-. /;■"■': / / ;- /'•;,' ■ NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 >■> U. S. Department of Health, Education, and Welfare Public Health Service I »< -^Wwt>;r.v\ *.\ ^;w^-ti I. &.&■> »ss^\ 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 () 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.( 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*-. U/2L B#47r 1113 \.:-iVs' '^ • '-*, >- s -*