uterus oblige
it to perform a pivot-like motion, which turns the occiput into
the hollow of the sacrum, descending along the inclined plane
ofthe right side ; whilst atthe 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 situated 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 fontanelle passes over the length of the sacrum, the
coccix and the perinseum to arrive at the bottom ofthe vulva.
At this moment the edge of the perinseum is considerably
stretched, and runs a greater risk of laceration than in the
preceding positions. The perinseum not being capable of
remaining stationary upon the inclined plane which the occi
APPENDIX. 303
put offers, retires suddenly towards the base of the neck of
the infant.
The posterior edge of the perinseum becomes then the
point of support, or axis, upon which the nape of the neck
revolves, whilst the occiput turns backwards towards the
anus ofthe woman. In proportion as the head turns back-
wards upon the perinseum, the face disengages from under the
pubis. We observe successively appear the forehead, the or-
bits, 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 after-
wards towards the pubis, and the right towards the sacrum.
That which is posterior, disengages the first, the other re-
maining stationary at that time.
Fifth Position. In this position the anterior fontanelle is be-
hind 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 unfrequently
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 po-
sition, 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 ofthe rectum on tbe left side ofthe pelvis, renders
this rotation more difficult, by preventing the occiput from
vol. n. 2 q
$06
APPENDIX.
turning freely iuto 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 should-
er is afterwards directed towards the pubis, and the left to-
wards the sacrum. The latter alone advances until it appears
at the vulva.
si.i-lh Position. In this position the anterior fontanelle is
behind the pubis. The sagittal suture is parallel to the small-
est 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 which the
occiput can take. Not only docs the head present its length
to the smallest diameter of the superior strait, but also the face
is anterior, as it regards the pelvis, as in the two preceding
positions. Happily it is tbe most rare of all. The rounded
form of the head, with difficulty permits it to remain fixed du-
ring labour against the projection of the sacrum, so that even
supposing it should answer to this part of the sacrum 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 sup-
pose, 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 towards one or other of tbe acetabula,
turns by a pivot-like motion towards the arch of the pubis,
from under which it is delivered.
We can distinguish but two periods in this position.
If tire expulsive forces of the uterus act upon the occiput as
occurs in the natural order, it progresses through the pelvis
before the sacrum. Whilst the forehead is applied against
the internal surface ofthe symphysis of the pubis, the occi-
put, which ought to be delivered first, considerably distends
the permsBum, passing over a curve line which extends from
the hollow of the sacrum to the lower edge of the vulva. At
APPENDIX.
307
this instant the perinseum retires backwards, and passes un-
der the nape of the neck, which revolves above it, w hilst the
occiput turns backwards towards the anus ofthe woman. As
soon as the occiput begins to turn backwards, the, different
parts of the face, which until then had been retained in the in-
terior 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
towards the pubis ; for it is uncertain which; and when the
change of position is procured by the aid of art, it is indiffe-
rent 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 ob-
serves, that the head may without doubt present at the supe-
rior 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 distinc-
tion, 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 ofthe anterior semi-circumference of tho
308 APPENDIX.
pelvis ; because that fontanelle turns gradually towards the
symphysis ofthe pubis, under which the occiput is ultimate-
ly situated.
The head, continues Baudelocquc, 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,
TABLE OF CASES OF LABOUR,
Which occurred at L'Hospice de la Maternite in Vara, from the 10th December 1797, to the Slsi July, 1806, inclusively.
12,751.
Women delivered 12,605. Infants born
Une 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
sucb haste, that there was no time to ascertain the part which presented, or the real position
* ?Jaily<,0f Ah,iS nu.mbef were "0* beyond the term of four or five months; and some from five to six, which reduces the number
to 12,633, ol those m 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 vrese nted, the number of Times , and their Positions.
Number of times. 1st. Position. 2nd. Position. 3rd. Position. 4th.. Position. 5th. Position. 6th. Position. Positions not ascertained.
The crown of the head or vertex 12,183
But four positions of all the other regions are admitted to exist.
. . 118 . . .
. .. 1 . . .
• . . .0 • . ■ • • -.0 • • • .....7 • • • . . . . 13 . . .
The left shoulder...............
12,633 213 130 51 48 J 8
'9
s
\
i
s
s
s
s
s
This Table to face p. 308 of vol. ii.
311
Comparative statement of the Labours which were accom-
plished by Nature alone, with those in which the aid of
Jirt 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 assis-
tance of art; some by means of the hand alone, others
with the forceps, or with the crotchet, after the perforation
of the Cranium, 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 pel-
vis, or from accidental circumstances, which render the la-
bour complex,
One hundred and thirty-two in all—which in proportion to
the whole, is as 1 to 96 3-5.
Viz: The child presenting
The face - - - - 18
The shoulders - - - 38
The crown of the head with the umbilical
cord 15
The breech 22
The feet.....11
The other parts specified in the table 24
On account of convulsions and floodings 4
Total 132
The forceps were applied in thirty-seven cases, which is as
1 to 344 2-3.
The child presenting the face - 2
The crown of the head - - 35
In ten on account of the exit of the cord ;
ten on account of the exhaustion of the
woman's strength.
Six on account of convulsions.
Seven on account of the unfavourable
situation of the head, which had been
thrown backwards, &c.
Two on account ofthe mal-conformation
of the pelvis.
The crochet was employed, or the cranium perforated in
nine-—which is in the proportion of 1 to 1,416 2-3 :
Viz : 1 on account of hydrocephalus in the child.
8 on account of great deformity ofthe pelvis.
One by gastrotomy to extract an extra-uterine fcetus*
Of these latter,
the forceps were<{
applied.
312
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 tho
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 11,7 bi. 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|.
Weight ofthe 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 i lb. to 4 3-4 lb.
1,317 from 5 1b. to 5 3-4 lb.
2,799 from 6 lb. to 6 S-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.
-- ^^Tt ---.
BOOK II.
CHAP. VI.
NOTE 1. p. 23.—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 practice, by
Rhoonhuysen, but was not divulged until about the middle of the last century*.'
It vas so constructed, as to be a very unsafe instrument, especially in rash
hand. Mr. Giffard, in the beginning of the century, had repeatedly used one
ofthe biades 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 simi-
lar 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
wi'h ore of the blades, improved on it, and converted it into a lever ; but the
dissimilarity ofthe two instruments at that time, is an objection to that opini-
on. Plates of the different forceps and levers at present in use, may be seen in
Savigny's engravings: and a very concise account of all the different improve-
ments and alterations of these instruments 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 im-
portance. I prefer those, however, proposed by Dr. Lovvderand Dr. Pole to
others. A particular kind of forceps, with three blades, was employed by Dr.
Leak, but it is never used.
NOTE 2. p. 32.—The signs of a dead child have been described 'to be
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 diminu-
tion of size, flaccid breasts which contain no milk, fcetor ofthe discharge from
the vagina, liquor amnii coloured apparently with meconium, although the
head presents, puffy feeling ofthe head, want of firm tumour formed by the
scalp when the head is pressed in a narrow pelvis, no pulsation in the cord,
&c. Most of the cases requiring the crotchet cannot be benefited by any marks
characterising death of the child in the progress of gestation , and we well
know, that the child may die dining labour, without testifying this for a length
314
of time by any sensible signs ; and that those enumerated above are deceitful, 1
believe every attentive and unprejudiced practitioner will join with me in main-
taining. Nothing but unequivocal marks of putrefaction of the child itself can
make us certain, and these cannot 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 has been for some time dead, we must watch lest her re-
covery prove bad.
NOTE 3. p. 36—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 tbe eighth Vol. of Med.
Facts, &c. has given several cases of its success.—See also Med. and Phys.
Journal, Vols. XIX. XX. and XXI. It may not be improper for me to men-
tion as a caution, that 1 have been called to consider theexpediency of evacuat-
ing the liquor an.nii, where there was no deformity of the pelvis, but merely a
collection of indurated faeces in the rectum.
CHAP. VII.
NOTE 1. p. 40.—I believe few will dispute, that the precise deformity re-
quiring the cxsarean operation, must, to a certain extent, be modified by the
dexterity ofthe 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 possi-
ble to use the crotchet, were he dexterous ; but he has not a belief that he
could accomplish the delivery with that instrument. Would that man be wrong
in performing the cxsarean operation ? In such a case I would say, upon the
principle that a man is to do the most good in his power, that if no operator
of more experience 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 cx-
sarean operation, by which he will save one life at least. By the opposite con-
duct, 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 delivery being accomplished ; four days
afterwards, the cxsarean operation was performed, and the woman died.
CHAP. VIII.
NOTE 1. p. 50.—Dr Bland is rather against delivery, and for trusti-ig to
nature. Dr. Garthshore, Jour. VIII. 359, says, more women have recovered
of this who were not delivered, than pf those who were violently delivered.—
Dr. Denman concludes, that women, in the beginning of labour, ought not to
be delivered, II. 381, and admits of it only when it can be done easily.—Bau-
delocque, says, that we ought not to be in haste to ddiver, and never to do it when
315
nature seems to be disposed to do it herself. Dr. Hull, Obs. &c. p. 245, jays,
that we should trust to the usual remedies, till the os uteri be easily dilata-
ble, or be dilated, and then deliver. He informs me, that in every case
which proved fatal, there was no dilatation ofthe os uteri.
NOTE 2. p. 50.—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 possible mari-
ner.—Dr. J. Hamilton, Annals, V. 318. et seqr. says, that when convulsions
occur during labour, delivery is to be accomplished as soon as possible.—Dr.
Leake, that when they seen! to proceed from the uterus, speedy delivery is
useful ; but when from "any cause independent ofthe state of pregnancy,"
delivery would be hurtful, II. 348.
NOTE 3. p. 52—In a case which 1 saw, the placenta was retained by a
spasmodic stricture, though the child was expelled ; every allowable attempt ,.
was made to extract it, but in vain. The uterus acted from the os uteri to-
wards the rent, which was at the fundus. The woman died. The placenta
was found still in utero. The intestines were inflamed. See also Crantz, de
Utero Rupto, p. 22 ; and Dr. Cathral's case in Med. Facts, vol. VIII. p. 146,
NOTE 4. p. 55—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. II. p. 338, is a case most incredible, where both the uterus and abdom-
inal integuments were torn during labour. The child escaped, and the wo-
man recovered.
NOTE 5. p. 56.—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 complained
cnly 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. XXII. p. 1000. Broomfield's pa-
tient did not get rid of the child, but she lived for many years, and after death
the rent was visible. Phil. Trans, vol. XLI. p. 696. In Dr. Sym's patient,
the process for expelling 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 instance, where
the uterus was ruptured on the 23d of April. On the 13th of May the pla-
centa was expelled ; on the 16th a tumor appeared at the linea alba, which
was opened, and a child extracted; the woman recovered. Obs. Tom. II. ob.
92.
NOTE 6. p. 56.—In a case communicated to Dr. Hunter, the forceps
were pushed through 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. Doug-
VOL. II. 2 R
316
ias relates the successful case of Mrs. Manning, in his Observations, p. 7. Df.
A. Hamilton gives a fortunate case, where delivery saved the mother. Out-
lines, p. 344 ; and Dr. J. Hamilton, relates one in his Cases, p. 138, where
the rent had contracted so much, as to give some difficulty to the delivery.
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 the
upper lateral part of the vagina, it is dangerous ; and at the anterior and
posterior part, near the bladder and rectum, it is generally mortal; bot 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 retovered. Several were produced by
attempts to reduce the arm of the child.
BOOK III.
CHAP. I.
Page 60, line 2.—If sloughing ofthe neck ofthe bladder should take place,
and a small opening be formed, a catheter must be kept in the urethra and blad-
der, and the wound dressed with a pledgit dipped in lime water, mixed with
tincture of myrrh; then a soft compress is to be cautiously introduced into the
vagina, to support the parts. Great attention is to be paid to cleanliness.
CHAP. III.
NOTE 1. p. 74.—Mr. White of Paisley describes it very well, as resem-
bling a printer's ball. Med. Com. vol. XX. p. 147. Sometimes it does not
pass through the os uteri. Denman, II. p. 351.
Mangetus, lib. IV. p. 1019, relates a fatal case, where the tumor 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, subultus, &c The subultus and frequent pulse continued for some
days, with smart fever, and inability to move. Med. and Phys. Jour vol. VI.
317
p. 50j. In the same volume, Mr. Primrose gives an instance where a grate
part ofthe uterus sloughed off, and the woman recovered.
NOTE 2. p. 75.—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 contin-
ued in Dr. Hamilton's case, Com. XVI. p. 315.
NOTE 3. p. 77.—The inverted uterus has been torn off with the crotchet,
Deing mistaken for the child's head.Jour.de Med. Tom. XLI. p. 40. A case of
successful extirpation is inserted in the same work for August 1786. Wris-
_ berg relates a case, where it was cut off by the midwife who had inverted it.
A successful case is given by Dr. Clarke, in Edin. Med. and Surg. Jour. vol.
II. p. 419. Another case is mentioned in the Recueil des Actes de la Societe
de Lyon. Mr. Hunter of Dumbarton gives a successful case, in Annals of
Med. vol. IV. 366. I have particularly examined this woman, several years
after the operation. Shewas delivered without any violence, after having been
twenty-four hours in labour. In about an hour the placenta came away. She
had considerable flooding and great weakness. She could not void her urine,
which in two days was drawn off with the catheter, and this was frequently
repeated. A fortnight after delivery, the womb came down, with pains. It
was replaced, but again came down. A foetid discharge took place, and the
woman waB reduced to a state of great weakness. A ligature was applied,
which, she says,' gave her a good deal of pain, and the tumor 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 pre-
sent, the vagina is of the usual length ; and at the top, a transverse aper-
ture 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 soft-
er than the os uteri, in a natural state. There is no cervix uteri. The mam-
mae are firm, and of good size, and she has not lost the sexual desire. She
is subject so dyspepsia. From the preparation in the possession of Dr. Jef-
fray, 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.
■as
chap. i\.
Page 85, /. 7.—When a patient is known to be subject to syncope or spasmodic
disease after delivery, a dose of spt. amnion, arom. combined with tincture 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. 104.—Dr. Denman, Vol. II. p. 493, considers puerperal fever as
contagious. He strongly advises early bleeding, giving an emetic or anrimo-
nial, so as to vomit, purge, or cause perspiration j and if this does good, he re-
peats 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 diarr-
hoea, he employs emollient clysters. The strength is to be supported by spt.
ether nit. or other cordials.
Dr. Leak, Vol.11, trusts much to blood-letting; if the patient be sick, he
gives a gentle vomit; if not, laxatives, and then antimonials; applies blisters,
and in the end restrains purging with opiates, and prescribes bark.
Dr. Gordon, p. 77, et seqr. depends on early and copious blood-letting, tak-
ing 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, bleed-
ing, though it be feeble.
Dr. Butter purges and bleeds only where there is well marked inflammation,
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.
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. Doulcet advises repeated emetics, followed by oily potions, and bark,
combined with camphor.
Mr. Whyte is against blood-letting. He gives at first a gentle emetic, fol-
lowed 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, together
with a moderate quantity of wine, along with sago. If there be much purg-
ing, the bark is to be omitted, till some rhubarb be given, or a vomit, if there
be little pain in the belly.^
319
Dr. Kirkland bleeds only if the patient have had but 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 inter-
mediate state. In the first he bleeds and purges, in the second he begins 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, Allen, 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 delivery, but becomes formed about the third day after it. He has
five different species. 1st. The gastrobilious, proceeding from accumulation
of bile during pregnancy. The essential symptom of this species is intense
pain in the hypogaslrium. 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 vio-
lent, that bilious matter is absorbed. It is marked by great debility, small or
intermitting pulse, tumor of the hypogastrium, with sharp pain and putrid
symptoms, aphthx, vomiting, foetid stools, &c. He advises vomits, laxatives,
and bark in great doses, with mineral acids, and clysters containing camphor.
3d, The pituitous fever, attended with vomiting of pituita. The surface is
pale, the pulse has not the force or frequency it has on the former species,
the heat in general not increased, anxiety, weight, and vertigo, rather than
pain of head, often miliary spots, and the usual symptoms of pain in the
belly, and subsidence of the breasts. He gives vomits, and afterwards three
or four grains of ipecacuanha every three hours. If he uses purgatives, he
conjoins them with tonics. 4th, With phlogistic affection, or inflammation of
the womb, attended with great weight about the pelvis, swelling, pain, and
hardness in the lower belly, suppression of evacuations, sharp frequent pulse,
acute fever, and the countenance not so sunk as in the putrid disease. He
advises venesection, leeches, and low diet- The same remedies, with blis-
ters, are to be used, if pleuritic symptoms occur. 5th, Sporadic fever, pro-
ceeding from cold, passions of the mind, &c. Puerperal fever he considers
as apt to terminate in milky deposits in the brain, chest, legs, &c.
When upon this subject, it may not be improper to mention, that a young
practitioner may mistake spasmodic affections, or cholic 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 ofthe belly, and the patient is troubled with flatulence. It re-
$20
quires Jaxatives, antispasmodics, anodyne clysters, and friction with campho-
rated spirits. Blood drawn in this disease, after it has continued for some
hours, even when the woman is not in childbed, is sizy, and it is always so
in the puerperal, as well as the pregnant state, although the woman be well
(HAP. WII.
NOTE, p. 108,/. S,—In some instances, the patient has been sensible ofthe
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 appear-
ed. After the pain and swelling have gone oil", the muscles are in some
ca:es left paralytic, and the joints loose and weak-
CHAP. XXII.
Page 121,/. 8.—Some women feel, after lyingin, 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 isrelieved by the appli-
cation of a broad firm band round the belly. This is also useful, especially
when made to act upon the hips, in that kind of uneasiness and dragging,
which is felt about the haunches and sacrum, or loins, when the uterus threat-
ens to prolapse in consequence of walking too soon after delivery. These
sensations, together with the disease, will continue long, and increase, if at-
tention be not paid.
Pain in the side, or in the abdomen, which is sometimes produced by nurs-
ing, is often relieved by friction, warm plasters, and an invigorating plan.
General weakness require tonics, which must be varied.
BOOK V.
CHAP. I.
$ 2. p- 128.—The white substance, found on the skin of new-born chil-
dren, feels unctuous like butter, but it does not melt by heat- When held in
the fire on a spatula, it soon resembles curd, and then crackles or detonates,
and flies off in small portions. It dissolves readily in spirit of wine, or oil of
turpentine, or fixed oils, and hence butter is sometimes used for removing it;
but it is also rendered miscible with water by means of soap.
NOTE 1- p. 131.—In chusing a nurse, it is necessary to be satisfied that
she enjoys good health, and has an adequate supply of milk. Certain rules
321
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
excoriated 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 accustom-
ed to. It is also proper that she be employed in some little duty in the fami-
ly, otherwise she becomes indolent and overgrown.
CHAP. IV.
i 7. p. 157.—The ignis sylvestris is sometimes accompanied with consider-
able inflammation round the small pustules on the face, which are intermix-
ed with herpetic spots and vesicles. This affection is very itchy. It is cured
by bathing the parts frequently with lemon juice, or applying an ointment
containing camphor and sulphur. An eruption of papulae like prurigo, or of
small vesicles with inflamed margins, sometimes appears at the same time
on the arms, and requires similar applications.
$ 17. p. 170>—The pityriasis seems sometimes to be infectious. A variety
of it appears like small red marks on the scalp. The circumference extends
and continues red, whilst the center becomes pale and scaly. It is accom-
panied with falling off of the hair.
NOTE 1. p. 188.—M. Mahon, from his observations in l'Hospice de
Vaugirard, says, that the symptoms appear as follows, trie most frequent
being put first. Ophthalmy ; purulent spots ; ulcerations ; tumors ; chancres
on the mouth, and aphthae; livid, ulcerating, and scabbing pustules : chan-
cres on the genitals, and about the anus ; excrescences ; peeling off of the
nails of the feet and hands.
NOTE 2. p. 188—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 part dry and clean, will enable the practitioner
to form a diagnosis, and the aspect ofthe sores will assist him. This frev-
$22
ting of thfe parts, and even some degree of excrescence may attend pr>oria.':i~,
and the herpetic spots of children formerly described j and in this case, e^
pecially 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 dis-
ease. Many children are rashly put upon a course of mercury, who do not
require it ; perhaps, because the practitioner thinks it a point of honour, to
determine the nature of the disease at the first glance.
NOTE 3. p. 192.—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 ten-
sion, and hardness 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 sen-
sation 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. 198.—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 wi'l 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 blis-
ters, 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
considerable, 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 sur-
face, 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 seqr.
323
CHAP. V.
NOTE, p. 230, /. 20.—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, as the pain is increased by exercise, 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 muscles of the eye, and is increased by looking
long at any object The patient is easily agitated, and, at a more advanced age,
would fccsaid to be hysterical. Laxatives, bark, and sea bathing, are useful
veil. if.
2 6
INDEX.
f£jp The letter n. after tbe number ofthe page, indicates that the article referred
to is contained in a note.
A
ABERNETHY, his mode of treating congenite marks, vol,
ii. page 138,139
Abscess in the labium, i. p. 43
.-------mammary, ii. p. 117
Abdomen, distention of, effect of pregnancy, i. p. 184.
,________gentle pressure on, excites uterine contraction, ii.
p. 63
Abortion, i. p. 195
Acid, citric, to be introduced into uterus in hemorrhage, ii.
p. 66 n.
Adams, Dr., his remarks on inoculation, ii. p. 198
After-pains, and treatment of, ii. p. 77 and seq.
___________distinguished from inflammation of uterus, &c.
ii. p. 78
Air, cool, proper in uterine hemorrhage, ii. p. 64
Amenorrhoea, i. p. 108.
Anus, excoriation about the, ii. p. 169
_,,..- imperforated, ii. p. 135
Aphthae of children, ii. p. 181
______- treatment of, ii. p. 184
.______on the tonsils, ii. p. 185
Arteries of the pelvis, i. p. 16 •
Articulation of bones of pelvis, i. p. 7
Ascarides, ii. p. 278
Ascaris lumbricoides, ii. p. 279
Ascites, effect of pregnancy, 1. p. 177
Asthma, acute of children, &c. ii. p. 245
.________treatment, ii. p. 246
Axis of the brim, and outlet of the pelvis, i. p. 23,
32&
INDEX.
£
Baudelocque, his positions of vertex explained, i. p. 281 and
ii. p. 293
■ ■ preternatural presentations—Table, i. p. 341
Bandage to be applied after delivery, ii. p. 58
Bathing, cold, when proper for infants, ii. p. 130
Bladder, its distention may produce puerperal convulsions, ii.
p. 49
■ ■ affections of, i. p. 63
..... -------the effect of pregnancy, i. p. 169
Blemishes and marks, ii. p. 138
Blisters to the head proper in puerperal convulsions, ii. p. i?>
---1- ■ ■ used to remove marks in infants, ii. p. 138
Boils and pustules in children, ii. p. 173
Bowels, constipated, producing fever, ii. p. 92
Brain, inflammation of the coverings of, ii. p. 113
Breech, presentation of, i. p. 317
Brim of pelvis, description of, i. p. 19
Breasts, swelling of, in infants, ii. p. 141
Bronchocele, after parturition, ii. p. 11^
Bronchitis, infantile, ii. p. 253
—' i treatment, ii. p. 254
Burns and scalds in infants, how cured, ii. p. 142
Bryce,. his use of vaccine scab, ii. p. 201.
C
Cavity of pelvis described, i. p. 20
CauiiHo-ver excrescence from the os uteri, i. p. 78
Calculi in uterus, i. p. 80
Camphor recommended in puerperal convulsions, ii. p. 50, ol
Cardialgia, effeet of pregnancy, i. p. 164
Cathartics proper after delivery, ii. p. 60
Cathartic to be given on 3rd day after parturition, ii. p. 90 n,
----------proper in intestinal fever, ii. p. 93
Canker or ulceration of gums, ii. p. 179
Catarrh, infantile, ii. p. 253
Cheek, erosion of, in children, ii. p. 179
INDEX,
527
Cheek, gangrene of, ii. p. 180
Chicken-pox, ii. p. 205
Children, on the management and diseases of, ii. p. 12* &
seq.
,_________still-born, treatment of, ii. p. 125
Child-murder, signs of, not decisive, ii. p. 127
Chorea, sancti viti, ii. p. 238
Citric acid, applied to uterus in hemorrhage, ii. p. 66 n.
Clitoris, description of, i. p. 35
__------diseases of, i. p. 51
Clysters, stimulating, recommended in puerperal convul-
sions, ii. p. 49
,______— proper after delivery, ii.p. 60
Cleanliness, dress and temperature of children, ii. p. 128
Coccyx, os, description of, i. p. 6
Conception, i. p. 122
Contraction, uterine, two kinds, i. p. 234
Coloured spots, effects of pregnancy, i. p. 171
Cough and dyspnoea, effect of pregnancy, i. p. 173
Convulsions, effect of pregnancy, i. p. 174
■______ in infants, ii. p. 232
______.----- treatment, ii. p. 235
____________attending hooping-cough, ii. p. 251
____________puerperal, ii. p. 45—venesection recommended
in, ii. p. 49—jugular vein to be opened, ibid.—enema stimu-
lating, proper, ibid.—blisters to the head, ibid.—purgatives
proper, ii. p. 50, 51—bladder to be evacuated, ii. p. 50—deli-
Tery ofthe child, when proper, ii. p. 50, 55, 56—opium, musk
and camphor, their use, ibid.—emetics not useful, ibid.—cam-
phor recommended by Hamilton, ii. p. 51
Cold, the application of, recommended in uterine hemorrhage,
ii. p. 65
Cold bathing, when proper for infants, ii. p. 130
Cooper, Astley, his mode of treating spina bifida, ii. p. 137
Corpus luteum, appearance of, after miscarriage, ii. p. 123
Cord, umbilical, how to be tied, ii. p. 124
Coagula, retention of in uterus, and expulsion* ii. p. 71
328 INDEX.
Contraction of uterus, how produced in flooding, ii. p. 72
Colic, after delivery, ii. p. 85
-----in infants, ii. p. 271
Costiveness, effect of pregnancy, i. p. 165
-----------in children, ii. p. 270
Cow-pox, or vaccine inoculation, ii. p. 199
--------spurious, ii. p. 200
--------test of, ii. p. 202
Cramp, effect of pregnancy, i. p. 184
------in stomach after delivery, ii. p. 86
Crinones, a species of pustule, ii. p. 174
Croup, ii. p. 240
treatment, ii. p. 241
------spasmodic, ii. p. 245
----------------treatment, ii. p. 246
Crusta lactea, ii. p. 157
Cutaneous diseases of infants, ii. p. 151
Cynanche trachealis, ii. p. 240
----------treatment, ii. p. 241
D
Death, sudden, from uterine hemorrhage, ii. p. 62
Decidua, membrane, i. p. 146
Deformity of pelvis from rickets, i. p. 28
------.—— from malacosteon, i. p. 29
----------from exostosis and tumours, i. p. 31
Delivery, treatment after, ii. p. 58
---------speedy, when proper in puerperal convulsions, ii.
p. 50, 55, 56
--------recent, signs of, ii. p. 121
Dentition, ii. p. 147
--------producing spasm of wind-pipe, ii. p. 248
Despondency, effect of pregnancy, i. p. 185
Dimensions of the pelvis, i. p. 19
Diet, what proper in the puerperal state, ii. p. 60
----proper for infants, ii. p. 130
Diarrhrea, effect of pregnancy, i. p. 167
INDEX. 329
Diarrhoea, after parturition, ii. p. 115
---------attending dentition, ii. p. 150
----------of children, ii. p. 259
------------->—----treatment, ii. p. 265
Diseases of organs of generation, i. p. 43
--------of pregnant women, i. p. 158
--------of infants, congenite and surgical, ii. p. 134 and seq.
■■ cutaneous, of infants, ii. p. 151
Douglas's case of rupture of uterus, ii. p. 52
Dress of infants, ii. p. 12 9 and 134.
Dropsy of the ovarium, i. p. 97
Dyspnoea and cough, effect of pregnancy, i. p. 173
--------in the puerperal state, ii. p. 85
Dysmenorrhcea, i. p. 116
E
Ears, foetid discharge from, ii. p. 143
----excoriation behind the, ii. p. 177
Ear-ache in infants, how to be treated, ii. p. 143
Ecthyma, a species of pustule, ii. p. 173
Eczema mercuriale, in infants, ii. p. 190
Emetics, their use doubtful in puerperal convulsions, ii. p. 50.
-------occasion expulsion of portions of the placenta, ii.
p. 72
--------proper in intestinal fever, ii. p. 93
Enemata, stimulating, proper in puerperal convulsions, ii,
p. 49
Enteritis of infants, ii. p. 272
Ephemeral fever or weed, ii. p. 86
___----------treatment, ii. p. 88
Erethema nodosum, of Dr. Willan, ii. p. 177
Erosion of the cheek, ii. p. 179
Eruption, miliary, of infants, ii. p. 160
---------anomalous, of infants, ii. p. 158
Erythema of infants, ii. p. 176
Erysipelas of infants, ii. p. 175
Evrat, his mode of checking uterine hemorrhage, ii. p. 66 n.
330
INDEX.
Excrescences ofthe labia, i. p. 17
Extra-uterine pregnancy, i. p. 150
—----------■------------treatment of, i. p. 153
Examination, per vaginam, i. p. 291
Exanthema, or herpes labialis, ii. p. 165
Excoriation of nipples, ii. p. 119
Excoriation behind the ears in infants, ii, p. 177
-----------of the tongue, ii. p. 186
— ■ ■ ■■----about the anus, ii. p. 169
■----------of navel in infants, ii. p. 142
Eyes, inflammation of, in infants, ii. p. 14*
Eye, spongoid disease of, in infants, ii. 144
F
Fallopian tubes, description of, i. p. 42
Fastidious taste, effect of pregnancy, i. p. 164
Febrile state of pregnancy, i. p. 160
Fever, milk, how obviated and relieved, ii. p. 60
-.......- milk, ii. p. 89
-----------treatment of, ii. p. 90,
—----ephemeral, or weed, ii. p. 86
-----------------treatment of, ii. p. 88
------miliary, ii. p. 90
_— , , treatment of, ii. p. 91, 92
------intestinal, ii. p. 92
------—-------treatment of, ii. p. 93
—----puerp- ral, ii. p. 101
----------------treatment of, ii. p. 104
------• in infants, ii. p. 286
■ • remittent, of older children, ii. p. 288
Fits, inward, ii. p. 233
Flooding from a detachment of part of the placenta, i. p. 23U
--------treatment proper in, vide hemorrhage, uterine.
Fluor albus, i. p. 59
Foetus, description of, i. p. 131
. peculiarities of, i. p. 136
INDEX.
331
Froenum of tongue, division of, seldom necessary, ii. p. 140
Furunculus, or acute boil, ii. p. 113
G
Gangrene of the cheek in children, ii. p. 180
Generation, external organs of, i. p. 34
-----------internal organs of, i. p. 38
Goklson's case of rupture of uterus, ii. p. 52
Griflitts, Dr., on vaccine scab or crust, ii. p. 201
Gums, on the treatment of, in dentition, ii. p. 149
------ulceration of, in children, ii. p. 178
H
Hand, introduced into the uterus in uterine hemorrhage, ii.
p. 65
Hare-lip of infants, ii. p. 134
Hemorrhage, uterine, i. p. 233
—--------•--------from retention of partx)f placenta, ii. p.
81
-------------------causes of, i, p. 238
-------------------effects of, i. p. 243
-------------------remedies for, i. p. 245
---------------from connexion of the placenta with
os uteri, i. p. 235
-------------------after delivery ii. p. 61 and seq.
--------------------symptoms of, ii. p. 63
-------------------apparent and concealed, ii* p. 69
-------------------after expulsion of placenta, ii. p. 71
-------------------pressure and bandage proper, ibid.
-------------------cold applications proper in, ii. p. 65, 66
—hand to be introduced, ii. p. 65—placenta not to be hastily
extracted, ii. p. 66—uterus to be stimulated, and how, ibid.
—Le Roy's advice injudicious, ii. p. 65 n.—Ice to be intro-
duced into uterus, ii. p. 66—Citric acid to be introduced, ibid,
11.—rest to be enjoined, ii. p. 67
Hemoptysis, effect of pregnancy, i. p. 173
vol. n. 2 t
332 INDEX.
Hemateniesis, effect of pregnancy, i. p. 173
Head of child, and its progress through the pelvis in labour,
i. p. 23
Head-ach, effect of pregnancy, i. p. 17 V
Heartburn, effect of pregnancy, i. p. 164
Heart, diseases of, may occasion death immediately after de-
livery, ii. p. 6.2 n.
------malformed, ii. p. 1 i t
Hernia, i. p. 49
------of uterus, i. p. 96
------umbilical, ii. p. 136
Herpes of infants, ii. p. 163
—----farinosus, ii. p. 16V
------miliaris, ii. p. 165
------labialis, or exanthema, ii. p. 165
------cxedens, ii. p. 166
------farinosus, ii. p. 166
Herpetic ulcer, ii. p. 167
Hectic fever, from retention of placenta, ii. p. 81
Hemiplegia, [puerperarum,] ii. p. Ill
Hepatitis of infants, ii. p. 283
Hives, or croup, ii. p. 210
------treatment, ii. p. 241
Hour-glass contraction of uterus, ii. p. 63
Hooping-cough, ii. p. 249
---------------treatment, ii. p. 250
Hull, Dr., his theory of phlegmatia dolens, ii. p. 610
Hymen, and orifice of vagina, i. p. 36
------diseases of, i. p. 52
Hydatids, ofthe uterus, i. p. 87
Hysteritis, i. p. 69
Hysteralgia, symptoms of, ii. p. 79 and seq.
------------distinguished from inflammation, ii, p. 80
----.--------treatment of, ii. p. 80
Hydrocele of infants, ii. p. 1VI
Hydrocephalus, acute, history, ii. p. 223
---------------treatment, ii. p. 228
---------------chronic, history, ii. p. 231
INDEX 333
Hydrocephalus, chronic, treatment, ii. p. 231
'------------secondary, ii. p. 231
I
Ice, to be introduced into uterus in uterine hemorrhage, ii.
p. 66
Ichthyosis of children, ii. p. 167
Ignis sacer, ii. p. 166
Imperforated anus, urethra, &c. ii. p. 135
Impetigo of children, ii. p. 169
Inflammation of viscera distinguished from after pains, ii.
p. 79
-------------distinguished from hysteralgia, ii. p. 80
-------------of uterus, ii. p. 94
-------------slight, ii. p. 94
------------------treatment of, ii. p. 95, 96
-------------of uterus, extensive, ii. p. 95, 96
---------------------treatment of, ii. p. 97
-------------peritoneal, ii. p. 98
-----------------------treatment of, ii. p. 99,100
-------------ofthe brain after delivery, ii. p. 113
-------------of mammae, after delivery, ii. p. 116
_—-----------of pleura, ii. p. 254
-------------of stomach, ii. p. 256
Inferior extremities, presentation of, i. p. 321
Intestinal fever, ii. p. 92
_____________treatment of, ii, p. 93
Intestine, protrusion of, at the umbilicus, ii. p. 136
Inoculation for small-pox, ii. p. 197
Intertrigo, ii. p." 156
Inversion of uterus, a cause of flooding, ii. p. 70
_________ii. p. 73 and seq.
_________its symptoms and causes, ii. p. 71
Inversion of uterus, its termination and treatment, ii. p. 75
_________partial, of uterus, ii. p. 76
_______________its treatment, ii. p. 76. n
•>J4 INDEX.
Inversion of uterus, distinguished from prolapsus, &c. ii. p. 7 7
Intussusceptio connected with diarrhoea, ii. p. 263
Invagination of intestines, frequent cause of diarrhoea, ii.
p. 263
Itch, or scabies, ii. p. 162
-----dry, of children, ii. p. 168
J
Jaundice, effect of pregnancy, i. p. 170
--------of infants, ii. p. 2S1
Junction, sacro-iliac, of pelvis, i. p. 8
--------vertebral, of pelvis, i. p. 9
Jugular vein to be opened in puerperal convulsions, ii. p. 49
K i
Kidney, pain in the region of, after delivery, ii. p. Ha
L
Labia, and nymphse, description of, i. p. 31
------abscess in the, i. p. 43
------ulceration of, i. p. 14
------excrescencies of, i. p. 47
—-----scirrhous tumours of, i. p. 48
------polypous tumours of, i. p. 48
------oedema of, i. p. 49
Laceration of parts of generation, i. p. 50
Labours, classification of, i. p. 280
Labour, natural, i. p 285
------stages of, i p. 285
------causes of, i. p. 300
------management of, i. p. 302
------premature, i. p. 313
------preternatural, i. p. 315
Laudanum, proper to prevent uterine hemorrhage, ii. p. 64
Le Roy, his advice in uterine hemorrhage, ii. p. 65 n. 67 n.
INDEX.
335
Lemon juice to be introduced into uterus in hemorrhage, ii.
p. 66 n.
Leg, swelled, or phlegmatia dolens, ii. p. 106
-------:— treatment of, ii. p. 109
Liquor amnii, and membranes, i. p. 145
----------redundance of, i. p. 179
Ligaments, diseases of, i. p. 103
Liver, diseased, of infants, ii. p. 282
______a diseased state of, frequently attends diarrhoea, ii.
p. 264
Lichen, ii. p. 155
^------lividus, ii. p. 174
Lochia, profuse, from rising too soon after delivery, ii. p. 61
Lochial discharge obstructed in hysteralgia, ii. p. 80
Lymphatics of pelvis, i. p. 19
M
Mastodynia, effect of pregnancy, i. p. 176
Mania, puerperal, ii p 111
------treatment of, ii. p. 112
Mamma, inflammation of, after delivery, ii. p. 116
--------abscess of, ii. p. 117
Malformed heart, ii. p. 141
Management and diseases of children, ii. p. 124 and seq.
Marks and blemishes, ii. p. 138
Marasmus of infants, ii. p. 273
Menstruation, i. p. 103
.________Hunter's theory of, i. p. 106
. ________diseases of, i. p. 108
Menses, cessation of, i. p. 121
Menorrhagia, i. p. 117
.____________lochialis, ii. p. 71
.____.________lochialis, treatment of, ii. p. 73
Membranes and liquor amnii, i. p. 145
Meconium, how to be evacuated, ii. p. 131
Meatus auditorius, imperforated, ii. p. 136
> o (5
INDEX.
Melancholy, puerperal, ii. p. 113
Mercurial disease in infants, ii. p. 190
.Measles, ii. p. 216
--------treatment of, ii. p. 219
Milk, secretion of, when it takes place, ii. p. 60
Milk-fever, how obviated, ii. p. 60
----------ii. p. 89
----------treatment of, ii. p. 90
Milk, as the diet of infants, ii. p. 131
Miscarriage, recent, signs of, ii. p. 121
Miliary fever, ii. p. 90
-------------treatment of, ii. p. 91. 92
Miliary eruption in infants, ii. p. 160
Moles, i. p. 86
Monsters and plurality of children, i. p. 337
Monro's case of rupture of uterus, ii. p. 52
Muscles of pelvis, i. p. 15
Muscular pain, effect of pregnancy, i. p. 182
Musk recommended in puerperal convulsions, ii. p. 50
N
Natural labour, description of, i. p. 285
Navel, excoriation of, in infants, ii. p. 142
Navel-string, how to be tied, ii. p. 121
Nervous and spasmodic diseases in the puerperal state, ii.
p. 81
Nerves of pelvis, i. p. 17
Nettle-rash, or urticaria, ii. p. 207
Nipples, excoriation of, ii. p. 119
Nose, foetid secretion from, ii. p. 113
Noma, or gangrene of the cheek, &c. in infants, ii. p. 180
Nymphse, diseases of, i. p. 50
0
Obliquity of pelvis, i. p. 9
(Edema of labia, i. p. 49
INDEX. 337
OSdeina, effect of pregnancy, i. p. 49
(Esophagus, rupture of, ii. p. 259
Oleum tcrebinthime, reeommended in taenia, ii. p. 280 n%
Opium, when proper in puerperal convulsions, ii. p. 50, 51
Opiates recommended in flooding after delivery, ii. p. 68, 72
Opthalmia infantilis, ii. p. 144
Os uteri, rigidity of, cause of rupture of uterus, ii. p. 52
________cauliflower, excrescence of, i. p. 78
Ossa innominata, description of, i. p. 2
Outlet of pelvis, i. p. 20
Ovaria, description of, i. p. 43
------dropsy of, i. p. 97
______other diseases, of i. p. 102
______. deficiency of, i. p. 103
Ovum, its connection with the uterus, i. p. 233
______hemorrhage, from its separation, i. p. 233
______blood effused in consequence of a partial detachment
of, i. p. 237
P
Palpitation, effect of pregnancy, i. p. 171
Pains, false, i. p. 277
Parturition, i. p. 280
Palpitation after delivery, ii. p. 84
Paralysis [puerperarum], ii. p. HO
Parrish, Dr., on scrofula interna, ii. p. 255 n.
Pelvis, bones of, general view, i. p. 1
______difference of female from male, i. p. 13
______brim and outlet of, i. p. 19
______above the brim, i. p. 22
Perinseum, laceration of, i. p. 53
Peritoneal inflammation, ii. p. 98
________treatment of, ii. p. 99, 100
Peritonitis puerperal is, ii. p. 98
__________. treatment of, ii. p. 99,100
Peritoneum, chronic inflammation of, ii. p. 101
338
INDEX.
Peritonitis in infants, ii. p. 272
Pemphigus of infants, ii. p. 159
Petechias, sine febrc, ii. p. 174
Pertussis, ii. p. 219
--------treatment, ii. p. 250
Phagedenic herpes, ii. p. 166
Phlegmatia dolens [puerperarum] ii. p. 106
-----------treatment of, ii. p. 109
Phrcnitis, puerperal, ii. p. 112
Phymosis of infants, ii. p. Ill
Phyma, or tedious ooil, ii. p. 173
Philadelphia, success of vaccination in, ii p. 20* n.
Pityriasis, or dandriff of children, ii. p. 170
Placenta, description of, i. p. 143
---------treatment after expulsion of, ii. p. 58
---------hemorrhage, after expulsion of, i. p. 61 and seq.
---------not to be hastily extracted in uterine hemorrhage,
% ii. p. 61, 65
---------portion of, remaining keeps up flooding, ii. p. 72
------------------how to be treated, ibid.
---------rashness in extracting, occasions inversion of ute-
rus, p. ii. 74
---------retention of part of, ii. p.. 81
_---------------treatment of, ii. p. 82
Plurality of children and monsters, i. p. 337
Pleurisy in the puerperal state, ii. p. 84
Pleura, inflammation of, in children, ii. p. 254
Pleuritis in infants, ii. p. 254
Pneumonia in the puerperal state, ii. p. 84
Presentation of breech, i. p. 317
___________of the inferior extremities, i. p. 321
__---------of superior extremities, i. p. 323
___________. ofthe trunk, i. p. 331
___________presentation of the umbjlical cord, i. p. 336
___________requiring turning, tabic of, i. p. 342
Polypous tumours of labia, i. p. 43
Polypi of uterus, i. p. 80
. , malignant, i. p. 8Sj
INDEX. 339
Posture erect, improper immediately after delivery, ii. p. 59
Pompholyx of infants, ii. p. 159
Porrigo, or scabies capitis, ii. p. 171
Pregnancy, extra-uterine, i. p. 150
----------signs of, i. p. 155
----------general effects of, i. p. 158
----------febrile state of, i. p. 160
Pregnant women, diseases of, i. p. 158
_______________treatment of, i. p. 195
Premature labour, i. p. 313
Preternatural labour, i. p. 315
Prolapsus uteri, i. p. 90
______________from rising too soon after delivery, ii. p. 61
—------ani, in infants, ii. p. 141
90
Prurigo of infants, ii. p. 161
Psoriasis of Dr. Willan, ii. p. 168
Puerperal state, treatment proper in, ii. p. 58 & seq.
Purge to be given on third day after parturition, is. p.
Purgatives recommended in puerperal convulsions, n. p. -*
& 51
Purpura, or petechias sinefebre, ii. p. 174
Pubis symphysis, description of, i. p. 7
Puerperal fever, ii. p. lOl
____________— distinguished from peritonitis, ii. p. I0o
______________treatment of, ii. p. 104
Puerperal mania, ii. p. Ill
,-------treatment of, ii. p. H2
Pustules and boils in children, ii. p. 173
R
Retention of part of the placenta, ii. p. 81
_______________\__________—treatment of, ii. p- 82
Respiration, how excited in new born children, ii. P- 126
Rheumatism distinguished from after-pains, ii P- 79
Rigidity ofthe os uteri, cause of rupture of uterus, n. p. °<*
Rickets, ii. p. 146
Roseola annulata, of Dr. Willan. ii. p. 208
vot<. u. 2 v
*>40 INDEX.
Roseola, infantilis sometimes mistaken for scarlatina, ii. p.
213
-------sestiva, ii. p. 221
------autumnalis, ii. p. 222
------infantilis, ii. p. 222
Rupture of the uterus, ii. p. 51
-------of the vagina, ii. p. 52
Rubeola or measles, ii. p. 216
-------treatment of, ii. p. 219
-------sine catarrho, ii. p. 221
S
Sacrum, os, description of, i. p. 5
Sacro-iliac junction, i. p. 8
Salivation, effect of pregnancy, i. p. 175
Scirrhous tumours of labia, i. p. 48
Scirrho-cancer in uterus, i. p. 72
Scalp, swelling of in infants, ii. p. 139
Scalds and burns in infants, how cured, ii, p. 142
Scrofula, ii. p. 145
--------treatment of, ibid.
Scabies capitis, or porrigo, ii. p. 171
Scabs from vermin, ii. p. 172
Scab, vaccine, employed in vaccination, ii. p. 201
Scarlatina simplex, ii. p. 209
---------.--------treatment of, p. 213
--------- anginosa, id. p. 210
------'•------------treatment of, id. p. 213
--------- maligna, id. p. 212
------------------treatment ef, id. p. 214, 215
Scrofula, interna of infants, ii. p. 255 n.
Scabies, or true itch, ii. p. 163
Separation of the bones of pelvis, i. p. 9
Secretion of urine diminished, ii. p. 57
Signs that a woman has been recently delivered, ii. p. 121
Skin-bound, ii. p. 190
--------- treatment of, id. p. 192
INDEX. 341
Sleeping not to be entirely prevented in flooding cases, ii. p. 69
Small-pox, distinct, ii. p. 192
-------— confluent, id. p. 195
Small-pox, re-infection from, ii. p. 203
Sore throat of infants, ii. p. 186
Spongoid tumour, i. p. 76
Spasmodic and nervous diseases in the puerperal state, ii. p.
84.
Spina bifida, ii. p. 137
Spongoid disease of the eye in infants, ii. p. 144
Spleen enlarged in infants, ii. p. 285
Spasms of wind-pipe in children, ii. p. 248
Stomach and duodenum, spasms of, i. p. 165
--------to be watched in uterine hemorrhage, ii. p. 68
--------inflammation of, in infants, ii. p. 256
-----------------------treatment, id. p. 257
Sterrility, i. p. 149
Stimulants generally improper after delivery, ii. p. 59
Strangury, ii. p. 83
Still-born children, treatment of, ii. p. 125
Strophulus intertinctus, ii. p. 151
---------albidus, id. p. 153
■ . confertus, ibid.
< candidus, id. p. 155
Superior extremities, presentation of, i. p. 323
Suppression of urine after delivery, ii. p. 56, 59
Swelled leg of puerperal women, id. p. 106
------_— treatment of, id. p. 109
Swathing infants, formerly practised, id. p. 129
Swelling of the breasts in infants, id. p. 141
Swine-pox, id. p. 207
Symphysis pubis, description of, i. p. 7
Syncope, effect of pregnancy, id. p. 172
_________produced by uterine hemorrhage, dangerous, ii. p.
68
__.— treatment proper in, ibid.
INDEX.
Syphylis in infants, ii. p. 186
--------treatment, id. p. 1S9
T
Table of presentations requiring turning, i. p. 342
Table of cases and presentations at I'Hospicc de la Maternite,
ii. p. 309
Tabes mesenterica, id. p. 271
Taenia, id. p. 280
Temperature proper for infants, id. p. 130
Teeth, on the formation and cutting of, id. p. 117, 148
'Tetter, dry. of infants, id. p. 161
-------scaly, of children, /,/. p. 168
Tcrminthus. a species of pustule,' id. p. 173
Thyroid gland, swelling of, id. p. ill
Throat, sore, in infants, id. p. 186
Tooth-ach, effect of pregnancy, i. p. 175
Torpor of uterus, occasioning flooding, ii. p. 62 k seq.
Tongue-tied, id. p. 139
Tongue, excoriation of, in infants, id. p. 186
Tonsils, aphthae on the, id. p. 185
Touching, or examination per vaginam, i. p. 291
Trunk, presentation ol", id. p. 331
Trismus nascentium, ii. p. 257
Trichuris, or long thread worm, id. p. 280
Tubes, fallopian, diseases of, i. p. 105
Tubercles in uterus, id. p. 75
Turning, Table of presentations requiring it, id. p. 5V2
Turpentine, oil of, used in expelling taenia, ii. p. 280 n.
Twins and monsters, i. p. 357
Tympanites of uterus, id. p. 90
U
I "Ice ration* of the la'jia, i. p. VI
.-------- of uterus, id. p. 70
---------ofthe gums in eLiiilren, ii. p. 178
INDEX. 343
Ulcer, herpetic, ii. p. 167
Umbilical, cord, i. p. 140
------. . . presentation of, id. p. 336
---------hernia, ii. p. 136
Undimiam of Avicenna, or humid erysipelas, id, p. 175
Uterus and its appendages, i. p. 40
------substance of, ibid.
------arteries of, id. p. 41
------nerves of, ibid,
------lymphatics of, ibid:.
------broad ligaments of, id. p. 42
■ . ■ round ligaments of, ibid.
------aqueous secretion from, id. p. 89
- ■■ ■ gravid, description of, id. p. 126
------developement of & state of it scervix, id, p. 127
------gravid, ligaments of, id. p. 129
------------. vessels of, id. p. 130
------retroversion of, effect of pregnancy, id, p. 186
■ antiversion of, effect of pregnancy, id, p. 192
------rupture of, effect of pregnancy, ibid,
■ rupture of, ii. p. 51
______symptoms of approaching rupture of, id, p. 53
__i----hour-glass, contraction of, id. p. 63
______torpor of, produces hemorrhage, id. p. 65
______ inversion of, id. p. 73 & seq.
__________________its symptoms and causes, id. p. 74
__________________terminations and treatment, id, p. 75
______inflammation of, id. p. 94
______________-------treatment of, id. p. 95, 96
______state of, after recent delivery, id. p. 121
Uterine hemorrhage, i. p. 233
___________________ after delivery, ii. p. 61 & seq.
____,_______________symptoms of, id. p. 63
______contraction, two kinds, i. p. 234
______contraction excited by gentle pressure on abdomen,
ii. p. 64
*
344 INDEX.
Uteri, prolapsus, from rising too soon after parturition, ii. p.
61
Urethra i. p. 35
-------excrescences in, id. p. 67
-------imperforated, ii. p. 136
Ureter, spasm of, effect of pregnancy, i. p. 185
Urine, suppression of, after delivery ii. p. 56
---- secretion diminished, id. p. 57, 59
----retention of, how caused by uterine hemorrhage, id. p.
71
Urticaria, or nettle-rash, id. p. 207
V
Vagina, description of, i. p. 38
. ■ imperfections of, id. p. 54
------* inflammation and gangrene of, id. p. 55
------- induration of, id. p. 56
-------ulceration of, ibid.
------- polypi of, ibid.
_----inversion of, ibid.
-------watery tumour of, id. p. 57
-------hernia of, ibid.
----.— encysted tumour and varices of, id. p. 58
-------erysipelatous, inflammation of, ibid.
-------rupture of, ii. p. 52
Varicose veins, effect of pregnancy, i. p. 182
Variola discreta, ii. p. 192
-------confluens, id. p. 195
Vaccination, id. p. 199
Varicella or cliicken-pox, id. p. 205
---------lenticular, id. p. 206
_________conoidal, ibid.
—i------swine or bleb, pox, id. p. 207
Vertebral junction and obliquity of pelvis, i. p. 9
Venesection recommended in puerperal convulsions, ii. p. 49
&50
INDEX.
345
Ventricles of heart, inequality of, may occasion death, ii. p.
62 n. '
Venereal disease in infants, ii. p. 186
-------------------------treatment, id. p. 189
Vermin, scabs from, id. p. 172
Vertex, six different presentations of, described, id. p. 293
Vomiting, effect of pregnancy, i. p. 162
■ . — sometimes useful in uterine hemorrhage, ii. p. 68
. . ■— in infants, id. p. 258
Vulva, gangrene of, in infants, id, p. 180
W
Watery discharge, effect of pregnancy, i. p. 181
Weed or ephemeral fever, ii. p. 86
----treatment of, id. p. 88
Weaning, treatment of women whilst, id. p. 121
--------period at which a child should be weaned, id. p. 133
Wine occasionally proper in uterine hemorrhage, id. p. 68
Willan, on cutaneous diseases, id. p. 151 & seq.
Wild fire, [eruption of infants] id. p. 165
Worms in uterus, i. p. 90
intestinal, ii. p. 278.
THE END.
AW. Wis*-.
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B#47r
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