ARMY MEDICAL LIBRARY FOUNDED 1836 WASHINGTON, D.C. / James's B^rns, Improved. THE PRINCIPLES MID W*IFE R Y: INCLUDING THE DISEASES WOMEN AND CHILDREN BY JOHN BURNS, M.D. REGIUS PROFESSOR OF SURGERY IN THE UNIVERSITY OF GLASGOW ETC. ETC. ETC. FROM THE SEVENTH LONDON EDITION, REVISED AND ENLARGED, WITH IMPROVEMENTS AND NOTES, BY T. C. JAMES, M.D. PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF PENNSYLVANIA. -----------p-^ecN censfiAi'se*' «■; OEC.-S—1901 NEW-YORK: |n ^ ^% CHARLES S. FRANCIS—252 BROADWAY. MUNROE & FRANClS^BpSTQH; M.DCCd.XX?fr: •. -.• ♦. / wa IS3I Entered, according to Act of Congress, in 1831, by Charles S. Francis, in the Clerk's Office, of the District Court of the Southern District of New-York. to* i ■ * ti - % New_«york : CLA\TON AND VAN MJKDF.N PRINTERS, 42 WILLIAM-STREET. ADVERTISEMENT BY THE EDITOR. TO HIS FIRST EDITION. The following highly flattering character of the ensuing work, was given in the Edinburgh Medical and Surgical Journal, for the year 1810; since which it has passed through four successive editions by the author, each of which has added considerably, not simply to the* size, but also to the intrinsic value of the work. " The author, equally experienced as a teacher and practi- tioner, has by a judicious arrangement, by a faithful exposi- tion of facts and observations, and by a methodical induction of the principles and practice of the art, accomplished in this work all that could be expected, in the present state of the science, to give a new interest to the subject. " The prominent advantage, that confers upon it a decided preference to all others, as a System or Class-book, is, that every subject, directly or indirectly connected with the practice of the accoucheur, is here brought into one connected view. " But what we are most disposed to recommend in this volume, is the pathological department, and the descriptions and treatment of the diseases of the puerperal women, and of children. A more copious, scientific, and judicious account of these diseases, is perhaps no where to be met with." One great advantage of this work to the student, solicitous of full and accurate information on the subjects of which it treats, is to be experienced in the very valuable notes and references of the author, to almost all that has been commu- nicated by practitioners of deserved celebrity on parallel sub- jects or cases. In this point of view, it may be considered as the Common-place book of an immense fund of the most useful practical knowledge, indispensable as a guide to the inexperience of the student, and earlier practitioner, and of no ordinary utility and aid to the maturer acquirements of advanced and established professional skill. This edition has been considerably enlarged and improved by the author. The sections on abortion and uterine haemor- rhage, will be found to have been very considerably extended, and rendered of far greater value;—indeed, they may now be considered, as containing the essence of his separate Trea- tises on those very interesting subjects, which have for some time enjoyed the approbation of the public. The new articles, totally omitted in the former edition, but IT by the author introduced into this, are those on pneumonia, on ephemeral fever, on weed or intestinal fever, and on diarrhoea, as existing in the puerperal state, and on chorea, on bronchitis, and on peritonitis, as the diseases of the infan- tile age. These, it is presumed, will not fail to give addition- al interest to the work. The editor has added a section on the difference be- tween the male and female pelvis ; which, as he conceived, the author ought not to have omitted ; and Dr. Clarke's ac- count of the cauliflower excrescence of the os uteri. Whether this is only a variety of the spongoid tumour, he will leave to the reader to decide. It appears to assume some difference in its form and train of symptoms. The history is from the pen of an accurate observer of nature, and a judicious and experienced practitioner. As Baudelocque has explained the mechanism of parturi- tion, more fully and minutely than almost any other writer, and as his work on midwifery has obtained considerable repu- tation with the medical public of the United States, it has been judged proper occasionally, to give a general view of his divisions of labour, together with the several species of pre- sentations, which it may be useful to keep in recollection in actual practice. Some tables, relative to this part of our sub- ject, from the last edition of his valuable work that have not, as far as we know, been hitherto translated, are also given in the appendix. These, it is hoped, will not be entirely devoid of interest, either to the student or practitioner. The chief mass of the notes in Dr. Chapman's edition of our author's production, have been, by permission, retained in this ; these are marked with the letter C. The notes added by the present editor, and those of the above mention- ed intelligent editor, of whose information we have availed ourselves, will be found to be altogether of a practical nature, and are intended solely to explain, or illustrate the text • as it has been found rarely necessary to differ in sentiment from one, whose opinions seems generally to be founded on the solid basis of practical truth. The author has rendered this fifth edition more interesting by some valuable additional matter, amounting to upwards of one hundred pages ; and the editor has subjoined a few notes which he hopes will not be found entirely nugatory. Philadelphia, November 9th, 1822. [The present edition is taken from the seventh London edition, which has been very considerably enlarged, as will be perceived by the author's preface. The notes and additions by the American editor have all been placed at the end of the work, with references in the text.] PREFACE. In preparing this work, I have endeavoured to proceed as much as possible upon the method of induction. I have collected with care the different cases which have been made public, as well as my own private observations. To these I have added the opinions and advices given by others, in so far as they seemed to be founded on facts, and supported by experience. From the whole I have deduced, in the different parts of my subject, both the symptoms and the practice. The anatomical descriptions I have given from dissections and preparations before me whilst writing. I intended to have added to the text copious re- ferences to the opinions and cases contained in sys- tems, or scattered through other publications. This would have rendered the present book, in some manner, an index to those already published, and been of considerable service to practitioners, who wished to consult them upon any particular point. But in spite of all my endeavours, the work has ex- tended to a length which rendered it necessary to strike out many references, and shorten the account of cases, to prevent it from swelling to a size wrhich would have rendered it less generally useful. Should this work fall only into the hands of those competent to judge in their profession, it would, if faulty or deficient, do little harm : but as it has been circulated extensively, it must, like other systems and elements, have an influence on the opinions and future practice of the student of midwifery ; and will prove useful or injurious to society, according to the correctness of the principles it contains. When I consider how important the diseases of women and VI children are, and how much depends on the prudent management of parturition, I feel the high responsi- bility which falls on those who presume to give lessons in midwifery. I do, however, sincerely trust, that the precepts I have inculcated shall be found agreeable to experience ;—and, on a review of the whole, I cannot say that I have either wasted the reader's time in idle theory, or misled his opinion by mere speculation. In preparing a seventh edition for the press, I have carefully revised the whole work. Six lines have been added to each page, so that this edition, though apparently smaller, has received additions, chiefly of a practical nature, equal to about sixty pages, as formerly printed. An index also has been added. Glasgow, June, 1828. CONTENTS BOOK I. OF THE STRUCTURE, FUNCTIONS, AND DISEASES OF THE PELVIS AND UTERINE SYSTEM, IN THE UNIMPREGNATED STATE, AND DURING GESTATION. CHAP. I.—Of the Bones of the Pelvis. J J r«g8 Section 1. General view *« 2. Ossa imnominata - - - - - *° 3. Sacrum and coccyx.....21 CHAP. II.—Of the Articulation of the Bones of the Pelvis, and their occasional separation. Section 1. Of the symphysis pubis . . . - 22 2. Sacro-iliac junction - - - . 3. Vertebral junction, and obliquity of the pelvis ib. 4. Separation of the bones ... - 24 CHAP. III.—Of the Soft Parts whicji line the Pelvis. Section 1. Muscles -...-.- 29 2. Arteries.......32 3. Nerves.......ib- 4. Lymphatics.....- 34 CHAP. IV.—Of the Dimensions of the Pelvis. Section 1. Brim and outlet ------ 34 2. Cavity.......36 3. Pelvis above the brim .... 37 4. Axis of the brim and outlet ... 38 CHAP. V.—Of the Head of the Child, and its progress through the Pelvis in Labour. Section 1. Bones of the head .... - 39 2. Size of the head 40 3. Passage of the head ... - - 41 CHAP. VI.—Of Diminished Capacity, and Deformity of the Pelvis. Section 1. Deformity from rickets .... 43 2. Deformity from tnalacosteon ... 45 3. Deformity from exostosis and tumours - - 47 4. Means of ascertaining the dimensions and size of the head when broken down - - - 52 CHAP. VII.—Of Augmented Capacity of the Pelvis. - - 53 CHAP. VIII.—Of the External Organs of Generation Sect ion 1. General view - 2. Labia and nympha3 3. Clitoris - 4. Urethra - 5. Orifice of vagina and hymen 6. Perinaeum - 54 ib. 55 ib. 57 58 CHAP. IX.—Of the Internal Organs of Generation and Rectum. Section 1. Vagina - ..... 59 2. Uterus and its appendages . - - - 60 3. Rectum.......66 CHAP. X.—Of the Diseases of the Organs of Generation. Section 1. Abscess in the labium ... 69 2. Ulceration of the labia ... - 70 3. Excrescences on the labia 72 4. Scirrhous tumours ..... 73 5. Polypous tumours ..... ib. 6. CEdema.......74 7. Hernia, laceration, &c. ib. 8. Diseases of the nymphaB .... 75 9. Diseases of the clitoris .... 77 10. Diseases of the hymen .... 78 11. Laceration of the perinseum ... 80 12. Imperfection of the vagina ... - 82 13. Inflammation jyid gangrene of the vagina - 83 14. Induration, ulceration, and polypi - - 85 15. Inversion .-.--- u ib. 16. Watery tumour......ib. 17. Hernia.......86 18. Encysted tumour and varices ... 87 19. Spongoid tumour.....88 20. Erysipelatous inflammation ib. 21. Fluor albus......90 22. Affections of the bladder 95 23. Excrescences in the urethra - - - 100 24. Deficiency and mal-formation of uterus - 102 25. Hysteritis, acute and chronic, and sensibility of the womb ...... 104 26. Ulceration of the uterus .... 109 27. Scirrho-cancer - - - - - 112 28. Tubercles - -.....117 29. Spongoid tumour - - - - - 119 30. Calculi.......120 31. Polypi - - ... 121 32. Malignant polypi - 126 33. Moles...... 127 Section 34. Hydatids - 35. Aqueous secretion 36. Worms 37. Tympanites 88. Prolapsus uteri - 39. Hernia 40. Dropsy of the ovarium 41. Other diseases of the ovarium 42. Deficiency ..... 43. Diseases of the tubes and ligamentfs Of Menstruation ..... Of Hysteria ..... —Of Diseased States of the Menstrual Action. Amenorrhcea ..... Formation of an organized substance - Dysmenorrhoea ..... Copious Menstruation - Menorrhagia - -Of the Cessation of the Menses Of Conception, and the term of Gestation —Of the Gravid Uterus. Size and position - Developement of the uterus and state of cervix .... 3. Muscular fibres - 4. Ligaments .... 5. Vessels - - - 6. Of the foetus 7. Its peculiarities - 8. Umbilical cord - 9. Placenta .... 10. Membranes and liquor amnii 11. Decidua .... CHAP. XVII.—Of Sterility - CHAP. XVIII.—Of Extra-uterine Pregnancy. Section 1. Symptoms, progress, and species - 2. Treatment - - CHAP. XIX.—Of the Signs of Pregnancy - Of the Diseases of Pregnant Women. CHAP. XL— CHAP. XII CHAP. XIII. Section 1 2 3 4 5 CHAP. XIV. CHAP. XV.- CHAP. XVI. Section 1 2 its CHAP. XX.- Section 1. 2. 3. 4. General effects Febrile state Vomiting - Heartburn - Fastidious taste Page 128 131 132 ib. ib. 141 ib. 151 152 ib. 153 156 160 169 ib. 171 ib. 180 181 184 186 187 ib. 188 ib. 194 198 201 206 207 209 211 218 220 224 228 230 232 233 X r.uo Section 6. Spasm of Stomach and duodenum - - 233 7. Costiveness _..-.- ib. 8. Diarrhoea......- 235 9. Piles - - - - - - -236 10. Affections of the bladder - - - - 237 11. Jaundice - - - - - - - 238 12. Coloured spots - 239 13. Palpitation......' ib. 14. Syncope.......240 15. Dyspnoea and cough ----- ib. 16. Haemoptysis and hsematemesis - - - 241 17. Headach and convulsions ib. 18. Toothach.......243 19. Salivation -......ib. 20. Mastodynia - - - - - - ib. 21. CEdema ..-.--- 244 22. Ascites.......245 23. Redundance of liquor amnii - - - 246 24. Watery discharge ..... 248 25. Varicose veins - - - . - - - 250 26. Muscular pain . - • - - - ib. 27. Spasm of ureter ..... 251 28. Cramp.......ib. 29. Sensibility, spasm, and inflammation of the uterus ib. 30. Distressing motion of the child - . . 252 31. Distention of the abdomen - - - - ib. 32. Hernia ------- 253 33. Despondency ...... 254 34. Retroversion of uterus - - - - ib. 35. Antiversion - - - - - . 262 36. Rupture of uterus ..... 263 37. Abortion, and treatment of pregnant women - 206 38. Uterine haemorrhage - - . . - 301 39. False pains.....- 337 BOOK II. OF PARTURITION. CHAP. I.—Of the Classification of Labours . . . 341 CHAP. II.—Of Natural Labour. Section 1. Stages of Labour - «j4^ 2. Duration of process - _ g^.%. 3. Of examination •---.. 35Q 4. Causes of labour - ^g 5. Management of labour - *■ . - 861 XI Page CHAP. III.—Of Premature Labour. .... 372 C L AP. IV.—Of Preternatural Labour. Order 1. Presentation of the breech ... * 37$ 2. Of the inferior extremities .... 379 3. Of the superior extremities * - - - ib* 4. Of the trunk......388 5. Of the face, &c. .....389 6. Of the umbilical cord ..... 392 7. Plurality of children and monsters - - 393 CHAP. V.—Of Tedious Labour. Order. 1. From imperfection or irregularity of muscular action.......397 2. From some mechanical impediment - - 415 CHAP. VI.—Of Instrumental Labours. Order. 1. Cases admitting the application of the forceps of lever - - - . . - - 419 2. Cases requiring the crotchet ... 447 CHAP. VII.—Of Impracticable Labour .... 458 CHAP. VIIL—Of Complicated Labour. Order 1. Labour complicated with uterine haemorrhage 463 2. With haemorrhage from other organs - • 464 3. With syncope ...... 465 4. With convulsions ..... ib. 5. With rupture of the uterus .... 475 6. With suppression of urine .... 481 BOOK III. OF THE PUERPERAL STATE. CHAP. I.—Of the Treatment after Delivery CHAP. II.—Of Uterine Hemorrhage CHAP. III.—Of Inversion of the Uterus CHAP. IV.—0/ After-pains . CHAP. V.—Of Hysteralgia. - CHAP. VI.—Of Retention of Part of the Placenta CHAP. VII.—Of Strangury .... CHAP. \ III.—Of Pneumonia .... CHAP. IX. — Of Spasmodic and Nervous Diseases CHAP. 483s 486 490 506 508 510 512 ib. 513 X.—Of Ephemeral Fever or Weed, and Remittent Fever 51P XII CHAP. XL—Of the Milk Fever - CHAP. XII.—Of Miliary Fever..... CHAP. mil.—Of Intestinal Fever - CHAP. XIV.—Of Inflammation of the Uterus CHAP. XV.—Of Peritoneal Inflammation - - - - CHAP. XVI.—Of Puerperal Fever..... CHAP. XVIL—Of Swelled Leg..... CHAP. XVIIL—Of Paralysis..... CHAP. XIX.—0/ Puerperal Mania and Phrenitis CHAP. XX.—Of Bronchocele...... CHAP. XXL—Of Diarrhea ------ CHAP. XXII.—Of Inflammation of the Mamma, and Excoria- tion of the Nipples - CHAP. XXIIL—Of Tympanites..... CHAP. XXIV.—Of the Signs that a Woman has been recently Delivered ------ BOOK IV. OF THE MANAGEMENT AND DISEASES OF CHILDREN. CHAP. I. —Of the Management of Children. Section 1. Of the separation of the child, and the treatment of still-born children .... 565 2. Of cleanliness, dress, and temperature - . 570 3. Of diet..... 572 CHAP. II.—Of Congenite and Surgical Diseases. Section 1. Harelip -......576 2. Imperforated anus, urethra, &c. - - - ib. 3. Umbilical hernia......578 4. Spina bifida ------ ib. • 5. Marks - - ...... 579 6. Swelling of the scalp ...... 580 7. Distortion of the feet.....ib. 8. Tongue-tied ------ ib. 9. Malformed heart.....ib. 10. Swelling of the breasts, hydrocele, prolapsus ani, umbilical haemorrhage, and excoriation, &c. 581 11. Foetid Secretion from the nose - . . 584 12. Ophthalmy...... 585 13. Spongoid disease of the eye - - - ib. Page 521 ib. 523 525 530 534 543 548 549 553 554 555 561 562 Xlll 5. 6 7. 8. 9. 10. 11. Section 14. Scrofula 15. Rickets CHAP. III.—Of Dentition CHAP. IV.—Of Cutaneous Diseases. Section 1. Strophulus intertrinctus 2. Strophulus albidus 3. Strophulus confertus 4 Strophulus candidus Lichen Intertrigo - Anomalous eruptions, pustules, and boils Pnmpholyx and pemphigus Mili iry eruption Prurigo Scabies 12. Herpes 13. Ichthyosis 14. Psoriasis 15. Pityriasis 16. Lepra 17. Impetigo 18. Porrigo 19. Scabs from vermin 20. Alopecia and ophiasis 21. Purpura or petechiae .... 22. Erysipelas and erythema 23. Excoriation behind the ears 24. Ulceration of the gums 25. Erosion of the cheek, sloughing ulceration o the pudendum .... Aphthae ...... Aphthae on the tonsils Malignant, aphthous, or putrid sore throat often attended with croup 29. Excoriation of the tongue, gums, and lips 30. Syphilis...... 31. Skin-bound ..... 32. Small-pox ..... 33. Cow-pox ...... 34. Chicken-pox ..... 35. Urticaria ---... 36. Scarlatina . . . 37. Measles ...... 38. Roseola - - . . CHAP. V.—Of Cerebral and Spinal Irritation CHAP. \X_ Of Hydrocephalus .... 26. 27. 28. Paga 586 587 ib. 592 593 ib. 595 ib. 596 ib. 598 ib. ib. 600 602 605 ib. 607 608 609 610 615 ib. 616 617 620 621 622 625 629 ib. 631 ib. 636 638 643 648 650 651 658 662 664 688 CHAP. VII.—Of Convulsions and Eclampsia CHAP. VIII.—Of Chorea and Paralysis CHAP. IX.—Of Croup - - CHAP. X.—Of Hooping-Cough CHAP. XL—Of Catarrh, Bronchitis, Inflammation of the Pleura, and of the Stomach and Intestines CHAP, mi.—Of Vomiting CHAP. XIII.—Of Diarrhea - CHAP. XIV.—Of Costiveness - CHAP. XV.—0/ Colic - CHAP. XVI.—Of Marasmus - CHAP. XVII.—Of Tabes Mesenlerica CHAP. XVIIL—Of IVorms CHAP. XIX.—Of Jaundice CHAP. XX.—Of Diseased Liver CHAP. XXL—Of Fever NOTES,.....- APPENDIX, ..... DESCRIPTION OF PLATES, p«g« 701 707 711 721 725 730 731 741 742 ib. 744 747 749 751 753 755 7 7 PRINCIPLES OF MIDWIFERY. BOOK I. OF THE STRUCTURE, FUNCTIONS, AND DISEASES OF THE PELVIS AND UTERINE SYSTEM, IN THE UN1MPREGNATED STATE, AND DURING GESTATION. CHAP. I. Of the Bones of the Pelvis. 1 SECTION FIRST. The practical precepts, and rules in Midwifery, are easily understood, and readily acquired. They arise evidently from the structure and actions of the parts concerned in parturition ; and whoever is well acquainted with this struc- ture and these actions, may, from such knowledge, deduce all the valuable and important directions which constitute the Practice of Midwifery. One of the first, and not the least important, of the parts concerned in parturition, is the pelvis, which must be exa- mined, not only on account of its connexion with the uterus and vagina, but also of its own immediate relation to the delivery of the child, and the obstacles which, in many instances, it opposes to its passage. the pelvis consists, in the full grown female, of three large bones, two of which are very irregular, having no near resem- A AS- blance to any other qbjeot ;'on wjucji accaunt they have been called the ossa innoniiriata. These, fqi;m tfie sides and front of the basin or pelvis. Th^^aBtpart consists of a triangular bone, called the os sacrum, to. tbeLui£erior>xtremity or apex of which, is attached,'fey-a imoveabl<^«ti\iculation, a small bone, which, from its sufrjfefelr&lrhfbjance to the beak of a cuckoo, has been named the'o?^uCcygis. The os innominatum, in infancy, consists of three separate pieces : the upper portion is called the ilium, or haunch bone ; the under, the ischium, or seat bone; and the anterior, which is the smallest of the three, is called the os pubis, or share bone. These all join together in the acetabulum, or socket, formed for receiving the osfemoris, and are connected by a very firm gristle or cartilage. This, before the age of puberty, is converted into bone, so that the three different pieces are consolidated into one, though the names given to the bones originally are still applied to the different parts of the united os innominatum. It has been observed, that women who have born children have, after their fortieth year, the centre of the expanding portion of the ilium considerably thinner than those who have not. The sacrum, also, which seems to consist only of one curved triangular bone, is really made up of several pieces, which, in the child, are nearly as distinct as the vertebrae, to which, indeed, they bear such a resemblance, that they have been considered as a continuation of thein ; but from their imper- fect structure, and subsequent union, thev have been called the false vertebrae. t The bones of the pelvis are firmly joined together, by means of ligaments and intermediate cartilages, and form a very irregular canal, the different parts of which must be briefly mentioned. SECTION SECOND. When we look at the pelvis, we observe, that the ossa innominata naturally divide themselves into two parts, the uppermost, of which is thin and expanded, irregularly convex on its dorsum or outer surface, hollow on the inside, which is called the costa, and bounded by a broad margin, extending in a semicircular direction from before backwards, which is called the crest of the ilium. The under part of the os inno- minatum is very irregular, and forms, with the sacrum, the cavity of the pelvis. The upper expanded part has little influence on labour, and serves, principally, for affording 19 attachment to muscles, and supporting the viscera. In the under part, we have several points to attend to. 1st. The upper and under parts form an angle with each other, marked by a smooth line, which is a continuation of the margin of the pubis, or anterior part of the bone. It extends from the symphysis pubis, all the way to the junction of the os innominatum with the sacrum, and is called the linea iliopectinea. It is quite smooth and obtuse at the sides, where the two portions form an angle; but at the anterior part, where the upper portion is wanting, it is sharp, and sometimes is elevated into a thin spine like the blade of a knife. 2d. The upper portion is discontinued exactly about the middle of this line, or just over the acetabulum; and at the termination, there is from this portion an obtuse projection overhanging the acetabulum, which is called the inferior spinous process of the ilium, to distinguish it from a similar projection about half an inch higher, called the superior spine. 3d. The under part of the bone is of the greatest impor- tance, and in it we recognise the following circumstances. Its middle is large, and forms on the outside a deep cup or acetabulum, for the reception of the head of the thigh bone. On the inside, and just behind this cup, it forms a smooth polished plate of bone within the cavity of the pelvis, which is placed obliquely with regard to the pubis, and has a gentle slope forward. Theconeof the child's head, in labour, moves downwards, and somewhat forwards, on this, as on an inclined plane; it maybe called the plane of the ischium, although a part of it be formed by the ilium. 4th. Standing off from the back part of this, about two inches beneath the linea iliopectinea, is a short projection, called the spine of the ischium, which seems to encroach a little on the cavity of the pelvis, and is placed, with regard to the pubis, still more obliquely than the plane of the ischium. It must, consequently, tend to direct the vertex, as it descends still more towanjp the pubis. 5th. Beneath this, the ischium becomes narrower, but not thinner ; on the contrary, it is rather thicker, and terminates in a rough bump, called the tuberosity of the ischium. 6th. Next, we look at the anterior part of the bone, and find, that just before the plane of the ischium, there is a large hole in the os innominatum. This is somewhat oval in its shape; and at the upper part within the pelvis, there is a depression in the bone, which, if followed by the finger or a 20 probe, leads to the face of the pelvis. The hole is called fjie foramen thyroideum. 7th. Before this hole the two ossa innominatajoin, but form with each other, on the inside, a very obtuse angle, or a kind of smooth rounded surface, on which the bladder partly rests. The junction is called the symphysis of the pubis. 8th. The two bones, where they form the symphysis, are joined with each other for about an inch and a half; then they divaricate, forming an angle, the limbs of which extend all the way to the tuberosity of the ischium. This separation or divarication is called the arch of the pubis, which is princi- pally constructed of the anterior boundary of the foramen thyroideum, consisting of a column or piece of bone about half an inch broad, and one fourth of an inch thick, formed by the union of the ramus of the pubis, and that of the ischium. 9th. At the upper part of the symphysis, or a very little from it, the os innominatum has a short obtuse projection, called the crest of the pubis, into which Poupart's ligament is inserted ; and from this there runs down obliquely, a ridge*on the outside of the bone, which reaches all the way to the acetabulum, and overhangs the foramen thyroideum. 10th. When we return to the back part of the os innomi- natum, we find, that just after it has formed the plane of the ischium, it extends backwards to join the sacrum; but in doing so, it "forms a very considerable notch or curve, the con- cavity of which looks downwards. When the sacrum is joined to the bone, this notch is much more distinct. It is called the sacro-sciatic notch or arch : for one side is formed by the ischium, and is about two inches long; the other is formed chiefly by the sacrum, and is about half an inch longer. In the recent subject, strong ligaments are extended at the under part, from the one bone to the other, so that this notch is con- verted into a regular oval hole. 11th. Lastly, this notch being formed, the bone expands backwards, forming a very irregular surface for articulation with the sacrum ; and the bones being joineqL we find that the os innominatum forms a strong, thick, projecting rid°-e, extending farther back than the spinous processes of the sacrum. This ridge is about two inches and three quarters long, and is a continuation of the crest of the ilium, but is turned downwards; whereas were the crest continued in its former course, it would meet with the one from the opposite side, behind the top of the sacrum, forming thus a neat semi- circle; but this ridge, if prolonged on both sides, would form 21 an acute angle, the point of junction being opposite the bottom of the sacrum. From this, strong ligaments pass to the sa- crum to join the two bones. SECTION THIRD. The sacrum forms the back part of the pelvis. It is a tri- angular bone, and gently curved ; so that, whilst a line drawn from the one extremity to the other, measures, if it subtend the arch, about four inches, it will, if carried along the surface of the bone, measure full half an inch more. The distance betwixt the first or straight line, and the middle of the sacrum, is about one inch. The breadth of the base of the sacrum, considered as an angular body, is full four inches : the centre of this base is shaped like the surface of the body of one of the lumbar vertebra?, with the last of which it joins, forming, however, an angle with it, called the great angle, or promon- tory of the sacrum.1 From this the bone is gently curved out- ward on each side, toward the sacro-iliac junction, contribu- ting to the formation of the brim of the pelvis. The upper half of the side of the bone is broad and irregu- lar for articulation with the os innominatum. The anterior surface of the bone is smooth and concave ; but often we ob- serve transverse ridges, marking the original separation of the bones of the sacrum. Four pair of holes are found dis- posed in two longitudinal vows on the face of the sacrum, communicating with the canal which receives the continuation of the spinal marrow; through these the sacral nerves issue. These holes slope a little outward, and betwixt the two rows is the attachment of the rectum. The posterior surface of the bone is very irregular; and, we observe, 1st. The canal extending down the bone, for receiving the continuation of the spinal marrow. 2d. At the upper part of this are two strong oblique processes, which join with those of the last lumbar vertebra. 3d. On a central line down the back of the canal, there is an irregular ridge, analogous to the spines of the vertebrae. 4th. The rest of the surface is very irregular and rough ; and we observe, corresponding to the holes for transmitting the sacral nerves on the exterior surface, the same number of foramina on this posterior surface, but in the recent subject, they are covered with membrane, leaving only a small opening for the exit of nervous twigs. The coccyx is an appendage to the sacrum, and as it is inclined forwards from that bone, the point of junction has been called the little angle of the sacrum. It is, at first, alto- 22 gether cartilaginous, and cylindrical in its shape, but it gradually ossifies, and becomes flatter, especially at the upper part, which has been called its shoulder. In men it is generally anchylosed with the sacrum, or at least moves with difficulty, but it almost always separates by maceration. In women it remains mobile, and, during labour, is pressed back so as to enlarge the outlet of the pelvis. By falls or blows it may be luxated ; and if this be not discovered, and the bone replaced, suppuration takes place about the rectum, and the bone is discharged. CHAP. II. Of the Articulation of the Bones of the Pelvis, and their occasional separation. SECTION FIRST. The bones of the pelvis are connected to each other, by intermediate cartilages, and powerful ligaments. The ossa innominata are united to each other at the pubis, in a very strong and peculiar manner. It was supposed that they were joined together by one intermediate cartilage ; but Dr. Hun- ter* was, from his observations, led to conclude, that each bone was first of all covered at its extremity with cartilage, and then betwixt the two was interposed a medium, like the intervertebral substance, which united them. This sub- stance consists of fibres disposed in a transverse direction. M. Tenont has lately published an account of this articula- tion; and is of opinion, that sometimes the one mode and sometimes the other obtains. I am inclined to think, that Dr. Hunter's description is applicable to the most natural state of the parts, which are joined by fibro-cartilaginous sub- stance ; but we often, in females, find that this intermedium, especially at the posterior part, is absorbed, and its place supplied with a more fluid substance ; or, on the contrary, anchylosis may sometimes take place; a circumstance which Dr. Hunter says he never saw, but which I have met with. Besides this mode of connexion, there is also in addition a very strong capsule to the articulation, the symphysis being * Vide Med. Obs. and Inq. Vol. II. p. 333. t Vide Mem. de 1' Institut. des Sciences, tome VI. p. 172. 23 covered on every side with ligamentous fibres, which con- tribute greatly to the strength of the parts. The fibro-cartila- ginous intermedium sometimes enlarges posteriorly, and, together with the capsule, encroaches a little on the diameter of the pelvis. SECTION SECOND- The ossa innominata are joined to the sacrum by means of a thin layer of fibro-cartilaginous substance, which covers each bone ; that belonging to the sacrum is the thickest: both are rough, and betwixt them is found a soft yellowish substance in small quantity. The connexion of the two bones, therefore, so far as it depends on this medium, cannot be very strong : but it is exceedingly strengthened by ligamentous fibres, which serve as a capsule; and behind, several strong bands pass from the ridge of the ilium to the back of the sacrum ; sometimes the bones are united by anchylosis. At the lower part, additional strength is obtained by two large and strong ligaments, which pass from the ischium to the sacrum, and therefore are called the sacro-sciatic ligaments. The inner- most of these arises from the spine of the ischium, is very strong, but at first not above a quarter of an inch broad ; it gradually expands, however, becoming at its insertion about an inch and a quarter in breadth. It passes on to the sacrum, and is implanted into the lower part of the side of that bone and the upper part of the coccyx. It converts the sacro- sciatic notch into a regular oval hole, the inferior end of which, owing to the neat expansion of the ligament, is as round and exact as the upper. As it makes a similar expansion down- wards, there is a kind of semilunar notch formed betwixt it and the coccyx. The outer ligament may be said to arise from the side of the sacrum, and, like the other, is broad at that part. It runs for some time in contact with the inner ligament, and parallel to it; but afterwards it separates, passing down to be inserted in the tuber ischii; and, when the ligaments separate, their surfaces are no longer parallel to each other. There is, in consequence of this separation, a small triangular opening formed betwixt the ligaments ; or rather there is an aperture like a bow, the string being formed by the under ligament, and the arch partly by the spine of the ischium, and partly by the upper ligament. SECTION THIRD. The pelvis is joined to the trunk above, by means of the 24 last lumbar vertebra; to the extremities below, by the insertion of the thigh bones into the acetabula ; and it is so placed that when the body is erect, the upper part of the sacrum and the acetabula are nearly in the same line. The brim of the pelvis, then, is neither horizontal nor perpendicular to the horizon, but oblique, being placed at an angle of 35 or 40 degrees. Were the ligaments of the pelvis loosened, there would, from this position, be a tendency in the sacrum to fall directly towards the pubis, the ossa innominata receding on each side. But the structure of the part adds greatly to the power of the ligaments; for it is to be observed, that in standing, and in various exertions of the body, the limbs re-act on the pelvis ; and the heads of the thigh bones pressing on the two acetabula, force the ossa innominata more closely on each other at the symphysis, and more firmly on the sacrum behind. It is not possible, indeed, to separate the bones of the pelvis, unless the connecting ligaments be diseased, or external violence be applied, so as to act partially or unequally on the pelvis. SECTION FOURTH. By external violence, the symphysis has been wrenched open, as was the case with Dr. Greene ;* or the sacro-iliac junction may be separated, as in the case of the young peasant, related by M. Louis.t By some morbid affection of the symphysis,'it may yield and become loosened during pregnancy, or may be separated during labour. Some have been inclined to consider this as a uniform operation of nature, intended to facilitate the birth of the child. Others, who cannot go this length, have never- theless conjectured, that the ligaments do become somewhat slacker; and have grounded this opinion on the supposed fact of the pelvis of quadrupeds undergoing this relaxation. But the truth is, that this separation is not an advantage, but a serious evil; and in cases of deformed pelvis, where we would naturally look for its operation, did it really exist, we do not observe it to take place.J * Phil. Trans. No. 484. t Vide Mem. del'Acad, de Chir. tome IV. p. 63. t Desault arid Beclard maintain that the articulations loosen, and Boyer says that in one case, he found the sacro-iliac connexion separated to the extent of half an inch; Chaussier, that he found the symphysis of the pubis separated to a greater degree, in an easy labour. Gardien observes that it only happens where there is a predisposition, for the head is too soft to force asunder the bones of the pelvis. Pari and Louis, and more lately Piet, suppose that the separation 25 When a person stands, pressure is made upon the sym* physis, and therefore, if it be tender, pain will then be felt. In walking, pressure is made on the two acetabula alternately, and the ossa innominata are acted on by the strong muscles which pass from them to the thighs, so that there is a tendency to make the one os pubis rise above the other ; but this, in a sound state of the parts, is sufficiently resisted by the ligaments. In a diseased state, however, or in a case of separation of the bones, there is not the same obstacle to this motion : and hence, walking must give great pain, or be alto- gether impossible : even attempts to raise the one thigh above the other in bed, must give more or less pain, according to the sensibility or laxity of the symphysis. Standing has also an effect on the symphysis, as I have mentioned ; but some- times the person can, by fixing one os innominatum, with all the muscles connected with it, and throwing the chief weight of the body to that side, stand for a short time, easier on one leg than on both. This is the case when one os innominatum has been more acted on than the other, at the sacro-iliac junction. The person can stand easiest on the soundest side. The patient also, especially if the relaxation be accompanied with any degree of relaxation of uterine attachments, in- stinctively crosses her legs when standing, thereby obtaining relief. From these observations, we may learn the mischievous con- sequences of a separation of the bones, and also the circum- stances which will lead us to suspect that it has happened. If the bones be fully disjoined, then, by placing the finger on the inside of the symphysis, and the thumb on the outside, we can readily perceive a jarring, or motion, on raising the thigh. It is well known to every practitioner, that owing to the distension of the muscles during pregnancy, very considerable pain is sometimes felt at the insertion of the rectus muscle into the pubis; and it is also known, that sometimes, in con- proceeds from swelling of the cartilages and simple extension of the ligaments; an opinion which Chaussier says he has confirmed by dissection. Baudelocque, on the other hand, asserts that it proceeds from extension of the ligament alone, the cartilages remaining the same in thickness. Pinault thought that the pro. cess of relaxation might be promoted by the use of baths and blood-letting; but this is correctly denied by Gardien, although both imagine that the relaxation is beneficial. Yet the continental calculators admit, that, in order to gain two lines in the antero-posterior diameter, there must be a separation of the pubis to the extent of one inch. Perhaps to obviate an objection which might be brought against the benefit of this natural separation, Plessman says that all the three articulations relax simultaneously, and thereby a greater advantage is gained, with less injury to the individual joinings. Maygrier is of the same opinion.2 B 26 sequence of pregnancy, the parts about the pelvis, and especially the bladder and urethra, and even the whole vulva, may become very irritable. This tender state may be com- municated to the symphysis; or some irritation, less in degree than that I have mentioned, may exist, which, in particular cases, seems to extend to the articulation, producing either an ^increased effusion of intersticial fluid in the intermediate car- tilage, and thus loosening the firm adhesion of the bones, or a tenderness and sensibility of the part, rendering motion painful. In either case exertion may produce a separation ; and certainly, in some instances, has done so. The separation is always attended with inconvenience, and often with danger, especially when it occurs during parturition ; for abscess may take place, and the patient sink under hectic fever ; or inflam- mation may be communicated to the peritoneum, and the patient die in great pain. When the accident happens during gestation, it sometimes takes place gradually, in consequence of an increasing relax- ation of the articulation, from slow but continued excitation. In the other instances, it happens suddenly after some exertion. It may occur so early as the second, or so late as the ninth month, and is discovered by the symptoms mentioned above ; such as pain at the pubis, strangury, and the effects of motion. In some instances, considerable fever may take place, but in general the symptoms are not dangerous, and I do not know any case which has terminated fatally before delivery. A state of strict rest, the application of a broad firm bandage round the pelvis, to keep the bones steady, and the use of the lancet and antiphlogistic regimen, if there be fever or much pain, are the chief points of practice. Nor must it be forgotten, for a moment, that although by these means the symptoms be removed, the patient is liable, during the remaining term of gestation, or at the time of delivery, to a renewal of the relaxation or separation, from causes which in other circumstances, would have had no effect. So far as I have been able to learn, a woman who has had this separation in one pregnancy, is not, in general, peculiarly liable to a return of it in a subsequent pregnancy, though there may be particular exceptions to this observation.* When it happens during parturition, it sometimes takes place in a pelvis apparently previously sound; but in most * Dr. Denman mentions an instance, where the patient, in three succeeding pregnancies, was progressively worse, and did not, until the lapse of eieht vears recover from the lameness produced by the third delivery. Intro'd. Vol I V» 16* 27 instances, we have, during some period of gestation, symptoms of disease about the symphysis; and so far from making labour easier, the woman often suffers more, when the symphysis is previously relaxed. The primary and immediate effects are the same as when the accident happens during pregnancy ; but the subsequent symptoms are frequently much more severe and dangerous, the tendency to inflammation being strong. The pain may be either trifling or excruciating at the moment, according to the sensibility of the parts. But even in the mildest case, great circumspection is required, violent inflammation having come on so late as a fortnight after the accident. The means used in the former case are to be rigidly employed, and the patient should keep her thighs together, and lie chiefly on her back. If the separation have been slight, re-union may take place in a few weeks, sometimes in a month ;* but if great injury have been sustained, it may be many months, perhaps years, before recovery be completed: and, in such cases, it is probable that, at last, an anchylosis is sometimes formed. The cold or shower bath, which is more convenient in this case than the plunge, is of service in promoting the recovery; and the bandage should be kept carefully applied. Either owing to the violence of the accident, or the peculiar state of the parts, it sometimes happens, that inflammation takes place to a very considerable degree in the symphysis; but it is to be remarked, that the symptoms are by no means uniformly proportioned in their severity to the degree of the separation. Inflammation is known by the accession of fever, with acute pain about the lower part of the belly, greatly increased by motion, succeeding to the primary effects ; or sometimes from the first, the pain is very great, and not anfrequently it is accompanied by sympathetic derangement of the stomach and bowels, such as vomiting, nausea, looseness, &,c. Presently matter forms, and a well marked hectic state takes place. The patient is to be treated, at first, by the usual remedies for abating inflammation, such as general and local evacuation of blood, fomentations and laxatives. When matter is formed, we must carefully examine where it is most exposed, and let it out by a small puncture.t *In one case, where the symphysis was divided, the patient was able to walk op the 15th day.-—In Pr. Smollet'e case, although in the 8tb4Donth ^>f gestation tj»e bones were found to rise above each other, yet the woman recovered in two months after delivery. Smellie, Vol. II. Coll. i. n. i. c. 2. + As an illustration of this disease, I shall relate the outlines of a case 28 The inflammation may be communicated to the peritoneum; producing violent pain in the lower belly, tumefaction and fever, and almost uniformly proves fatal; though frequently the patient lives until abscess takes place in the cellular substance within the pelvis. If any thing can save her, it must be the prompt use of blood-letting and blisters. In almost every case of separation of the pubis considerable pain is felt in the loins, even although the junction at the sacrum be entire, and the ossa pubis very little asunder. But when the separation is complete, and in any way extensive, then the articulation of the sacrum with the ossa innominata,* especially with one of them, is more injured,t and the person is lame in one or both sides, and has acute pain about the posterior ridge of the ilium,$ and in the mentioned by Louis, in the memoirs of the Royal Academy of Surgery. A woman in ths second month of her pregnancy, after pressing in a drawer with her foot, felt a considerable pain at the lower part of her belly, greatly increased by every change of posture; and along with this she complained of strangury. She was bled, and purged, and kept at rest, by which means, especially by the last, she grew better. But in the two latter months of pregnancy, the symptoms were renewed, so that presently she could neither walk, nor even turn in bed, without great pain; but her greatest suffering was caused by raising the legs to pull on her stockings, as then the bones were more powerfully acted on. A slight degree of hectic fever now appeared. Her delivery was accomplished easily; but on the evening of the 3d day, when straining at stool, after having received a clyster, the pain, which had troubled her little since her labour, returned with as much severity as ever. On the 5th day the pulse was very weak and frequent, she sweated profusely, and had a wildness in her countenance, With symptoms of approaching delirium. In the afternoon the pulse became full and tense, with vertigo and throbbing of the arteries of the head. The pain at the symphysis was excruciating, and although she was fomented and bled seven times, she obtained no relief. On the 8th day the pain abated, but diffused itself over the rest of the pelvis, particularly affecting the left hip and the sacrum. On the 11th day she died. On opening the body, there was found a separation of the bones at the pubis, but the capsule was entire, and much distended. It contained about an ounce and a half of matter. Whether the timely evacuation of this matter might have saved the patient, is a question worth our consideration. I am disposed to answer it in the affirmative, from observing that wherever the patient has recovered in such circumstances, it has uniformly happened, that a discharge of matter has taken place. * Dr. Laurence showed Dr. Smeliie a pelvis, where all the bones were separated to the extent of an inch. t In a case related by De la Malle, the pain did not appear till the 14th day after delivery,'And was felt first in the groin. The patient was unable to move the leg, and had acute fever, which proved fatal. The sacrum was found separated three lines from the ilium. In the operation of dividing the pubis in a parturient woman, it was found that one side yielded more than the other, and consequently that side would surfer most at the sacrum. Baudelocque, L'Art. &c. section 2063. J_Dr. Smeliie relates an instance, where, during labour, the woman felt violent-pain at the right sacro-iliac symphysis. On the 5th day this pain was extremely severe, and attended with acute fever; but the symptoms were abated 29 course of the psoas and glutei muscles. The mischief may also commence in the sacro-iliac articulation, and the symphysis may be little affected. The general principles of treatment are the same as in the former case. When suppuration takes place about the sacro-iliac articulation, the danger is greatly increased. A slight straining of the sacro-sciatic ligament is sometimes combined with a similar condition, only to a greater degree, of the muscles, the levator ani, for instance, or the pyriformis, or both. This is productive of pain in walking, shooting as it were directly back along the side of the pelvis at the outlet, or near the perineum and inside of the thigh, or, in the case of the pyriformis, it goes more round the trochanter. Rest, and the use of a roller, are the best remedies. In all cases of separation, when the patient has recovered so far as to be able to move, the use of the cold bath accelerates the cure; the general health is to be carefully attended to, and any urgent symptom intervening, is to be obviated by suitable remedies.8 CHAP. III. Of the soft Parts which line the Pelvis. SECTION FIRST. VARIOUS strong and large muscles, pass from the spine and pelvis to the thigh bones, and act as powerful bands, strengthening, in a very great degree, the articulations of the pelvis. These it is not requisite to describe, but it will be useful, briefly to notice the soft parts which line the pelvis, and which may be acted on by the child's head during labour. 1st. When we remove the peritoneum and fascia from the cavity of the pelvis, we first of all are led to observe, that all the under portion of the os innominatum, and part of the sacrum, are covered with a layer of muscular fibres, which arises a little below the brim of the pelvis, and can be traced all the way down to the extremity of the rectum. This is the levator ani; it is a strong muscle, with many glossy tendinous by blood letting, and a clyster, and fomentations, which produced a copious perspiration. She was not able to walk for five or six months without crutches, but was restored to the use of the limb, by the means of the cold bath. Coll. 1- n. i. c. I. 30 fibres, especially at the fore part, where it lines the ossa pubis. It does not arise from the front of the pubis, and indeed only from the outer part of the smooth portion of the bones lying between the symphysis and the margin of the thyroid aperture. But it takes its origin at the upper edge of the thyroid foramen, and continues to arise from the aponeurosis, which covers the obturator internus, and all the way back to the spine of the ischium. Its fibres tend toward the perineum and anus, so that the muscle closes up partially the outlet of the pelvis, not however like a funnel, to which it has been compared, for it is incomplete both before and behind, and is rather like two hands coming down from within, on each side, to hold up the contents of the pelvis. The anterior portion of the outlet, it is evident, cannot be occupied by the muscle, nor shut up, nor protected by it. For it sweeps down the pubis, and its margin forms either a semicircle, or an angular aperture, more or less acute, which embraces the sides of the vagina, as the fibres pass on to terminate in the extremity of the rectum, the sphincter ani, perineum, and partially on the orifice of the vagina, which does not pierce the muscle, but the muscle winds along the sides of the vagina, which may be said to rest on it at its passage. The anterior portion of the outlet being unsupported, so far as the levator is concerned, a different kind of defence or support is employed ; after removing a superficial fascia, extending from the arch of the pubis downward to the perineum, we find a deeper and stronger fascia arising from the arch of the pubis and the inside of the rami of the pubis, and ischium, all the way back to the tuberosity. This forms a sheet of strong fascia or thin ligament, extending across the upper or anterior part of the outlet, and is similar to the ligamentum triangulare, as it has been called, of the male. The urethra passes, as in the other sex, either through the ligament at its border, or it may in both cases pass by the very margin, firmly and intimately connected to it by a production or detachment of the fascial substance. In different individuals dissection would lead to the opinion, that sometimes the one and sometimes the other mode prevailed. Usually the urethra in the female passes loosely through it, that is to rsay, is not firmly fixed, whilst the levator passejs down by the sides of the urethra, on the inside of thie triangular ligament. The ligament, or fascia, is extended over the sides of the vagina, and prolonged forward on its 31 extremity toward its orifice, and is thus insensibly lost. A similar prolongation, but of consequence very small, accom* panies the urethra. It is thus evident that the pelvic viscera must be supported, and the outlet of the pubis secured, not merely by the firmness of the perineum, and the tough substance of which it is composed, and by its transverse muscles, but also and essentially by the levator ani and triangular ligament. A strong layer of the pelvic fascia also, as in the male, is reflected off to the pelvic viscera, and greatly contributes to the firmness and support of the parts. This passes off to and over the bladder, the upper part of the vagina, the cervex uteri, and anterior part of the rectum, and it is the due connexion and firm support of all the differ- ent parts of the aperture, which secures the female against displacement or protrusion of the uterus, vagina, or bladder, and even of the rectum itself. In pregnancy, some of those parts must be more or less stretched and relaxed; and in labour both the muscles and fascia may be greatly stretched. But as the anus is brought forward during the passage of the child's head, the fibres of the levator passing along the vagina are not so much distended as they would otherwise be; still there is a risk of a feeling of want of support, or of bearing down, being experienced after parturition. When the head has entered the pelvis in labour, we sometimes feel the fascia behind stretched like a ligament across the front of the rectum, and extending to the sides of the pelvis, and sometimes fasces collecting in the rectum above this vagino- rectal reflection, may produce a kind of sac. If carried a little more forward by being stretched, it may be pressed down as well as backward, which should be its only direction, and then it not only affords some resistance to the forehead, and we know how any slight resistance sometimes retards labour, or causes an unfavourable position, but also is greatly extended, and contributes afterwards to the production of prolapsus. 2d. Under the levator, on each side, we have, arising from the membrane that fills up the thyroid hole, and also from the margins of the hole and the inner surface of the ischium, the obturator internus, which forms at that part a soft cushion of flesh, the fibres running backwards and downwards, and terminating in a tendon, which passes over the sacro-sciatic notch, running on it as on a pully, in order to reach the root of the trochanter. 3d. We find the pyriformis, arising from the under part of 32 the hollow of the sacrum, and also passing out at the notch, to be inserted with the obturator ; and in laborious parturi tion, the injury or pressure which these muscles sustain is one cause of the uneasiness felt in moving the thighs. 4th. From the spine of the ischium, originates the coc- cygeus, which runs backward to be inserted into the side of the coccyx, in order to move and support it. This gradually becomes broader, as it recedes from its origin, and is spread on the inside of the sacro-sciatic ligament. Thus the cavity of the pelvis is lined with muscular substance, whose fibres are disposed in a very regular order, and which are exhibited when the peritoneum and its cellular substance are removed. 5th. When we look at the upper part of the os inno- minatum, we find all the hollow of the ilium occupied with the iliacus internus, the tendon of which passes over the fore part of the pelvis, to reach the trochanter of the thigh. Part of this muscle is covered by the psoas, which arises from the lumbar vertebrae, and passes down by the side of the brim of the pelvis to go out with the former muscle : though just upon the brim, it does not encroach on it, so as perceptibly to lessen the cavity. These muscles afford a soft support to the intestines and gravid uterus. SECTION SECOND. Running parallel with the inner margin of the psoas muscle, and upon the brim of the pelvis, along the posterior half of the linea iliopectinea, we have the iliac artery and vein ; the artery lying, for the upper half of its course, above the vein, and for the under half on the outside of it; when filled, they, especially the vein, encroach a little on the brim. About three inches from the symphysis, they quit the brim runing rather more outward, over the part which forms the roof of the acetabulum, and pass out with the psoas muscle. The great lash of arteries and veins connected with the pelvis and inferior extremities, is placed on the sacro-iliac junction. The iliac vessels are so situated, that they escape pressure during labour, when the head enters the cavity of the pelvis • but the hypogastric vessels must be more or less compressed according to the size or position of the head, yet the circula- tion is never interrupted. SECTION THIRD. When we attend to the nerves, we find, 1st. Upon the ilium, at least four branches of cutaneous nerves, traversing 33 the iliac, and psoas muscles, in order to pass out below Poupart's ligament. The largest of these cutaneous nerves is the outermost, which has its exit towards the spine of the ilium. These nerves, which supply chiefly the skin of the thigh, cannot suffer during labour; but sometimes may, from the position of the child, or the inclination of the uterus, sustain pressure, during gestation, and occasion numbness and anomalous sensations in the thigh. 2. Between the two muscles, and in part covered by the outer margin of the psoas, is the anterior crural nerve, which is formed by the second, third, and fourth lumbar nerves. It is of considerable size, and has a greater share than the others, in producing the uneasy sensations I have mentioned. 3d. Running parallel with the brim of the pelvis, but three quarters of an inch below it, in the cavity of the pelvis, is the obturator nerve, coming from the third lumbar, and which may be traced all along the side of the ilium to the thyroid hole. In many cases, it cannot fail, during labour, to be pressed on by the head. 4th. Beneath the vessels at the sacro-iliac junction, we have the great nerves which form the sciatic nerve, which is made up of the fourth and fifth lumbar nerves and the first sacral nerve, which is as large as either of the former ; to these are added the second and third sacral, which are much smaller. The fourth lumbar nerve passes down on the sacro- iliac junction, and is quite covered with the vessels. The fifth traverses that curved part of the sacrum, which lies betwixt its promontory and side; like the former, it is hid by the vessels. In going to form the sciatic nerve, the fourth lumbar nerve passes under the gluteal artery, or the common trunk of gluteal and ischiatic arteries, and the fifth passes over it. The first sacral nerve passes along the upper margin of the pyriform muscle, to join with these at the sacro-sciatic notch. There, a large plexus is formed, which, uniting into a single trunk, passes out, and is the greatest nerve in the body. The lumbar nerves may be pressed on, early in labour ; but from the cushion of vessels and cellular substance which defends them, they suffer little. When the head has descended lower, and is beginning to turn, the first sacral nerve may be compressed. Pressure of the nerve produces pain, numbness, and cramp in the thigh and leg. Different nerves are acted on in different stages of labour. In the very beginning, the anterior crural nerve may be irritated or gently compressed, producing pain in the fore part of the 'high ; next the obturator, producing pain in the inside; and C 34 last of all, the back part suffers from the pressure on the ischiatic nerve. 5th. The second and third sacral nerves are small, compared to the first. They are covered by the pyriformis muscle, but part of thein pierce it, forming a plexus, which joins the sciatic nerve, and sends twigs to the bladder, rectum, &c. This plexus may be pressed in the last stage of labour; and the irritation thus produced may be one cause of the passage of the fasces, which generally takes place involun- tarily. 6th. The fourth sacral nerve is altogether devoted to the extremity of the rectum, and its vicinity. The great plexus, forming the sciatic nerve as it lies in the sacro-sciatic notch, yields to any pressure it may receive, and cannot suffer in labour, at least so as to cause inconvenience; but the nerves going to it may suffer, and the person not only have cramp and pain during labour, but palsy and lameness for a long time afterwards. Friction, and the warm bath, at first, may relieve the pain ; and then, the cold bath may, with much advantage, be employed for perfecting the cure : a roller is also useful. SECTION FOURTH. The lymphatics in the upper part of the pelvis follow the course of the iliac vessels, forming a large and very beautiful plexus, from Poupart's ligament to the lumbar vertebras. These are out of the way of pressure during labour. Numerous glands accompany them, which are sometimes enlarged by disease, but they do not interfere with parturition. The lymphatics of the cavity of the pelvis have glands in the course of the vagina and rectum ; and these, if enlarged, may impede delivery. CHAP. IV. Of the Dimensions of the Pelvis. SECTION FIRST. The pelvis has been divided into the great and the little the first being formed by the expansion of the ilia, and the second, comprehending all that part which is called the cavity of the pelvis, and which lies below the linea ilio-pectinea. The cavity of the pelvis is the part of the chief importance in 35 Midwifery, and consists of the brim, or entrance, the cavity itself, and the outlet. The brim of the pelvis, owing to the projection of the top of the sacrum behind, and of the ossa pubis before, has no regular shape, but approaches nearer the oval than any other. The short diameter of this, extends from the symphysis of the pubis to the top of the sacrum. This has been called the conjugate, sacro-pubic, or antero- posterior diameter, and measures four inches. The lateral diameter measures from five inches and a quarter, to five and a half, or sometimes to six ; and the diagonal diameter, o* a line drawn from the sacro-iliac symphysis to the opposite acetabulum, measures from five inches and an eighth, to five and a half; but as the psoae muscles, and iliac vessels, over- hang the brim a very little at the side, the diagonal diameter, in the recent subject, often appears to be the longest. From the sacro-iliac symphysis to the crest of the pubis, on the same side, is four inches and a half. From the top of the sacrum, to that part of the brim which is directly above the foramen thyroideum, is three inches and a half. The line, if drawn to the acetabulum, in place of the foramen, is a quarter of an inch shorter ; a line drawn across the fore part of the brim, from one acetabulum to another, is nearly four inches and a quarter. The outlet of the pelvis is not so regular as the brim, in its shape, even when the soft parts remain ; but it is then some- what oval. The long diameter extends from the symphysis pubis to the coccyx, and measures, when that bone is pushed back, as in labour, five inches, but an inch less when it is not. The transverse diameter, from the end of one tuberosity of the ischium to the other, measures four inches. But a little higher or farther back where the inferior sacro-sciatic ligament is inserted, it measures above half an inch more. Farther forward where the rami begin, the distance is only two inches and three quarters.* The outlet of the pelvis differs materially from the brim, in this respect, that its margins are not all on the same level; an oval wire will represent the brim, but, if applied to the outlet, it must be curved. The outlet, from the symphysis pubis to the tuberosity of the ischium, is semi-oval; but behind, it becomes more irregular, and bends upwards and backwards. The arch of the pubis, or the fore part of the outlet, is four inches broad at its base; and a perpendicular * The pelvis of the Negress is smaller in all its dimensions. That of an Egyptian mummy, dissected by Dr. Granville, measured five and a half inches in the lateral, and four and a half in the antero-posterior diameter. 3G hne, dropped from its centre to the base, is fully two inches long. The top of the arch will permit a circular body to come in contact with it, whose diameter is an inch and a quarter. The length of each limb of the arch is throe inches and a quarter. The outlet is arched to a height of about three inches, and the pillars of this arch recede gradually toward the tuberosities. The latero-posterior boundaries formed by the sacro-sciatic ligament, represent on each 6ide, an oblique line running inward and backward, whilst between these, the coccyx forms a peak directed forward. This irregular aperture is longer than it is broad, but is by no means oval. AVhen the soft parts are added, and we connect it with the cavity of the pelvis, we then say, that in labour it forms an ovoid opening of an ovoid tube, but the shape of the aperture will vary according to the stage of propulsion, SECTION SECOND. The cavity of the pelvis is the next part to be attended to ; and the most important observation to be made, is, that it is of unequal depth- At the back part, it measures from five to six inches, according as the coccyx is more or less extended ; at the side, a line drawn from the brim, to the tuberosity of the ischium, measures three inches and three fourths. At the fore part, the depth of the symphysis pubis is an inch and a half. When the surface of the child's head, then, is parallel to the lower edge of the symphysis, the head is still far from having entered fully into the cavity of the pelvis ; it cannot be considered in the cavity, until it be lodged fairly in the hollow of the sacrum. It may be proper to notice the dimensions of different parts of the cavity itself. An oblique line, drawn from the sacro-iliac junction, on one side, down to the opposite tuberosity, measures six inches; and the long axis of the child's head, before it takes the turn forwards, corresponds to this line. From the ramus of the ischium, to the opposite sacro-iliac junction, is five inches. From the posterior margin of the inclined plane of the ischium, or anterior margin of the sacro-sciatic notch, to the opposite side, is six inches, or six and a quarter. The diameter at the anterior margin, or edge of the thyroid hole, at the same level, is four and three quarters. The plane therefore at the lower part is two inches nearer the opposite side before than it is behind or at its posterior margin. From the top o^ the arch of the pubis, or orifice of the urethra, to the second bone of the 37 . have known examples.* An enlarged ovarium,t or vaginal hernia,! may also obstruct delivery, even so much as to require the crotchet; and therefore, although they be not indeed instances of deformed pelvis, yet as they diminish the capacity of the cavity, as certainly as any ofthe former causes which I have mentioned, it is proper to notice them at this time. Vesical hernia, or prolapsus ofthe bladder, may impede labour. Enlarged glands in the course of the vagina, polypous excrescences about the os uteri or vagina, scirrhus ofthe rectum, and firm encysted tumours in the pelvis, may likewise afford an obstacle to the passage of the child. Some tumours, however, gradually become diffused by pressure, but re-appear after the child is born ; others burst, and have their contents effused into the cellular substance. A large stone in the bladder may also be so situated during labour, as to diminish very much the cavity of the pelvis ; and it may be even necessary to extract the stone before the child be delivered, if it have not been pushed above the brim in proper time. Tumours in the pelvis are produced either by enlargement of some of its contents, as for instance the ovarium or glands; or, by new formed substances. The ovarian kind are often moveable; the others generally fixed, and they may consist of fatty or fibrous substance, or fluid contained in a cyst.§ Some * Dr. Denman mentions a fatal case of this kind, to which Dr. Hunter was called. The child was delivered by the crotchet, but the patient died on the fourth day. A firm fatty excrescence, springing from one side of the sacrum, was found to have occasioned the difficulty. Vide Introd. Vol. II. p. 72.— Baudelocque in the 5th vol. of Recueil Periodique, relates a case, where, in consequence, of a scirrhous tumour adhering to the pelvis, the crotchet was necessary. In a subsequent labour, the Caesarean operation was performed, and proved fatal to the mother. Dr. Drew records an instance where the tumour adhered to the sacro-sciatic ligament, and was successfully extirpated during labour. It was 14 inches in circumference. Vide Edin. Journal Vol I p. 23. + A fatal case of this kind occurred to Dr. Ford, and is noticed by Dr. Denman, Vol. II. p. 75.—Another fatal instance is recorded by M. Baude- locque, L'Art. section 1964. See also a case by Dr. Merriman, Med. and Chir. Trans. III. 47. This ovarium contained a fluid, and probably might have been opened during labour with advantage. Of the proposal to extirpate the ovarium, I shall hereafter speak. t Several cases of this kind have been met with, and in one related bv M Brand, and noticed by Dr. Sandifort, in his Obs. Anat. Path, the woman died undelivered. § A very important case of this kind is related by Mr. Jackson, in the Med. Rep. for March, 1826. The tumour, which was very large, was situated behind the rectum, and filled the sacrum so completely, as only to permit of bringing down the child by the feet with great difficulty. The finger inserted into the rectum, after delivery, ascertained the existence of fluctuation between the rectum 49 of these have only cellular attachments, and are removed easily by making an incision through the vagina, and turning out the tumour, or evacuating its contents** Other tumours are cartilaginous, and instead of being connected only by cellular matter, are attached to the pelvis firmly, or grow from it. They adhere either by a pedicle, or by an extensive base* In the first case the tumour is more moveable than in the second, where the fixture is firmer. These can only be extir^ pated by cutting deeply into the cavity of the pelvis, and the incision requires to be made through the perineum and levator ani, like the incision in the operation of lithotomy in the male subject. We are much indebted to Dr. Drew for the first case of an operation of this kind; and as the tumour adhered by a neck, it was easily cut off, and the success was complete. In a dreadful case which I met with some years ago, the attachments were extensive, and the tumour so large as to fill the pelvis, and permit o|ly,one finger to be passed between it at the right side ofVthe basin. It adhered from the symphysis pubis round to^he sacrum, being attached to the urethra, obturator muscle, $q£ rectum ; intimately adhering to the brim of the pelvis, and eveji overlapping it a little towards the left acetabulum. It was hard, somewhat irregular, and scarcely moveable. The patient, Mrs. Broadfoot, was in the 9th month of pregnancy. There was no choice, except between the Cesarean operation, and the extirpation of the tumour. The latter was agreed on; and with the assistance of Messrs. Cowper and Russel, I performed it on the 16th of March, a few hours after slight labour pains had come on. An incision was made on the left side of the orifice of the and coccyx ; a puncture was made, and six pints of straw-coloured fluid eva- cuated, and the patient recovered completely, but not without great suffering from pain of the head, tenderness of the vertebra, numbness of the lower ex- tremities, quick pulse, &c. From these symptoms the collection seems to have been connected with the sacral portion of the spinal cord, or at least with the nerves given off by it, and those situated behind the rectum. * M. Peleten details several cases of tumours within the pelvis, some of them fatty or fibrous, and easily turned out, merely by making an incision over them, through the vagina ; one encysted containing puriform matter; and one about an inch long, of a cartilaginous nature, adhering to the descending branch of the pubis, the vagina being divided, it was cut off with scissors. Clinique Chinir- gicale, torn. I. 203, 206, 224, 228, 250. Mr. Park likewise relates several cases, chiefly of tumours, containing liquid or soft contents, and which were pierced from the vagina during labour. Med. Chir. Trans. II. 293. See also a valuable paper on the same subject by Dr. Merriman, in the 10th vol. of that work, p. 50, and his Synopsis, p. 57, and remarks by Dr. Davis in his Elements, p. 105. Also a case by Boyer, Traite\ torn. X. p. 394. - 50 vagina, perineum, and anus, through the skin, cellular substance, and transversalis perinei. The levator ani being freely exposed, the tumour was then touched easily with the finger. A catheter was introduced into the urethra, and the tumour separated from its attachments to that part. It was next separated from the uterus, vagina, and rectum, partly by the scalpel, partly by the finger. I could then grasp it as a child's head, but it was quite fixed to the pelvis. *An incision was made into it with a knife, as near the pelvis as possible; but from the difficulty of acting safely with that instrument, the scissors, guided with the finger, were employed when I came near the back part; and instead of going quite through, I stopped when near the posterior surface, lest I should wound the rectum^oji^large vessel, and completed the operation with a sngrtu^Ar^ie>Uimour was then removed, and its base or at^kment to th\ bones dissected off as closely as possible?^ L/ttle^)lo^\was last. The pains immediately becjyffe* stj#&nj£cand lrefire she was laid down in bed they were yfoQ pjf^s^T AnJM* hours she was delivered of a still-born /qfoild, /fobvfXh^dierage size. Peritoneal inflammation, W&h cf§rsid/^abj% c/istitutional irritation, suc- ceeded ; but bVcfche promjAjitl active use of the lancet and purgatives, the dngiW^yrff soon over, and the recovery went on well. In th^trrtJnth of May the wound was healed. On examining per vaginam, the vagina was felt adhering, as it ought to do, to the pelvis, rectum, . 136 pressed against the front ofthe vagina near the uterus seems to discover almost a rent or separation ofthe connexion above. Frequent parturition, fluor albus, dancing during menstrua- tion, and whatever tends to weaken or relax the parts, may occasion prolapsus. Sometimes a fall brings it on. No age is exempt from it.* AVhen symptoms indicating prolapsus uteri manifest themselves, we ought to examine the state of the womb, the patient having lately been, or rather being, in an erect posture. The symptoms sometimes at first turn the attention rather to the bladder or pubis, than the womb ; but a practitioner of experience will think it incumbent on him to ascertain the real situation of that viscus. If we find that there is a slight degree of uterine descent, we must imme- diately use means to remove the relaxation ofthe vagina; for nothing can directly act on the fascia. These consist in the frequent injection of solution of sulphate of alumin, either in water, or decoction of oak bark, repeated ablution with cold water, tonics, and the use ofthe cold bath, at the same time that the bowels are kept regular, all exertion avoided, and a recumbent posture much observed. This last advice, it is evident, must, in the early stage, be the most effectual of all, as it allows time and opportunity for the parts to recover their tone or tightness. If these means fail, or if the disease exist to a considerable degree, then, besides persisting in them, we must have recourse to the assistance of mechanical means. These consist of supporting substances called pessaries, which are placed in the vagina, and, resting on the perineum, or kept up, if oval, by pressing on the sides ofthe stretched vagina, they keep up the womb. They always give immediate relief; but where the relaxation is considerable, they only mitigate, but do not entirely remove the sensation, which must continue more or less, as long as the relaxation remains. It must also be remembered, that they generally excite a mucous discharge from the vagina ; on which account, as well as from the dislike many patients have to them, they are seldom employed in the commencement ofthe complaint, or till other means have failed. In recent cases, or where the relaxation is not great, a perseverance in the use of the spring-support, topical astringents, and general tonics, with a * Dr. Monro mentions a procidentia uteri, in a very young girl. It w«a preceded by bloody discharge. Works, p. 535. Another case is related by Saviard, Obs. 15. in which the prolapsed uterus was mistaken for the male penis; and as Goldsmith's soldier believed they would allow him to be born in no parSh, so this girl was in danger of being determined to have no sex. 137 recumbent posture, may accomplish a cure. Fatigue or exertion must always be avoided. The liberal use of tincture of kino internally, has been fruitlessly advised, to act as an astringent on the vagina and muscles, at the outlet ofthe pelvis ; topical applications are more effectual, in so far as the vagina is concerned, and in no other way can we expect them to do good. Osiander advises the insertion of a bag of fine linen, filled with powdered oak bark, at the same time that the patient is confined for three weeks to bed. Much relief is obtained by the use of the spring-support, immediately to be spoken of. • Pessaries are made of wood, and are of different shapes, s»me oval, some flat and circular, some like spindles, or the figure of eight, others globular. Of all these, the globular pessary is the best, and it ought to be of such size as to require a little force to introduce it into the vagina ; that is to say, it must be so large as not to fall through the orifice, when the woman moves or walks.20- It is retained by the orifice of the vagina, and rests on the perineum. Whichever be employed, it ought to be taken out frequently, and cleaned. * By diminishing gradually the size of the pessary, and using astringents, we may perhaps be able at last to dispense with it. In all the stages, a firm broad bandage applied round the abdomen, frequently relieves the uneasy sensations about the bowels, back, and pubis. The cold bath is also useful. It is farther necessary to mention, that the symptoms and treatment of prolapsus may be modified by circumstances which precede it, but with which it is not essentially connected. For instance, a tender or inflamed state of the uterus, and the appendages, may take place after delivery, and when convalescent, the patient may rise too soon, or sit up, striving to make the child suck, and thus bring on a degree of prolapsus. In this case, it is evident that the symptoms may be more acute or painful, and they will not be removed by a pessary, until by continual rest, laxatives, and occasional * Morand relates the case of a woman who had fcetid discharge from the vagina, accompanied with pain. On examination, fungous excrescences were discovered in the vagina, and amongst these a hard substance, which being extracted, was found to be part of a silver pessary. The vagina, contracted at this spot, and thus, though in a disagreeable way, prevented a return ofthe prolapsus. Pessaries have also ulcerated through into the rectum ; and Mr. Blair mentions a woman in the Lock Hospital, who had introduced a quadran- gular piece of wood into the vagina as a pessary, and which ulcerated through into the rectum, producing great irritation. Med. and Phys. Journal, Vol. X. p. 491. It is likewise necessary, if the pessary have an opening in it, to observe that the cervix uteri do not get into the opening, and become strangulated. Q 133 fomentations, the morbid sensibility of the parts within the pelvis be got rid of. When the relaxation is great, it has been proposed to use a hollow elliptical pessary, so large, as that by pressing against the sides ofthe vagina, it may support both itself and the womb; but it generally gives pain, and the relaxed vagina turns up within it, and becomes irritated. I am then lore clearly of opinion, that the oval pessary should, though hollow, have no large aperture. The long diameter must vary from 2£ to 3£ inches, according to the degree of relaxation. In such cases of relaxation, if the oval pessary do not succeed in removing the distressing sensation ofthe abdominal viscera being about to fall out, then, in addition to it, or the globe pessary, benefit may be derived from supporting the perineum itself, with a soft pad, with a spring on a similar principle with that used for prolapsus ani. A contrivance of this kind is to be had of any instrument maker ; but it is necessary that it be ofthe proper size or length, so as to press exactly on the perineum, and also, perhaps, a very little beyond it, towards the orifice ofthe vagina. This, in general, is more useful and more comfortable than a pessary, but in bad cases the latter may require to be conjoined. This, or a firm T-bandage, must also be employed with a large globe pessary, where the perineum is greatly lacerated. But if the lace- ration do not extend to the rectum, I am not sure that it would not be advisable to make the edges of the rent raw, and then use stitches; or, by applying caustic, to try and procure some more healing or contraction, by granulations. If we fail, we are not worse than before the trial.2 If a procidentia be large, and have been of long duration, the reduction of the uterus may disorder the contents of the abdomen, producing both pain and sickness. In this case, we must enjoin strict rest in a horizontal posture. The belly should be fomented, and an anodyne administered. Sometimes it is necessary to take away a little blood ; and we must always attend to the state ofthe bladder, preventing an accumulation of urine. When the symptoms have abated, a pessary must be introduced,* and the woman may rise for a little, to ascertain how it fits ; but, as in other cases, she ought for some time to keep much in a horizontal posture, and avoid for a still longer period every exertion. If there have existed inflam- • Dr. Denman very properly advises, that a pessary should not be introduced immediately after the uterus is reduced. Lond. Med. Journal vol VII p. 56. 139 mation of the displaced bowels, during the continuance of the procidentia, serious consequences may result from the reduction, owing to the adhesions which have formed. Should there be much difficulty and pain attending the attempt to reduce, it ought not to be persisted in. If the tumour, from having been much irritated, or long protruded, be large, hard, inflamed, and perhaps ulcerated, it will be impossible to reduce it until the swelling and inflam- mation be abated, by a recumbent posture, fomentations, saturnine applications, laxatives, and perhaps even blood- letting.* After some days we may attempt the reduction, nnd will find it useful previously to empty the bladder. The reduction, in general, causes, for a time, abdominal uneasiness, which sometimes increases to a great degree, accompanied with constipation, rendering it necessary to allow the tumour again to come down. If the uterus cannot be reduced, and be much diseased, it has been proposed to extirpate the tumour. This has been done, it is true, with success,t but it is extremely dangerous ; for the bladder is apt to be tied| by the ligature, which is put round the part; and as the intestines fall down above the uterus into the sac, formed by the inverted vagina, they also are apt to be cut$ or constricted. As a palliative, Richter advises the use of a suspensory bandage. A prolapsus uteri does not prevent the woman from becom- ing pregnant; || and it is even of advantage that she should * M. Hoin succeeded in reducing a very large, hard, and even ulcerated procidentia, by fomentations, rest, and low diet. Mem. de I'Acad. de Chir. torn. III. p. 365. t See Rossuet, Plater and Platner, Inst. Chir. section 1446. Wedelius de Procid. Uteri, c. 4. Volkamer, in Miscel. cur. an. 2. ob. 226. Another case may be seen in Journal de Med. torn. LXVIII. p. 195. Par£, ffiuvres, p. 970.—Carpus extirpated it with success. Vide Langii Epist. Med. lib. II. epist. 39.—Slevogtius relates a distinct case, where the womb was found in the vagina, as if in a purse. Dissert. 12.—Benevenius says he saw a woman whose uterus sloughed off. De Mirand. Morb. Causis, cap. 12.—Dr. Elmer supposes he has met with a similar case. Med. Phys. Journal, vol. XVIII. p. 344.— A distinct case is related by Laumonier. The patient was long subject to prolapsus utori, but at last the womb, with the vagina, was forced out so violently, that she thought all her bowels had come out. At the upper part of the tumour there was a strong pulsation. It was extirpated chiefly by ligature. The woman died some years after this, and the womb was found wanting. La Med. Eclare", par Fourcroy, torn. IV. p. 33. M. Baudelocque, however, says, that the uterus was only partially extirpated. Vide Recueil Period, torn. V. p. 332. See also cases by Marschall, Fodere", and Langenbeck. t This happened in Ruysch's case. Obs. Anat. vii. § This occurred in a case related by Henry, ab Heers, Obs. Med. p. 192. || Hervey relates a case, where the tumour was as large as a man's head, ulcerated, and discharged sanies. It was proposed to extirpate the prolapsed 140 become so, as we thus, at least for a time, generally cure the prolapsus. But we must take care, lest premature labour* be excited; for the uterus may not rise properly, or may again prolapse, if exerticm i,o used. Sometimes, especially if the person receive a fall,t or have a wide pelvis, the uterus may prolapse during pregnancy, although the woman have not formerly had this disease. Our first care ought to be directed to the bladder,! lest fatal suppression of urine take place.§ Our next object is to replace the uterus, and enjoin a state of rest in a recumbent posture. When there is no protrusion, but a mere descent, rest alone is all that is necessary, and in neither case would 1 advise a pessary. If it cannot be reduced,|| a very rare state indeed, the uterus must be supported by a bandage,*f[ until, by delivery, it be emptied of its contents. It is then to be reduced. I have never known any instance of protrusion; but I have found the uterus so far prolapsed as to have its orifice at, or a little beyond, that of the vagina. The neck, even in the beginning of the ninth month, in such cases, was conical, and less developed than usual, whilst the lips were thick and protuberant. The finger could be passed up beyond the lips, along the cervix, and excepting a feeling of bearing-down, no inconvenience was experienced, nor was there any difficulty in voiding the urine. The management of prolapsus during labour will be afterwards considered. If prolapsus be threatened, or have taken place, after uterus, but the following night a foetus was expelled, spithama longitudine. Opera, p. 558. See also a case by Mr. Antrobus, in Med. Museum, vol. I. p. 227. * Vide Mr. Hill's case, in Med. Comment, vol. IV. p. 88. t Dr. Burton had a patient, who in the fourth month of pregnancy fell, and was thereafter seized with suppression of urine. The os uteri was found almost at the orifice of the vagina. He drew off about three quarts of urine, raised up the womb, and introduced a pessary. System, p. 156. t Mr. Dray mentions a case, where in the fourth month of pregnancy, the woman was seized with pains, like those indicating abortion, accompanied with suppression of urine. The os uteri was very near the orifice of the vagina. This disease proving fatal, the bladder was found to be thickened, enlarged, and in part mortified. Vide Med. and Phys. Journal, vol. III. p. 456. § Reink mentions a woman who was pregnant of twins. In the fourth month the womb prolapsed, and caused a fatal suppression of urine. The vagina at the upper part was corrugated and inverted. Haller, Disp. Chir. torn, III. p. 585. || See a remarkable case of prolapsus in the gravid state, where the whole uterus protruded, and reduction was not accomplished till after delivery, by P. C. Fabricus, m Haller Disp. Chir. torn. III. p. 434 IT Vide Memoirs by M. Sabatier, in Mem! de ' I'Acad. de Chir. torn. III. p. 370. A case is lately (1826) published by Siebold, in his Journal, of a large prolapsus in the pregnant state. 141 delivery, in consequence, for instance, of getting up too soon, we must confine the woman to a horizontal posture, till it have regained its proper size and weight; and this diminution is to be assisted by gentle laxatives, particularly the daily use ofthe sulphas potasse cum sulphure, in doses of from two to three drachms. The bandage, formerly noticed, is also useful and comfortable. In some cases, the cervix uteri lengthens and descends lower in the vagina, though the body of the womb remains in situ. This is not to be confounded with prolapsus, for it is really a preternatural growth of part of the uterus ; and this portion, or elongation, has been removed by ligature. The anterior lip has descended to a great degree in labour, insomuch, that it has been mistaken for presentation of the placenta. SECTION THIRTY-NINTH. Inguinal hernie of the uterus have been long ago described by Sennert, Hildanus, and Ruysch, and very lately by Lalle- ment. This species of displacement may occur in the unim- pregnated state, and the woman afterwards conceive ; or it may take place when pregnancy is somewhat advanced. If it be possible to reduce the uterus, this must be done ; and in one stage an artificial enlargement of the foramen, through which the uterus has protruded, may assist the reduction. If, however, gestation be far advanced, then the incision may require to be made into the uterus when pains come on, that the child may be extracted. But it has happened, that even in this untoward situation, the natural efforts have expelled the child by the vagina, although the uterine hernia, protrud- ing by a separation of part of the abdominal muscles, hung down at first so low as the knee. SECTION FORTIETH. The ovarium is subject to several diseases, of which the most frequent is that called dropsy. The appellation, however, is not proper, for the affection is not dependent on an increased effusion of a natural serous secretion or exhalation, but is of the nature of what has, perhaps not very properly, been called encysted sarcoma, and consists in a peculiar change of structure,* and the formation of many cysts, * Le Dran says, this dropsy always begins with a scirrhus, and is only a symptom of it.—Dr. Hunter says, he never found any part of a dropsical ovarium in a truly scirrhous state, and he is right 142 containing sometimes watery, but generally viscid fluid, and having cellular, fleshy,* or indurated substance interposed between them, frequently in considerable masses. They vary in number and in magnitude. There is rarely only one large cyst containing serous fluid ; most frequently we have a great many in a state of progressive enlargement; the small ones are perhaps not larger than peas, others are as large as a child's head, whilst the one which has made most progress may surpass in size the gravid uterus at the full time. The inner surface of the cysts may either be smooth, or covered with eminences like the papille of a cow's uterus.t Their thickness is various, for sometimes they are as thin as bladders, some- times fleshy, and an inch thick. The fluid they contain is generally thick and coloured, and frequently fetid, and in some instances, mixed with flakes of fleshy matter, or tufts of hair; occasionally, it is altogether gelatinous, and cannot be brought through a small opening ; or it contains masses of white substance, like boiled white of egg; or the thick fluid may vary at different stages of its flowing, being sometimes like oil, and sometimes yellow or brown. Occasionally the whole quantity is nearly serous, as in ascites. The analysis of this has not led to any result of practical utility. The male testicle is subject to a similar disease, and I have, in the male, found, in consequence of a blow, the same disease increasing in the abdomen to a very great size. The tumour has been made up entirely, or in part, of hydatids.$ This, however, is not quite the same disease, although it may be conjoined with it. There is no diagnosis, nor is this of any importance, as both are alike intractable, excepting in so far as the cy'sts may be, for a time, emptied by puncture. This disease is more apt to affect those who have borne children, than the unmarried ; and the latter very rarely till they are past the age of twenty-five, oftener not till consider- ably older. Scrofulous habits are most liable to it. The effects or symptoms of this disease of the ovarium, may all be referred to three sources, pressure, sympathetic * Dr. Johnson's patient had the right ovarium converted into a fleshy mass, weighing nine pounds, and full of cysts. Med. Comment, vol. VII. p. 265. + I have seen the inner surface of the ovarium studded over with nearly two dozen of large tumours. M. Morand notices two cases, in which a similar structure obtained. t Sampson, in the Phil. Trans. No. 140, describes an ovarium filled with hydatids, containing 112 pounds of fluid.—Willi mentions a tailor's wife, whose ovarium weighed above 100 pounds, and contained partly hydatids, partly gelatinous fluid. Haller, Disp. Med. torn. IV. p. 447. 143 irritation, and action carried on in the ovarium itself. It sometimes, though not often, begins with pretty acute pain about the groins, thighs, and side of the lower belly, with disturbance of the stomach and intestines, and occasionally syncope. A few patients feel pain very early in the mamma? ; and M. Robert affirms, that it is felt most frequently in the same side with the affected ovarium. In some cases milk is secreted.* But generally the symptoms are at first slight, or chiefly dependant on the pressure or irritation of the parts within the pelvis. The patient is costive, and subject to piles or strangury, which, in a few instances, may end in a complete retention of urine ; the bowels are inflated, and in almost every instance, from this cause, the belly is very early enlarged, and the circumscribed tumour is lost in the general fulness. Sometimes one of the feet very early swells. By examining, a tumour may often be felt betwixt the vagina and rectum, and the os uteri is thrown forward near the pubis; so that, without some attention, the disease may be taken for retroversion of the womb.t In some time after this, the tumour, in general, rises out ofthe pelvis,t and these symptoms go off. A moveable mass can be felt in the hypogastric, or one of the iliac regions.^ This gradually enlarges, and can be ascertained to have an obscure fluctua- tion. The tumour is moveable, until it acquire a size so great, as to fill and render tense the abdominal cavity. It then resembles ascites, with which it in general comes to be ultimately combined.|| Little inconvenience is produced, * In a case detailed by Vater, the patient had symptoms of pregnancy, secreted milk, and even thought she felt motion. The belly continued swelled, and she had bad health for three years and a half, when she died. The abdomen con- tained much water, and the right ovarium was found to be as large as a man's head, containing capsules, filled with purulent-looking matter. The uterus was healthy, but prolapsed, and the ureter was distended from pressure. Haller's Disp. Med. torn. IV. p. 401. This was not a case of extra-uterine gestation, for the ovarium was divided into cells, and had no appearance of foetus. t Mr. Home's case, related by Dr. Denman, vol. I. p. 130, had very much the appearance of retroversion. t In some cases it does not ascend out of the pelvis, or if it do, the inferior part of the tumour sinks again into it. Morgagni relates an instance where the ovarium weighed 24 pounds; and the lower part of it filled the pelvis so well, that when it was drawn out, it made a noise like a cupping-glass when pulled away from the skin. Epist. 39. art. 39. § Swelling and induration of the iliac glands may somewhat resemble this disease ; but they are more fixed, more irregular to the feel, and more painful on pressure, II It may be combined with effusion of water in the abdominal cavity. Dr.- Bosch's patient had 16 pints of water in the abdomen, and both ovaria were enlarged so as to weigh 102 pounds. This patient complained of great pain 144 except from the weight of the tumour, and the patient may enjoy tolerable health for years. But it is not always so, for the tumour sometimes presses on the fundus vesice, producing incontinence of urine, or on the kidney, making part of it to be absorbed ; and it often irritates the bowels, causing uneasy sensations, or an acute pain with vomiting or purging, and sometimes hysterical affections, all of which are most likely to occur, or be worse, at the menstrual period.* It augments in size, and carries up the uterus with it ;t so that the vagina is elongated; and this is especially the case, if both ovaria be enlarged-! In many instances, however, the uterus, in place of rising, prolapses, and occasions repeated attacks of retention of urine, by pressure on the orifice of the bladder. The urine is not in the commencement much diminished in quantity, unless this disease be conjoined with ascites ; and the thirst, at first, is not greatly increased. But when the tumour has acquired a great size, the urine is generally much diminished or obstructed. If, how ever, the bulk be lessened artificially, it is often, for a time, increased in quantity, and the health improved. This is well illustrated by the case of Madame de Rosney,§ who in the space of four years, was tapped twenty-eight times; for seven days after each punc- and weight in the lower belly, and over the right hip. She was much emaciated, but the menses were regular. When she was tapped, not above two tea-cups-full of fluid were discharged. Med. and Phys. Journal, vol. VIII. p. 414.—Mr. French met with a case of ascites and dropsy of the ovarium. The ovarium extended from the pubis to the diaphragm. This patient had voracious appetite. Mem. of Medical Society, vol. I. p. 234. * Case by Sir Hans Sloane, in Phil. Trans. No. 252.—Dr. Pultney'3 patient, whose ovarium weighed 56 pounds, had excruciating pain in the left side, spasms, and hysterical fits. Mem. of Medical Society, vol. II. p. 265. t This point is well considered by M. Voison, in the Recueil Period, torn. XVII. p. 371. et seq.—The bladder may also be displaced, as in the case of Ma- demoiselle Argant, related by Portal, Cours d'Anat. torn. V. p. 549. t If only one of the ovaria be enlarged, or if both be affected, but only one much increased, the uterus is often not raised, because the ovarium turns on its axis, and the uterus lies below it. In a case with which I was favoured by the late Dr. Cleghorn, both ovaria were greatly tumefied, and could be felt on each side ofthe navel, whilst immediately beneath that, they seemed to be united by a flat hard substance; and when the urine was long retained, a fluctuation could be perceived before that part. Upon dissection, a firm thick substance Was found extending from the pubis to the navel, betwixt the ovaria. This was the uterus and vagina. The uterus itself was lengthened, the cervix was three inches long, and all appearance of os tineas was destroyed. Her complaints began after being suddenly terrified ; first she felt severe pain in the right groin, with weakness of the thigh, and soon afterwards perceived a tumour in the belly ; presently another appeared in the left 6ide. She was tapped 16 times. § Portal, Cours d'Anat. torn. V. p. 549. 145 ture, she made water freely, and in sufficient quantity ; the appetite was good, and all the functions well performed; but in proportion as the tumour increased, the urine, in spite of diuretics, diminished, and at last came only in drops. The woman generally continues to be regular for a considerable time, and may even become pregnant. In the course of the disease, the patient may have attacks of pain in the belly, with fever, indicating inflammation of part of the tumour, which may terminate in suppuration,* and produce hectic fever ; or the attack may be more acute, causing vomiting, tenderness of the belly, and high fever, proving fatal in a short time ; but in many cases, these symptoms are absent, and little distress is felt until the tumour acquire a size so great as to obstruct respiration, and cause a painful sense of distension. By this time, the constitution becomes broken, and dropsical effusions are produced. Then, the abdominal coverings are often so tender, that they cannot bear pressure ; and the emaciated patient, worn out with restless nights, feverishness, want of appetite, pain, and dyspnea, expires. The symptoms of this disease, all arising either from pressure or irritation, must vary according to the nature of the parts most acted on, and the peculiar sympathies which exist in the individual. When we consider that, in many instances, the whole constitution, as well as different organs, may bear without injury, a great, but very gradual irritation, it is not surprising that this disease, which, for a long time, operates only mechanically, should often exist for years with- out affecting the health materially, whilst in more irritable habits, or under a different modification of pressure, much distress, too often referred to hysteria, may be produced. This tumour has sometimes appeared to be occasioned by injury done to the uterus in parturition, as, for instance, by hasty extraction of the placenta; or by blows, falls, violent passions, frights, or the application of cold ; but very often, no evident exciting cause can be assigned. In all cases after delivery, when the patient complains of any degree of fixed pain above or behind one groin, and particularly when this is increased by pressure, and attended with irregular and protracted febrile condition, we should, besides the usual attention to the bowels, detract blood from the arm, or topically by cupping or leeches, and then apply a blister. * An obscure case is related by Dr. Taylor, where a very large abscess is supposed to have formed in the ovarium.—Quarterly Journal, July, 1826. R 146 Although some may be subjected to this active practice, who might have done well without it, yet many others would be saved from an incurable disease, the foundation of which is now laid. In the unmarried, as well as the married, pain in the ovarian or uterine region at the menstrual period, when different from that to which the female has been accustomed, demands attention, and at any time it is not to be over- looked, especially if combined with constipation, or following exposure to cold. This disease is at first sometimes misunderstood, from the most prominent symptom often being tympanites. Even careful examination cannot always early discover a tumour amidst the inflated intestines. Afterwards fluctuation is discernible, and the disease may be taken for ascites, but in general, the fluctuation is more obscure and circumscribed, being seldom felt in the lumbar region. In the first stage of this complaint, we must attend to the effects produced by pressure. The bladder is to be emptied by the catheter, when this is necessary, which is not often ; and stools are to be procured. It may be considered, how far, at this period, it is proper to tap the tumour from the vagina, and, by injections or other means, endeavour to pro- mote a radical cure. When the patient is pregnant, and the tumour opposes delivery, there can be no doubt of the propriety of making a puncture,* before having recourse to the crotchet.22 But this has only been resorted to, in order to obviate particular inconveniences, and affords no rule of con- duct in other cases where no such urgent reason exists. I am inclined to dissuade strongly from any operation at this period, because in a short time the tumour rises out of the pelvis; and then the patient may remain tolerably easy for many years. Besides, the ovarium in this disease contains, in general, numerous cysts ; and as these, in the first stage, are small, we can only hope to empty the largest. Perhaps we may not open even that; and although it could be opened and healed, still there are others coming forward, which will soon require the same treatment. Puncturinp;, then, can only retard the growth of the tumour, and keep it longer in the pelvis, where its presence is dangerous. * In a case noticed by Dr. Denman, the labour was obstructed until the ovarium was emptied, by piercing it from the vagina. The woman died six months afterwards. Introd. vol. II. p. 74. In Dr. Ford's case, related by Dr. Denman, the crotchet was employed. See also a case by M. Baudelocque PArt des Accouch. 1964. ' 147 When the tumour has risen out ofthe pelvis, we must, in our treatment, be much regulated by the symptoms. The bowels should be kept open, but not loose, by rhubarb and magnesia, aloetic pills, cream of tartar, or Cheltenham salt. Dyspeptic symptoms may sometimes be relieved by prepara- tions of steel, combined withsupercarbonate of soda, or other appropiate medicines, thoflgh their complete removal cannot be expected so long as the exciting cause remains. General uneasiness, or restlessness occasionally produced by abdominal irritation, may be lessened by the warm bath, saline julap, and laxatives ; whilst spasmodic affections are to be relieved by fetids; and if these fail, by opiates. If, at any time, much pain be felt, we may apply leeches, and use fomentations, or put a blister over the part; or if the activity be great, general blood-letting may be required. But I wish most distinctly to state my conviction, that beyond the object of palliating symptoms, the medical art can, at present, not extend ; and it argues, in so far as our skill, at least as yet goes, a most unsupported confidence in the power of physic to propose more. Upon the supposition of this disease being a dropsy, diuretics have been prescribed, but without success,* and often with detriment. Some have supposed, that diuretics do no good whilst the disease is on the increase ; but that, when it arrives at its acme, they are of service. But this disease is never at a stand ; it goes on increasing, till the patient be destroyed. When they produce any effect, it is chiefly that of removing dropsical affections combined with this disease; and in this respect, they are most powerful immediately after paracentesis. With regard to their power, or the power of any other medicine, of diminishing the size of the ovarium, my opinion is, that they have no more influence on it, than they have over a mellicerous tumour on the shoulder, or over the disease, when it occurs in the testicle, or over the con- figuration of the patient's nose. In one case, fomentations and poultices, were supposed to have discussed a tumefied ovarium ;t and Dr. Hamilton has lately stated, that he has * Dr. Denman justly observes, that diuretics have no effect, vol. I. p. 122. And Dr. Hunter remarks, that " the dropsy of the ovarium is an incurable disease, and that the patient will have the best chance for living longest under it, who does the least to get rid of it. The trocar is almost the only palliative." Med. Obs. and Inq. vol. II. p. 41. Willi, however, relates a case of 11 years' standing, which was cured by diu- retics; and it was calculated that the tumour contained 100 pounds of fluid Haller, Disp. Med. torn. IV. p. 541. Are such tales correct ? t Vide Dr. Monro's fourth case, in Med. Essays, vol. V. 14H cured seven cases by percussion, or patting for a length of time daily on the tumour, using a bandage so as to make constant compression, giving solution of muriate of lime, and employing the warm bath.* As some tumours seem to diminish, or be absorbed, under the influence of nauseating medicines, it might be supposed that in this formidable disease they might be tried with propriety; but continued sickness for such a length of time as would be required to produce any sensible effect on the tumour, would be as hurtful at last as the disease it was meant to remove ; whilst certainly during its operation it is much more distressing. The strongest objection, however, is, that the proposal is just as useless as any other which has been made. Having palliated symptoms until the distention become troublesome, we must then tap the tumour, which gives very great relief; and, by being repeated according to circum- stances, may contribute to prolong life for a length oftime.t As the uterus may be carried up by the tumour, it is proper to ascertain, whether it be the right ovarium or the left which is enlarged ; and we should always tap the right ovarium on the right ride, and vice versa : by a contrary practice the uterus has been wounded.f When the disease is combined with ascites, it is sometimes necessary to introduce the trocar twice, and the difference between the two fluids drawn off is pften very great. We must neither delay tapping so long as to injure by great irritation and distension, nor have recourse to it too early, or too frequently, for the vessels ofthe cavity excrete much faster and more copiously after each operation ; and it is to be remembered, that this is a cause of increasing weakness, not only from the expenditure of gelatinous fluid, but also from the increased action performed by the vessels, which must exhaust as much as any other species of exertion. finally, ii has been proposed, to procure a radical cure, * Hamilton on Mercurial Medicine, p. 202. t Dr. Denman advises the operation to be deferred as long as possible, and I believe he is right; for every operation is followed by re-accumulation, which is a debilitating process ; yet it is astonishing how much may in the course of time be secreted, without destroying the patient. Mr. Ford tapped his patient 49 times, and drew off 2786 pints. The secretion was at last so rapid, that three pints and three ounces were accumulated daily. Med. Commun. vol. II. p. 123.—Mr. Martineau tapped his patient 80 times, and drew off 6831 pints, or 13 hogsheads ; at one time he drew off no less than 108 pints. Phil. Trans, vol. LXXIV.p. 471. t In a ctse of this kind related by M. Voison, the uterus was wounded, and the patient felt great pain, and fainted. She died on the third day after the ope- ration. Recueil Period, torn. VII. p. 373, &c. 149 by laying open the tumour, evacuating the matter, and preventing the wound from healing, by which a fistulous sore is produced ; or by introducing a tent, or throwing in a stimu- lating injection.* Some of these methods have, it is true, been successful, but occasionally they have been fatal ;t and in no case which I have seen, have they been attended with benefit. There are two powerful objections to all these practices, besides the risk of exciting fatal inflammation : the first is, that the cyst is often irregular on its interior surface, and therefore cannot be expected to adhere ; the second is, that as the ovarium, when dropsical, seldom consists of one single cavity, so, although one cyst be destroyed, others will enlarge, and renew the swelling ; and indeed, the swelling is seldom or never completely removed, nor the tumour emptied, by one operation. Hence, even as a palliative, the trocar must sometimes be introduced into two or more places. We sometimes, in dissections, meet with a solitary bag of serum connected with the ovarium, and can suppose, that if this, after acquiring a certain size, were felt distinctly fluctuating, per vaginam, it might first be punctured, and then have means used for producing obliteration. It has * Le Dran relates two cases in the Mem. de I'Acad. de Chir. torn. III. In the first, the cyst was opened, and the woman cured ofthe dropsy, but a fistulous opening remained, p. 431. In the second, he made a pretty large incision, and introduced a canula into the sac. The operation was followed by fever, delirium, and vomiting; the woman retained nothing but a little Spanish wine for three weeks- ^he discharged daily 8 or 10 ounces of red fluid. At length all of a sudden 15 ounces of white pus were evacuated, and then the symptoms abated ; but a fistula remained for two years; then it healed; p. 442. Dr. Houston relates the case of a woman in this neighbourhood, in whom he made incision 2 inches long into the ovarium, and then with a fir splint turned out a great quantity of gelatinous matter and hydatids. He kept the wound open with a tent, and succeeded in curing the patient. The disease was attributed to rash extraction of the placenta, and had existed for thirteen years. It was attended with violent pains. Phil. Trans. XXXIII. p. 5. M. Voison relates a case, which was palliated by tapping, and keeping a fistula open. Recueil Periodique, torn. XVII. p. 381. And Portal gives an instance, V?efe' 1,y keePing the canula in the wound for a short time, a radical cure was obtained, and the person afterwards had children. Cours d'Anat. torn. V. p. 554. t De la Porte tapped a woman who had a large tumour in the belly, but nothing came through the canula. He made an incision of considerable length, and in the course of two hours and a half, extracted 35 lb. of jelly. The lips of the wounds were then brought together. Next day 15 lb. of jelly were evacu- ated, but presently vomiting and fever took place , and she died on the thirtieth °ay, having discharged altogether 671b. of fluid. This disease was of sixteen months' standing, and was attributed to hemorrhage. Mem. de I'Acad. de Chir. ton>. HI. p. 152. Dr. Denman notices the case of a patient, who died the sixth day after inject. mg the ovarium. Vol. I. p. 422. 150 of late been proposed to extirpate the ovarium after punc- turing it,* in order to reduce its size; or the operation may, on the same principle, be performed early, when the tumour is still small and moveable, and this I should conceive to be a much more favourable time, than after the ovarium had been allowed to acquire a great size. The operation is full of danger, but simple in its performance. We have only to make an incision into the abdomen, proportioned to the size of the tumour, and after tying a ligature around the pedicle, cut away the mass, replace the intestines, and stitch the wound. But how few patients could be expected to recover from this operation. It may be said they must die at any rate, and this gives a chance of complete recovery. True, but if performed early, we have a great probability of the patient dying in a few hours ; whereas, by palliatives, she might have lived for many years. If delayed till a late period, he constituion is broken down, and the chance of recovery t still less. It has happened, that a cyst has adhered to the intestine, + and burst into it, the patient discharging glairy or fetid matter by stool.$ Such instances as 1 have known, have only been palliated, but not cured, by this circumstance. Sometimes the fluid has been evacuated per vaginam,§ or the * This, we are told, has successfully been done by Dr. Nathan Smith, of America. Vide Edin. Journal for October, 1822. Mr. Lizars has lately pub- lished two cases, where this operation was performed, and seems to have been encouraged by a wonderful history of a woman in America, who thought so little ofthe operation, that in five days thereafter she was found making her bed. In one case both ovaria were diseased, and only one was taken away. The woman survived. In the other case, the operation was fatal. Other two cases of abdominal operation are contained in the work ; in the one, no tumour of the ovarium existed ; in the other, the extirpation, for good reasons, was not persisted in. t Dr. Monro, in Med. Essays, vol. V. p. 773. details the history of a patient who had a diseased ovarium, and in whom the tumour pointed about four inches below the navel. It was opened, but nothing but air came out, followed next day by faeces : on the fifth day some pus was discharged. She gradually improved in health, and the tumour of the belly subsided; but in two years afterwards the suppuration was renewed, and she died. In this case, the colon had probably adhered to the ovarium. t Dr. Denman relates the case of a patient, who, having for some time suf- fered from pain and tenderness about the sacrum and uterus, and uterine haemorrhage, was suddenly seized with vomiting, syncope, pains in the belly, and costivene^s; presently a tumour was felt in the right side, and this soon occupied the whole abdomen. This patient was cured, after purging a gela- tinous fluid. Med. and Phys. Jour. vol. II. p. 20. § Dr Monro relates a case of supposed pregnancy, in the tenth month of which the tumour was removed by an aqueous discharge from the vagina. In a future attack, however, violent bearing-down pains were excited, and the woman 151 ovarium has opened into the general cavity ofthe abdomen, and the fluid been effused there. There is another disease, or a variety ofthe former disease, in which bones, hair, and teeth, are found in the ovarium.* The sac, in which these are contained, is sometimes large, and generally is filled with watery or gelatinous fluid. The bony substance, and teeth, usually adhere to the inner surface of the cyst. This disease produces no inconvenience, except from pressure. It has been deemed by some, to be merely an ovarian conception ; but it may undoubtedly take place without impregnation ; nay, similar tumours havebeenfound in the male sex.t It is to be treated as the former disease. SECTION FORTY-FIRST. The ovaria are sometimes affected with scrofula, and the tumour may prove fatal by producing retention of urine. When it rises out of the pelvis, it is often productive of hypochondriasis, and very much resembles the ovarian disease, formerly mentioned, but is firmer, seldom gives a sensation of fluctuation, and sometimes is very painful when pressed. It rarely terminates in suppuration ; but when it does, the fluid, as Portal observes, is blanchatrc, filamenteux, grumeleux, mat digcre. The substance of the ovarium is soft, and similar to that of other scrofulous glands. Occasionally it contains a cheesy substance, which is found, at the same time, in the mesenteric and other glands. Burnt sponge, cicuta, mercury, electricity, laxatives, Sec. have been employed, but seldom with benefit. The most we can do, is to palliate symptoms, such as retention of urine, costiveuess, dyspepsia, or pain. died exhausted. The left ovarium was found greatly enlarged with vesicles, M ed. Essays, vol. V. p. 770. * See Dr. Baillie's Morbid Anatomy, chap. 20. Dr. J. Cleghern mentions a woman who died ten days after being tapped. The right ovarium was found greatly enlarged, and had many cells, some containing hair, cretaceous matter, fragments of bone and teeth, others gelatinous fluid. Trans, of Royal Irish Acad. vol. I. p. 80. In Essays Phys. and Literary, vol. II. p. 300. a case is mentioned, in which the one ovarium contained many vesicles ; the other con- tained a mass, like brain, with bones and teeth. In the museum attached to the hospital at Vienna, there is a large ovarium, the inner surface of which is covered with hair. Horstius met with an ovarium, containing hair, purulent- looking and oily matter. Oper. p. 249. Schenkins met with fat and hair, p. 556. and Schacher relates a similar case in Haller's Disp. Med. torn. IV. p. 477. Ruysch, in his Adversaria, says, he met with bones and hair, and le Rich, in the Hist, de I'Acad. des Sciences, 1743, met with hair and oil, in cells, together with bones and teeth. See also Recueil Period, torn. XVII. p. 462. t Duverney saw a tumour extirpated from the scrotum, containing fleshy matter and bones, ffiuvres, torn. II. p. 562. And M. Dupuytren presented 152 The ovarium may also be enlarged, and become hard and stony,* or converted into a fatty substance.t Sometimes it is affected with the spongoid disease, and is changed into a substance like brain, with cysts containing bloody serum. The tumour in this disease feels tense and elastic. It may burst through the abdominal parietes, and throw out large fungous excrescences. Frequently we find, on cutting an enlarged ovarium, that part of it resembles the spongoid structure, having bloody fungous cysts ; part is like firm jelly, and part like cartilage, or dense fat. Often the uterus participates in the disease. I have seen a mass of this kind weigh thirteen pounds. I have never found the ovarium cancerous. SECTION FORTY-SECOND. The ovaria may be wanting on one or both sides, or may be unusually small.23 In such cases, it sometimes happens, that the growth of the external parts stop early, and the marks of puberty are not exhibited. The ovarium may form part of a herniary tumour. SECTION FORTY-THIRD. The tubes may be wanting, or impervious, and are subject to many ofthe diseases ofthe ovaria. The round ligaments may partake of the disease of the during the remaining period' of gestation, will renew the pain ip 2 L 282 Violent exercise, as dancing, for instance, or much walking, or the fatiguing dissipations of fashionable life, more especially in the earlier months, by disordering the nervous system, and affecting the circulation, may vary the distribution of blood in the uterus, so much as to produce rupture ofthe vessels, or otherwise to destroy the ovum. There is also another way in which fatigue acts, namely, by subducting action and energy from the uterus: for the more energy that is expended on the muscles ofthe inferior extremities, the less can be afforded or directed to the uterus ; and hence abortion may be induced at an early stage of gestation.* Fatigue also, by the effect produced on the medulla spinalis, may directly injure the nerves of the uterus. Even at a more advanced period, inconvenience will be produced upon the principle formerly mentioned; for the nerves ofthe loins conveying less energy, in many instances, though not always, to the muscles, they are really weaker than formerly, and are sooner wearied, producing pain, and prolonged feeling of fatigue for many days after an exertion, which may be considered as moderate. This feeling must not be confounded with a tendency to abortion, though it may sometimes be combined with it, for generally by rest the sensation goes off. Neither must we suppose that the child is dead, from its being usually quiet during that period, for as soon as the uterus, which has been a little impaired in its action, recovers, it moves as strongly as ever. In the next place, I mention the death of the child, which may be produced by syphilis, or by diseases perhaps peculiar to itself, or by that state which produces too much liquor amnii, or by injury ofthe functions ofthe placenta, which may arise from an improper structure of the gland itself, or aneurism, or other diseases of the cord. But in whatever way it is produced, the effect is the same in checking the action of gestation, unless there be twins, in which case it has been known, that the uterus sometimes did not suffer universally, but the action went on, and the one child was born ofthe full size, the other small and injured.t The length of time * The same effect is observable in the stomach and other organs. If a delicate person, after a hearty meal, use exercise to the extent of fatigue, he feels that the food is not digested, the stomach having been weakened or injured in its actions. t It has even been known, that, in consequence ofthe death of one child the uterus has suffered partially, and expulsion taken place ; but the other child con- tinuing to live, has preserved the action of gestation in that part of the uterus, which,- properly speaking, belonged to it, and pregnancy has still gone on. This, however, is an extremely rare occurrence; for in almost every instance, the death 283 required for producing abortion from this cause is various: sometimes it is brought on in a few hours ; at other times not for a fortnight, or even longer.** In these and similar cases, when the muscular action is commencing, the discharge is trifling, like menstruation, until the contraction become greater, and more of the ovum be separated. When symp- toms of abortion proceed from this cause, it is not possible to prevent its completion; and it would be hurtful even if it were possible. When, therefore, after great fatigue, profuse evacuations in delicate habits, violent colic, or other causes, the motion of the child ceases, the breasts become flaccid, and the signs of gestation disappear, we need not attempt to retard expulsion, but should direct our principal attention to conduct the woman safely through the process. Another cause is, any strong passion of the mind. The influence of fear, joy, and other emotions, on the nervous system, is well known ; and those of the uterus are not exempted from their power; any sudden shock, even of the body, has much effect on this organ. The pulling of a tooth, for instance, sometimes suddenly produces abortion. A thunder storm or violent cannonade has been supposed to cause abortion by the concussion ofthe air: but it is more probable when they have that effect, that it is owing to mental trepi- dation. Emmenagogues, or acrid substances, such as savin and other irritating drugs, more especially those which tend to excite a considerable degree of vascular action, may produce abortion. Such medicines, likewise, as exert a violent action on the stomach or bowels, will, upon the principle formerly men- tioned, frequently excite abortion; and very often are taken designedly for that purpose in such quantity as to produce fatal effects ;* hence emetics, strong purgatives, diuretics, or a full course of mercury, must be avoided during pregnancy. of one child produces an affection ofthe action of gestation in the whole uterus, and the consequent expulsion of both children. " It is an old observation, that those purgatives which produce much tenes- mus will excite abortion; and this is certainly true, if their operation be carried to a considerable extent, and continue long violent. Hence dysentery is also apt to bring on a miscarriage. Those strong purges which are sometimes taken to promote premature expulsion, not only act by exciting tenesmus, but likewise by inflaming the stomach and bowels, and thus affect the uterus in two ways. It cannot be too generally known, that when these medicines do produce abortion, tfce mother can seldom survive their effect. It is a mistaken notion, that abortion can be most readily excited by drastic purges, frequent and copious bleeding, &c. immediately after the woman discovers herself to be pregnant; on the contrary, 284 If any part witb which the uterus sympathizes have its action greatly increased during pregnancy, the uterus may come to suffer, and abortion be produced. Hence the accession of morbid action or inflammation in any important organ, or on a large extent of cuticular surface, may bring on miscarriage, which is one cause why small-pox often excites abortion, whilst the same degree of fever, unaccompanied with eruption, would not have had that effect. Hence also increased secre- tory action in the vagina, if to a great degree, though it may have even originally been excited in consequence of sympathy with the uterus, may come to incapacitate the uterus for going on with its actions, and therefore it ought to be moderated by means of an astringent injection. Even when there is no immediate and natural sympathy, a violent local ailment may disorder the whole frame, so as to injure the uterine action. An obstinate pleurisy, for instance, particularly if we require to bleed freely to subdue it, generally is followed by prema- ture labour. Mechanical irritation ofthe os uteri, or attempts to dilate it prematurely, will also be apt to bring on muscular contrac- tion. At the same time, it is worthy of remark, that the effect of such irritation is generally at first confined to the spot on which it acts, a partial affection of the fibres in the immediate vicinity of the os uteri being all that is, for some time, produced ; and therefore slight uneasiness at the lower part ofthe belly, with or without a tendency in the os uteri to move or dilate, whether brought on by irritation at the upper part of the vagina or os uteri, or by the affection of the neck of the bladder, &lc. maybe often prevented from extending farther, by rest, anodynes, and having immediate recourse to such means as the nature of the irritation may require for its removal.* The irritation of a prolapsus ani, or of inflamed piles, witb or without much sanguineous discharge, may excite the uterus to contract; and if the bleeding from the anus have been the action of the uterus is then more independent of that of other organs, and therefore not so easily injured by changes in their condition. I have already shown, that abortion more frequently happens when the pregnancy is farther advanced, beciuse then not only the uterus is more easily affected, but the foetus seems to suffer more readil)T. It is apt, either from diseases directly affecting itself, or from changes in the uterine action, to die about the middle ofthe third month, in which case expulsion follows within a fornight. * Chronic inflammation of the heart is generally attended with pain at the bottom ofthe abdonmn, which is sometimes mistaken for symptoms of calculus. In one case abortion seemed to proceed from this disease ofthe heart. 265 profuse, and the woman weakly, it may destroy the child. The piles ought, therefore, never to be neglected. Tapping the ovum, by which the uterus collapses, and its fibres receive a stimulus to action, is another cause by which abortion may be produced ; and this is sometimes, with great propriety, done at a particular period, in order to avoid a greater evil. It is now the general opinion, that contraction will unavoidably follow the evacuation of the waters. But we can suppose the action of gestation to be in some cases so strong as not, at least for a very considerable time, to stop in consequence of this violence, and, if it do not stop, contrac- tion will not take place. I do not, however, mean to say, that all discharges of watery fluid from the uterus, not followed by abortion, are discharges of the liquor amnii. On the contrary, I know, that most of these are the consequence of morbid action about the os uteri, the glands yielding a serous, instead of a gelatinous fluid, and this action may continue for many months. In all these cases, the woman must be confined to bed, and have an anodyne every night at bedtime, for some time, premising venesection if the pulse indicate it, and conjoining gentle laxatives. There is just so much probability of gesta- tion going on, as to encourage us to use endeavours to con- tinue it. In those instances where the discharge is small, and the oozing pretty constant, we conclude that it is yielded chiefly by the glands about the os uteri, and may derive ad- vantage from injecting three or four times a day a strong in- fusion of galls, or solution of alum. The woman ought to use no exertion, as the membranes are apt to give way. It is sometimes necessary to lay down rules for the manage- ment of pregnant women, even although they may not have been liable to abortion. These are to be drawn from the remarks already delivered, and it is only requisite to add, that in all cases it is proper to attend to the effects of utero-gesta- tion, or the diseases of pregnancy, which are to be mitigated, when severe, by suitable remedies. The danger of abortion is to be estimated by considering the previous state of the health, by attending to the violence ofthe discharge, and the 'difficulty of checking it; to its duration, and the disposition to expulsion which accompanies it; to the effects which it has produced in weakening the system, and to its combination with hysterical or spasmodic affections. In general, we say that abortion is not dangerous, yet in some cases, even at a very early period of gestation, and 286 under vigorous treatment, it does prove fatal very speedily, either from loss of blood, or spasm in the stomach, or convul- sions. I knew one instance which proved fatal so early as the end of the second month. It is satisfactory, however, to find, that this termination is rare, that these dangerous attendants are seldom present, and that a great hemorrhage may be sustained, and yet the strength soon recover. But if there be any disposition in a particular organ to disease, abortion may make it active, and thus, at a remote period, carry off the patient. Miscarriages, if frequently repeated, are also very apt to injure the health, and break up the constitution. When abortion is threatened, the process is very prone to go on to completion ; and it is only by interposing, before the expulsive efforts are begun, that we can be successful in preventing it; for whenever the muscular contraction is universally established, marked by regular pains, and attempts to distend the cervix and os uteri, nothing, I believe, can check the process. As this is often the case before we are called, or as in many instances abortion depends on the action of gestation being stopped by the causes, whose action could not be ascertained until the effect be produced, we shall frequently fail in preventing expulsion. This is greatly owing to our not being called until abortion, that is to say, the expulsive process, has begun ; whereas, had we been applied to upon the first unusual feeling, it might have been prevented. What I wish then particularly to inculcate is, that no time be lost in giving notice of any ground of alarm, and that the most prompt measures be had recourse to in the very beginning ; for, when universal uterine contraction has commenced, then all that we can do is to conduct the patient safely through a confinement, which the power of medicine cannot prevent. The case of threatened abortion, in which we most frequently succeed, is that arising from slipping ofthe foot, or from causes exciting a temporary over-action of the vessels, producing a slight separation ; because here the hemorrhage immediately gives alarm, and we are called before the action of gestation be much affected. Could we impress upon our patients the necessity of equal attention to ofher preceding symptoms and circumstances, we might succeed in many cases where we fail from a delay, occasioned by their not understanding that an expulsion can only be prevented by interfering before that process begins ; for when sensible signs of contraction appear, the mischief has proceeded too far to be checked. Prompt 287 and decided means used upon the first approach of symptoms indicating a hazardous state of ihe uterus, or on the earliest appearance of hemorrhage, may, provided the child be still alive, be attended with success. In considering the treatment, I shall, first of all, notice the most likely method of preventing abortion in those who are subject to it; next, the best means of checking it, when it is immediately threatened ; and, lastly, the proper method of conducting the woman through it, when it cannot be avoided. The means to be followed in preventing what may be called habitual miscarriage, must depend on the cause supposed to give rise to it. It will, therefore, be necessary to attend to the history of former abortions ; to the usual habitudes and constitution of the woman ; and to her condition when she becomes pregnant. In many instances, a plethoric disposition, indicated by a pretty full habit, and copious menstruation, will be found to give rise to it. In these cases, we shall find it of advantage to restrict the patient almost entirely to a vegetable diet, and, at the same time, make her use considerable and regular exercise. The sleep should be abridged in quantity, and taken, not on a bed of down, but on a firm mattress, at the same time that we prevent the accumulation of too much heat about the body. The bowels ought to be kept open, or rather loose, which may be effected by drinking Cheltenham water, or taking some other laxative. We must not, however, carry this plan too far, nor make a sudden revolution in the constitution, as this may be productive of permanent mischief, and occasion the diseases which proceed from a broken habit. Whenever the strength is diminished, the appetite impaired, or any other bad effect is produced, we have gone too great There is, in plethoric habits, a weakness of many, if not all, of the functions ; but this is not to be cured by tonics, but by continued and very gradually increased exercise, laxa- tives, and light diet, consisting chiefly of vegetables. This plan, however must not be carried to an imprudent length, nor established too suddenly ; but regard is to be had to the previous habits. It is a general rule, that exercise should not if n'^Ki ° !Gngth °f fatiS"e' and ^at it should be taken, in A ,J?heLcountly; whilst late hours, and many of the modes of fashionable life, must be departed from. We 288 must remember that an excifable state ofthe nervous system is apt to take place, and must endeavour to lessen this by strict attention to the bowels, friction, with some stimulating embrocation on the spine, and the use of the shower bath, or sea bathing, if they do not produce dullness or languor. There is, I believe, no remedy more powerful in preventing abortion than the cold bath, and the best time for using it is in the morning. By means of this, conjoined with attention to the vascular system, and prudent conduct on the part of the patient, I suppose that nine tenths of those who are subject to abortion, may go on to the full time. If the shower bath be employed, we must begin with a small quan- tity of water ; and, in some instances, may at first add so much warm water as shall make it just feel cold, but not to give too great a shock. If the cold bath cause headach, this may often be prevented by premising one or two doses of physic. After conception, the exercise must be taken with circum- spection : but the diet must still be sparing, and the use of the cold bath continued. If the pulse be at any time full, or inclined to throb, or if the patient be of a vigorous habit, a little blood should be taken away at a very early period. In some cases where the action is great, we must bleed almost immediately after the suppression of the menses. It is not necessary to bleed copiously ; it is much better to take away only a few ounces, and repeat the evacuation when required, and we should manage so as to avoid fainting. The cold bath should be conjoined.* Injecting cold water into the vagina, twice or thrice a day, tras often a good effect, at the same time that we continue the shower bath every morning. When there is much aching pain in the back, it is of service to apply cloths to it, dipped in cold water, or gently to dash cold water on it ; or employ a partial shower bath, by means of a small watering-can. In this, as in all other cases of habitual abortion, we must advise, that impregnation shall not take place until we have corrected the system ; and after the woman has conceived, it is requisite that she live absque marito, at least until gestation be far advanced. I need hardly add, that when consulted respecting habitual abortion, the strictest prudence is required on our part, and that the situation of the patient, and many * The acetate of lead has been recommended by the late ingenious and justly eetebrated Dr. Rush, of Philadelphia, in doses of from one to three grainy given three times a day. Of this practice I cannot speak from my own experience; but Dr. Rush informed me that in his hands it had been attended with great success. 289 of our advices, should be concealed from the most intimate friends of the patient. In other cases, we find that the cause of abortion is connected with sparing menstruation. This is often the case with women whose appearance indicates good health, and who have a robust look. This is not often to be rectified by medicine, but it may by regimen, &c. Here, as in the former case, we find it useful to make the greatest part of the diet consist of vegetables ; but it is not necessary to restrict the quantity. When, on the other hand, the patient has a weakly, delicate appearance, it will be proper to give a greater proportion of animal food, and two glasses of wine, in the afternoon, with some mild bitter laxative, so as to strengthen the stomach, and at the same time keep the bowels open. We also derive in both cases, advantage from the daily use ofthe warm bath, made of a pleasant temperature ; but this is to be omitted after conception; at least for the first ten or twelve weeks ; after which, if there be symptoms of irrita- tion, or feeling of tension about the belly, or pain about the groins, or pubis, it may be employed, and is hoth safe and advantageous. But when the patient is of a phlegmatic habit, or subject to profuse fluor albus, it is not indicated, and sometimes is pernicious. The internal use ofthe Bath waters, previous to conception, is often of service ; or where the circumstances ofthe patient will not permit this, we may desire her to drink, morning and evening, a pint of tepid water, con- taining half a drachm of sweet spirit of nitre. Throwing up into the vagina, tepid salt water twice or thrice a day, seems also to have a good effect. I have already mentioned, that abortion is sometimes the consequence of too firm action, the different organs refusing to yield to the uterus, which is thus prevented from enjoying the due quantity of energy and action. These women have none of the diseases of pregnancy, or they have them in a slight degree. They have good health at all times, but they either miscarry, or have labour in the seventh or eighth month, the child being dead; or if they go to the full time, I have often observed the child to be sickly, and of a constitw tion unfitting it for living. Blood-letting is useful by making the organs more irritable. The tepid bath is in general of advantage, and may be employed every second evening for some time. There is another case in which all the functions are healthy 2M 290 and firm, except the circulation, which is accelerated by the uterine irritation. This is more or less the case in every preg- nancy ; but here it is a prominent symptom. The woman is very restless, and even feverish, and apt to miscarry, especially if she be of a full habit. I am satisfied that in many instances this state is produced by irritation ofthe origin ofthe cardiac nerves, and is quite independent of plethora. Immediate relief is given by venesection, which is the only effectual remedy, but must not be carried to an extreme degree. The bowels are also to be kept regular. When, on the contrary, abortion arises from too easy yielding of some organ, we must keep down uterine action, by avoiding venery, and injecting cold water often into the vagina, or pouring cold water every morning from a watering- can, upon the loins and ilia; at the same time we must attend to the organ sympathizing with the uterus. Sometimes it is the stomach which is irritable, and the person is often very sick, takes little food, and digests ill. A small blister, or leeches, applied to the pit of the stomach, often relieves this; a little ofthe compound tincture of bark, taken three or four times a day, is serviceable ; or a few drops of the tincture of muriated iron, in a tumbler glassful of aerated water. At other times the bowels yield, and the patient is obstinately costive. This is cured by aloetic pills, or manna, with the tartrate of potass. When the muscular system yields, producing a feeling of languor and general weakness, the use of the cold bath, with a grain of opium at bedtime, will be of most service. It is evident, that it is only by attending minutely to the history of former miscarriages, that we can detect these causes; and we shall generally find, that in each individual case, it is the same organ in every pregnancy which has yielded or suffered. Previous to future conception, we may, with propriety, endeavour to render it less easily affected. General weakness is another condition giving rise to abortion ; and upon this 1 have already made some remarks. I have here only to add, that the use of the cold bath, the exhibition of the Peruvian bark, and wearing flannel next the skin, constitute the most successful practice. Syphilis is likewise a cause of abortion. When it occurs in the mother, it often unfits the uterus for going on with its actions. At other times, more especially when the father labours under venereal hectic, or has not been completely cured, the child is evidently affected, and often dies before 291 the process of gestation can be completed. In these Cases* a course of mercury alone can effect a cure. But we are not to suppose that every child, born without the cuticle in an early state of pregnancy, has suffered from this cause ; on the contrary, as some of these instances depend on causes already mentioned, and which cannot be cured by mercury, I wish to caution the student against too hastily concluding that one of the parents has been diseased, because the child is born dead or putrid at an early period. It is not always easy to form a correct judgment; but we may be assisted by finding that the other causes which I have mentioned are absent; that we have appearances of ulceration on the child, and that there are some suspicious circumstances in the former history and present health of the parents. A child may be born dead, and even putrid, not only in consequence of syphilis, but also of some malformation of the foetus itself, or of its appendages; or of a general imperfection ofthe ovum, usually combined with an increased quantity of liquor amnii; or of original debility of constitution, unfitting the child for coming to maturity ; or of fatal derangement of structure, or action, taking place in utero, from causes not very obvious; or from weakness or imperfect action of the uterus itself, or such a condition of it as sometimes produces epilepsy ; or it is in certain cases occasioned by a convulsion. Most of these causes are not under our control; and indeed, with the exception of the case of syphilis, we can only propose to prevent the death of the child, by the use of such general means as invigorate the constitution of the parent; or as obviate palpable predisposing causes of injury to the uterine functions. Advancement in life, before marriage, is another cause of frequent abortion, the uterus being then somewhat imperfect in its action. In general we cannot do much in this case, except avoiding carefully the exciting causes of abortion; and by attending minutely to the condition of other organs, during menstruation or pregnancy, we may, from the princi- ples formerly laid down, do some good. It is satisfactory to know, that although we may fail once or twice, yet by great care, the uterus comes at last to act more perfectly, and the woman bears children at the full time. After these observations, it is only necessary to add, that in every instance of habitual abortion, whatever the condition may be which gives rise to it, we find it is essential that the greatest attention be paid to the avoiding of the more evident 292 and immediate exciting causes of miscarriage, such as fatigue, dancing, art to which the placenta is attached, for there the vessels ire large and numerous ; and the cervix uteri, because here the greatest changes are going forward. At one or »ther of these two places, rupture is most likely to take place, ind it will happen still more readily if the placenta be ittached at or near to the cervix. It may be excited either by oo much blood circulating permanently in the system, or by a temporary increase of the strength and velocity of the circulation, produced by passion, agitations, stimulants, foe. A plethoric state is a frequent cause of haemorrhage in the young, the vigorous, and the active: the decidua is separated, and a considerable quantity of blood flows : perhaps the placenta is detached, and the haemorrhage is more alarming. In some cases, the rupture is preceded by spitting of blood, or bleeding at the nose, and in these cases the lancet may be of much service. We sometimes find that extravasation is produced by an increased action ofthe uterine vessels themselves, existing as a local disease. In this case, the patient, for some time before the attack, feels a weight and uneasy sensation about the hypogastric region, with slight darting pains about the belly or back. These precursors have generally been ascribed to a different c»use ; namely, rigidity of the ligaments of the womb or ofthe fibres ofthe uterus itself. Spasmodic action about the cervix uteri, must produce a separation ofthe connecting vessels. The causes giving rise to this in the advanced period of gestation, are not always obvious, neither can we readily determine the precise cases in which this action excites flooding. We should suspect that the discharge ought always to be preceded by pain, but we know that motion may take place in some instances about the cervix uteri without much sensation; and, on the other hand, many cases of flooding, not dependant on motion of the uterine fibres, are attended with uneasiness or irregular pain about the abdomen. This spasmodic action is not unfrequently produced by hanging pregnant animals. Whatever stops prematurely the action of gestation, may srive rise to a greater or less degree of haemorrhage. For in his case, the development of the cervix takes place quickly, ind the ovum must be separated. The quantity of the 307 discharge* will depend upon the state of the circulation—the magnitude of the vessels which are torn—the contraction of the uterus—and the care which is taken ofthe patient. Hence it follows as a rule in every premature labour, more especially in its first stage, that we prevent all exertion, refrain from the use of stimulants, and confine the patient to a recumbent posture. It sometimes happens, that effective contraction does not take place speedily after the action of gestation ceases, but a discharge appears. This may stop by the induction of syncope, or the formation of clots. The blood which is retained about the cervix and os uteri putrifying, produces a very offensive smell. Milk is secreted as if delivery had taken place, and sometimes fever is excited. In this state the patient may remain for some days, when the haemorrhage is renewed, and the patient may be lost if we do not interfere. Some undue state of action about the os uteri, removing or ceasing to form that jelly which naturally ought to be secreted within it, is another cause. This is generally productive of a discharge of watery fluid, tinged with blood ; and if the patient be not careful, pure blood may be thrown out in considerable quantity. It may even happen, that the haemorrhage, under certain circum- stances, may prove fatal; and yet, upon dissection, little or no separation of the ovum be discovered, the discharge taking place from the vessels near the os uteri itself.t In some instances where a portion ofthe placenta has been detached, I have observed, that near the separated part, the structure ofthe placenta was morbid, being hard and gristly. In these cases, I could not detect any other cause of separation, and suppose that by the accidental pressure ofthe child upon the indurated part, the uterus may have been irritated. The insertion of the placenta over the os uteri,J may give rise to flooding in different ways. The uterus and placenta may remain in contact until the * I. 'hose cases where the contraction becomes universal and effective, we haye little dIScharge, and the patient is merely said to have a premature labour; but if the contraction be partial, and do not soon become effective, then we have considerable discharge, and the patient is said to have a flooding t \ide a case in point, by M. Heinigke, in the first volume of Brewer's Bi- Diioth. (jerm. X bo far as I have observed, uterine hemorrhage, when profuse, is produced most ipqucntly by this cause ; at least two thirds of those cases requiring delivery proceed, I think, from the presentation of the placenta; and in the majority of th. remaining third, it will be found attached near to the cervix. Most of those 308 term of natural labour, the one adapting itself to the other ; but whenever the os uteri begins to dilate, separation and consequent haemorrhage must take place. It is rare, however, for the accident to be postponed so long. In general, at an earlier period, in the eighth, or by the middle of the ninth month, we find that either the uterus and placenta no longer grow equally, in consequence of which the fibres about the os uteri are irritated to act ; or so much blood as must ne- cessarily, in this situation, circulate about the cervix uteri, interferes with its regular actions, and induces premature contraction of its fibres, with a consequent separation of the connecting vessels. In order to ascertain whether the haemorrhage proceed from this cause, we ought, in every case to which we are called, carefully to examine our patient. The introduction of the finger is sometimes sufficient for this purpose, but frequently it may be necessary to carry the whole hand into the vagina. If the placenta present, we shall feel the lower part of the uterus thicker than usual, and the child cannot be so distinctly perceived to rest upon it. This is ascertained by pressing with the finger on the fore part ofthe cervix, betwixt the os uteri and bladder, and also a little to either side.* If the os uteri be a little open, then, by insinuating the finger, and carrying it through the small clots, we may readily ascertain whether the placenta or membranes present, by attending to the difference which exists betwixt them. But in this examination, we must recollect, that only a small portion of the edge of the placenta may present, and this may not readily be felt at first. To conclude this part ofthe subject, I remark in general, that haemorrhage from the uterus is not merely arterial, but also venous, and the orifices of these latter vessels are extremely large. Almost immediately after conception, the veins enlarge and dilate, contributing greatly to give to the uterus the doughy feel which it possesses. In the end of gestation the sinuses are of immense size, and their extremities so large that in many places they will admit the point of haemorrhages, which are cured without delivery, proceed from the detachment of the decidua alone, or of a very small portion ofthe placenta, which has been separated under circumstances favourable for firm coagulation. * When a large coagulum occupies the lower part of the uterus, we may be deceived if we trust to external feeling alone, without introducing the finger within the os uteri. If the uterus have its usual feel, and the child be felt distinctly through it, then we are sure that, however near the placenta may be to the o* uteri, it is not fixed exactly over it. 309 the finger. Now, as all the veins communicate more freely tham the arteries, and as they have in the uterus no valves, we can easily conceive the rapidity with which discharge will take place, and the necessity of encouraging coagulation, which checks venous still more readily than arterial haemor- rhage. In whatever way flooding is produced, it has a tendency to injure or disturb gestation, and to excite expulsion ; but these effects may be very slowly accomplished, and in a great many instances may not take place in time to save the patient or her child. Having already noticed those changes produced on the womb itself by haemorrhage, ami the danger of trusting to them for the recovery of the patient, I will not recapitulate, but proceed very shortly to mention the effects produced on the system at large. During the continuation of the haemorrhage, or by the repetition ofthe paroxysms, if this be allowed to take place, certain alterations highly important are taking place. There is much less blood circulating than formerly ; and this blood, when the haemorrhage has been frequently renewed, is less stimulating in its properties, and less capable of affording energy to the brain and nerves. The consequence of this is, that all the actions of the system must be performed more incorrectly, and with less strength. The body is much more irritable than formerly, and slight impressions produce greater effects. This gives rise to many hysterical, and sometimes even to convulsive affections. The stomach cannot so readily digest the food—the intestines become more sluggish—the heart beats more feebly—the arteries act with little force—the muscular fibres contract weakly—the whole system descends in the scale of action, and must, if the expression be allowable, move in an inferior sphere. In this state, very slight ad- ditional injury will sink the system irreparably—very trifling causes will unhinge its actions, and render them irregular. If the debility be carried to a degree farther, no care can recruit the system—no means can renew the vigour of the uterus. We may stop the haemorrhage, but recovery will not take place. We may deliver the child, but the womb will not contract. When much blood has been lost, particu- larly if some irr.tat.on be conjoined, an approximation is made to a state of fever. The pulse is feeble, but sharp ; the shin rather warm ; and the tongue more or less parched. ibis state of the vascular system is dangerous, both as it exhausts still more a frame already very feeble, and also as it 310 tends to renew the haemorrhage. It will often be found i<) depend upon slight uterine irritation, upon accumulation in the bowels, upon pulmonic affections, upon muscular pain, or upon the injudicious application of stimuli. But, as has been explained in a former section, the mere loss of blood can also produce a febrile state. Such organs as have been previously disposed to disease, or have been directly or indirectly injured during the continu- ance of protracted flooding, may come to excite irritation, and give considerable trouble. An acute attack of haemorrhage generally leaves the patient in a state of simple weakness ; but if the discharge be allowed to be frequently conjoined, and the case thus protracted, the state of the vascular system which is produced, adds to the danger, and excites, if the patient be not delivered, more speedy returns. A woman seldom suffers much in a first attack of haemor- rhage. If she be stout and plethoric, she may lose a great quantity of blood, and yet, to appearance, not be greatly injured. The haemorrhage may come on in every different situation ; in bed she may awake suddenly from a dream, and feel herself swimming in blood ; or it may attack her when walking ; or may be preceded by a desire to make water, and she is surprised to find the chamber-pot half filled with blood. She recovers from her consternation ; perhaps in spite of every injunction, she walks about as usual, and finds no bad effect from motion ; the feeling of heaviness which may have preceded the accident is gone, she is lighter and better than she was before it, and hopes all is well; but in a few days the haemorrhage is repeated, and again stops ; at last, after one or two attacks, for the time is uncertain, the os uteri becomes soft, and opens a little, perhaps without pain, or she feels dull slight pains, which, however, give her very little uneasiness. This state may take place early, and without dangerous debility ; it may take place in the second or third attack ; or possibly the haemorrhage may never have entirely ceased, continuing for a day or two like a flow of the menses, and then being suddenly increased, or flowing in a torrent. But although this state may take place without alarming debility, it may also, and that very suddenly, be attended with the utmost danger, or may be accompanied with so much haemorrhage as to prove absolutely fatal. The patient is found without a drop of blood in her face, the extremities cold, the pulse almost gone, the stomach unable to 311 fetain drink. She is in the last stage of weakness, but it is iot the weakness produced by fever or disease, for we find her voice good, and generally the intellect clear. The haemor- rhage has, perhaps, stopped, and a young man would suppose it still possible for her to recover. But although not a drop of blood be afterwards lost, the debility increases, the pulse is quite gone, she breathes with difficulty, and gives long sighs, wavers in her speech, and in a short time expires. We may lay it down as a general observation, that few cases of profuse ha'inorrhage, occurring in an advanced stage of gestation, can be cured without delivery or the expulsion ofthe child. For when the discharge is copious or obstinate, the placenta is generally separated, sometimes to a very considerable extent, and are-union, without which the woman can never be secure against another attack, can rarely be expected. If the placenta present, the haemorrhage, although suspended, will yet to a certainty return, and few shall survive if the child be not delivered. But in those cases where only a portion ofthe decidua, or a little bit ofthe margin ofthe placenta* has been detached, and the communicating vessels opened, either by a state of over-action in the vascular system, or by too much blood in the vessels, or by some mechanical exertion, if proper care be taken, the haemorrhage may be completely and permanently checked ; or if it should return, it may be kept so much under, or may consist so much of the watery discharge from the glands about the os uteri, as neither to interfere with gestation, nor injure the constitution ; yet it is to be recollected, that even these cases of flooding may sometimes proceed to a dangerous degree, requiring very active and decided means to be used : and in no case can the patient be considered as safe, unless the utmost care and attention be paid to her conduct. It would thus appear, that some haemorrhages almost inevitably end either in the delivery ofthe child, or the death of the parent ; whilst others may be checked or moderated without an operation. A precise diagnostic line, liable to no exceptions, cannot be drawn betwixt these cases ; and there- fore, whilst we believe that rapid and profuse haemorrhages, which indicate the rupture of large vessels, can seldom be permanently checked, we still, provided the placenta do not present, are not altogether without hopes of that termination, * In this case, after labour is over, we may discover the separated portion bj the difference of colour; it is generally browner and softer than the rest. 312 which is more desirable for the mother, and safer for the child, than premature delivery. In slighter cases, our hope is joined with some degree of confidence. A second attack, especially if it follow soon after the first, and from a slight cause, or without any apparent cause, greatly diminishes the chance of carrying the woman to a happy conclusion without manual interference. In forming our opinion respecting the immediate danger of the patient, we must consider her habit of body, and the previous state of her constitution. We must attend to the state of the pulse, connecting that in our mind with the quantity and rapidity of the discharge. A feeble pulse, with a haemorrhage, moderate in regard to quantity and velocity, will, if the patient have been previously in good health, generally be found to depend on some cause, the continuance of which is only temporary. But when the weakness of the pulse proceeds from profuse or repeated haemorrhage, then although it may sometimes be rendered still more feeble by oppression, or feeling of sinking at the stomach, yet, when this is relieved, it does not become firm. It is easily compressed, and easily affected by motion ; or, sometimes, even by raising the head. If the paroxysm be to prove fatal, the debility increases— the pulse flutters and becomes imperceptible—the extremities first, and then the whole body, become cold and clammy— the breathing is performed with a sigh—she calls to be raised and have the windows opened—is in constant motion, with great anxiety, perhaps vomits—and syncope closes the scene. If irritation be conjoined with haemorrhage, or the vascular system be excited, then the pulse is sharper, and although death be near, it is felt more distinctly than when irritation is absent. The termination in this case is often more sudden than a person unacquainted with the effect of pain and irritation on the pulse, would suppose. For when the pulsation is distinct, and even apparently somewhat firm, a slight increase of the discharge, or sometimes an exertion without discharge, speedily stops it, the heat departs, and the patient never gets the better ofthe attack. We must likewise remember, that a discharge which takes place gradually can be better sustained than a smaller quantity, which flows more rapidly. For the vessels in the former case come to be accustomed to the change, and are able more easily to accommodate themselves to the decreased quantity. 313 But when blood is lost rapidly, then very speedy and universal contraction is required in the vascular system, in order that it may adjust itself to its contents, and this is always a debilitating process. The difference too betwixt the former nnd the present condition of the body, is rapidly produced, and has the same bad effect as if we were instantly to put a free liver upon a very low and abstemious diet. In all cases of considerable flooding, we find, that during the paroxysm, the pulse flags, and the person becomes faint. Complete syncope may even take place; but this in many cases is more dependant on sickness or oppression at the stomach, than on direct loss of blood. In delicate and irritable habits, the number of fainting fits maybe great, but unless the patient be much exhausted, we generally find that the pulse returns, and the strength recruits. The prognosis here must depend greatly on the quantity and velocity of the. discharge; for it may happen, that the first attack of haemorrhage may produce a syncope, from which the patient is never to recover. When we are called to a patient recently attacked with flooding, our most obvious duty is immediately to restrain the violence of the discharge; after which we can take such measures as the nature of the case may demand, either for preserving gestation, or for hastening the expulsion of the child. A state of absolute rest, in a horizontal posture, is to be enforced with great perseverance, as the first rule of practice. By rest alone, without any other assistance, some haemor- rhages may be cured; but without it, no patient can be safe. Even after the immediate alarm of the attack is over, she must still recollect her danger. She should be confined to bed, upon a firm mattress for several days, and ought not to leave her apartment for a much longer period. In general, the patient has gone to bed before we are called ; and, perhaps, by the time that we arrive, the bleeding has in a great measure ceased. The partial unloading of the vessels, produced by the rupture, the induction of a state approaching to syncope in consequence of the discharge, the fear ofthe patient, and a horizontal posture, may all have conspired to stop the haemorrhage. The immediate alarm from the flooding having subsided, the patient often expresses herself as more apprehensive of a premature labour, than ofthe haemorrhage,which she considers as over. If the attack have been accompanied with slight abdominal pain, her fears are increased. But we are not t* 2P 314 enter into these views of the case; we are to consider the discharge as the prominent symptom, as the chief source of danger. We are to look upon the present abatement as an uncertain calm ; and whatever advice we may give, whatever remedies we may employ, we are not to leave our patient until we have strongly enforced on her attendants the danger of negligence, and the necessity of giving early intimation should the haemorrhage be renewed. There is no disease to which the practitioner can be called, in which he has greater responsibility than in uterine haemorrhage. The most prompt and decided means must be used; the most patient attention must be bestowed ; and, whenever he undertakes the manage- ment of a case of this kind, whatever be the situation of the patient, he must watch her with constancy, and forget all considerations of gain and trouble. His own reputation, his peace of mind, the life of his patient, and that of her child, are all at stake. I am doing the student the most essential service, when I earnestly press upon his attention these considerations. And when I entreat, implore him to weigh well the proper practice to be pursued, the necessary care to be bestowed, I am pleading for the existence of his patient, and of his own honour and happiness. Procrastination, irresolu- tion, or timidity, have hurried innumerable victims to the grave; whilst the rash precipitation of unfeeling men has only been less fatal, because negligence is more common than activity. I shall endeavour to point out the proper treatment in the commencement of uterine haemorrhage, and the best method of terminating the case when the patient cannot be conducted with safety to the full time. After the patient is laid in bed, it is next to be considered how the haemorrhage is to be directly restrained, and whether we may be able to prevent a return. It is at all times proper to ascertain exactly the situation of the patient by examination, as we thus learn the state of the cervix and %os uteri, and whether there be any tendency to labour; whether the discharge be stopped by a coagulum in the mouths of the vessels,* or by a large clot in the upper part ofthe vagina; whether the placenta be attached to the os uteri, or whether the membranes present. We likewise endeavour to ascertain the quantity of blood which has been lost—the rapidity with which it flowed—the effect * We may conjecture that this is the case, if we find no clot in the vagina plugging the os uteri. We are not warranted to thrust the finger forcibly within the os uteri, in this examination; or to rub away the small coagula which may ba formed within it, and which may be restraining the haemorrhage. 315 which it ha^produced upon the mother or child—and the cause which appeared to excite the haemorrhage. The first remedy which, upon a general principle, offers itself to our attention, is blood-letting. In those cases, where the attack has been produced by over-action of the vessels, or a plethoric condition ; or where it seems to be kept up by these causes, this remedy, employed early, and followed by other means, may be effectual not only in checking the present paroxysm, but also in preventing a return. By the timely and decided use of the lancet, much distress may be avoided, and both the mother and the child may be saved from danger. But we are not to apply the remedy for one state to every condition ; we must have regard to the cause, and consider how far the haemorrhage is kept up by plenitude or morbid activity of the vessels. In those cases where the attack is not excited by, or connected with, plethora, or undue action in the vascular system, venesection is not indicated. We have in these cases, which are, I believe, by far the most numerous, other means of safely and powerfully moderating vascular action, without the detraction of blood, which, in this disease, it ought to be a leading principle to save as much as possible ; and it must be impressed on the student, that venesection is rarely required in the disease in question. Whatever lessens materially or suddenly the quantity of blood, must directly enfeeble, and call for a new supply, otherwise the system suffers for a long time. We shall find, that except under those particular circum- stances which I have specified, and where we have ground to believe that the rupture of vessels has been dependant on their plenitude or over-action, the circulation may be speedily moderated by other means, and especially by the application of cold. This is to be made not only by applying cloths dipped in cold water to the back and vulva, but also by sponging over the legs, arms, and even the trunk, with any cold fluid; covering the patient only very lightly with clothes, and promoting a free circulation of cold air, until the effect upon the vessels be produced. After this we shall find no advantage, but rather harm, from the further application of cold. All that is now necessary, is strictly and constantly to watch against the application of heat, that is, raising the temperature above the natural standard. The extent to which this cooling plan is to be carried, must depend upon circumstances. In a first attack, it is in general to be used in all its vigour: but where the discharge, either 316 towards the end of this attack, or in a subsequent paroxysm, has gone so far as to reduce the heat much belowthe natural standard, the vigorous application of cold might sink the system too much. In some urgent cases it may even be necessary to depart from our general rule, and apply warm cloths to the hands, feet, and stomach. This is the case where the discharge has been excessive, and been suffered to continue profuse or for a long time, and where we are afraid that the system is sinking fast, and the powers of life giving way. There are cases in which some nicety is required in deter- mining this point, and in these circumstances we must never leave our patient, but must watch the effects of our practice. This is a general rule in all haemorrhages, whatever their cause may have been, or from whatever vessel the blood may come. A cold skin and a feeble pulse never can require the positive and vigorous application of cold; but on the other hand, they do not indicate the application of heat, unless they be increasing, and the strength declining. Then, we cautiously use heat to preserve what remains, not rashly and speedily to increase action beyond the present state of power. In the application of cold, regard must also be paid to the previous condition of the patient, and her tendency to rheumatism or pectoral complaints. When an artery is divided, it is now the practice to trust for a cure of the haemorrhage to compression, applied by a ligature. We cannot, however, apply pressure directly and mechanically to the uterine vessels, but we can promote coagulation, which has the same immediate effect. Rest and cold are favourable to this process, but ought only in slight cases to be trusted to alone. In this country it has been the practice to depend very much upon the application to the back or vulva, of cloths dipped in a cold fluid, generally water, or vinegar and water; but these are not always effectual, and sometimes, from the state of the patient, are not admissible. Astringent injections are seldom of benefit in any discharge which deserves the name of haemorrhage. They commonly do good as a stillicidium, rather troublesome from its duration, than hazardous from its extent. In urgent cases they are hurtful, by washing away coagula. Plugging the vagina with a soft handkerchief,* answers * The insertion of a small piece of ice in the first fold of the napkin, is attended with great advantage, and has often a very powerful effect. Dr. Hoffman employed the introduction of lint, dipped in solution of vitriol, but this was rather as an astringent than a plug, and he does not propose it as a general.practice. He considers that he was obliged to have recourse ad ane«p» 317 every purpose which can be expected from them, in producing coagulation of the blood at the mouths of the vessels ; and whenever a discharge takes place to such a degree as to be called a flooding, or lasts beyond a very short time, this ought to be resorted to. The advantage is so great and speedy that I am surprised that it ever should be neglected. I grant that some women may, from delicacy and other motives, be averse from it; but every consideration must yield to that of safety ; and it should be impressed deeply on the mind ofthe patient as well as the practitioner, that blood is most precious, and not a drop should be spilled which can be preserved. Unless the flooding shall in the first attack be permanently checked, which, when the separated vessels are large and numerous, is rarely accomplished, we may expect one or more returns before expulsion can be accomplished. The more blood, then, that we allow to be lost at first, the less able shall the patient be to support the course of the disease, and the more unfavourable shall delivery, when it comes to be performed, prove to her and to the child. It is of consequence to shorten the paroxysm as much as possible ; and, therefore, when circumstances will permit, we should make it a rule to have from the first a careful nurse, who may be instructed in our absence to use the napkin without delay, should the haemor- rhage return. But whilst I so highly commend, and so strongly urge the use of the plug, I do not wish to recommend it to the neglect of other means, or in every situation. In the early attacks of haemorrhage, when the os uteri is firm, and manual inter- ference is improper, I know of no method more safe or more effectual for restraining the haemorrhage and preserving the patient. But when the haemorrhage has been profuse, or frequently repeated, and the circumstances of the patient demand more active practice, and point out the necessity of delivery, then the use of the plug cannot be proper. If trusted to, it may be attended with deceitful and fatal effects. We can indeed restrain the haemorrhage from appearing outwardly; but there have been instances, and these instances ought to be constantly remembered, where the blood has collected within the uterus, which, having lost all power, has become relaxed, and been slowly enlarged with coagula ; the strength has et eztremum auxilium. Vide Opera Omnia, tom. IV. Leroux employed the plug more freely. Vide Observations sur les Pertes, 1776. Some modern writers hold it in little estimation; and Gardien says, that when the placenta is attached over in the os uteri it is injurious, by exciting the uterus to dilate the mouth. Tom. II. p. 404. 318 decreased—the bowels become inflated—the belly swelled beyond its size in the ninth month, although the patient may not have been near that period ; and in these circumstances, whilst an inattentive practitioner has perhaps concluded that all was well with regard to the haemorrhage, the patient has expired, or only lived long enough to permit the child to be extracted. All practical writers warn us against internal flooding; nay, so far do some carry their apprehension, that they advise us to raise the head of the child, and observe whether blood or liquor amnii be discharged ;* an advice, however, to which I cannot subscribe, because in those cases where the membranes have given way, or been opened, the head cannot be thus moveable, nor these trials made, unless we have waited until a dangerous relaxation have taken place in the uterine fibres; and if, on the other hand, we have delivery in contemplation, it is our object to confine the liquor amnii as much as possible, until we turn the child. Blood may also collect in the upper part of the vagina, to a dangerou£ quantity, when the plug has been trusted to, too late. At a very early period, I do not think there is much ground for fear on this point, but still it is well to remember the possibility of the occurrence, and examine the actual state of the patient at proper intervals. Besides using these means, it will also, especially in a first attack, and where wre have it not in contemplation to deliver the woman, be proper to exhibit an opiate,53 in order to allay irritation; and this is often attended with a very happy effect. On this subject long experience enables me to speak with decision, and to recommend, in every instance where the haemorrhage does not depend on plethora, the exhibition of a full dose of laudanum, which tranquilizes the patient, allays irritation, and checks, for the time, the discharge. Such are the most effectual methods of speedily or imme- diately stopping the violence of the haemorrhage. The next points for consideration are, whether we can expect to carry the patient safely to the full time, and by what means we are to prevent a renewal of the discharge. It may, I believe, be laid down as a general rule, that when a considerable portion of the decidua has in the seventh month, or later, been separated, the haemorrhage, although it may be checked, is apt to return. When a part of the placenta has been detached, and more especially if that organ be fixed * Vide Dr. Johnson's System of Midwife^, p. 157, and Dr. Leak's Disease* of Women, vol. II. p. 280. 319 over the os uteri, gestation cannot continue long ; for either such injury is done to the uterus, as produces expulsion and a natural cure, or the woman bleeds to death, or we must deliver, in order to prevent that dreadful termination. If the discharge be in small quantity, and have not flowed with much rapidity—if it stop soon or easily—if no large clots be formed in the vagina—if the under part of the uterus have its usual feel, showing that the placenta is not attached there, and that no large coagula are retained within the os uteri— if the child be still alive—if there be no indication of the accession of labour—and if the slight discharge which is still coming away be chiefly watery, we may in these circumstances conclude, that the vessels which have given way are not very large, and have some reason to expect, that by care and prudent conduct, the full period of gestation may be accomplished. It is difficult to say, whether in this event the uterus forms new vessels to supply the place of those which have been torn, or whether re-union be effected by the incor- poration of those with corresponding vessels from the chorion. In the early months we know that re-union may take place ; but when, in the advanced period of pregnancy, the decidua has become very thin, soft, and almost gelatinous, it is not established that the circulation may be renewed. At all events, we know that the power of recovery or reparation is very limited, and can only be exerted when the injury is not extensive. The means for promoting re-union of the uterus and decidua, are the same with those which we employ for preventing a return ofthe haemorrhage ; and these we advise, even when we have little hope of effecting re-union, and making the patient go to the full time, because it is our object to prevent as much as possible the loss of blood. When the placenta is partly separated, all the facts of which we are in possession, are against the opinion that re-union can take place. If the spot be very trifling, and the vessels not large, we may have no return of the bleeding ; a small coagulum may permanently restrain it; but if the separation be greater, and the placenta attached low down, or over the os uteri, the patient cannot go to the full time, unless that be very near its completion. We judge of the case by the profusion and violence of the discharge ; for all great haemorrhages proceed from the separation of the placenta; and by the feel ofthe lower part ofthe uterus—by the quantity of clots, and the obstinacy ofthe discharge, which may perhaps 320 require even actual syncope to stop the paroxysm—a circum- stance indicating great danger. The best way by which we can prevent a return, is to moderate the circulation, and keep down the action of the system to a proper level with the power. The propriety of attending to this rule will appear, if we consider, among other circumstances, that when a patient has had an attack of flood- ing, a surprise, or any agitation which can give a temporary acceleration to the circulation, will often renew the discharge. The action of the arteries depends very much upon that of the heart; and the action of this organ again is dependant on the blood. When much blood is lost, the heart is feebly excited to contraction, and in some cases it beats with no more force than is barely sufficient to empty itself. This evidently lessens the risk of a renewal of the bleeding; and in several cases, as, for example, in hemoptysis, we, by suddenly detracting a quantity of blood, speedily excite this state of the heart. Whatever tends to rouse the action of the heart, tends to renew haemorrhage ; and if the proposition be established, that the rapidity with which the strength and action of the vessels are diminished is much influenced by the rapidity with which a stimulus is withdrawn, the converse is also true; and we should find, were it practicable to restore the quantity of blood as quickly as it has been taken away, that the same effect would be produced on the action ofthe heart, as if a person had taken a liberal dose of wine. It has been the practice to give nourishing diet to restore the quantity of Mood; but until the ruptured vessels be closed, or the tendency to haemorrhage stopped, this must be hurtful. It is our anxious wish to prevent the loss of blood; but it does not thence follow, that, when it is lost, we should wish rapidly to restore it. This is against every principle of sound pathology; but it is supported by the prejudices of those who do not reflect, or who are ignorant of the matter. When a person is reduced by flooding, even to a slight degree, taking much food into the stomach gives considerable irritation ; and if much blood be made, vascular action must be increased. What is it which stops the flow of blood, or prevents for a time its repetition ? Is it not diminished force of the circu- lation which cannot overcome the resistance given by the coagula ? Does not motion displace these coagula, and renew the bleeding ? Does not wine increase for a time the force of the circulation, and again excite haemorrhage ? Is it 321 not conformable to every just reasoning, and to the expe- rience of ages, that full diet is dangerous when vessels are opened? Do we not prohibit nourishing food and much speaking in haemorrhage from the lungs ? and can nourishing diet and motion be proper in haemorrhage from the uterus ? If it were possible to restore in one hour the blood which has been lost in a paroxysm of flooding, it is evident, that unless the local condition of the parts were altered, the flooding would at the end of that hour be renewed. The diet should be light, mild, given in small quantity at a time, so as to produce little irritation ;* and much fluid, which would soon fill the vessels, should be avoided. We shall do more good by avoiding every thing which can stimulate and raise action,! than by replenishing the system rapidly, and throwing rich nutriment into the stomach. It is, however, by no means my intention to say, that we must, during the whole remaining course of gestation, (provided that that go on, the attack having been permanently cured,) keep down the quantity of blood. I only mean that we are not rapidly to increase it. Even where the strength has been much impaired by the profusion of the discharge, or the previous state of the system, it is rather by giving food so as to prevent further sinking, than by cramming the patient, that we promote recovery ; and I beg it to be remembered, that although I talk of the management of those who are much reduced, yet I am not to be understood as in any degree encouraging the practice of delay, and allowing the patient to come into this situation of debility ; but when we find her already in this state, it is not by pouring cordials and nutriment profusely into the stomach, that we * Such as animal jellies, sago, toasted bread, hard biscuit, &e. These articles, given at proper intervals, are sufficient to support the system without raising the action too much. t The system with its power of action, may, for illustration, be compared to a man with his income. He who had formerly two hundred pounds per annum, but has now only one, must, in order to avoid bankruptcy, spend only one half of what he did before ; and if he do so, although he have been obliged to live lower, yet his accounts will be square at the end ofthe year. The same applies to the system. When its power is reduced, the degree of its action must also be reduced; and, by carefully proportioning the one to the other, we may often conduct a patient through a very great and continued degree of feebleness. At the same time, it must be observed, that as there is an income so small as not to be sufficient to procure the necessaries of life, so also may the vital energy be so much reduced as to be inadequate to the performance of those actions which are essential to our existence, and death is the result. But surely he who should attempt to prevent this by stimulating the system, would only hasten the fatal termination. Voe* not heat overpower and destroy those parts which have been frost-bit. 2Q 322 are to save her; it is by giving mild food, so as gradually to restore the quantity of blood and the strength; it is by avoiding the stimulating plan on the one hand, and the starving system on the other, that we are to carry her safely through the danger. Some medicines possess a great power over the blood vessels, and may therefore be supposed to enable us, in haemor- rhage, to cure our patient with less expense of blood than we could otherwise do. Digitalis is of this class. Acetate of lead has also been proposed, in doses of two grains every hour, till at least twelve grainswere taken ;51 but I cannot hold out with confidence a reliance on either of these. At the same time that we thus endeavour to diminish the action of the vascular system, we must also be careful to remove, as far as we can, every irritation. I have already said all that is necessary with regard to heat, motion, and diet. The intestinal canal must also be attended to, and accumu- lation within it should be carefully prevented by the regular exhibition of laxatives. A costive state is generally attended with a slow circulation in the veins belonging to the hepatic system, and of these the uterine sinuses form a part. If the arterial system be not proportionally checked, this sluggish motion is apt, by retarding the free transmission along the meseraic veins, to excite the haemorrhage again. Uneasiness about the bladder or rectum, or even in more distant parts, should be immediately checked ; for in many cases haemorrhage is renewed by these irritations. In those cases, or when the patient is troubled with cough, or affected with palpitation, or an hysterical state, much advantage may be derived from the exhibition of opiates. In many instances, where an attack of flooding is brought on by some irritation affecting the lower parts of the uterus in particular, or the system in general, or where the bowels are pained, and the pulse not full nor strong, rest, cool air, and an adequate dose of tincture of opium, will terminate the paroxysm, and perhaps prevent a return. This is especially the case, if only a part ofthe decidua have been separated, and the discharge have not been profuse. When the vascular system is full, •venesection is necessary before the anodyne be administered, and the digitalis may either succeed the opiate or be omitted, according to* the state ofthe pulse and ofthe stomach. It may happen that we have not been called early in a first attack, a ud that some urgent symptom has appeared. The most frequent of these is a feeling of faintness or complete syncope. This Reeling often arises rather from an affection 323 ofthe stomach than from absolute loss of blood ; and in this case it is less alarming than when it follows copious haemor- rhage. In either case, however, we must not be too hasty in exhibiting cordials. When the faintishness depends chiefly upon sickness at the stomach, or feeling of failure, circum- stances which may accompany even a small discharge, it will be sufficient to give a few drops of hartshorn in cold water, and sprinkle the face with cold water: a return is prevented by an anodyne draught, or opium pill. When it is more dependant on absolute loss of blood, we may find it necessary to give a full dose of opium or laudanum, with the addition of small quantities of wine warmed with aromatics ; but the latter, even in this case, must not be given with a liberal hand, nor too frequently repeated.* It is scarcely necessary for me to add, that we are also to take immediate steps, by the use of the plug, &c. for restraining the discharge. This I may observe once for all. Sickness and faintness also may depend on spasm of the uterus.55 Complete syncope is extremely alarming to the by- standers : and, if there have been a great loss of blood, it is indeed a most dangerous symptom. It must at all times be relieved, for although faintness be a natural mean of checking haemorrhage, yet absolute and prolonged syncope is hazardous. We must keep the patient at perfect rest, in a horizontal posture, with the head low, open the windows, sprinkle the face smartly with cold vinegar, apply volatile salts to the nostrils, and give sixty or eighty drops of laudanum internally* and occasionally a spoonful of warm wine. Universal coldness is also a symptom which must not be allowed to go beyond a certain degree, and this degree must be greatly determined by the strength of the patient, and the quantity and rapidity of the discharge. When the strength is not previously much reduced, a moderate degree of coldness is, if the haemorrhage threaten to continue, of service; but when there has been a great loss of blood, then, universal coldness, with pale lips, sunk eyes, and approaching deliquium, may too often be considered as a forerunner of death. When we judge it necessary to interfere, we should apply warm cloths to the hands and feet, a bladder half filled with tepid « As syncope and loss of blood have both the effect of relaxing the muscular fibre, as is well known to surgeons, it may be supposed that they should increase the flooding by diminishing the contraction ofthe uterus, if that have already taken place. But the contrary is the case, for by allowing coagula to form, syn- cope restrains hsemorrhage, and therefore ought not to be too rapidly removed in a first attack, and before the os uteri has become dilatable. 324 water to the stomach, and give some hot wine and water inwardly. Vomiting is another symptom which sometimes appears. It proceeds very generally from the attendants having given more nourishment or fluid than the stomach can bear, or from a gush of blood taking place soon after the patient has had a drink. It in this case is commonly preceded by sickness and oppression, which are most distressing, and threaten syncope, until relief be obtained by vomiting. Sometimes it is rather connected with an hysterical state, or with uterine spasm. If frequently repeated, it is a debilitating operation, and by displacing clots may renew hsemorrhage ; but some- times it seems fortunately to excite the contraction of the uterus, and gives it a disposition to empty itself. For abating vomiting, we may apply a cloth dipped in laudanum, and camphorated spirits of wine, to the whole epigastric region ; or give two grains of solid opium, or even more; if the weakness be great. Sometimes a little infusion of capsicum is of service. It should just be gently pungent. In flooding, it is of importance to pay much attention to the state of the stomach, and prevent it from being loaded; on the other hand, we must not let it remain too empty, nor allow its action to sink. Small quantities of pleasant nourishment should be given frequently. We thus prevent it from losing its tone, without oppressing it, or filling the system too fast. Hysterical affections often accompany protracted floodings, such as globus, pain in the head, feeling of suffocation, palpi- tation,* retching, in which nothing but wind is got up, &,c. These are best relieved by some foetid or carminative substance conjoined with opium. Laxatives are also of essential service. The retching sometimes requires an anodyne clyster, or the application of a camphorated plastert to the region of the Btomach. After having made these observations on the management of flooding, and the best means of moderating its violence, of preventing a return, and of relieving those dangerous symp- toms which sometimes attend it, I next proceed to speak of * The quantity of blood lost is sometimes so great as to do irreparable injury to the heart, and ever after to impede its action. One well marked instance of this is related by Van Swieten, in his commentary on Aph. 1304, where for twelve years the woman, after a severe flooding, could not sit up in bed without violent palpitation and anxiety. t This may be made by melting a little adhesive plaster, and then adding to it a large proportion of camphor, previously made into a thick liniment by rubbing it with olive oil. 325 the method of delivering the patient when that is necessary. I have separated the detail of the medical treatment of a paroxysm from the consideration of the manual assistance, which may be required; because, however intimately connected ihe different parts of our plan may be, in actual practice, it is useful, in a work of this kind, in order to avoid confusion, that I lay them down apart. As some peculiarities of practice arise from the implanta- tion of the placenta over the os uteri, I shall confine my present remarks to those cases in which the membranes are found at the mouth of the womb, desiring it to be remembered, however, that this circumstance does not necessarily indicate that the haemorrhage does not proceed from separation of the placenta, which may be fixed very near the cervix, although it cannot be felt. The operation of delivering the child is not difficult to describe or to perform. I am generally in the practice of giving, a quarter of an hour before I begin, fifty drops of tincture of opium. The hand, previously lubricated, is then to be slowly and gently introduced completely into the vagina. The finger is to be introduced into the os uteri, and cautiously moved, so as to dilate it; or if it have already dilated a little more, two fingers may be inserted, and very slow and gentle attempts made at short intervals to distend it; and the practi- tioner will do well to remember, that he shall succeed best when he rather acts so as to stimulate the uterus and make it dilate its mouth, than forcibly to distend it. On the part of the operator, is demanded much tenderness, caution, firmness, and composure; on the part of the patient is to be desired patience and resolution. The operator is to keep in mind, that painful dilatation is dangerous, it irritates and inflames the parts, and that the woman should complain rather of the uterine pains which are excited, than of the fingers of the practitioner. More or less time will be required fully to dilate the os uteri, according to the state in which the uterus wras when the operation was begun. If the os uteri be soft and pliable, and have already, by slight pains, been in part distended, a quarter of an hour, or perhaps only a few minutes, will often be sufficient for this purpose; but if it have scarcely been affected before by pains, and be pretty firm, though not unyielding, then half an hour may be required. I speak in general terms, for no rule can be given applicable to every case. Not unfrequently, although the patient have felt scarcely any pains, and certainly no regular pains, theos uteri 326 will be found as large as a penny piece, and its margin soft and thin. The os uteri being sufficiently dilated, the mem- branes are to be ruptured, the hand introduced, the child slowly turned and delivered, as in footling cases; endeavouring rather to have the child expelled by uterine contraction than brought away by the hand. Hasty extraction is dangerous, for the uterus will not contract after it. And, therefore, if when we are turning, we do not feel the uterus acting, we must move the hand a little, and not begin to deliver until we perceive that the womb is contracting. The delivery must be but slow until the breech is passing ; then we must be careful that the cord be not too long compressed before the rest of the child be born. The child being removed, and the belly properly supported, and gently pressed on by an assistant, the hand should again be cautiously introduced into the womb, and the back of it placed on the surface of the placenta, so as to press it a little, and excite the uterus to separate it. The hand may also be gently moved in a little time, and the motion repeated at intervals, so as to excite the uterus to expel its contents; but upon no account are we to separate the placenta and extract it. This must be done by the uterus ; for we have no other sign that the contraction will be sufficient to save the woman from future haemorrhage. The whole process, from first to last, must be slow and deliberate, and we are never to lose sight of our object, which is to excite the expulsive power ofthe uterus. It is not merely to empty the uterus—it is not merely to deliver the child, that we introduce our hand; all this we may do, and leave the woman worse than if we had done nothing. The fibres must contract and press upon the vessels ; and as nothing else can save the patient, it is essential that the practitioner have clear ideas of his object, and be convinced on what the security of the pa- tient depends. But to teach the method of delivery, and say nothing of the circumstances under which it is to be performed, would be a most dangerous error. I have, in the beginning of this section, pointed out the effect of haemorrhage, both on the constitution and on the uterus ; and I have stated, that the action of gestation is always impaired by a certain loss of blood, and a tendency to expulsion brought on. But before the uterine contraction can be fully excited, or become effec- tive, the woman may perish, or the uterus be so enfeebled as to render expulsion impossible. Whilst then we look, upon the one hand, to the induction of contraction, we must not, on 327 the other, delay too long. We must not witness many and repeated attacks of haemorrhage, sinking the strength, bleach- ing the lips and tongue, producing repeated fainting fits, and bringing life itself into immediate danger. Such delay is most inexcusable and dangerous ; it may end in the sudden loss of mother and child ; it may enfeeble the uterus, and render it unable afterwards to contract; or it may so ruin the constitu- tion, as to bring the patient, after a long train of sufferings, to the grave. Are we then uniformly to deliver upon the first attack of flooding, and forcibly open the os uteri ? By no means : safety is not to be found either in rashness or procrastination. The treatment which I have pointed out, will always secure the patient until the delivery can be safely accomplished. As long as the os uteri is firm and unyielding—as long as there is no tendency to open, no attempt to establish contraction, it is perfectly safe to trust to the plug, rest, and cold. But I must particularly state to the reader, that the os uteri may dilate without regular pains ; and in almost every instance it does, whether there be or be not pains, become dilatable. Did I not know the danger of establishing positive rules, I would say, that as long as the os uteri is firm, and has no disposition to open, the patient can be in little risk, if we understand the use of the plug ; we may even plug the os uteri itself, which will excite contraction. But if the patient be neglected, then I grant that long before a tendency to labour or contraction be induced, she may perish. I am not, however, considering what may happen in the hands of a negligent practitioner, for of this there would be no end, but what ought to be the result of diligence and care. It is evident, that when the uterus has a disposition to contract, and the os uteri to open, delivery must be much safer and easier than when it is still inert, and the os uteri hard. We may, with confidence, trust to the plug, until these desirable effects be produced; and in some instances, we shall find, that by the plug alone we may secure the patient: the contraction may become brisk, if we have prevented much loss of blood, and expulsion may naturally take place. Who would, in those circumstances, propose to turn the child, and deliver it ? Who would not prefer the operation of nature to that of the accoucheur ? To determine in any individual case whether this shall take place, or whether delivery must be resorted to, will require deliberation on the part ofthe prac- 328 titioner. If he have used the plug early and effectually, and the pains have become brisk, he has good reason to expect natural expulsion; and the labour must be conducted on the general principles of midwifery. But if the uterus have been enfeebled by loss of blood—if the pains be indefinite—if they have done little more than just open the os uteri, and have no disposition to increase, then he is not justified in expecting that expulsion shall be naturally and safely accomplished, and he ought to deliver. When he dilates the os uteri, he excites the uterine action, and feels the membranes become tense. But he must not trust to this ; he must finish what he has begun. Thus it appears, that by the early and effective use of the plug, by filling the vagina with a soft napkin, or with tow, we may safely and readily restrain the haemorrhage, until such changes have taken place on the os uteri as to render delivery easy; and then we either interfere or trust to natural expulsion, according to the briskness and force of the contraction, and state ofthe patient. By this treatment, we obtain all the advantage that can be derived from the operations of nature; and, where these fail, are enabled to look with confidence to the aid of artificial delivery. But it may happen that we have not had an opportunity of restraining the haemorrhage early ; we may not have seen the patient until she have suffered much from the bleeding.* In this case, we shall generally be obliged to deliver, and must, upon no account, delay too long ; yet if the os uteri be very firm, without disposition to open, and require hazardous force to dilate it, we shall generally find that the sinking is temporary : we may still trust for some time to the plug, and give opiates to support strength. Haemorrhage is naturally restrained by faintness. A repetition is checked in the same way ; and faintness takes place sooner than formerly. In one or two attacks, the uterus suffers, and the os uteri becomes dilatable. Slight pains come on, or are readily excited by attempts to distend the os uteri. Syncope then will, in general, even when the plug has not been used, and the patient has been neglected, restrain haemor- rhage, and prevent it from proving fatal until the os uteri have relaxed; but a little delay beyond that period will destroy * We are not to confine our attention to the quantity which has been lost, but to the effect it has produced ; and this will ceteris paribus be great in proportion as the haemorrhage has been sudden. 329 the patient; and it is possible, by giving wine, and otherwise treating her injudiciously, to make haemorrhage prove fatal, even before this take place. But although I have considered it as a general rule, that where the os uteri is firm and un- yielding, we may, notwithstanding present alarm, trust some time to the plug, yet I beg it to be remembered, that there may be exceptions to this rule; for the constitution may be so delicate, and the haemorrhage so sudden, or so much increased by stimulants, as to induce a permanent effect, and make it highly desirable that delivery should be accomplished ; but such instances are rare; and although I have spoken of the effects of syncope in restraining haemorrhage, I hope it will not be imagined by the student that I wish to make him familiar with this symptom. It is very seldom safe, when we have our choice, to wait till syncope be induced; and if it have occurred, it is not usually prudent to run the risk of a second attack. The old practitioners, not aware of the value of the plug, nor acquainted with the sound principles of physiology, had no fixed rule relating to delivery, but endeavoured to empty the uterus early ; but it was uniformly a remark, that those women died, who had the os uteri firm and hard.* What is this but to declare, that the rash and premature operation is fatal ? It is an axiom which should be deeply engraved on the memory of the accoucheur, and which should constantly influence his conduct. Pain and suffering are the immediate consequence of the practice; whilst a repetition ofthe flooding after delivery, or the accession of inflammation, are the messen- gers of death. It was the fatal consequence of this blind practice, that suggested to M. Puzos the propriety of puncturing the mem- branes, and thus endeavouring to excite labour. His reasoning was ingenious; his proposal was a material improvement on the practice which then prevailed. The ease of the operation, and its occasional success, recommend it to our notice; but experience has now determined that it cannot be relied on, and that it may be dispensed with. If we use it early, and on the first attack, we do not know when the contraction may be established; for even in a healthy uterus, when we use it on account of a deformed pelvis, it is sometimes several days before labour be produced. We cannot say what may take place in the interval. The uterus being slacker, the haemorrhage is more apt to return, and we may ■ Vide the Works of Mauriceau, Peu, f."— Crantz's History of Greenland, vol. I. p. 161. Long tells us, that the'American Indians, as soon as they bear a child, go into the water and immerse it. One evening he asked an Indian where his wife was ; "he supposed she had gone into the woods, to set a collar for a partridge." In about an hour she returned with a new-born infant in her arms, and coming up to me, said in Chippeway, " Oway saggonash payshik shomagonish;" or, " Here, Englishman, is a young warrior." Travels, p. 59. " Comme les accouchemens sons tres-aises en Perse, de meme que dans les autres pais chauds de l'Orient, il n'y a point de sages femmes. Les parentes ag^es et les plus graves, font cet office, mais comme il n'y a gueres de vieilles matrones dans le harem, on et fait venir dehors dans le besoin." Voyages de M. Chardin, torn. IV. p. 230. Lempriere says, "Women in this country (Morocco) suffer but little inconve- nience from child-bearing. They are frequently up next day, and go through all the duties ofthe house with the infant on their back." Tour, p. 328. Winterbottom says, that " with the Africans, the labour is very easy, and trusted solely to nature, nobody knowing of it till the woman appears at the door ofthe hut with the child." Account of Native Africans, &c. vol. II. p. 209. The Shangalla women " bring forth children with the utmost ease, and never rest or confine themselves after delivery ; but washing themselves and the child with cold water, they wrap it up in a soft cloth, made of the bark of trees, and 350 in those countries where heat conspires to relax the fibres. The quality or quantity of the food has much less influence than the general habit of life upon the process of parturition. In a savage state, women, though living abstemiously, and often compelled to work more than men, bear children with facility; whilst in this country, women who live on plain diet are not easier than those who indulge in rich viands. In all ranks, we often find the os uteri considerably dilated, and occasionally meet with instances of labour making great progress with scarcely any pain, and I have even known cases when the patient declared she had no pain, even at the last, but only a sensation of strong pressure, so that she expressed her amazement that the child was born. A knowledge of this fact, of which I am well assured from my own observation, may prove of importance in some questions of jurisprudence. On the same aceount, I add, that the pains sometimes become suddenly, and very unexpectedly, bearing-down, whether severe or not, and the child may be born before the patient can be got into bed, or removed from the night-chair, if she had been at stool. We, there- fore, never, in an advanced stage of parturition, allow the patient to rise, at least if the process have been going on regularly, and at no time without due precaution. SECTION THIRD. The existence and progress of labour, and the manner in which the child is placed, are ascertained by examination per vaginum. For this purpose the woman ought to be placed in bed, on her left side,* with a counterpane thrown over her, if she be not undressed. The hand is to be passed along the back part of the thighs to the perinaeum, and hang it up on a branch, that the large ants with which they are infested, and the Berpents,may not devour it." Bruce's Travels, vol. II. p. 553. In Otaheite, New South Wales, Surinam, &,c. parturition is very easy, and many more instances might, if necessary, be adduced. We are not, however, to suppose that in warm climates women do not sometimes suffer materially. In the East Indies, " many ofthe women lose their lives the first time they bring forth." Bartolomeo's Voyage, chap. II. Undomesticated animals generally bring forth their young with considerable ease; but sometimes they suffer much pain, and, when domesticated, occasionally lose their lives. * A standing or half-sitting position has been proposed by some, and mav doubtless, in certain diseases of the uterus, be proper, that it may, by its weight come within reach. Sometimes in the early months of pregnancy, it is allowable from the same motives; but, during labour, it is not often that the uterus is so high that the examination cannot be performed in a recumbent posture. 351 thence immediately to the vagina, into which the fore-finger is to be introduced. It never ought to be carried to the fore part of the vulva, and from that back to the vagina. The introduction is to be accomplished as speedily and gently as possible, and the greatest delicacy must be observed. The information which we wish to procure is then to be obtained by a very perfect but very cautious examination of the os uteri and presenting part of the child, which gives no pain, and consequently removes the dread which many women, either from some misconception, or from previous harsh treatment, entertain of this operation. The application of the hand to the abdomen, during the continuance ofthe pain, may ascer- tain, from the temporary hardness ofthe uterus, that its fibres are contracting universally,* and this is an evidence that we should never overlook. When a woman is in labour, we should, if the pains be re- gular, propose an examination very soon after our arrival. It is of importance that the situation of the child be early ascertained, and most women are anxious to know what progress they have made, and if their condition be safe. As it is usual to examine during a pain, many have called this operation " taking a pain;" but there is no necessity for giving directions respecting the proper language to be used, as every man of sense and delicacy will know how to behave, and can easily through the medium of the nurse, or by turning the conversation to the state ofthe patient, pro- pose ascertaining the progress of the labour. Some women, from motives of false delicacy, and from not understanding the importance of procuring early information, of their condi- tion, are averse from examination, until the pains become se- vere. But this delay is very improper; for, should the pre- sentation require any alteration, this is easier effected before the membranes burst, than afterwards. When the presenta- tion is ascertained to be natural, there is no occasion for re- peated examinations in the first stage, as this may prove a source of irritation, and, should the stage be tedious, may be a mean of exciting impatience. Sometimes merely touching the os uteri with the finger produces sickness and faintness. In that case it must not be repeated, as even the natural dila- tation renders these effects distressing for a time. In the se- cond stage, the frequency of examination must be proportion- ed to the rapidity of the process. * This mark has been properly insisted on by Mr. Power, in his ingeniou* Treatise on Midwifery, p. 25. 352 In order to avoid pain and irritation, it is customary to anoint the finger with oil or pomatum ; but unless this practice be used as a precaution to prevent the action of morbid matter on the skin, it is not very requisite, the parts being, in labour, generally supplied with a copious secretion of mucus. It is usual for the room to be darkened, and the bed curtains drawn close, during an examination ; and the hand should be wiped with a towel, under the bedclothes, before it be withdrawn. The proper time for examining is during a pain ; and we should begin whenever the pain comes on. We thus ascertain the effect produced on the os uteri, and by retaining the finger until the pain go off, we deter- mine the degree to which the os uteri collapses, and the pre- cise situation of the presenting part, which we cannot do during a pain, if the membranes be still entire, lest the pres- sure of the finger should, were they thin, prematurely rup- ture them. An examination should never, if possible, be proposed or made while an unmarried lady is in the room, but it is always proper that the nurse or some other matron be present. The existence of labour is ascertained by the effects of the pains on the os uteri; and its progress, by the degree to which it is dilated, and the position of the head with regard to different parts of the pelvis. A preliminary question may here be put, does the development of the os uteri, or its opening to an evident degree, imply the actual existence of labour? The answer must depend somewhat on the definition of labour. If we understand by it the universal and regular contraction of the uterine fibres, I would say that the mere opening of the os uteri, with or without pain, does not prove the actual existence of labour, for it may open considerably, for a week or two, before universal and expulsive efforts be made, and this partial effect may be attended with pain ; I doubt very much if it be attended with hardness and contraction of the body and fundus of the uterus. If in any one case of this kind the whole uterus were felt during a pain to become hard, then we must admit that labour, in the strictest sense of the word, may begin, and afterwards be entirely suspended for a fortnight or longer. Before labour begins, the os uteri is generally so closed, that the finger cannot, without force, be introduced within it and it is directed backwards towards the sacrum. The os uteri is in one respect an appendage to the uterus, and hangs down in a cylindrical form. It is not muscular, but i« 353 somewhat elastic, for on being dilated it contracts if the force be suspended. The case is different with the cervix, for it is muscular, and the fibres may act either circularly or longi- tudinally. But at first they act on the os uteri alone. If they early acted circularly, they would operate as a sphincter. If the finger be introduced during labour into the os uteri, not yet quite distended, then, although its own proper substance may yield more or less, yet the hard boundary of the lower margin of the cervix is felt as a resisting circle within, or higher, and this must relax, and the fibres act in no farther degree circularly than is necessary to keep the longitudinal fibres together, otherwise the head cannot pass. The first effect of the pains is to develope the os uteri, that is, to destroy its projection or protuberance, and next to open it. Sometimes the development goes on quickly, and the os uteri becomes thin and expanded like a funnel. In other cases it remains thick and flabby, and circle after circle expands abruptly from above downward, and at last a mere hard orifice, admitting only the tip of the finger, and quite flat, is felt. Even when the os uteri is considerably dilated by the pains, it, from its elasticity, falls together again in the absence of a pain ; and although at this stage it may be re-distended by the finger, yet the finger cannot, as I have just noticed, distend the cervix. When we examine in the commencement of labour, the os uteri is to be sought for near the sacrum, at the back part ofthe pelvis, whilst between that spot and the pubis, we can pass the finger along the fore part of the cervix uteri. On this, the presenting part ofthe child rests, so that, in natural labour, it assumes somewhat the shape of the head ; and, for the sake of dis- tinction, I shall call it the uterine tumour. In some, it is so firmly applied to the head, and so tense, that a superficial observer would take it for the head itself. In this case th« labour often is lingering when the os uteri is high and far back ; but if it be more forward, and soft, and thin, it is rather a good sign. This tumour, or portion of the uterus, is broad in the beginning of labour, but becomes narrower as the os uteri dilates, until at last it be completely effaced, the head, either naked or covered with the membranes, occupying the vagina. The breadth of this portion of the uterus, therefore, as well as the examination ofthe os uteri, will serve to ascertain the state, of the labour. The os uteri gradually dilates by the pains of labour, but this dilatation is more easily effected in some cases than in others. 2 U 354 In tome, though the pains have lasted for many hours, and have been frequent, the os uteri will be found still very little opened. In others, a very great effect is produced in a short time ; nay, we find, that the os uteri may be partly, even greatly, dilated without any pain at all. We cannot exactly foretel the effect which the pains may have by any general rule, nor estimate the progress and probable duration alto- gether by the sensation. We find, in different women, the os uteri in very opposite states. In some it is thick, soft, and dependant like a cylinder ; in others, thin and infundibuliform ; sometimes it is not very early dependant, but the edges of the mouth are on the same plane, like the mouth of a purse ; these edges may be thin or thick, and both these states may exist with hardness or softness ofthe fibre. In some cases, they seem to be swelled, as if they were oedematous, and this state is often combined with oedema ofthe vulva, or it may proceed from ecchyinosis. Now, of these conditions, some are more favour- able than others; a rigid os uteri, with the lips either flat or prominent, is generally a mark of slow labour ; for as long as this state continues, dilatation is tardy ; a thick oedematous feel ofthe os uteri is also,unfavourable ; and usually a project- ing or tubulated mouth, especially if the margin be thick and hard,* is connected with a more tedious labour than where the os uteri is flat. In some cases of slow labour, after the pro- jection ofthe os uteri is developed, its orifice for many hours is scarcely discernible, resembling a dimple or small hard ring, perfectly level with the rest ofthe uterus. But although these observations may assist the prognosis, yet we never can form an opinion perfectly correct; for a state ofthe os uteri, apparently unfavourable, may be speedily exchanged for one very much the reverse, and the labour may be accomplished with unex- pected celerity. Our prognosis, therefore, should be very guarded. When the pains produce little apparent effect on the os uteri; when they are slight and few; and when the orifice ofthe uterus is hard and rigid, or thick and puckered during a pain ; or hangs flabby and projecting during a pain, whilst the lower fibres ofthe cervix feel, when the finger is introduced within the os uteri, firm and contracted ; or when the os uteri does become flatter during a pain, but falls together and projects when it goes off, and especially if the cervix be rigid ; there is much ground to expect that the labour may be * If the margin be thin and soft, the os uteri sometimes, in the course of ar hour, loses its projecting form, and becomes considerably dilated. 355 lingering. On the other hand, when the pains are brisk, the os uteri thin and soft, we may expect a more speedy delivery; but as in the first case, the unfavourable state ofthe os uteri may be unexpectedly removed, so, in the second, the pains may become suspended or irregular, and disappoint our hopes. The os uteri seldom dilates equally in given times, but is more slow at first in opening than afterwards. It has been supposed, that if it require three hours to dilate the os uteri one inch, it will require two to dilate it another inch, and other three to dilate it completely. This calculation, however, is subject to great variation, for in many cases, though it require four hours to dilate the os uteri one inch, a single hour more may be sufficient to finish the whole process. The os uteri is, in the beginning of labour, generally pretty high; but as the process advances, the uterus descends in the pelvis, along with the head; and, in proportion as it descends, the os uteri dilates, whilst the uterine tumour dimi- nishes in breadth. Should the os uteri remain long high, even although it be considerably dilated, but more especially if it be not, there is reason to suppose that the labour shall be continued still for sometime. On the other hand, should the uterus descend too rapidly, there may be a species of prolapsus induced, the os uteri appearing at the orifice of the vagina. This state is generally attended with premature bearing-down pains, and indicates a painful, and rather tedious labour. The protrusion of the membranes, and discharge of the liquor amnii, ought to bear a certain relation to the advance- ment of labour. Whilst the os uteri is beginning to dilate, the membranes have little tension ; they scarcely protrude through the os uteri, until it be considerably opened. But in proportion as the dilatation advances, and the pains become of the pressing kind, the membranes are rendered more tense, protruding during a pain, and becoming slack, and receding when it goes off. In some cases, by examination, we find the membranes forced out very low into the vagina, like a portion of a bladder, tense and firm during a pain, but disappearing in its absence. Sometimes, although the head be so high as not to touch the perinaeum, the membranes protrude the perimcum, and the faeces are evacuated or pressed out, as if the head were about to be expelled. When the membranes burst, the head is in such cases often delivered in a few seconds, but the pains may remit for a short time, and the woman be easier than formerly. The protrusion of the mem- branes, which has been described by some as constituting a 356 part of a natural labour, is by no means a universal occur- rence ; for in numerous instances the membranes protrude very little, and scarcely form a perceptible bag in the vagina. When the pains have acted some time on the membranes, pushing the liquor amnii against them, and especially when they become pressing, the membranes burst, and the water escapes, sometimes in a considerable quantity ; but in other cases, very little comes away, the head occupying the pelvis so completely, that most of the water is retained above it, and is not discharged until the child be born. If there be great irregularity in the degree to which the membranes protrude, there is no less in the period at which they break. In some cases, from natural feebleness or thinness, they break very early, and the liquor amnii comes away slowly. Sometimes they break in the middle or latter end ofthe first stage, in the commencement of the second, or not until the very end, when the head is about to be born. The opening is sometimes very large, and the head, enlarging it, passes through it; at other times it is small, and the membranes are not perforated by th« head, but they come along with it like a cap or cover. By examination, we ascertain the state of the membranes, and may be assisted in our judgment of the progress of the labour. When the membranes feel tense, and are protruded during a pain, we may be sure that the action of the uterus is brisk and good. When much water is collected beneath the head, forming a pretty large bag in the vagina ; or when, during the pain, there is a tense protrusion of the membranes, though they be flat, forming a small segment of a large circle, we may expect, that if the pains continue as they promise to do, the membranes will soon burst, and the pains become more press- ing. If during each pain, after the rupture, a quantity of water come away, it is probable, that whenever the uterus is pretty well emptied ofthe fluid, it will contract more power- fully. Should the membranes break when the os uteri is not fully opened, perhaps only half dilated, we may, if there be a large discharge, expect a brisker action, and that the full dilatation of theos uteri will be soon accomplished ; but if the water only ooze away, and the pains become less frequent, and not more severe, the labour may probably be protracted for some time. In the first stage of labour, the head will be found placed obliquely along the upper part of the pelvis, with the vertex directed toward one of the acetabula. The finger can easily ascertain the sagittal, and afterwards the lambdoidal suture; 357 the central portion of the sagittal suture is the point from which we set out, and, if the finger be readily led to the angle formed by the posterior edges of the parietal bones, we may be sure that the presentation is favourable. If, on the other hand, we can feel the anterior fontanelle, the vertex is generally directed to the sacro-iliac articulation. The vertex and the ear both merit particular attention, in ascertaining the position of the head. When the pelvis is well formed, and the cranium of due size, the head may commonly be felt in every stage of labour ; but there are cases in which, even although the pelvis be ample, it is not easily touched for some time. Such instances, however, are rare : and whenever we are long of feeling the presentation, and do not discover a round uterine tumour, we may suspect that some other part of the child than the head presents. Even in the end of pregnancy, and long before labour begins, the head can usually be discovered resting on the distended cervix uteri ; but different circumstances may for a time prevent it from being felt; the head perhaps in some cases, as from a fall, for instance, being for a short time displaced towards one side. In proportion as the head descends in the pelvis, the vertex is turned forward ; so that, when the whole head has entered the pelvis, the face is thrown into the hollow ofthe sacrum, and the sagittal suture rests on the perinreum, whilst the occiput is placed under the symphysis pubis, or on its inside. This takes place earlier in one case than in another. When the head comes to present at the orifice ofthe vagina, or passes a line drawn from the under edge ofthe symphysis pubis back to the sacrum, the perinaeum and skin near the tuberosities of the ischia become full, as if swelled, but not tense. This at first proceeds from, relaxation of the muscles, and some degree of descent ofthe vagina and rectum. Whenever this is felt, we may be sure that the head is descending; but although a few pains may distend the perinaeum, it may yet be some hours before this takes place, the pains for all that time appearing to produce very little effect, although the pelvis be well formed. Should the peri- neum become stretched, and the anus be carried forward a little during the pain, we may expect that delivery is at hand. If the woman have already borne children, the child is some- times delivered within a few minutes after the perinaeum is first felt to become full. When the pelvis is well formed, the head generally descends without much change of the scalp ; but when it is 358 contracted, or the head rests long on the perinaeum, the scalp is either wrinkled, or protruded like a tumour filled with blood. By examination, we ascertain the presentation, and the progress which the labour has made ; but in forming an opinion respecting the probable duration of the process, we must be greatly influenced by the state of the p.iins, and in part also by our knowledge of former labours, if the woman have borne many children. The different stages of labour are generally marked by a different mode of expressing pain. In the first stage, the pains are sharp, and the woman either moans or frets, or sometimes bears in silence. The second stage is marked by a sound, indicating a straining exertion, a kind of protracted groan, so that, by the change of the cry, a practitioner may often determine the stage of the labour. Sometimes in this stage the woman clinches her teeth, or holds in her breath, so that she is scarcely heard to complain. In the moment of expelling the head, some women are quite silent, or utter a low groan, others scream aloud. When the pains in the first stage are increasing in frequency, in severity, and in duration, and when they are accompanied with a corresponding dilatation ofthe os uteri, and especially when it, together with the head, gradually descends, the prognosis is very favourable. When the pains, after the os uteri is considerably dilated, become forcing, with an inclination to void the urine or faeces, and when these pains are accompanied with a full dilatation of the os uteri, the head at the same time descending lower, and the cervix beginning to turn round, we may look for a speedy delivery. But if the pains in the first stage be weak and few, and occur at long intervals, or, though not unfrequent, if they last only for a few seconds, and especially, if at the same time the os uteri be high up, or hard, or thick, we may conclude that the process is not likely to be rapid. If, when the os uteri is little dilated there be an inclination to bear down, the labour is generally slow, and hence all attempts to press with the abdominal muscles are improper ; for whether these be made voluntarily or involuntarily, they, during this stage, add to the suffering, fatigue the woman, produce a tendency to prolapsus uteri, so that, in some instances, the os uteri is forced to the orifice of the vagina, and render the labour always slow and severe. When the head is brought so low as to protrude the perinaeum, the pains generally become more frequent and 359 severe, and very soon effect the expulsion. But if they be forcing, and propel the head considerably each time, but it recedes completely thereafter, it is likely that the delivery of the head will be difficult and painful; for in some cases, the external parts are long of yielding, and require repeated efforts to distend them before the head can safely be expelled. Sometimes the pains, after beginning regularly and briskly, become suspended, or less effective, and this alteration cannot be foreseen. It is a popular opinion, that if a woman be not delivered within twelve hours after she is taken ill, the labour will become brisker at the same hour at which it began, that is to say, twelve hours after its commencement; and this opinion is, in many instances, countenanced by fact. In other cases, the labour becomes decidedly brisker six hours after its commencement. Most women begin to complain during the night, or early in the morning, and a great majority are delivered betwixt twelve at night and twelve o'clock noon. SECTION FOURTH. Different attempts have been made to explain why labour commenced at the end of the ninth month of pregnancy. The mysterious power of numbers, the influence of the planets, the distention of the uterine fibres, the pressure of the child upon the developed cervix and os uteri, have all in succession been enumerated, as affording a solution of the question. It can serve no good purpose to enter into the investigation, for the purpose of refuting these opinions, which might be easily done, especially as I have no satisfac- tory explanation to offer. We know, that whenever the process of utero-gestation is completed, the womb begins to contract. If, by any means, this process could be protracted, then labour would be kept off; and, on the other hand, if this process be stopped prematurely, either from some peculiarity connected with it, by which it is completed earlier than usual, or from being interrupted by extraneous causes, acting either on the uterus, or by killing the child, then contraction does very soon commence. The immediate cause ofthe delivery ofthe child has been attributed to efforts made by the foetus itself, the expulsive force ofthe abdominal muscles, or the contraction of the uterus. The first is fully set aside, by our finding, that the fcetus, when dead, is born ceteris paribus, as easily as when it is alive and active. That the muscles alone cause the expulsion of the child, is dis- 360 proved, by observing, that in the early part of labour they are perfectly quiescent, and no voluntary effort made with them is attended with any good effect. That the delivery is in a great measure owing to the action of the uterus, is proved by observing, that the Uterus contracts in proportion as the delivery advances, and when the child is born, it is found to be very greatly diminished in size. But we have still a more positive proof of this, in attempting to turn the child, for we then feel very powerfully the action of the uterus, and the efforts which it makes to expel its contents. It is not just, however, to consider the action of the womb itself, as the sole agent in parturition ; for in the second stage, the abdominal muscles do assist in the expulsion, not only by supporting the uterus, and thus enabling it to contract better, but also directly, by endeavouring to force the uterus, and consequently its contents, down through the pelvis. Two purposes are intended by the uterine action; the first is to open the os uteri, the second to propel the fcetus through it. Whilst, then, the fibres of the uterus itself contract, those of the os uteri must relax and dilate, and in proportion as the fcetus advances through the pelvis, the uterine fibres must shorten themselves. Thus the uterine cavity is gradually diminished, so that the placenta can very easily, by a continuation ofthe same process, be thrown off; and the uterine vessels having their diameter greatly lessened, haemorrhage is prevented after the separation of the placenta. There are then two processes taking place during parturition, contraction and relaxation, and these are in natural labour proportionate to each other. As the os uteri relaxes, the rest ofthe uterus increases in the activity of its contraction. This fact, I fear, has not been sufficiently attended to, and a very great mistake has often been made in supposing that there is greatest contractive or expulsive effort made when the resistance is greatest. This is no doubt true if we look to duration, but not if we attend to the degree exhibited in a given time. Were there no resistance offered, the uterus would contract at once, and expel the fcetus by a single effort; and this, or nearly this, in a few cases has taken place, and no great pain has attended the process. On the other hand, even a very sught resistance does in many cases diminish the degree of contraction, or expulsive effort, and in proportion as this resistance is removed, so does the con- traction increase. Hence, as the os uteri relaxes or opens, so does the expulsive power augment, and it is experience 361 alone which can convince us how small a resistance may be the mean of parrying, if I may use the expression, the contraction of the fibres, or preventing them from acting briskly and quickly. Labour, therefore, is more certainly shortened, by promoting relaxation,and diminishing resistance, than by means intended to stimulate to action. At the same time, it must not be forgotten, that continued resistance does at last rouse up the uterine action, and call forth frequent and powerful efforts, often accompanied with great pain. These are more easily excited, when the resistance proceeds from the pelvis or perinaeum, and orifice of the vagina, or the position of the child, than when it arises from the state of the os uteri, or even ofthe membranes, in which case the uterine action is long feeble or inefficient. It is necessary farther to remark, that often a mistake is committed by confounding frequent and painful contraction ofthe uterus, with powerful and efficient action. Parturition is a muscular action, and we might in one view conceive that it should be most speedy and easy in those who possessed a powerful muscular system, and great vigour. But this is far from being the case, for the process is tedious or speedy, easy or difficult, according to the relation which the power bears to the obstacle to be overcome. Now, in many weak and debilitated women, the parts very easily relax and dilate, and a very small power is required to complete the expulsion ; whilst we often find, that those who possess a tense fibre, and great strength of the muscular system, accomplish the dilatation of the os uteri, not without much pain and repeated efforts. A fundamental principle then in midwifery is, that relaxa- tion or diminution of resistance is essential to an easy delivery: and could we discover any agent capable of effecting this rapidly and safely, we should have no tedious labour excepting from the state of the pelvis, or position of the child. This agent has not yet been discovered. Blood-letting does often produce salutary relaxation, but it cannot always be depended on, neither is it always safe. SECTION FIFTH. Women in a state of nature make little preparation for their delivery, and conduct the process of parturition without much ceremony. They retire to the woods, or seclude them- selves in a hut or bower, until they bear the child; after which, if the religious customs of their country do not require 362 their separation for a time, they return to their usual mode of living. In Europe, we find that the process of parturition is con- ducted with more care, and is supposed to require greater preparation. Different countries have different customs in this respect. In some, women are delivered upon a chair of a particular construction ; in others, seated on the lap of a female friend. Some women use a little bed, on which they rest, until the process is completed: and others are delivered on the bed on which they usually sleep. This last, for many reasons, is the best and most proper practice ; but in order to prevent the bed from being spoiled, or wet with the liquor amnii or blood, and also from other motives of comfort, it is usual to make it up in a particular manner. The mattress ought to be placed uppermost, and a dressed skin, or folded blanket placed on that part of it on which the breech ofthe woman is to rest. The bed is then to be made up as usual; after which, a sheet folded into a breadth of about three feet, is put across the under fold ofthe bed-sheet. This is intended to absorb the moisture ; and after delivery, if not during labour, that part which is wet, is to be drawn completely away, so that a dry portion may be brought under the woman. This arrangement is generally attended to by the nurse, whenever labour begins. When the pains begin, the patient generally dresses in dishabille; but when the process is considerably advanced, it is necessary to undress, and lie in bed. Some, at this time, put on a half shift, that is to say, one that does not reach below the waist, so that it is not liable to be wet. Others are satisfied with having the shift pushed up over the pelvis, so as to be kept dry; its place, in either case, is supplied with a petticoat. These, and other circumstances relating to dress, and to the quantity of bed-clothes, must be determined by the woman herself, and the season ofthe year. It is of consequence that the room be not overheated bv fire, or the patient kept too warm with clothes. Heat makes her restless and feverish, adds to the feeling of fatigue, and often, bv rendering the pains irregular or ineffective, protracts the labour. i\o more people should be in the room than are absolutely necessary. The nurse and one female friend are perfectly sufficient for every good purpose ; and a greater number, by their conversation, disturb the patient, or by their imprudence, may diminish her confidence in her own powers, and also in her necessary attendants. The mind in estate of distress, is easily alarmed; and therefore whispering, 363 and all appearance of concealment, ought to be prohibited in the room. . If the patient be disposed to sleep betwixt the pains, she ought not to be disturbed, but allowed to indulge in repose. If she have not this inclination, and be not fatigued, cheerful conversation, upon subjects totally unconnected with her situation, will be very proper. Women have seldom an inclination for food whilst they are in labour ; and, if the process be not long protracted, there is no occasion for it. If, however, the patient have a desire to eat, she may have a little tea or coffee, with dry toast, or a little soup, or some panado ; but every thing which is heavy or difficult of digestion, must be avoided, lest she be made sick and restless, or have her recovery afterwards interrupted. Even very light food is apt at this time to sour, and cause heartburn. Stimulants and cordials, such as spiced gruel, cinnamon water, wines, and possets, were at one time very much employed, but now are deservedly abandoned by those who follow the dictates of nature. Given in liberal doses, they are productive of great danger, disposing to fever or inflammation after delivery ; and in smaller doses, they disorder the stomach, and often, instead of forwarding, retard the labour. If, however, the woman be weak, or the process tedious, then a small quantity of wine, given prudently, may be of consider- able advantage. Some women wish to keep out of bed as much as possible, in order that labour may be forwarded by walking about; others have the same desire from feeling easier when they are sitting. In this respect, they may be allowed to please them- selves, but they ought to be as much as possible out of bed, provided they do not feel tired. The urine ought to be regularly and frequently evacuated ; and for that purpose, the practitioner should occasionally leave the room. If the patient be costive, or the rectum con- tain faeces, a clyster ought always to be given early, which facilitates the labour. On the other hand, if the bowels be very loose, a few drops of tincture of opium may be given with much advantage. It is immaterial in what posture the patient place herself during the first stage of labour; but in the second stage, when delivery is approaching, it is proper that she be placed on her side, and it is usual for her to lie on the left side, as this enables the practitioner to use his right hand. Ihe 364 knees are a little drawn up, and generally at this time kept separate by means of a small pillow placed between them. Many women wish to have their feet supported, or pressed against by an assistant, and it is customary to give a towel to grasp in the hand. This is either held by the nurse, or fastened to the bed-post. We must, however, be careful that these contrivances do not encourage the woman to make too strong and exhausting efforts to bear down. When the patient is in bed, it is proper to have a soft warm cloth applied to the external parts, in order to absorb any mucous or water that may be discharged, and this is to be removed when it is wet. Attempts to dilate the os uteri or the vagina, and the appli- cation of unctuous substances, to lubricate the parts, are now very properly abandoned by well instructed practitioners. The membranes ought generally to be allowed to burst, by the efforts of the uterus alone, for this is the regular course of nature ; and a premature evacuation of the water either disorders the process and retards the labour, or, if it acce- lerate the labour, it renders it more painful. I cannot, how- ever, go the length of some, who say, that the evacuation of the water is always hurtful ; for there are circumstances in 4 which it may be allowable and beneficial. It is allowable when the os uteri is fully dilated, and the membranes pro- truded, perhaps even out ofthe vagina. In such a case, they would, in a few pains at farthest, give way; but by rupturing them we can take precautions to keep the person dry, and more comfortable than she would otherwise have been. Even if the membranes be not considerably protruded, if the os uteri be completely dilated, no injury can arise from ruptur- ing them, for they ought, in the natural course of labour, to give way at this time. But although the practice be not detrimental, yet it does not thence follow that it is always expedient; and it will be an useful rule to adhere to, that the seldomer we interfere in this respect in natural labour, the more prudent shall our conduct be. Examination ought, in the first stage of labour, to be prac- tised seldom; but in the second stage we must have recourse to it more frequently; and, when the pains are becoming stronger and the head advancing, we must not leave the bed- side. At this time we should be prepared for the reception ofthe child. A pair of scissors, with some short pieces of narrow tape, must be laid upon the bed or chair, and a warm cloth or receiver must be at hand, or spread under the clothes 365 to wrap the child in. As the faeces are generally passed at this time involuntarily, a soft cloth is to be laid on the perinaMjm ; and when the second stage of labour is drawing to a conclusion, the hand is to be placed on this, in order to prevent the rapid delivery of the head, and the consequent laceration of the perinaeum. This is a point of very great im- portance, and which requires to be carefully considered by the practitioner. There are several arguments againstthis prac- tice; for we should, a priori, conceive, that as parturition is a natural process, it ought not in any part to be defective, or to require the regulation of art. Next, we should strengthen this doctrine, by finding, that in the savage state, a lacerated perinaum is rarely discovered, and in all those women who are speedily delivered by themselves, the recto-vaginal septum is seldom torn. But on the other hand, the fact is ascertained beyond all dispute, that the perinaeum is sometimes lacerated, notwithstanding these presumptive proofs against the occur- rence of the accident. This being ascertained, it becomes our duty, however rare the case may be, to determine its causes, and prevent its occurrence in every instance; for we cannot exactly say who the unfortunate individuals may be to whom it is to happen. We may decidedly say, that the perinaeum is torn in consequence of distention ; but in every delivery, the perinaeum must be distended, and in some to a great degree. In proportion to the facility of the distention, and the ease with which the vagina dilates, is the risk of laceration diminished. It has, therefore, become a practical rule, to resist, with the hand placed on the perinaeum, the delivery of the head, until the parts be sufficiently relaxed; and this pressure ought to be exerted over the whole tumour, but especially at the fourchette; for although the perinaeum have been perforated by the head, which did not pass through the orifice of the vagina, yet usually, the rent begins at the four- chette and proceeds backwards to a greater or less degree. In every case, the fourchette, and a small part of the posterior surface of the vagina, are lacerated, though the integuments of the perinaeum remain sound. By firmly supporting the perinaeum, and, at the same time, exhorting the patient not to force down during a pain, and thus retarding the delivery of the head until we feel the vulva, as well as the perinaeum relaxing, we may generally prevent laceration ; and, therefore, this accident will seldom, if ever happen in the hands of a prudent practitioner. Still it is possible for the perinaeum to be torn under good management. A little bit of it is not 366 unfrequently lacerated, notwithstanding all our precaution ; and although, in this slight degree, it is of no consequence, yet we thus see that art cannot completely prevent the accident. Sometimes the restlessness of the patient almost inevitably prevents the necessary precautions from being used ;* and it may happen that the frame is so very irritable, that the perinaeum unexpectedly lacerates at the time when it is supposed to be in a favourable state. As there must be some point where the resistance must stop, else the labour would be unnecessarily protracted, or perhaps even the uterus ruptured, it is possible that such resistance may be made, as generally is sufficient to prevent the accident, but which may not in some particular case, owing to the irritable state ofthe perinaeum, be adequate to the intended purpose; or the power of the uterus may be so strong as to expel the head, in spite of every allowable resistance ; and in some of these cases it is possible for the perinaeum to be torn. It is not sufficient that the practitioner support the peri-- naeum, until the head is going to be expelled; he must continue to do so whilst it is passing out, for there is then a great strain on the part, as the forehead is nassing over the perinaeum, and even the face moving along it, may produce injury. After the head is delivered it is still necessary to place the hand under the chin, and on the perinaeum, for the arm ofthe child comes next to press against this part, and may either tear it by pressure, or by coming out with a jerk. Farther, to prevent injury and avoid pain, the body of the child should be allowed to pass out in a direction corresponding to the outlet of the pelvis, that is to say, moving a little forwards. But there is no occasion that the child should be carried forward betwixt the thighs, for in a natural labour, the back ofthe child is directed to the thighs ; he can easily bend, and will naturally so incline himself in the delivery, as to take the proper direction. The last advice to be given respecting this stage of labour is, that as we retard rather than encourage the expulsion of the head, so we are not to accelerate the delivery ofthe body. Women in a state of pain call for relief, and expect that the midwife is to assist the delivery ofthe child ; but no entreaties ought to make us hasten the expulsion of the head, and after that event, there is little inducement to accelerate the labour. Sometimes, * Dr. Denman, a most worthy and experienced practitioner, with a candour which does him honour, acknowledges, that from this cause the accident occurred in his own practice. 367 in a few seconds the child is expelled, but there may be a cessation of pain for some minutes. In the first case, we take care that the body be not propelled rapidly, and with a jerk : in the second, we attend to the head, examining that the membranes do not cover the mouth, but that the child be enabled to breathe, should the circulation in the cord be obstructed. There is no danger in delay, and rashly pulling away the child is apt to produce flooding and other dangerous accidents. Should there, however, be a considerable interval betwixt the expulsion of the head, and the accession of new pains, we may rub gently on the belly, or pull the child slightly, so as to excite the uterus to contract. Or, should the woman have several pains without expelling the body of the child, it may be allowable gently to insinuate the finger, and bring down the shoulder ; but even this assistance is rarely required, and on no account ought we to attempt the delivery by pulling the head. Sometimes a delay is produced by the cord being twisted round the neck ; and in this case, all we have to do is to slip it off over the head. The child being born, a ligature is to be applied on the cord very near the navel, and another about two inches nearer the placenta.59 It is then to be divided betwixt them, and the child removed. The hand is next to be placed on the belly, to ascertain that there be not a second child;60 and the finger may, for the same purpose, be slid gently along the cord to the os uteri. The hand of an assistant should be applied on the abdomen, and gently pressed on the uterus, which may excite it to action, and prevent torpor. If the placenta be not expelled soon, the uterine region may be rubbed with the hand, to excite the contraction ofthe womb. Immediately after the expulsion of the child, there is often a copious evacuation of water, which is sometimes mistaken by the woman for a discharge of blood. But haemorrhage never takes place so instantaneously, in such quantity. It is generally a minute or two, sometimes much longer, before flooding come on ; against the occurrence of this, we are to be on our guard. The woman, after the delivery of the child, feels quite well, and expresses, in the strongest language, the transition from suffering to tranquillity. But in a short time, generally within half an hour, one or two trifling pains are felt, and the placenta is expelled, which completes the last stage of parturition; and when the process goes on regularly, nothing 368 is required in this stage, except watchfulness, lest haemorrhage supervene. The full and universal contraction of the uterus after the child is expelled, must, by diminishing its surface, detach the placenta, whilst the membranes being thinner and more pliant, may wrinkle and continue their, adhesion, and some- times do so till they be peeled off, as the placenta protrudes. Haemorrhage is prevented, even when the placenta is detached, by the contraction of the uterine fibres on the vessels, and by the adhesion of the membranes still to the uterus, which, for a time at least, will prevent blood from flowing, unless the extravasation be considerable. But to these causes we must also add the condition of the uterine vessels themselves, which, immediately after delivery, have, if the state be natural, their circulation much affected by the alteration in the action of the nerves of the uterus itself. But it sometimes happens, that the placenta does not come away so early or so readily as we expect. It may be retained for many hours, or even for some days. This retention can be caused by preternatural adhesion of the placenta, or by the uterus contracting spasmodically round the placenta, forming a kind of cyst, in which it is contained ; or the uterus may not contract on the placenta so strongly as to expel it. Some, from a confidence in the powers of nature, have inculcated as a rule of conduct, that unless flooding take place, the placenta ought not to be extracted. Others have, with equal zeal, advised it to be brought away, immediately after the birth of the child. The safest practice seems to lie betwixt the two extremes. To leave the expulsion of the placenta altogether to nature, is a step attended with great danger ; for so long as it is retained, we may be sure that the uterus has not contracted strongly and regularly. If, then, in these circumstances, the placenta should be partially or completely detached, haemorrhage is very likely to occur. If it still adhere to the uterus, the risk of haemorrhage certainly is diminished, for those vessels alone, which opened on the decidua, can be exposed; but we have no security that this adhesion shall remain universal for any given time. As long, then, as the placenta is retained, the patient is never free from the risk of flooding. In many cases, she has died from this cause before the placenta was expelled; or if, after a long delay, the placenta have come away, its exclusion has 369 sometimes been followed by fatal haemorrhage.* But this, although a dreadful accident, is not the only one arising from retention of the whole or part of the placenta. For great debility, constant retching, and fever, are often produced by this cause, and may ultimately carry off the patient.61 It is therefore not without great reason, that women are anxious for the expulsion of the placenta ; and this prejudice may have a good effect in operating against the conceits of speculative men, who suppose that nature is, in every instance, adequate to the accomplishment of her own purposes. On the other hand, daily experience must convince every one, that there is no occasion for extracting the placenta immediately after the birth of the child, for it is usually expelled, with perfect safety, within forty minutes after the child is delivered. Nay, we find, that the speedy extraction of the placenta is directly hurtful: both as it is painful, and also as it is sometimes followed by uterine haemorrhage, or if rashly performed, by inversion of the womb. The practice then, I think, may be comprised in two directions :—First, that we ought never to leave the bed-room, until the placenta be expelled ; and, secondly, that if it be not excluded within an hour after delivery, we ought to extract it. This point being adjusted, it is next to be inquired, how the retention is to be prevented, and if not prevented, how the placenta is to be extracted. With regard to the first question, it may be answered, that the placenta will be less apt to be retained, if the expulsion of the child be conducted slowly, and the uterus made to contract fully upon it. The action, if not likely soon to lake place, may be sometimes excited by pressing on the uterine region, and rubbing the abdominal covering over the uterus, or gently grasping the womb through the relaxed parietes. As to the mode of extracting the placenta, we can be at no loss, if we recollect that the expulsion is accomplished by the contraction of the uterus. Our object, then, is to excite this when the placenta is retained, in consequence of the womb not acting strongly. The hand is to be slid slowly and cautiously into the uterus, which is often sufficient to make it contract ; but if it do not, the hand is to be moved a little, or pressed gently on the placenta, at the same time that we pull very slightly by the * Mr. Whyte has, in his Treatise on the Management of Pregnant and Lying-in Women, p. 507, relat?d several cases where the practice of leaving the placenta to be expelled by nature alone, was productive of fatal hemorrhage ; ana iii one instance, this event took place, although the placenta was at last expeuea, 2 Y 370 cord, or lay hold of the detached placenta with our hand, and with caution extract it slowly. This requires no exertion, for the uterus is pressing it down, and, if any force be used, we do harm. Attempts to bring away the placenta, by pulling strongly at the cord, whether the hand be introduced into the uterus or not, are always improper. If persisted in, they generally end, either in the laceration of the cord, or the inversion of the uterus. There are two circumstances, however, under which the placenta may be retained, which require some modification of the practice. The first is when the placenta is retained by spasm. In this case, when the hand is conducted along the cord through the os uteri, the placenta is not perceived, but it is led by the cord to a stricture, like a second, but con tracted os uteri, beyond which the placenta is lodged. This contraction, usually seated in the upper part of the cervix, must be overcome before the placenta can be brought away, which may be accomplished by gradual attempts to introduce one, two, and ultimately all the fingers, through it; and these, if cautiously made, are perfectly safe. It will, however, be observed, that the uterus, at short intervals, contracts, which is accompanied with pain ; but this contraction is confined to the stricture alone, the cavity of the womb not being lessened by it; and during this state, all attempts to dilate the aper- ture are hurtful. We must be satisfied with keeping the fingers in their place, to preserve the ground we have gained. Opiates have been proposed to remove this spasm, and render the introduction ofthe hand unnecessary; they seldom, how- ever, succeed alone; given in a full dose they may make the manual attempt more easy ; but should there be haemorrhage, it is evident we cannot delay till they take effect. Sometimes the sudden application of a cloth, dipped in cold water, to the belly, has the effect of relaxing the spasm, perhaps by exciting suddenly the more universal contraction of the uterus. A retention ofthe placenta from spasm, is rarely a simple consideration, for in the majority of instances it is attended with haemorrhage, and will fall to be noticed again in another chapter. Here I must add. that even with very little discharge, there is a great feeling of sinking and often of sickness, a feeling almost invariably attending this spasm, and which is only relieved by introducing the hand so as to dilate the stricture, at the same time that we excite the uterus to more general and uniform contraction. Opiates are also proper; and if the symptoms be urgent, wine must be given, 371 for some patients may die if this state continue long, although there ha ve been little haemorrhage. The second circumstance to which I alluded is, adhesion ofthe placenta, which usually is only partial. This may occur with or without a change of structure; but in general, the structure is more or less altered, the adhering part being denser than usual, and sometimes almost like cartilage. The separation of the adhering portion should not be attempted hastily, nor by insinuating the finger between it and the uterine surface. It is better to press on the surface of the placenta, so as thus to excite the uterine fibres to contract more briskly at the spot; or by gently rubbing, or as it were, pinching up the placenta between the fingers and thumb, it may be separated. If, however, the adhesion of the part of the placenta be very intimate, we must not, in order to destroy it, scrape and irritate the surface of the uterus, but ought rather to remove all that does not adhere intimately, leaving the rest to be separated by nature.* But in taking this step, we are not to proceed with impatience, nor to attempt to bring away the non- adhering portion, until a considerable time have elapsed, and cautious efforts have been made to remove the entire placenta; thus satisfying ourselves ofthe existence of an obstinate and intimate union. Cases where this conduct is necessary, are very rare, and when they do occur, there is usually an indu- ration of the adhering part. It is generally thrown off in a putrid state in forty-eight hours. Sometimes the placenta adheres when it is unusually tender and soft, and then we must with peculiar care, avoid hasty efforts, by which the placenta would be lacerated, and part left behind, which would be hurtful afterwards; whereas by a little more patience, and gentle pressure on the surface of the placenta, the uterus might have been excited to throw the whole off. In every case, the utmost caution and gentleness must be employed in removing or extracting the placenta, lest disorder, or inflammation of the uterus, to a greater or less degree, be excited. h * Dr. Smeliie relates two cases of this kind. In the first, he brought away the indurated portion, but the woman died from haemorrhage. In the second, he left the adhering portion, and the woman recovered. Col. 23. c. Land 2. See also Gifford's Oases, c. 119 and 127; and La Motte, c. 358 and 362. In these, although the adhesion was very intimate, he brought away the placenta in pieces. 372 CHAP. III. Of Premature Laboui. When a woman bears a child in the seventh or eighth month of pregnancy, she is said to have a premature labour ; and this process forms a medium between abortion and natural labour. In some cases, the uterus is fully developed before the usual term of gestation, and then contraction commences; but, in a great majority of instances, premature labour proceeds from accidental causes, exciting the expulsive action ofthe uterus, before the cervix and os uteri have gonethrough their regular changes. The cervix must, therefore, relax, and be expanded, before the os uteri can be properly dilated ; and this prepara- tory stage is generally marked by irregular pains, and not unfrequently by a feverish state, preceded by shivering. A feeling of slackness about the belly, with different anomalous sensations, often accompany this stage of premature labour. When the cervix is expanded, then theos uteri begins to dilate, and this part ofthe process is often more tedious than the same period of natural labour, and generally as painful. It is also frequently attended with a bearing-down sensation. The second stage of labour is usually expeditious, owing to the small size of the child. The decidua being thicker than at the full time, the protrusion of the membranes is often attended with more sanguineous discharge ; and if the woman move much, or exert herself, considerable haemorrhage may take place. The third stage is likewise slow, for the placenta is not soon thrown off. In the last place, spasmodic contrac- tion ofthe uterus is more apt to take place in all the stages of premature than of natural labour. A variety of causes may excite the action of the uterus prematurely, such as distention from too much water; or the death ofthe child, which is indicated by shivering, subsidence of the breasts, cessation of motion, and of the\v'"Ptonis of pregnancy; or the artificial evacuation of the liquor amnii; or violent muscular exertion; or drugs acting strongly on the stomach and bowels ; or passions of the mind ; or acute diseases; or affections ofthe uterine fibres. Certain general conditions of the system render the operation of these causes more easy, such as plethora, debility, and great irritability. 373 Colic in some instances, and diarrhoea in others, seems to be a cause and in such cases anodyne clysters are useful Premature labour is often preceded by severe shivering, druing or immediately before which the child dies, and in some time thereafter, pains come on. It is worthy of notice, that a much larger proportion of premature labours are preternatural, than of labours at the full time. A tendency to premature labour is to be prevented by the means pointed out when treating of abortion. I have only to add, that when the abdomen is tense and hard, or painful, indicating a sensibility ofthe uterine fibres, or ofthe abdominal muscles, tepid fomentations, gentle laxatives, repeated small bleedings, and anodyne clysters, are useful. When a woman is threatened with premature labour, we ought, unless there be very decided marks of the death ofthe child, to endeavour to check the process, which is done by exhibiting an opiate, keeping the patient cool and tranquil, and removing any irritation which may exist. If she be plethoric, or the pulse be throbbing, blood is to be detracted. When labour is established, it is*to be conducted much in the same way with parturition at the full time; but the following observations will not be improper. The patient must avoid much motion, lest haemorrhage be excited. Frequent examination and every irritation are hurtful, by retarding the process, and tending to produce spasmodic contraction. If this contraction take place, marked by paroxysms of pain referred to the belly or pubis, often attended with feeling of sinking, whilst little or no effect is produced on the os uteri, a full dose of tincture of opium should be given, after the administration of a clyster. Severe pains, with premature efforts to bear down, and a rigid state ofthe os uteri, require venesection, and afterwards an opiate. The delivery ofthe child is to be retarded, rather than accelerated in the last stage, that the uterus may contract on the placenta. This is farther assisted, by rubbing gently the uterine region after delivery. If the placenta be long retained, or haemorrhage come on, the hand is to be gently introduced into the uterus, and pressed on the placenta, to excite the fibres to throw it off; or we may stimulate the uterus to act, by rubbing exter- nally. We should not rashly attempt to remove it, for we are apt to tear it; neither are we to pull the cord, for it is easily broken. In those cases where premature labour is connected with redundance of liquor amnii, I think it useful to introduce the hand immediately on the delivery of the 374 child, for I have observed, that the placenta is apt to be retained by irregular contraction. We do not instantly extract the placenta, but is it desirable to get the hand in contact with it before the circular fibres contract. Great attention is to be paid to the patient for some days after delivery, as she is liable to a febrile affection, which may be either of the inflammatory type, or ofthe nature of weed, to be afterwards noticed. CHAP. IV. Of Preternatural Labour. Various signs have been enumerated, by which it was supposed, that malposition of the child might be discovered antecedent to labour. An unusual shape of the abdomen ; some peculiar feeling, of which the mother is conscious, and which she has not felt in any former pregnancy ; greater pain or numbness in one leg than in the other; a sensation of the child rising suddenly towards the stomach ; have all been mentioned as indicating this, but are all, even when taken collectively, uncertain tokens. We cannot determine the presentation until labour have begun. In a great majority of instances, the head, during the end of gestation, may be felt resting on the cervix uteri; but, in repeated instances, I have not been able to distinguish it in a pregnancy which ended in natural labour. Sometimes, in consequence of a fall, or other causes, the head seems to recede, but afterwards returns to its proper position. When labour begins, we may generally distinguish the head by its proper character; but, if it lie high, and especially if the pelvis be deformed, we may not find it always easy to ascertain the presentation at a very early period. In such cases, it is of great consequence to preserve the membranes entire. When the head does not present, the presentation is generally more distant, and longer of being distinctly ascertained.* The lower part of the uterus is more * When the presentation is long of being felt, we have been advised to examine the woman in a kneeling posture, or even to introduce the hand into the vagina, and rupture the membranes. This last advice is sometimes useful, as it enables us if the presentation require it, to turn the child at a time when it can be easily done. But this is not to be hastily practised, nor adopted till the os uteri be well dilated, or at least quite dilatable. 375 conical, and the tumour formed by the cranium cannot be felt through the membranes or cervix uteri: when the finger touches the part through the membranes, it very easily recedes, or seems to rise up. If the child lie more or less across the uterus, the os uteri is generally long of being fully dilated, the membranes protrude like a gut, and sometimes, during the pains, the woman complains of a remarkable pushing against the sides. The pains are severe, but in cross presentations, she is sensible that they are not advancing the labour. It is a fact well ascertained, that although the head have been felt distinctly in the commencement of labour, yet when the membranes break, it may be exchanged for the shoulder,* or some other part. On this account, as well as for other reasons, it is always proper to examine immediately after the membranes have given way. ORDER FIRST. The breech is distinguished by its size and fleshy feel, by the tuberosity ofthe ischia, the shape ofthe ilium, the sulcus between the thighs, the parts of generation, and by the discharge of meconium, which very often takes place in the progress of labour.t After the breech has descended some way into the pelvis, the integuments may become tense or swelled, so as to make it resemble the head. Before the membranes burst, the presentation is usually very mobile, and bounds up readily from the finger ; but in some instances it is from the first firmly pressed down in the pelvis, and felt through the uterus very much resembling the head. Many have advised, that when the breech presented, the feet should be brought down first; but the established practice now is, when the pelvis is well formed, and other circumstances do not require speedy delivery, to allow the breech to be expelled without any interference, until it has passed the external parts. The breech, and consequently the body of the child, may vary in its position with regard to the mother;62 but there are chiefly two situations requiring our attention, because the rest are ultimately reduced to these. First, where the thighs of the child are directed to the sacro-iliac junction of the pelvis; and secondly, where they are directed to the aceta- * I have been informed of a case, where the shoulder was exchanged for the head, and Joerg seems to have met with the same circumstance. Hist. Partus, p. 90. t A discharge of liquor amnii, apparently coloured with meconium, is no proof that the breech presents, neither is it a sign that the child is dead. 87C buluni. In either of these cases, delivery goes on with equal ease, until the head come to pass. Then, if the thighs have been directed to the fore part ofthe pelvis, the face will also be turned toward the pubis, and cannot clear its arch so easily as the vertex. When the thighs are directed to the back part of the pelvis, we find that the process of delivery is as follows : The breech generally descends obliquely, one tuberosity being lower than the other. The lowest one follows the same turns as the vertex does in natural labour, and observes the same relation to the axis ofthe brim and outlet ofthe pelvis. The breech is expelled with one side to the symphysis of the pubis, and the other to the coccyx ; and after the presenting tuberosity protrudes under the arch of the pubis, the other clears the perinaeum, like the face in natural labour. Whilst the breech is protruding, it gradually turns a little round, so that the shoulders ofthe child come to pass the brim diagonally, the diameter from the acetabulum to the sacro-iliac junction being the greatest. The breech being delivered, a continuance of the pains pushes it gradually away, in the direction of the axis of the outlet, until the legs come so low as to clear the vagina. When this takes place, the head is generally passing the brim obliquely, the face being turned toward the sacro- iliac junction ; and most frequently the arms pass along with it, being laid over the ears. They then slip down into the vagina, by the action ofthe uterus, and the head alone enters the cavity of the pelvis. The face turns into the hollow of the sacrum, and the chin tends towards the breast of the child. Then it clears the perinaeum, which slips over the face, and the vertex comes last of all from under the pubis. If, however, the chin be folded down on the breast, before the head has descended into the pelvis, then, from the unfavourable way in which it enters the brim, there may be some difficulty to the passage, for it in some respects resembles a presentation of the face. The hand should be introduced, and the face pressed up. In one case, Dr. Smeliie found so much difficulty, that he applied the crotchet on the clavicle. Now the management of this labour is very simple. Whilst the breech is coming forth, the perinaeum is to be supported, and nothing more is to be done till the knees are so low as to be on a line with the fourchette. If they do not naturally bend, and the feet slip out, the finger of one hand is to be employed to bend the leg gently, and bring down the foot; the knee, in this process, pressing obliquely on the abdomen 377 of the child. But whether the legs be expelled naturally, or be brought down, we must carefully protect the perinaeum, lest it should be torn by a sudden stroke of the leg in passing. Next, the cord is to be pulled gently down a little, to make the circulation more free. Thirdly, we attend to the arms; if these do not descend by the natural efforts, we introduce a finger, and gently bring down first one, and then the other, using no force, lest the bone should break. The perinaeum is also to be guarded, to prevent a slap of the arm from injuring it. Fourthly, if the head do not directly turn down, the finger is to be carried up, and placed upon the chin or in the mouth, in order gently to depress it toward the breast, and this is generally sufficient. To guard the perinaeum, the hand must be applied on it, and the body ofthe child moved near the thighs of the mother, that the vertex may more readily rise behind the pubis whilst the face is passing. If the body be, on the contrary, removed farther from the mother, and nearer the operator, the head can neither pass so easily into the pelvis, nor out from the vagina. In a natural labour, after the head is expelled, the whole body should be allowed to be slowly born by the efforts of the womb alone. But in breech cases, should the process, after the breech is expelled, be slow, the delivery of the body and head must, by the means I have related, be accelerated, lest the umbilical cord suffer fatal compression. The first symptom of danger is a convulsive jerk of the body, and if the head be not speedily brought down, the child will be lost. Should delay inevitably arise, we must try to bring the cord to the widest part ofthe pelvis. But even although all pressure could be removed, the child cannot live long, if it be not delivered, as the function ofthe placenta is soon destroyed, that organ being often entirely detached from the womb, following the head whenever it is born. When the thighs, in breech cases, are directed to the pubis or acetabulum, then the face cannot turn in to the hollow of the sacrum. It rests for some time on the pubis, and it comes out with difficulty under the arch ; for in breech and footling cases, the face is generally born before the vertex. In order to prevent this difficulty, it will, as soon as the breech is expelled, and the feet are delivered, be proper to grasp the breech, and slowly endeavour to turn the body round ; but, should this not succeed, or not have been attempted till the shoulders have come down, and the head be about to pass the brim, the practice is dangerous, and the neck may be 2 Z 378 materially injured. It is, in this case, better to introduce a finger, and press with it on the head itself, endeavouring thus to turn the chin from the acetabulum to the sacro-iliac junc- tion ofthe same side. If the position be not rectified, then we assist the descent by depressing the chin, and gently bring- ing it under the pubis ; and this may be facilitated by press- ing the vertex upward and backward, and making it turn up on the curve of the sacrum, to favour the descent of the face. We must be careful ofthe perinaeum. When the pelvis is contracted or deformed, it will be prudent, at an early stage of the labour, to bring down the feet. But if this have been neglected, then, should the difficulty of delivery, or the length of time to which the labour is protracted, require it, some insinuate a blunt hook, or a soft ribband over one ofthe groins, and thus extract the breech ; but the forceps may be applied with much more advantage. When the resistance is slight, the insinuation of the fingers over the groin may sometimes enable us to use such extracting force, as at least excites the uterus more briskly to expel. Should the head not easily follow the body, we must not attempt to extract it by pulling forcibly at the shoulders, as we may thus tear the neck, and leave the head in u'ero.* The cord is, first of all, to be freed as much as possible from compression; then we gently depress the shoulders, in the direction of the axis ofthe brim, at the same time that we with a finger act upon the chin. Should this not succeed, we must apply the lever over the head, and depress in the proper direction. If this fail, the only resource is to open the cranium above or behind the ear, and fix a hook in the aperture; but this is not to be done until we have fully tried other means, and by that time the child will be dead. When the breech presents, and parturition is tedious, the parts of generation are often swelled and livid. When the parts are merely turgid a little, and purple from congestion of venous blood, nothing is necessary to be done. But when inflammation takes place, it is more troublesome, for being of the low kind, it is apt to end in gangrene. Fomentations are useful, but often mild spiritous applications succeed best. * La Motte, Chapman, Smeliie, and Perfect, give examples ofthe head being left in utero without the body, and the body without the head. There are chiefly two sources of danger; the first and most immediate is uterine haemorrhage; the second is the consequence of putrefaction, which produces sickness, nausea, fever, and great debility. The head may be extracted, by fixing a finger in the mouth, or by the crotchet, with or without perforation. 379 ORDER SECOND. Presentation of the feet is known, by there being no rounded tumour formed by the lower part of the uterus.63 The membranes also protrude in a more elongated form than when the head or breech present. The presenting part, when touched during the remission of the pain, is felt to be small, and affords no resistance to the finger. When the membranes break, we may discover the shape of the toes and heel, and the articulation at the ankle. Sometimes both the feet and the breech present. Two circumstances contribute to an easy delivery ; first, that the toes be turned toward the sacro-iliac junction of the mother; and, secondly, that both feet come down together. The best practice is to avoid rupturing the membranes till the os uteri be sufficiently dilated ; then we grasp both feet, and bring them into the vagina ; or, if both present together at the os uteri, we may allow them to come down unassisted. In either case, we do not accelerate the delivery till the cord be in a situation to suffer from pressure, that is, till the knees be fully protruded, and the thick part ofthe thighs, near the breech, can be felt; then, if the face be towards the belly ofthe mother, we grasp the thighs, and gently turn the body round. The manage- ment is the same as in breech cases. There is little danger of the feet of two different children being brought down together, as twins are included in separate membranes. But as the case is possible, it is proper to ascertain that the feet be right and left. Sometimes a knee and foot, or the knees alone, present; and as they form a larger tumour than the feet, they may at first be taken for the breech or the head. Generally only one knee presents, and it lies obliquely, with its side on the os uteri. It is known by its shape, and the flexure of the joint. Some advise that the case should be left altogether to nature, but it is often advantageous to bring down the feet. ORDER THIRD. When the shoulder or arm presents, the case has the general characterofpreternatural presentations.64 The round tumour, formed by the head in natural labour, is absent, whilst we can ascertain the shape and connexion of the arm and shoulder. A shoulder presentation can only be confounded with that of the breech. But in the former case, the shape of the scapula, the ribs, the sharpness of the shoulder joint, and 380 the direction ofthe humerus, together with our often feeling in our examination either the hand or neck, will be distin- guishing marks. In-the latter, the round shape and greater firmness of the ischium, the size of the thigh, its direction upwards, and its lying in contact with the soft belly, the spine ofthe ilium, the parts of generation, the size ofthe tuberosity ofthe ischium, and the general shape of the back parts of the pelvis, contribute with certainty to ascertain the nature of the case. The hand and arm may present under different circum- stances. The original presentation may have been that ofthe shoulder, but the arm may have, in the course ofthe labour, been expelled ; or the hand may rest upon the os uteri, before the membranes have broken ; or the fore arm may, for a length of time, lie across the os uteri, the hand not being protruded for some hours. Sometimes both hands are felt at the os uteri, and even both arms may be expelled into the vagina ; but in most cases this does not happen, unless an improper conduct be pursued. In some rare instances, the hands of twins have been found presenting together, both sets of membranes having given way; it is more common to find both the hands and feet of the same child presenting; and this, next to the presentation ofthe feet alone, is the easiest case to manage.* It is not uncommon, in this case, to find the cord presenting at the same time, and then, by delay, the child may be lost. In most cases where the superior extremities present, the feet of the child are found in the fore part of the uterus, toward the navel of the mother. But their situation may be known by examining the presentation. If we feel the shoulder, we know, that if the scapula be felt toward the sacrum, the feet will be found toward the belly. If the arm be protruded into the vagina, the palm of the hand is found in supination, directed toward the side where the feet lie. It is easy to know which hand presents. If we examine with the right hand, we shall find, that if the palm of the child's hand be laid upon our palm, the thumb ofthe right hand, or the little finger of the left hand, will correspond to our thumb. In these preternatural presentations, the ancients were acquainted with the practice of turning, and delivering the » If the uterus be firmly contracted, the liquor amnii having been all evacuated it may sometimes be necessary to carry the hand up to the knees, before we can change the situation. 381 child by the feet.* But their remarks on this subject formed no general rule of conduct; on the contrary, practitioners were almost invariably in the habit of endeavouring to remove the presentation, and to bring the head to the os uteri. Pare was among the first who advised turning as a general practice; but even his pupil Guillimenu disregarded the rule, and left it to Mauriceau to enforce it both by reasoning and practice.! Franco also was an advocate for turning. There may, how- ever, be cases, where it would not only be safe, but also more proper, to resort to the old practice, although, as a general rule, it ought to be abandoned. For instance, if the patient be known usually to have a short labour, if the pains be brisk, the os uteri dilated, or in a relaxed and easily dilatable state, the liquor amnii retained, and the child moveable, then the head may, without any difficulty, or much irritation, be placed in the proper position, with a fair and reasonable chance of success. This 1 have held to be a maxim in practice, and see no reason to alter it. The labour, no doubt, is slower than if we had brought down the feet, but the child is in much less danger, and this I hold to be the great inducement to return, in favourable cases, to an old practice. On the other hand, if the liquor amnii have been evacuated, or any irritation attend the rectification ofthe presentation, it is better at once to bring down the feet, and insure a delivery, safe at least to the mother. Were the head in such a case made to present, the irritation employed might throw the uterus into spasmodic action; or it might not act with any efficiency, and a tedious labour, ofthe worst and most dangerous kind, might be the consequence of this injudicious practice, whereby both parent and child might be lost. We should be careful, in all cases, not to rupture the membranes prematurely; and more effectually to preserve them entire, we must prevent exertion, or much motion, on * They also tried, by changing the posture ofthe patient, to alter the position of the child. Mr. Buchanan, of Hull, informs me, that he succeeded, in one instance lately, where "the left side ofthe breast ofthe foetus lay diagonally over the pelvis, with the head forward," in bringing the head right, by making the patient kneel and raise the breech, whilst the shoulders were brought as low as possible. The water had not been discharged. The situation of the head, when it came down, was made more favourable by the finger. The child was alive. t Mauriceau justly observes, that although, after much fatigue, (the water having run off,) the head can be brought to the os uteri, the woman may not have strength to finish the delivery.— In a case mentioned by Dr. Smeliie, the patient died of flooding.—Joerg still admits the propriety of bringing the head, when it is nearer than the feet, to the os uteri, or the foetus is so placed, that the feet cannot, without difficulty and danger, be brought down. 382 the part ofthe mother. As soon as the os uteri is soft, and easily dilatable, the hand should be introduced slowly into the vagina, the os uteri gently dilated, and the membranes ruptured. The hand is then to be immediately carried into the uterus, and, if we have decided on turning, upwards until the feet be found. Both65 feet are to be grasped betwixt our fingers, and brought down into the vagina, taking care that the toes be turned to the back ofthe mother. The remaining steps have been already described. This operation is not very painful to the mother; it is easily accomplished by the accoucheur, and it is not more hazardous to the child than an original presentation of the feet. But it is necessary, in order to render this assertion correct, that the operation be under- taken before the liquor amnii be evacuated ; and it is of importance to fix upon a proper time. We are not to attempt the introduction of the hand whilst the os uteri is hard and undilated; this is an axiom in practice ; on the other hand, we are not to delay until the os uteri be dilated so much, as to be apparently sufficient for the passage of a bulky body. In the cases now under consideration, the os uteri does not dilate so regularly, and to so great a degree, before the mem- branes break, as when the head presents. If we wait in this expectation, the membranes will give way before we be aware. If the os uteri be dilated to the size of half a crown, thin and lax, the delivery ought not to be delayed, for every pain endangers the rupture of the membranes. If they do give way, we are immediately to introduce the hand, and shall still find the operation easy, for the whole ofthe water is not discharged at once, nor does the uterus immediately embrace the child closely. If the liquor amnii have been discharged in considerable quantity previous to labour, or if the mem- branes have burst at the commencement of it, when the os uteri is firm and small, we must, by a recumbent posture, try still to preserve a portion of the waters, till the orifice will permit delivery. The introduction ofthe hand into the vagina and os uteri may be rendered easier, and less painful, by previously dipping it in oil or linseed tea, or any other lubri- cating substance. But if the water have been long evacuated, then the fibres of the uterus contract strongly on the child, the presentation is forced firmly down, and the whole body is compressed so much, that the circulation in the cord frequently is impeded, and, if the labour be protracted, the child may be killed. This is a very troublesome case, and requires great caution. 383 If the pains be frequent, and the contraction strong, then all attempts to introduce the hand, and turn the child, must not only produce great agony, but if obstinately persisted in, may tear the uterus from the vagina, or lacerate its cervix or body. After a delay of some hours, however, the uterus may be less violent in its action, but it is better at once to moderate it by art. Copious blood-letting, certainly, has a power in many cases of rendering turning easy, but it impairs the strength, and often retards the recovery. If the patient be restless and feverish, it may, to a certain extent, be necessary and proper; but if not, we shall generally succeed, by giving a powerful dose of tincture of opium, not less than sixty or eighty drops. Previous to this, the bladder is to be emptied, lest it should be ruptured during the operation; and, if necessary, a clyster is to be administered. The patient is then to be left, if possible, to rest. Sometimes in half an hour, but almost always within two hours after the anodyne has been taken, the pains become so far suspended, as to render the operation safe, and perhaps easy. But it must not be forgotten, that the effect of the opiate is merely to suspend the forcing pains, not to prevent the action of the uterus if it be excited. We must, therefore, speedily and steadily, but not hurriedly, take advantage of the uterus having ceased to press down strongly the presentation, and endeavour to slip the hand beyond it before strong action be again excited. Our first object being to get the hand into the uterus, we must raise up the shoulder a little, working the fingers past it, by cautious and steady efforts, quicker or slower, according to the degree of contraction and resistance. The cervix often contracts spasmodically round the presentation, and is the chief obstacle to the delivery, but the opiate generally allays this :* and we are not to be in too great a hurry to overcome this. We must wait the effect of the anodyne, and are never to use force or violence. I believe that slow efforts after the use of opium shall always prove successful. Our efforts generally renew the pains, which, although they may not prevent the operation, yet make it more painful, and cramp and benumb the hand. Having passed the hand beyond the cervix, we carry it on betwixt the body of the child and the surface of the uterus, which is felt hard and smooth, from the tonic or permanent action of the fibres, * The spasm may yield rather suddenly to the hand, as if rupture of the fibres had taken place. I was informed of one case of this kind, but the womb \^s entire, and no bad symptom came on. 384 until we reach the feet, both of which, if possible, we seize and bring down ; but if we cannot easily find both, one is to be brought down into the vagina, and retained there.66 The child will be born, with the other folded up on the belly. In bringing down the feet, as well as in carrying up the hand, we must not act during a pain, but should keep the hand flat on the child, for a contrary practice may lacerate the uterus. It is sometimes very difficult, even after the feet are found, to bring down the breech. This is the case when there is strong spasmodic contraction. Before introducing the hand, we must ascertain, by examining the presentation, which way the feet lie, that we may proceed directly to the proper place. We must also consider, whether we shall succeed best with the right or the left hand. If the right shoulder or arm present, some have made it a rule to deliver with the left hand, others with the right; but much must depend on the dexterity of the operator, and the position of the patient. The most common position is the same as in natural labour. Sometimes we may find it useful to make the patient lie forward on the side ofthe bed, with her feet on the ground, and to place ourselves behind her. Dr. Breen advises that we should bring down the knees rather than the feet, at the same time pushing up the presentation. If we should in any case, from spasm or other causes, find it very difficult to turn the child, we must consider how far it is practicable to make the head present, and use the forceps if spasm still prevent delivery. When the hand and arm have been protruded, and the shoulder forced down in the vagina, it has been the practice with many, before attempting to turn, to return the arm again within the uterus ; and when this was impracticable, it has been torn or cut off,67 especially if the child were supposed to be dead. Others advise, that we should not attempt to reduce the arm ; nay, even say, that in difficult cases we shall facilitate the operation, by bringing down the other arm, in order to change, to a certain degree, the position of the child. So far from it being necessary to replace the arm, we may sometimes find advantage from taking hold of it with one hand, whilst we introduce the other along it ; as the parts are thus a little stretched, and it serves as a director by which we slip into the uterus. By the means pointed out, and by a steady, patient conduct, we may, in almost every instance, succeed in delivering the child. But it must be acknowledged, that in sfJme cases, from neglect or mismanagement, the woman is 385 brought into great danger, or may even be allowed to die undelivered. This catastrophe proceeds sometimes from mere exhaustion, or from inflammation, but oftener, I apprehend, from rupture of the uterus; or in a neglected case, so much irritation may be given to the system, as well as to the parts concerned in parturition, that although the delivery be easily accomplished, the worn in does not recover, but dies, either from pulmonicor abdominal inflammation, or fever,or flooding. Moreover, such tedious cases generally end unfavourably for the child. When turning has not been practicable, if the child were supposed to be alive, the os uteri has been cut, or the Caesarean operation has been proposed and practised.* If dead, it has been extracted, by pulling down the breech with a crotchet ;t and sometimes, in order to assist delivery, the body has been mutilated ;f or the head opened with the perforator. It is in general sufficient to carry the finger between the perinaeum and the thorax to the abdomen, pierce it, and either by means of the finger or a hook fixed on the pelvis, it may be pulled down. This ought always to be done, when, on the one hand, the presentation cannot be raised to admit of turning ; and, on the other, there is no appearance ofthe process immediately to be described, under the name of spontaneous evolution, taking place. When the child has been small or premature, it has happened that the arm and shoulder have been forced out of the vagina, and then, by pulling the arm, the delivery has been accomplished.§ In other cases, the child has been expelled double. There have been many instances, where a spontaneous evolution or doubling of the child has taken place, and the breech has been expelled first. The action of the uterus is exerted in the direction of its long axis, and therefore tends to push its contents through the os uteri. The child forms an ellipse; and either in natural labour, or presentation of » Vide memoir by M. Baudelocque, in Recueil Period, tome V. table I. cases 5 and 12. t Pea, in one case where both arms were protruded, applied a fillet over the breech to brin<* it down. Pratique, p. 412.—Sm3llie, in 1722, brought down the breech with the crotchet. Col. 35. case 3.— Giifard did the same in 1725. Case 3. X Vide Perfect, vol. I. p. 351.—Dr. J. Hamilton's Cases, p. 104. He found it necessary to separate three of the vertebrae. — Dr. Clarke twisted off the arm, and perforated the thorax freely. At the end of 36 hours the foetus was expelled double. Med. and Phys. Jour. vol. VIII. p. 394. § Giffard, case 211; and Baudelocque, L'Art, § 1533, in a note.—In Mr. Gar. diner's case, the head followed the shoulders. Med. Comment, tom. V. p. 307, 3 A \ 386 the breech, the long axis of the ellipse corresponds to the long axis ofthe uterus. But, in a shoulder presentation, the axis of the ellipse lies obliquely with regard to that of the uterus, or to the direction of the force ; and therefore the continued action of the uterus may tend, by operating on the side ofthe ellipse, to depress the upper end, and force it gradually into the pelvis. Dr. J. Hamilton justly observes, that the evolution can only take place when the action ofthe uterus cannot be exerted on the presenting part, or where that part is so shaped that it cannot be wedged in the pelvis. It may also be added, as a requisite, that the uterus contract efficiently, and not spasmodically. This evolution was first of all noticed, I believe, by Schcenheider ;* but Dr. Denmant was the first who, in this country, called the attention of practitioners to it. He collected no less than thirty cases, but in these only one child was born alive. It does not appear that the child being large, is an obstacle to the delivery.! A diversity of opinion has prevailed as to the mode in which expulsion takes place. Dr. Denman supposed that the lower extremities descended during a pain, and made room for the upper, which ascended as the others came down, till, the body turning round on its axis, the breech was expelled, "as in an original presentation of that part." This was disputed by Dr. Douglas, who maintained that it was impossible for the upper extremities to mount up into the contracting uterus; that therefore no part of the child, which once protruded, ever receded ; and consequently, the process is not that of spontaneous turning, but that of expelling the child double. According to him, the shoulder is forced lower by strong pains; the clavicle lies under the arch of the pubis ; the ribs press out the perinaeum, and then appear at the orifice of the vagina. As the expulsion goes on, the clavicle is found on the pubis, and the acromion rises to the top ofthe vulva. Presently the arm, shoulder, and one side ofthe chest, are protruded, and the breech has got into the hollow of the sacrum. By farther efforts the breech and extremities are expelled, but neither the arm nor the shoulder ever retire. Dr. Cooeh gives the same account, in the 6th vol. ofthe Medical Transactions. * Acta Havn. tom. ii. art. xxiii. t Lond. Med. Jour. vol. V. p. 64.—See also case by Mr. Outnwait, in New Lond. Med. Jour. vol. II. p. 172.—Mr. Simmons, Med. Facts and Obs. vol. I, p, 76,—Perfect's cases, II. 367.—Med. and Phys. Journ. vol. III. p. 5,— Medico-Chirurgical Review, vol. I. 2d series. X Mr. Key's case, in Lond. Med. Journ. vol. V. p. 305, 387 Dr. Kelly agrees with Dr. Denman as to the existence of an actual revolution or turning ofthe child ; but differs from him in maintaining that the original presentation can only recede, not during the action ofthe uterus, but during its re- laxation. The breech, or upper end of the ellipse, he sup- poses, is pressed down by the action ofthe uterus ; and then, by the elasticity ofthe child, the shoulder, or presenting part, goes up the moment the uterus relaxes. After all that has been written on the subject, there appears no ground for doubting the explanation given by Dr. Douglas, and however extraordinary it may appear, it seems nevertheless true, that when the process once begins, that is to say, when the child is brought so low as to enable the breech to get into the hollow ofthe sacrum, it is soon accomplished. In one of Mr. Denman's cases, the third, he says, " the exertions ofthe mother were wonderfully strong: I sat down whilst she had two pains, by the latter of which, the child was doubled and the head expelled." This case merely establishes the rapidity with which the delivery may be accomplished; but as it partakes much of the obscurity of the oracles of old, it may be quoted both by Dr. Douglas and Dr. Kelly. When it is impossible from the strong action of the uterus, to .turn the child, we may have some hope of this evolution taking place, when the strong pains carry the shoulder so much downward and forward, as to bring the thorax fairly into the pelvis. When the breech has got into the hollow ofthe sacrum, and the perinaeum is by the trunk greatly distended, the process may be considered so near its completion as scarcely to be prevented by any injudicious effort. A knowledge of this fact does not exonerate us from making attempts to turn ; for although a considerable number of cases are recorded where it has taken place, yet these are few in proportion to the number of presentations ofthe shoulder. In this city, which contains more than 150,000 inhabitants, I cannot learn that more than one case of spontaneous evolu- tion has taken place, though some women have either died undelivered, or have not been delivered until it was too late to save them.63 I need therefore scarcely add, that the short remarks I have made on this subject are not derived from personal experience, but from consideration ofthe subject. Sometimes the arm presents along with the head, and this can only render delivery tedious or difficult, by encroaching on the dimensions of the pelvis. This case does not require 388 turning; but if we can, we should return the arm beyond the head ; if we cannot, we may succeed in bringing it to a place where it will not interfere much with the passage ofthe head. In a case most probably at first of this description, the arm had protruded as in an ordinary presentation of the upper extremity, and the shoulder had descended as low as the os externum. Mr. Wausbrcugh, carrying bis finger from the presentation along by the curve of the sacrum, felt the chin of the child, the face presenting within the pelvis, and the occiput reflected against the vertebrae of the child. Very strong pains had no effect in propelling the (hild; but delivery was effected by means of the long forceps.* Sometimes the head is placed pretty high, being retained by a spasmodic contraction of a band of fibres round it, and the arm is the only presentation vhich can be felt, until the hand be introduced. Opiates, in this case, may be of service. We must never attempt by force alone to destroy the stricture, in order either to return the arm or bring down the head. Occasionally both a hand and the feet have been found presenting with the head, or the feet and head present. In such cases, we can, if necessary, bring down the feet altogether, and this is in general proper. Besides these presentations, we may meet, with the back part ofthe neck, and the upper part of the shoulder ; or the nape of the neck alone; or the throat.69 These, which are very rare, require turning. They are recognised by their relation to the head and shoulders. ORDER FOURTH. The hips, back, belly, breast, or sides, may, though very rarely, present, the child lying more or less transversely.70 The hip is sometimes taken for the head,t but is to be distinguished by the shape and relations ofthe iliurn. In all the other cases, the presentation remains long high ; but when the finger can reach it, the precise part may be ascertained by one who is accustomed to feel the body of a child. If the child lie transversely, it may remain long in the same position, and the woman may die if it be not turned. But if, as is more frequently the case, it be placed more or less obliquely, then, if the pains continue effective and regular, either the breech or the shoulder will be brought to the os uteri, according as * Med. Repository, vol. XIII. p. 8. t La Motte was of opinion that no part resembled the head more than the hip Vide Obs. 283. and 284. 389 the original position favoured the descent of one or other end of the ellipse formed by the child. In these presentations the hand should be introduced, to find the feet, by which the child is to be delivered. But this rule is not absolute with regard to the presentation of the hip, which only renders labour tedious. ORDER FIFTH. The child may present the head, and yet it may be im- properly situated, an A give rise to painful and tedious labour. The uterus, even when a slight obstacle is opposed, as in some stages of those presentations, frequently does not, as it were, put forth its strength, but the pains remain trifling, and are felt by the patient to be inefficient. If the presentation be rectified the pains often become speedily effective ; if it be not, they are at last excited, but often not till after the lapse of several hours. 1st. The forehead, instead ofthe vertex, may be turned to the acetabulum.71 In this case, the presentation is felt in the first stage high up, smooth, and flatter than usual. In a little longer, we discover the anterior fontanelle, and the situation ofthe sutures. By degrees the head enters the cavity ofthe pelvis, the vertex being turned into the hollow of the sacrum ; and by continuance ofthe pains, the forehead either turns up within the pubis, and the vertex passes out over the perinaeum ; or the face gradually descends and the chin clears the arch of the pubis, the vertex turning up within the perinaeum towards the sacrum, till the face he born. The first is the usual process in this presentation ; all the steps ofthe labour are tedious, and often, for a considerable period, the pains seem to produce no effect whatever. In the last stage, the perinaeum is considerably distended, and it requires care and patience to prevent laceration. This presentation is difficult to be ascertained, at an early stage, before the membranes burst; and sometimes the duration of the labour is attributed to weakness ofthe uterine action, and not to the position of the head. If it be discovered early, it is certainly proper to rupture the membranes, and turn the vertex round; a proceed- ing which is easily accomplished, and which prevents much pain and fretfulness. If this opportunity be lost, we may still give assistance. Dr. Clarke says, that, in thirteen out of fourteen cases, he succeeded in turning round the vertex, by introducing either one or two fingers between the side ofthe head near the coronal suture, and the symphysis ofthe pubis, 390 and pressing steadily, during a pain, against the parietal bone.72 Ofthe advantage of this practice, I can speak from my own observation ; and I have, even when the head had descended so low as to have the nose on a line with the arch ofthe pubis, succeeded in turning the face round to the hollow of the sacrum with great promptitude, and with so much facility, that the patient did not know that 1 was doing more than making an ordinary examination. We should keep up the forehead during a pain, by means of two fingers introduced into the vagina, or press it up gently during the absence of pain, to make the vertex descend. It has been advised that we should, with the finger, depress the occiput, but this is more difficult to be done. The fontanelle, or crown of the head, may also present, although the face be turned to the sacro-iliac junction. In this case it is felt early, and, by tracing the coronal suture, we may ascertain whether the frontal bones lie before or behind. It is a more common presentation than that noticed above. The labour is, at first, a little slower than in a natural presentation, but, by degrees, the head becomes more oblique, the vertex descending; and this may be assisted, by supporting the forehead with the finger during a pain, or pressing it up during the remission, and preserving the ground we have gained, by steady support with the finger, when the uterus acts. This usually renders the pains efficient, although before, they had been teasing the patient rather ttan making any impression. Should any untoward accident require the delivery to be accelerated, we have been advised to turn the child, and in doing so, to use the left hand, if the occiput lie on the left acetabulum, and vice versa. But this operation can seldom be requisite. The crown of the head may also present with the face to the pubis or the sacrum, but these positions are extremely rare.73 In time, the head will generally become more diagonal, and descend obliquely, but we ought not to trust to this. We should rectify the position, for it is by no means difficult to move the head with the finger, if we attempt it early. We may even carry the forehead from the pubis to the sacro-iliac junction. The process is still more simple, when the occiput is turned to the pubis, if we perform it early. If, however, we neglect it, we find that in a few instances the head does not turn at all, but enters the pelvis in the original direction, where it soon stops,74 requiring the use of instruments. This is oftenestthe case, when the occiput is turned to the pubis; 391 for the forehead being broad, does not, by a continuance of labour, slip to the side of the promontory of the sacrum so readily as the occiput would do. 2d. The side of the head may present. In this case, the presentation is long of being felt, but it is recognised by the ear. If, however, it have been long pressed in the pelvis, it is extremely difficult to determine the case. It is very rare, and has even been deemed to be impossible. In some instances the child has been turned, but it is most common to rectify the position ofthe head, by introducing the hand. 3d. The occiput may present, the triangular part of the bone being felt at the os uteri. It is known by its shape, by the lambdoidal suture, and its vicinity to the neck. The forehead rests on the margin of one of ttie psoae muscles, and from this oblique position of the head, the labour is tedious. It has been proposed, in this case, to turn; but it is better, to rectify the position of the head with the hand, by raising the occiput a little. Nature is, however, adequate to the delivery, even if not assisted. Some advise, that the woman should, by a change of position, endeavour to remedy the obliquity, making the child incline, so as to affect the situation ofthe head, but this has not much power in altering the position of the presentation, at least after the water has been evacuated. 4th. The face may present with the chin to one of the acetabula, or to the sacro-iliac junction, or to the pubis, or sacrum. The first two are the best, the second is more troublesome, and the last is worst of all. When the face presents, the labour is generally tedious and painful, for it is little compressible, and affords a broad surface, not well calculated to take the proper turns in the pelvis. The head, also, being thrown back on the neck, a larger body must pass, than when the chin is placed on the breast. By a continue nee of the pains, the face becomes swelled; and although at first it was recognisable by the mouth and features, yet now it is indistinct, and has been taken either for a natural presentation or the breech. By rude treatment, the skin may be torn; and even under the best management, the face, when born, is very unseemly, and sometimes quite black and elongated, so that it has been known to measure nearly seven inches. Thii is especially the case when the chin is directed to the sacrum, and some children die from obstructed circulation, owing to the continued pressure on the jugular veins. 392 Face presentations have been attributed sometimes to con- vulsive vomiting, cough, or frequent examination, but gene- rally no evident cause can be assigned ; and in the beginning of labour, the face itself does not present, but only the forehead; hence La Motte tells us, that although at first he thought the head presented properly, yet, when the membranes broke, the face came down. Some have advised that the child should be turned; others that the chin should be raised up, to make the upper part of the face come down : or that if the head be advanced, a finger should be inserted into the mouth, to bring down the jaw under the pubis. Others leave the whole process to nature; but many endeavour with the hand to rectify the position. If the presentation be discovered early, there can be no doubt as to the propriety of rectifying the position, which will require the hand to be introduced, so as to grasp, or at least act effectually on the head, and place it right; but if the labour be advanced, this is difficult; and then it only remains that we should endeavour, if the labour be severe and tedious, to make the face descend obliquely, by cautiously but firmly supporting with a finger, during the pains, the chin, or end which is highest, in order to favour the descent of the lower end. When the chin has advanced so far as to come near the arch ofthe pubis, we may follow a different method, and gently depress it, which assists the delivery, for generally the chin is first evolved. If, however, the process goon regularly and tolerably easily, we need not make these attempts. As the perinaeum is much stretched, we must support it, and avoid all hurry in the exit of the head. When the chin is directed to the sacrum, the labour is often so tedious as to require the application of instruments. ORDER SIXTH. Sometimes the cord descends before, or along with the presenting part of the child. This has no influence on the process of delivery, but it may have a fatal effect on the child ; for, if the cord be strongly compressed, or compressed for a length of time, the child will die, as certainly as if respiration were interrupted after birth. If the cord be discovered presenting before the membranes burst, or if the os uteri be properly dilated when they burst, the best practice is to turn the child. It has indeed been proposed, to push the cord beyond the presenting part, or hook it upon one of the limbs; but, if the hand is to be introduced so far, it is 393 better at once to turn the child.* If the os uteri be not sufficiently relaxed, we must not use force to expand it; and little can be done except by rest, to prevent, as. much as possible, the evacuation ofthe water. As soon as the os uteri will admit the introduction of the hand, the child should be turned, if it can be easily done. But if the presentation be advanced before we are called, and turning be difficult, then we must endeavour to keep the cord slack, or remove it to that part ofthe pelvis where it is least apt to be compressed ; or it will be still better, to endeavour with two fingers to push the cord slowly past the head, and prevent it, for two or three pains, from coming down again.75 This is less violent, and safer, than attempts to turn in an advanced stage of labour. Should this not be practicable, and the pulsation suffer, or the circulation be endangered, we must accelerate labour by the forceps. If the pulsation be stopped, and the child dead, when we examine, then labour may be allowed to go on, without paying any attention to the cord. The sum of the practice then is, that when the os uteri is not dilated, so as to permit of turning, we must not attempt it: when turning is practicable, it is to be performed; when the head has descended into the pelvis, the cord is to be replaced, or secured as much as possible from pressure; but if the circulation be impeded, the woman must be encouraged to accelerate the labour by b.aring down, or instruments must be employed. When the presentation is preternatural, these directions are likewise to be attended to, and the practice is also to be regulated by the general rules applicable to such labours. ORDER SEVENTH. Various signs have been mentioned, whereby the presence of a plurality of children in utero might be discovered, previous to their delivery. These are, an unusual size, or an unequal distention of the abdomen, an uncommon motion within the uterus, a very slow labour, or a second discharge of liquor amnii during parturition. These signs, however, are so completely fallacious, that no reliance can be placed upon them, nor can we generally determine the existence of twins, until the first child be born. Then, by placing the * It has been proposed to push back the cord, and tben retain it with a sponge, and the instrument-mongers have invented and depicted contrivances for this purpose. Some have even advised that the cord should be tied ! why not also cut ? Osiander, not certainly a theorist, proposes to lodge the cord in the midst of a sponge, and replace it; why not—if it can bs done ? 3B 394 hand on the abdomen, the uterus is felt large,* if it contain another child; and, by examination per vaginam, the second set of membranes, or some part of the child, is found to present. This mode of inquiry is proper after every delivery. Soon after the first child is born, pains usually come on like those which throw off the placenta, but more severe; and they have not the effect of expelling it, for it is generally retained till after the delivery of the second child. No intimation of the existence of another child is to be given to the mother, but the practitioner is quietly to make his examination, rupture the membranes, if they have not given way, and ascertain the presentation. If it be such as require no alteration, he is to allow the labour to proceed according to the rules of art, and usually the expulsion is very speedily accomplished. If the first child present the head, the second generally presents the breech or feet, and vice versa; but sometimes the first presents the arm, and, in that case, when we turn, we must be careful that the feet of the same child be brought down. This one being delivered, the hand is to be again introduced, to search for the feet of the second child, which are to be brought into the vagina, but the delivery is not to be hurried. It sometimes happens, that after the first child is born, the pains become suspended, and the second is not born for several hours. Now this is an unpleasant state, both for the patient and practitioner. She must discover that therein some- thing unusual about her; he must be conscious that hemor- rhage, or some other dangerous symptom, may supervene. The first rule to be observed is, that the accoucheur is apon no account to leave his patient till she be delivered. The second regards the time for delivering. Some have advised that the case be entirely left to the efforts of nature,t whilst others recommend a speedy delivery. The safest practice, if the head present, lies between the two opinions. If eflective pains do not come on in a quarter of an hour, the uterine contraction should be excited by gently rubbing the abdominal tumor with the hand. If this do not soon excite the pains, * In a case related by Mr. Aiken, the uterus was felt, after delivery, large and hard, as if it conlcinrd another child, lut none was dissevered. In the course of a fortnight the tumour gradually disappeared. Med. Comment vol II. p. 300. + A case is mentioned in the Bulletin de la Faculty for 1818, p. 6. where a second child was born by aid ofthe forceps after the interval of more than a day. Were the forceps necessary in the first delivery ? On what principle can we justify such a delay ? 395 the child ought to be delivered by turning. The forceps can seldom be required; for if the head have come so low as to admit of their application, the delivery most likely shall be accomplished without assistance. If the second child present in such away, as that the feet are near the os uteri, as for instance, the breech, or any part ofthe lower extremities, then the feet are cautiously, but without delay, to be brought down to the vagina, and the expulsion afterwards left, if nothing forbid it, to nature. If, however, the position of the second child he such as to require turning, we are to lose no time, but introduce the hand for that purpose, before the liquor amnii be evacuated, or the uterus begin to act strongly on the child. Turning, in such circumstances, is generally easy. In the event of haemorrhage, convulsions, or other danger- ous symptoms, supervening between the birth ofthe first and second child, the delivery must be accelerated, whatever be the presentation, and managed upon general principles. When there are more children than two, the woman seldom goes to the full time, and the children survive only a short time. There is nothing peculiar in the management of such labours. It still remains to be observed, that we ought to be peculiarly careful in conducting the expulsion ofthe placentae of twins. Owing to the distention ofthe uterus, and its continued action in expelling two children, there is a greater than usual risk of uterine haemorrhage taking place. The patient must be kept very quiet and cool, moderate pressure should be made with the hand externally on the womb, or gentle friction may be employed, and no forcible attempts are to be permitted, for the extraction of the placentae, by pulling the cords. If haemorrhage come on, then the hand is to be introduced to excite the uterine action, and the two placentae are to be extracted together. The application ofthe bandage, and other subsequent arrangements, must be conducted with caution, lest haemorrhage be excited. The placentae are often connected, and therefore they are naturally expelled together, but this adds nothing to the difficulty of the process. Sometimes they are separate, and theoueis thrown off before the other, or it may even happen, that the placenta of the first child is expelled before the second child be born, but this is very rare, and is not desirable. Women, who have borne a plurality of children, are more disposed than others to puerperal diseases, and must there- 396 fore be carefully watched. It rarely happens, that they are able to nurse both children without injury. It has happened that when the first child presented the feet, and was so far delivered, the head of the second child got down into the pubis before that ofthe first, which remained above it, and could not be extracted without great difficulty. There can be no hope of the child being born alive in this case, and as little expectation of our being able to push up the head ofthe second child. It has, therefore, been proposed to sever the body of the protruded child, which would permit the delivery, either by nature or the use of the forceps, of the second child, after which the head which had been severed could be extracted. If this be not adopted, still the patient may not die undelivered. Mr. Allan, who has proposed the plan just advised, has published a case, where both heads were expelled at once by a powerful pain.* It is possible for two children to adhere, or for one child to have some additional organ belonging to a second, as, for example, an arm or a head. Such cases of monstrosity may produce a considerable difficulty in the delivery; and the general principle of conduct must be, that when the impediment is very great, and does not yield to such force as can be safely exerted, by pulling that part which is protruded, a separation must be made, generally of that part which is protruded, and the child afterwards turned, if necessary.t Unless the pelvis be greatly deformed, it will be practicable to deliver, even a double child, by means of perforation ofthe cavities, or such separation as may be expedient, and the use of the hand, forceps, or crotchet, according to circumstances. A great decree of deformity may render the Caesarean operation necessary. * Vide Med. and Phys. Journ. for February, 1824. + In the seventh volume of the Nouv. Journal, p. 164, is a case where two children were born at the full time, united by the inferior part of the belly, from the centre of which came the cord. The vertebral columns almost touched at the lower part. The two children, who were of different sexes, lived, we are told twelve days, but nothing is said ofthe labour. In the Bulletins for 1818, p. 2, two children, who were joined by the back at the sacrum, are stated to have been born, and lived till the ninth day. The first child presented the head, but the midwife could not well tell how the second got out. There is another case at page 32, of a woman who, after many days' labour, bore a monster double in the upper parts. The spinal column was united from the sacrum to the top of the dorsal vertebrae, there the cervical vertebras divided to form two necks. The midwife, finding the head to present along with the cord and a hand, tried to turn, but could discover nothing but superior extremities. She therefore let her alone. The head was afterwards expelled, but neither nature nor art could deliver the body. M. Ratel, finding the head and two arms already almost sepa- rated from the body, cut these parts off, then introducing his hand, he found an" other head, turned the child, and brought away the whole mass. 397 With respect to children who are monstrous from deficiency of parts, I may take the present opportunity of observing, that no difficulty can arise, during the delivery, except in ascer- taining the presentation, if the malformation be to a great ex- tent, as, for instance, in acephalous children. CHAP. V. Of Tedious Labour. ORDER FIRST. If the expulsive force of the uterus be diminished, or the resistance to the passage of the child be increased, the labour must be protracted beyond the usual time, or a more than ordinary degree of pain must be endured. Tedious labour may occur under three different circum- stances : First. The pains may be from the beginning wreak 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 ofthe 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. It is farther necessary for me to premise, that the same patient, in different labours, shall be delivered with varying celerity and ease, although the size ofthe children be the same. The protraction, therefore, cannot depend on purely mecha- nical causes, but is rather to be attributed to resistance afforded by the soft parts, as living organs, and the state of action of the uterine fibres. The delivery of the child depends on contraction of the uterus, and relaxation of its orifice, and that ofthe vagina and muscles connected with the perinaeum ; and these two processes are not only influenced by, but are also generally proportionate to each other. Easy and speedy relaxation is productive of rapid and great contraction, which is not to be measured or determined by the degree of pain or 398 sensation, but by its efficiency. Powerful contraction of the uterus, is attended with proportionally rapid relaxation ofthe opposing soft parts, or at least ofthe os uteri ; and if the latter state do not take place, the former cannot easily exist. When mechanical assistance does stimulate to more frequent and violent action.it is often more in appearance than reality, at least so far as the uterus is concerned. The sensation may be greater, but the actual effort made by the uterus, is not always so great as the sensation would imply. The abdo- minal muscles act more powerfully, and doubtless the uterus itself is at last roused or excited to strong action, when the resistance is continued, as, for instance, by a contracted pelvis, or bad position ofthe child. The patient says, she feels as if she would burst; and in some cases the uterus is actually ruptured, but in many more, inflammation is excited by the efforts; nevertheless, even in this kind of resistance, which does not depend on the os uteri, it is usual for the action of the uterus at first to be impeded ; the primary stage of labour is slow, and the pains inefficient. But this is more lemarkably the case, when the resistance is seated in the os uteri ; for then, although the pains may be frequent, they are long of becoming powerful. Then the abdominal muscles co-operate strongly and press down the uterus, along with the head, into the pelvis. This is particularly illustrated by cases of morbid contraction, or obliteration ofthe os uteri. Various cruises may protract labour; and although I have thought it right to divide tedious labour into two orders ; yet, in point of fact, the causes sometimes operate in such a way, as to make the case a mixed one, referable partly to both divisions. They may be arranged under the following heads: First, feeble or sluggish and languid action of the uterus. Second, partial or spasmodic action of the uterus. Third, restrained action, the energy of the uterus bring prevented from being put forth by some other cause. Fourth, an unusual obstacle to the issue of the child. These states or causes may be excited by circumstances in many respects differing from one another, and which, at first view, we would not suppose to act on one principle. The most important of these, we must presently consider separately. When again we come to view the means which we possess of counteracting these causes, and accelerating labour, in order that we may choose the one best adapted to the case, we find that they may be referred to the following: First, diminishing resistance, or promoting relaxa- tion, which increases contraction. Under this head may be 399 included blood-letting, gently dilating the os uteri, rupturing the membranes, improving the position of the presentation. Second, exciting the action of the uterus by stimulating its fibres, directly or by sympathy. Under this head may be included, the effect of cordials prudently given, heat, gentle exercise, clysters, spontaneous vomiting. Friction has also often a good effe :t in exciting the action of the uterus after its mouth is dilated, or nearly so. It is best employed by placing the flat hand over the region of the fundus uteri, and making the abdominal parietes move backward and forward over the uterus. The hand is not moved so as to rub the skin, but is kept steadily on the same part, so as to carry the skin along with it in its motions. This is only to be done during the existence of a pain, when the uterus is felt to become hard, and different parts of it, particularly those which feel softest, may be successively acted upon. It has often a decided effect in rendering the pains more uniform and efficient; but, as it also increases the sensation of pain, it is apt to be objected to. If it be to prove beneficial, it does so soon. Third, suspending weak and useless, or wearing-out, action, by a suitable anodyne, in order that the energy ofthe womb and of the system may recruit by rest. Fourth, removing partial or spasmodic action by a full dose of opium. Fifth, diminishing high excitement of the nervous and vascular system, marked by heat of skin, frequency and throbbing of the pulse, confusion of the head or delirium, by the timely use ofthe lancet, cool air and tranquillity. Sixth, allaying general irritation ofthe system, which is interfering with the individual action ofthe uterus, by a small or moderate dose of laudanum, and thus concentrating the action in the uterus : premising venesection, if the state of the vascular system indicate this. Laudanum in this case seems to have the effect of a stimulant on the uterine fibres. The ergot, or secale cornutum,76 has been recommended nearly half a century ago for this purpose, and lately its use has been revived by Dr. Dewees, in cases of tedious labour, arising from deficient pains. It is given in the dose of a scruple of the powder, every quarter of an hour. And he says that it is seldom necessary to give more than three doses. Sometimes half a drachm is given at once, or, two drachms may be infused in a breakfast cupful of boiling water for at least ten minutes. The infusion, which is of a red or pink colour, and has a strong peculiar smell, is to be drank by the patient, and may be repeated if necessary in half an hour. We are cautioned, 400 however, not to use this medicine, until the water have been discharged, and the os uteri completely dilated. Under these circumstances it is expected speedily to increase the pains and finish the delivery ; but if given earlier, we are told that the child is destroyed. That this remedy is fully to be depended upon can hardly be admitted—otherwise it would not have fallen for so many years into neglect; but that it has occasionally a decided effect in accelerating the delivery, I am well satisfied of, by the trials made by my friends and myself of this substance, which some years ago was kindly furnished to me by Dr. Dewees, and is now abundantly supplied in this country. So far as my experience goes, it produces a feeling of increased heat, but the pulse becomes rather slower than quicker; whilst tie pains, when any effect is produced upon them, become rapidly more severe and effective. If the dose be too large, sickness and vomiting are produced.* Chemical analysis has detected morphium in the ergot, but whether its effects upon labour are to be attributed to this or some other principle, remains yet to be decided. In favour of its effects depending upon morphium, it may be remarked, that the same benefit is frequently derived under similar circumstances from the administration of laudanum, 30 drops of which may be given with the effect of exciting the pains, when they have for a time been weak or inefficient. Experiments have been made on rabbits with ergot, and it was found that death was produced by injecting its infusion into the veins. An imme- diate effect was paralysis ofthe posterior extremities. It has been observed that children born after the exhibition of ergot very often are dead, and in that case are blanched and bloodless. This has been attributed to the strong action of the uterus, but we find this action equally strong in other cases without the production of this effect. It has also been supposed to proceed from the separation ofthe placenta before the birth ofthe child; but this evidently must be conjectural. I would rather attribute it to the specific effect produced on the uterus itself, which has an influence on the ovum, but fortunately this effect on the child is by no means invariable, though I must acknowledge it is frequent. Sixth, removing undue action from other parts which are acting in place of * Desgranges remarks that it often causes vomiting, and this aids farther the labour; but he does not attribute its effect to this. It is active in proportion to the minuteness of the powder and its recency. It fatigues those of a delicate and nervous constitution, but produces no effect on labour if given before the o» uteri be dilated four or five lines. Nouv. Journ. tom. I. p. 54. 401 ihe uterus, and checking or subducting its action, on the principle of the sympathy of equilibrium, which I have alluded to in page 323, and more fully explained in another work. Seventh, if none of these are applicable or effectual. then it only remains to employ artificial or instrumental aid. Having made these general remarks, I now proceed to consider particular states. The first to be noticed is that dependant on a weak or inefficient action of the uterine fibres. This may be occasioned by general debility, or inactivity, but more frequently it proceeds from the state ofthe 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 labour 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, however, it proceed from general debility, we often find, that if the first stage be tedious, the powers are thereby so exhausted, that the second can with difficulty be accomplished. Hence, although consumptive patients often have a rapid delivery, yet if the first stage be slow, the head frequently cannot be expelled without assistance. It is not always easy to say what the cause of this slow action of the uterus is. Sometimes it proceeds from contraction com mencing rather prematurely ; or from the membranes breaking very early, and the water oozing slowly away; or from some other organ becoming too active; 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 combined with a dull leucophlegmatic habit, or with a consti- tution disposed to obesity ; or from general weakness of the system. In a state of suffering and anxiety, the mind is apt to exaggerate every evil, to foresee imaginary dangers, to become peevish or desponding, and to press with injudicious impa- tience for assistance, which cannot safely be granted. Great forbearance, care, and judgment, then, are required on the part of the practitioner ; who, whilst he treats his patient with 3 C 402 that gentleness and compassionate encouragement, which humanity and refinement of manners will dictate, is steadily to do his duty, being neither swayed by her fears and entreaties, nor by a selfish regard to the saving of his own time. Some women seem constitutionally to have a lingering labour, being always slow. In such cases, unless the process be considerably protracted, or attended with circumstances requiring our interference, it is neither useful nor proper to do more than encourage the patient, and preserve her strength. A variety of means were at one time employed for exciting the action of the uterus, such as forcible dilatation of the os uteri, and the use of emetics, purgatives, or stimulants. A very different practice now happily obtains ; the patient is kept cool, tranquil, and permitted to repose : the mildest drink is allowed ; all fatiguing efforts are prohibited ; and she is encouraged by the mental stimuli of cheerfulness and hope, rather than by wine and cordials. But, whilst in cases where labour is only a little protracted, and the cause not very well marked, 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 uterine 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 ofthe skin, full pulse, with thirst and restlessness, perhaps starting or delirium. If so, and especially if the os uteri be not relaxed, venesection will be of great benefit, by making the uterus act with more freedom, and its mouth yield with great readiness. We know that in most cases of uterine haemorrhage, the os uteri, even where there is no effective labour, and scarcely any pain, is not merely dilatable, but is partially 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 before labour commences, and pains do not come on till the loss of blood excite them. We learn, however from this example, the influence of haemorrhage in relaxing the os uteri, and if we can do this without impairing the 403 power of the womb, we have certainly a powerful mean of accelerating labour ; venesection does this in certain cases. In cases where the parts through which the child must pass are rigid or dry, or hot and tender, or where the pains are great, but irregular and inefficient, or the membranes have given way prematurely, the pains sharp, but abortive, and the os uteri thick or hard, or the patient is feverish, blood- letting is safe, and may be expected to do good. That it is safe, we know from the experience of former ages and other countries, as well as from our own observation in cases of convulsions, where a great quantity of blood is taken away with present advantage and future impunity. It is, however, a remedy, which if imprudently employed may do much mischief. In cases of exhaustion, for instance, it must be dangerous ; or where the resistance is afforded by a contracted pelvis, all other circumstances being right; and in every constitution, and under every circumstance in which it would, independent of labour, be improper to evacuate, it is evident that it will be hurtful, unless we can thereby save the patient prolonged exertion and exhaustion. In natural labour, it is neither necessary nor proper ; in labour not greatly protracted, nor unusually severe and slow in its steps, it is not to be resorted to. It is better to trust, in these cases, to the use of clysters, to gentle motion and change of posture, or to sleep, if it offer naturally, and the patient require to be recruited. The effect of venesection in shortening the process of labour, and in rendering the pains in many cases brisker, is to be explained by its power in relaxing the parts, and diminishing the resistance afforded. It is a fact not sufficiently attended to, that in many cases a very moderate resistance, which we should think the uterus might easily overcome, does retard the expulsive process, and render the pains irregular or inefficient. Thus, I know from experience, that the membranes may be so tough as not readily to give way, and in this case the pains do become less effective, and the labour is protracted till they be opened. Whenever the resistance is removed, the pains become brisk and forcing. In the same way, relaxing the os uteri by blood-letting excites the uterine fibres to brisker action. This is the direct effect of venesection, but it also insures safety, and subsequently accelerates delivery, when it removes an existing febrile state, or one of general excitement, which is interfering with the due performance of uterine action. Further, it cannot be disputed that the uterus must be influenced bv the state of its nerves; and I 404 beg it to be remembered, that there maybe a condition of those nerves, removable by venesection, which, although referrible to excitement, does retard instead of producing muscular contraction. The nerves, or division of nerves destined for sensation, are more affected than those on which the proper function of uterine contraction depends. If the patient be fatigued or debilitated, and the pulse weaker than in lingering labour, we shall derive advantage from the use of a smart clyster, followed by thirty drops of laudanum, or a proportional quantity in an injection. This does not suspend the pains, but rather excites them. A similar stimulus is sometimes given by a gentle purge, but this is more slow and uncertain in its effects. When there is a strong tendency in the pains to remit, or keep off, we are to follow pretty nearly the same conduct with regard to venesection, in the circumstances which I have pointed out, as admitting of it; but it is much more rarely required in those cases, than where the pains are more frequent. 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 laudanum, 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 remiss, 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 woman. 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. We must take care that we do not delay delivery too long, or trust too much to nature. Premature, but spontaneous breaking of the membranes, and discharge of part of the liquor amnii, often has no effect in retarding labour, but in some cases it does so, by occasioning spasmodic action of the uterus, or irregular and inefficient pains ; in others, a little water passes between the head of the child and the os uteri during every pain, and the effect is rather to press out gradually the water, than to open the oa 405 Uteri, which is seldom effectually acted on, till the whole, or almost the whole water have been evacuated, so as to allow the head to be pressed on the orifice, and the uterine fibres to act on that orifice over the presenting part. In a natural state, the bag remains entire, until the os uteri have been considerably opened, and every pain gently dilates it, both by the uterus acting on the orifice, and also by the membranes when pushed out, doing naturally, what is effected in some cases artificially by the finger, that is, mechanically dilating the mouth. The pressure of the membranes also excites active pains. When the presentation is preternatural, the os Uteri is longer of opening than when the head presents ; the membranes do not protrude so broadly, nor does the presen- tation act so well on the os uteri, or excite it so effectually. Whilst rupture ofthe membranes, then, may, in some cases, prove a useful stimulus, in others, whec it is without judgment or necessity resorted to, it must be prejudicial. If the water be discharged very early in labour, or before the pains come on, the process is often lingering, but is not always so. The os uteri is, when we first examine, projecting, then it becomes flat, but the lips thick ; then they become thinner and more dilated, and presently very thin; and the lower part of the uterus is perhaps applied so closely to the head, that at first it might be taken for the head itself. In favourable cases these changes may take place quickly, but they may also be very slow, and the labour tedious, the pains 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 uneasiness in the back, lasting for nearly a minute after the pain; indicating in general the existence of spasmodic action. 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 ofthe water; for, whenever this is accomplished, naturally or artificially, the action becomes much stronger. It is also useful to detract blood, if the os uteri be rigid, the parts not disposed to yield, and the pains very severe. It is peculiarly proper when the woman has 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 40G action of the uterine fibres more efficiently towards the os uteri, which sometimes thus clears the head ofthe child very quickly, and the pains, which formerly were severe, but, in the language of the patient, 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 foundation of inflammatory affections afterwards. On no account are we either to use force, or even to continue for a length of time such more gentle endeavours as shall irritate or tease the os uteri. When the pains are irregular, and are succeeded by aching ofthe back, if the state of the os uteri do not indicate venesection,, a full dose of laudanum, not less than forty drops, may be given with advantage. In the case I have just considered, I have spoken of the effects of dilating the os uteri, but I do not mean to say, that the practice is useful in such a case alone; for, in most cases of tedious labour, it is beneficial, and, as the subject is important, I shall explain my sentiments on it fully. Forcible and irritating dilatation of the os uteri, even when it is not productive of dangerous consequences, is vr^t to occasion irregular or spasmodic action ofthe uterus. Two circumstances are necessary to render it safe : the os uteri must be lax, dilatable, and generally speaking, the edges must be thin ; and the dilatation must be gradually and gently effected duringthe continuance of a natural pain. If attempted in the absence of pain, and especially if attempted so as to give pain, it is apt to excite partial or spasmodic action, and, under any circumstance, violent or forcible dilatation, besides injuring the uterine action, may lay the foundation of future disease. It is done best by pressing on the anterior edge of the os uteri, during a pain, with two fingers, with such moderate force as shall not give additional pain, and shall appear to excite the natural dilatation as much as to produce mechanical opening. By doing this for several pains in succession, or occasionally during a pain, at intervals, according to the effect produced and the disposition to yield, we shall soon have the os uteri completely dilated. This is an old principle, but it was rashly practised, and too universally adopted, which made it meet with just reprobation, and some, knowing this, may be surprised at meeting with such an advice in modern times. Let not the principle suffer from its abuse, else where is the plan which could stand its ground f It is perfectly clear, that 407 when the process is going on well, interference is improper, but it is no less evident, that if a long time is to be spent in accomplishing the first stage of labour, or dilatation ofthe os uteri, the vigour of the uterus and strength of the patient may be impaired so much as to render the subsequent stage dangerously tedious, or to prevent its completion, at least consistently with safety ; the first stage of labour ought always to be accomplished within a certain time, varying somewhat according to the constitution ofthe patient, and the degree of pain. It is an undeniable proposition, that there is in every case a period beyond which it cannot be protracted without exhaustion; and it is no less certain, that if we wish to avoid this exhaustion, which may be followed by pernicious effects, we have only the choice of either suspending the action altogether for a time, or of endeavouring to render it more efficient, and of effecting the desired object within a safe period. The first is sometimes adopted, but is not always practicable, nor is it always prudent to counteract uterine action by strong opiates. The second is safer, and one ofthe means of doing so is that under consideration. If the pains be continuing without suspension, or an interval of some hours, and the labour be going on all the time, but slowly, it is a good general rule to effect the dilatation of the os uteri within ten or twelve hours, at the farthest, from the commencement of regular labour. This is done, if the os uteri be flat and applied to the head, by the method above described. If it be somewhat projecting, it is aided by introducing two fingers, and extending them laterally with gentleness, during a pain. The dilatation is easily and safely effected, if the case be proper for it; if not, bleeding or an opiate, if the former be not indicated, will soon bring about a favourable state. Ofthe benefit and perfect safety of this practice I can speak positively, and am happy to strengthen my position by the authority of Dr. Hamilton, who makes it a rule, to have the first stage of labour finished within a given time. I need scarcely, however, add, that, in enforcing this rule of conduct, it should be recollected that, to render it proper, the pains must be continuing so often and so decidedly, that the patient can be said to be in actual labour all the time. There are many cases where pains, at first regular, have gone off for many hours, or where they have come occasionally in a dull slight way, for a couple of days, but they have given little inconvenience, have scarcely interrupted sleep, and had little effect on the os uteri. They are more of the nature of false pains ; the patient 408 can hardly be said to be in labour, and is in no respect fatigued. If interference be proper in such cases, it is by other means, by opiates, by enemata, or remedies and applica- tions evidently pointed out by the nature of the pains which have formerly been considered. If, again, in lingering labour, the membranes be entire, the os uteri soft, lax, and considerably dilated, and the presenta- tion natural, it is allowable and beneficial to rupture the membranes; and this is more especially proper, if the uterus be unusually distended. The evacuation of the water is succeeded by more powerful action, a circumstance which, whilst it points out the advantage of the practice in the case under consideration, forbids its employment in natural labour, where the process is going on with a regularity and expedition, consistent with the view s of nature, and the safety ofthe woman. I have also already pointed out the injurious effects which frequently follow premature evacuation of the water; but under the circumstances at present enumerated, the rupture of the membranes is beneficial. Taking away, at a favourable time, the resistance afforded, tends to excite efficiently the action of the uterus, and promotes labour. If the os uteri be Jax,and especially if its edges be thin and soft, and the orifice considerably dilated, the same effects may be produced on it by this practice, that would follow, in cases of greater rigidity, from venesection; for both excite labour by diminishing resistance. The more that the os uteri is dilated beyond the size of half-a-crown, the more beneficial, ceteris paribus, will the practice be; on the other hand, when the os uteri is firm and little dilated, and the other soft parts rigid, this practice, so far from being useful, is hurtful and dangerous. An erect posture is another mean which operates in part on the same principle, for it calls in the aid of gravity, adding the pressure of the child to the action of the uterus. The water is allowed to run freely out. and the continued applica- tion of the presentation to the dilating os uteri, excites action. The child must be more easily propelled, surely, if it be in such a situation as to allow it to fall out by its own weight, were it not prevented by the soft parts, than if it rested on a horizontal surface, and required to be moved along that, by muscular effort, as is the case in a recumbent posture. The difference of facility, then, becomes truly a stimulus. Besides the muscular motion, or walking, which is employed in an erect position, does good, either by exciting the womb directly, or by removing sympathetic pains in the muscles. 409 Sometimes, after the first stage has advanced, and the o§ uteri is nearly dilated, the second does not commence for some hours; but the first kind of pains continue in different degrees of severity, without producing any perceptible effect. If no particular cause require our interference, it is best to trust to time ; but, if there be no change soon, labour may be accele- rated by rupturing the membranes, or, if they have already broken, we may place two fingers on the margin of the os uteri, which is next the pubis, and gently assist it, during the pains^A slip over the head. WhWa woman is greatly reduced in strength, previous to labour, that process is looked forward to with apprehension. 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 haemorrhage do not take place after delivery, or that it be promptly 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 comes 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 misshapen, there is only a swelling of the scalp, the finger can be passed round the head, and two or three strong pains might expel it. The propriety of employing the forceps in such cases, will soon be considered. An inefficient state of uterine action may be produced, by some other part acting too much, or being in a state of irrita- tion ; and so long as that continues, the womb Cannot be expected to contract briskly. Such a state is often produced by changes in the action or condition of the origins of the nerves supplying the uterus, caused by the particular action of their extremities, and thus nerves arising near the same place, or otherwise connected with them, though going to very different organs, or distributed more universally, come to be affected, and the remote actions thereby excited, may have a powerful and injurious effect on the uterine action. Do we not sometimes even find convulsions produced by the accession of a labour pain, and these again carrying off the pain almost as soon as it begins? We ascertain this state by examining the sensations and state of the patient. If the stomach be irritated, she is sick and oppressed, and probably desponding, 3D 410 and sometimes, almost at every pain, has an inclination to vomit. This is often the effect ofthe connexion between the nerves of the os uteri and stomach, and in that case is always increased by an examination, or the slightest irritation ofthe os uteri. The treatment must depend somewhat on a know- ledge ofthe habitudes of the patient, with regard to certain medicines. If opium agree with her, a moderate dose alone, or with some aromatic, is useful ; a little spirit of lavender, or a glassful of hot water, or a little hartshorn, may be employed, or the epigastric region rubbed with some siMmilant embrocation, but in general it is best to do very Irwle, and trust to time. Vomiting, without distressing sickness, and not dependant on exhaustion, but occurring early in labour, often excites rather than retards the action. In other cases, the bowels suffer, and, in these, twenty drops of laudanum generally give relief. A distended bladder also is a cause of protracted labour. In other cases, the muscles of the back or belly become painfully affected, producing what Daventer called "wild and wandering pains," or that state in which the pains no sooner seem to come on than they "are changed into a colic or a cramp, and an impotency of labour." In such cases he forbade forcing medicines, and advised anodynes. This advice is a good one ; and, in all these cases, twenty-five drops of laudanum will be useful, at the same time that the pained part be rubbed with the hand, or an embrocation. In cases of muscular pain, walking or change of posture often gives relief; when there is no particular organ or part affected, but only a general irritation, attended with teazing, inefficient pains, the same remedy is often of service, and the energy is directed presently to the uterus. In all these kinds of cases, it is also useful, in general, to endeavour to excite the uterus itself by a warm saline enema, or by some of the other means already or still to be mentioned, or by rubbing the uterine region itself, in the manner I have described. Mr. Power, who has insisted more than any other writer on metastasis of action, and on the utility of friction in exciting uterine action, effects it by drawing the fingers and thumb rapidly together over the uterus, so as to make a brisk friction on the part; but this is more uncomfortable and less efficient than the plan I have proposed of moving the abdominal parietes over the uterus. That general agitation ofthe muscular system known under the name of rigor, which often attends the first, stage of labour, if carried too far, or continued too long, may also retard delivery, but, in general, it goes off spontaneously, and 411 the action concentrates more powerfully in the uterus. Hence, it is a practical remark, that these rigors often are followed by a brisk labour. This effect, and consequently the propriety of interfering, must depend on their prolongation, and on their influence in carrying off the uterine pain. When we require to interpose, the practice consists in blood-letting, the use of opiates, or administration of a clyster, according as the vascular or nervous system, or bowels, seem to be principally concerned. Sometimes friction on the uterus during a pain seems to concentrate the action. 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 process 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 introduced. It is not necessary that the practitioner remain constantly 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 firmness and judgment. The second general cause of tedious labour is irregular action of the uterine fibres. After the child is born, the uterus sometimes contracts like a sand-glass, and retains the placenta. The same spasmodic action may occur before the child be expelled, and it usually affects the circular fibre of the cervix. Many causes, and some of them obscure, may excite spasm; it is apt to take place when the membranes have given way prematurely, and before the os uteri be in a relaxed state, or have begun to dilate. Improper irritation of the os uteri often excites it, especially attempts to dilate it in absence of a pain, or hurriedly during one. Letting out the water, when the uterus is not contracting, and where there is no pain at the time, may also cause it, probably by allowing the lower part of the uterus to collapse suddenly around the head or presentation. Preternatural distention of the womb may also produce it, even previous to the discharge of the water. Irritation ofthe bowels, and mental anxiety, may also be causes of spasmodic action. It is marked by pain coming or increasing at intervals, like proper pains, but it has little effect on the os uteri, or in forcing down the child; nay, the os uteri sometimes seems even to contract 412 during a pain. If there be any bearing down,the pressure is only momentary. The pain does not go entirely off as in natural labour; but the patient complains of constant uneasi- ness in the back, or some part of the belly, but usually in the former. The paroxysm of pain is generally described by the patient as affecting some part of the belly, particularly the lower part corresponding to the cervix uteri. The contraction does not go off with the pain, it only lessens; hence the band of fibres still compresses the child, or ovum, and, if the membranes have not broken, they are often kept so tense, as at first to resemble a part of the child, and may mislead the practitioner with respect to the presentation. There is often a frequent desire to void urine,—the spirits are generally depressed, and very often there is a feeling of sinking or sickness, and oppression of stomach,from the nervous sympathy between the nerves of the stomach, and those of the cervix uteri. If this spasmodic affection be slight, it may soon go off; but if strong, it sometimes continues for many hours. A smart clyster is often of great service. Blood letting sometimes does good, but I prefer opening the membranes if the presentation be good, and the os uteri lax ; this I have found very successful. If, on the contrary, the os uteri be rigid or undilated, and especially if the 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. In such cases, and even when the state of the os uteri has warranted the rupture of the membranes, but the expected benefit has not accrued, we may derive advantage from giving a large dose of laudanum; for in this spasm, like tetanus, it may be taken in great doses. Even ten grains of opium have been given, but in general sixty drops of laudanum are sufficient, and when it remains on the stomach, is, from its more speedy effect, preferable to solid opium ; or an anodyne clyster may be employed. 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 haemor- rhage 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 continuance of feeble and useless pains. In the first 413 case, the pains are sharp and frequent, but do not dilate the os uteri properly, nor advance the process in general. It may be produced by irregular action of the fibres, or by rupture ofthe membranes before the cervical fibres be disposed to relax. In the second case, the pains are lingering, short, and usually weak. I have already considered the remedies for these states; blood-letting, clysters, gentle dilatation of the os uteri, &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 them more effective ;77 and upon this subject, I refer to what I have already said in the beginning of this chapter. Unproductive action ought never to be allowed to continue so long as materially to impair the action ofthe 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 recognised 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 patient cool in bed, and giving some saline julap ; at the same time that the mind is to be tranquillized. If these means do not immediately abate the heat, frequency of pulse, foe. and render the pains more effective, it will generally be proper to detract blood, especially if the head or chest be pained. When local inflammation accompanies fever, it is commonly of the pleura, or peritonaeum, or vagina. The first is discovered by pain in the thorax, cough, and dyspnoea; the second by pain in the belly, gradually increasing and becoming constant; pressure increases it, and in some time the patient cannot lie down, but breathes with difficulty, or is greatly oppressed, and vomits. The labour pains are sometimes suspended ; on other occasions, they do ultimately expel the foetus, but the woman dies in a few hours. On the first appearance of these symptoms, blood should be freely detracted, the bowels opened, and a gentle perspiration excited. In all these cases of inflammation, if immediate relief be not obtained, the child must be delivered by thfl forceps. If the vagina be hot and dry, we are also to deliver immediately, as these symptoms indicate danger from inflammation.78 414 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 descends in the pelvis before the os uteri be dilated, and the process is often both painful and protracted. These premature bearing-down pains may often be mitigated by a recumbent posture, and the use of a mild clyster to empty the rectum. In some cases, the womb prolapses, so that its mouth appears at the orifice ofthe vagina. This prolapsus may take place during pregnancy, or after parturition begins. It is often met with, in a slight degree, whilst the os uteri is not greatly dilated, and uniformly injures the labour. We are to prevent it from increasing by supporting the head or the uterus with two fingers, during the continuance of a pain ; at the same time that the woman avoids, as much as possible, every bearing-down effort, and remains in a recumbent posture. If the os uteri be slow of dilating, some blood should be taken away, and an opiate administered, or the os uteri gently but completely dilated, during successive pains. It has happened that, by neglecting these precautions, the uterus has protruded beyond the external 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 be done, the os uteri, if lax and yielding, must be gently further dilated, the membranes ruptured, the child turned, and the uterus replaced.t The os uteri has been cut,f but this can never be necessary if the structure of that part be natural. When the womb does not actually protrude, the vagina may be inverted like a prolapsus ani. A soft cloth, dipped in oil, should be placed on the part, and pressure made with the hand. Giesman cut the inverted vagina on a probe, but this operation can never be required. If the womb prolapse before labour, as happened to Roederer's patient, we must manage the case as a simple prolapsus. She had severe pains, although she was not in labour. The anterior lip ofthe os uteri has become prolonged, and extended, during labour, for some inches into the vagina, or has even protruded at its orifice with great pain. It ought to * Vide Mem. of Med. Soc. vol. I. p. 213. •t Vide Portal's 10th Obs.; and Decreux's case, in Mem. de I'Acad. de Chir. ine III. p. 368. See also a case by Saxtorph. There is a case by Fasola, where the uterus with the child appears to have been protruded for thirty hours. The child was expelled by a rent, and, the placenta being extracted, the mother recovered. X Vide a case by Dr. Archer, New York Med. Rep. vol. I. p. 323. 415 be supported with the finger, and very gradually pushed above or over the head. It has been mistaken for the placenta. ORDER SECOND. 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 completely 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 generally, but not always, slow; the second is uniformly so ; the head is long of descending into the pelvis, it rests long on the perinaeum, the pains are frequent, severe, but often not very forcing, and the woman says they are doing no good. Now this stale requires both patience and discretion. The bowels should be opened with a laxative ; the urine regularly expelled or drawn off; the strength preserved by quietness, avoiding unnecessary exertion, indulging any disposition to sleep which may exist, and taking a little light nourishment occasionally; the mind is to be soothed, and the hopes supported. The rule formerly laid down, with regard to effecting the dilatation of the os uteri, or accomplishing the first stage of labour, within a certain period, is, if practicable, to be attended to, by which the energy ofthe uterus is saved, and it is enabled to go through the second stage more readily and safely. If the pains begin to slacken, whilst the strength remains good, an opiate may be given to procure some rest. How long the case may be trusted to nature, must depend on the strength of the patient, and the degree of suffering; but, assuredly, we are not at liberty to carry the trial to a great extent. The consideration of this question, however, must be reserved for the next chapter. Malposition ofthe head may likewise retard the labour; but this has already been considered. Much suffering may be avoided by attending to this cause, as the position is often rectified by pressure with the finger alone. Another cause of tedious labour is, rigidity ofthe soft parts, which may be dependant 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, 41(i along with this, there be premature rupture of the membranes* the difficulty is usually increased. When it exists in the os uteri, that part is \ery long of dilating ; the effect of the pains, for a long time, is rather to soften than to dilate ; and after the woman has been many hours in labour, it is found, when the pain goes off, to be collapsed, and projecting like the os uteri in the eighth month of pregnancy. In this case, the first stage is very slow, lasting, if we do not interfere, some- times two or three days; and the second is likewise tedious. The whole process takes up, perhaps, three days or more. When the rigidity exists chiefly or partly in the external parts, they are found to be at first dry, tight, and firm. By degrees, they become moister and more relaxed ; but they may still be so unyielding, as to keep the head for many hours resting on the perinaeum. Some methods have been proposed for abating the rigidity; such as baths, fomentations, and oily applications; or digitalis and sickening medicines given inter- nally ; but these have no good effects, and some of them do harm.79 Blood-letting is the best remedy in such cases. Dr. Rush informed me, that in America it has been used with great advantage; and Dr. Dewees politely sent me a disserta- tion on this subject, containing very good cases of its efficacy, when pushed freely. In some instances, fifty ounces were taken before the parts relaxed, but this I hold to be a dangerous extent. In determining on the use of blood-letting, we must attend to the state and habit ofthe patient. Debili- tated women,* 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 country, bear blood-letting better, and derive more benefit from it. In them it is especially proper, if any degree of fever attend the labour, and in whatever part the rigidity exists, if the patient be not previously reduced, or very delicate, blood should be extracted pro viribus. If, however, the state of the patient forbid this, then an opiate clyster is the appro- priate remedy. It may also be proper to try the effect of applying extract of belladonna, diluted with oil to the consist- ence of cream, to the os uteri, by means of a small syringe, as proposed by Chaussier, who says it generally acts within forty minutes. As it has not, however, come into general use, it is evident that it cannot be relied on. * Dr. Dewees bleeds even delicate women, and those who are disposed to faint en being bled, but takes a smaller quantity from them. 417 The direction already given, respecting the completion of the first stage of labour within a reasonable time, must «be attended to, and is always practicable when the means of relaxation have been employed. When the head descends to the perinaeum, it is of service to keep the patient, for some time, in an erect or kneeling posture. We must not allow either the general or the uterine vigour to be too much diminished, but must finish the labour by the forceps, before any considerable exhaustion takes place. In some cases, the os uteri or external parts, instead of being rigid, are tumid, and apparently oedematous.80 In these, the labour is often protracted for several hours, especially when the os uteri is affected. In tedious labour, the os uteri sometimes becomes swelled, as if blood were effused into its interstices. This requires venesection, and then a smart clyster. The os uteri may be naturally very small. In some instances, 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 gradually dilated. Venesection is, in this state, of service. Sometimes it is hard and scirrhous, so that it has been deemed necessary to make an incision into the os uteri to make it dilate.* It is also possible for the os uteri to be closed in consequence of inflammation, so that it has been necessary to make an artificial opening,? Contraction and cicatrices in the vagina, likewise retard * A case of this kind occurred to Dr. Simson, of St. Andrews, and another to a practitioner in America. Dubosc mentions a woman 40 years of age, who had convulsions for two days, during labour, from this cause. The face was pale and the extremities cold. The orifice was very rigid, and little dilated. He cut it, and she was delivered of a dead child. Gautier mentions a case where, after labour had continued 15 hours, no os uteri could be found. The uterus had descended considerably in the pelvis, and there was no reason to suppose the os uteri was high from obliquity; an incision was made, and the child extracted by the forceps. In six weeks the patient menstruated, and when examined after that, the uterus was found in an adherent state of antiversion. Other cases are to be met with in the Diet, des Sciences Medic. Art. Hystertomie. + Vide case by Campardon, in Recueil Period, tom. XII. p. 227. Moscati gives a case where, in consequence of injury by the forceps, the os uteri was so small that it would not admit a probe. A number of incisions were made round it, alter which it dilated. In the next pregnancy slighter incisions sufficed, and in the last none were required. Aubertin performed, in a case of the kind, the v^eesarian operation. In a subsequent pregnancy, in the 7th month, the cicatrix was ruptured, and, by very little enlargement, a child was successfully extracted. in a case given by Gautier, the os uteri was obliterated after a labour in which TT snoulder presented. The menses were retained and required a perforation tor their evacuation. 3E 413 labour, and cause very great pain, until they either relax or be 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 tumours81 attached to the ligaments, or a stone in the bladder, may all obviously retard the labour, some of them so much as to require instruments. A stone in the bladder ought, if possible, to be pushed up beyond the head ; if not, it must be extracted. A hernia of the bladder, by one side of the vagina, or a descent of the bladder in front, has the effect of rendering labour tedious. The urine should be drawn off, and the bladder supported cautiously during a pain. I refer to Book I. chap. x. sect. 22. for a description and farther remarks on this subject, and for the mode of distinguishing between the descending bladder and the membranes ofthe ovum. A small vagina may require a long time to be dilated. A great degree of obliquity ofthe uterus protracts labour. The os uteri may be turned very much to one side, but oftener it is directed backwards and upwards, and may be out ofthe reach ofthe finger. Time rectifies this, but much time and pain may be spared, by gently drawing the os uteri forward with the finger. The patient may also be placed for some time on her back, with the hips somewhat raised with a pillow. The fundus uteri may also be elevated or supported by the hand placed on the abdomen. Daventer, who was both a candid and an experienced man, has perhaps made the moderns too attentive to obliquity of the womb, by going to the opposite extreme. Retroversion of the uterus may likewise prove a cause of tedious labour, and can only be remedied by cautiously attempting to press down the os uteri from above the pubis. Malformation of the organs of generation may afford great obstacles to the passage ofthe child, so that even an incision may be required, as happened in the case related by Mr. Bonnet, in the thirty-third volume of the Philosophical Trans- actions. By shortness ofthe umbilical cord, or still more frequently, 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 419 up again upon the recession of each pain.82 It often remains lono- in a position, which we should expect to be capable of very quick delivery. By patience, the labour shall be safely terminated; but it may often be accelerated, by keeping the person for some time in an erect posture, 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 hadbegun, would be checked, or the circulation in the cord be obstructed. Some have advised that the cord should be divided, after applying the double ligature, but this is rarely necessary, for the child may be born, even although the cord remain about the neck.83 Preternatural strength of the membranes may also to a certainty prove a cause of tedious labour. This is at once obviated, by tearing them, which is done by laying hold of them when slack, during the remission of the pains. It sometimes requires a considerable effort to rupture them. CHAP. VI. Of Instrumental Labour. ORDER FIRST. Various causes may render it necessary to accelerate deliv- ery, such as, spitting of blood, convulsions, uterine haemor- rhage, emphysema, the existence of aneurism, foe. These are, however, to be considered as in some respects adventi- tious ; and, at present, I mean to confine myself to an account of those, which are more immediately connected with the power of expulsion. It must be very evident, that if the head of the child be unusually large, or the capacity of the pelvis be diminished, a mechanical obstacle must arise to the delivery of the child. Of theso two state', the last is by far the most frequent, and constitutes one prominent cause of instrumental labour. I have already explained the effect of resistance in checking the free and brisk action ofthe uterus, until, at last, the muscular power is more roused, and strong efforts made. These circumstances require to be maturely considered, for, in such 420 cases, the first stage of labour is very frequently, although not invariably, slow ; and if not accelerated by proper management, the action ofthe uterus is apt to become exhausted, and its vigour prove inadequate to the safe accomplishment of the second stage. Different effects must be produced by the resistance, according to its degree, the constitution of the patient, and concomitant circumstances. A slight opposition may operate,chiefly by impeding or rendering irregular and inefficient the action ofthe uterus, and the consequences may vary much in different labours, and under different treatment. A greater degree of resistance must invariably produce, from the obstacle afforded, a protracted and severe labour ; and in particular, we apprehend the occurrence of two different conditions which are very often conjoined. First, the head, by the gradual and severe efforts of the uterus, and abdominal muscles, is pressed more or less into the pelvis, and becomes impacted there, so that it cannot, by the power of nature, be forced lower, and may even, in mar.y cases, require consider- able pressure to raise it in any degree upward by the accoucheur. This is known technically under the name of the locked head, or case of impaction. It is evident, that in this state natural delivery is next to hopeless, for all farther efforts are generally unavailing. Secondly, the continued pressure ofthe head on the soft parts is productive of farther diminution ofthe capacity ofthe pelvis, for inflammation is excited, and, at the same time, the return of blood by the veins is obstructed, and of serum by the lymphatics. This impairs the power of the soft parts, and renders the inflam- mation of the low kind, so that, even when delivery is accomplished, sloughing succeeds, whereby very dreadful or loathsome effects are produced, if these, indeed, be not prevented by the death of the patient, in consequence of a similar low inflammation being communicated to the uterus or peritonaeum. This swelling ofthe parts contained within the pelvis, may take place, although the head be not impacted, but the head cannot be long impacted without producing that. Here, then, is one effect of a most formidable and alarming nature, which we apprehend in the case under consideration. But this is not the whole of the evil; for the upper part of the vagina, or the cervix uteri, may be lacerated in consequence of this debilitated state, or any part of the uterus may be ruptured by strong or spasmodic action; or uterine or peritonaeal inflammation may be excited previous to delivery, proving fatal in a few hours after labour is terminated; or 421 haemorrhage may occur to a fatal degree from want of energy in the uterus after delivery ; or general irritation and exhaus- tion are produced, the pulse becomes frequent and at last feeble, the mouth parched, the skin hot, the mind confused, and the strength sunk ; or the powers of life may be worn out, so that the patient shall die without any decided inflammation, or disease referrible to a common nosological system. Such may, and must, in general, be the result, if assistance be long withheld, or if the patient, from unusual strength, or some fortunate yielding ofthe cranial bones, be able at last to bring forth her child. AVhen we turn from the mother to the fcetus, we find that this continued pressure alters the shape of the head, and affects the action of the brain, or the important function of circulation : first, the scalp tumifies, and we think the head is descending, when in reality it is stationary, and the integument is only becoming raised ; then, the bones are squeezed closer together, and the presenting part of the cranium forms an angle, more or less acute, which has been compared to a sow's back. In some instances, the two parietal protuberances are not more than two inches and a half distant from one another, but the head is not always lengthened in the same proportion ; on the contrary, in a few cases, it is even shortened, from one bone sliding under another. Children ha ve been brought to me, where the bones have been separated, and the one parietal bone forced completely beneath the other. Farther, we are not to estimate the possibility of propulsion by the approximation of the parietal or more compressible bones ; for not only the greatest breadth, but the greatest resistance, is near the ear, from the one zygoma to the other, and if the whole of the upper part of the cranium were totally wanting, still delivery would not be facilitated. The very yielding ofthe parietal bones, allows the margin of the less compressible portion to become more distinct, and to be more readily caught by the brim ofthe pelvis, and also to make, by its ridge, more injurious pressure on the bladder and other soft parts. Last of all, partly from pressure on the brain, but, independently of that, from continued pressure on the cord or organs of circulation, the child perishes; and whether born by the natural efforts, or delivered by art, is dead. Such, then, are the effects, to parent and child* of a locked head; effects which can only be avoided by accelerating the progress of labour, and calling in the aid of extraneous force. When we talk of a case of impaction, which is not a very happy term, we must not, however, suppose that the head is 422 literally and entirely immovable. That it is, in the strict sense of the word, sometimes impacted, and cannot be moved, is no doubt true ; but this is not a case in which we can safely use the forceps, and more frequently the hand can make it recede a little, although the uterus cannot make it advance any more. Levret took the word in its strictest meaning, and imagined that the head was jammed between two points ofthe pelvis. Rcederer went farther, and maintained that every part ofthe head was so fixed and pressed on, that not even a needle could be passed any where between it and the pelvis. If so, how can the forceps be applied ? If the head be jammed at every point, even making allowance for the elasticity of its bones, we could not introduce the finger between it and the pelvis, or reach the ear. This case of universal impaction rarely exists, and when it does, it requires the head to be opened. The impacted head, admitting of the use ofthe forceps, is stopped by the promontory ofthe sacrum on the one hand, and part ofthe pubis on the other. The resisting point generally is the projection of the sacrum ; but, even in this case, the verm impaction is not strictly proper, for, if the forceps can be used, the head can be a little raised, and the blades must be capable of being introduced. We can be at no loss to ascertain the existence of this state. The slow progress of the labour, the severity of the pains, the tardy descent, or stationary condition of the head, its gradual impaction, or increasing immobility, its alteration of shape, the deformity or diminished capacity ofthe pelvis, the progressive tumefaction of the vagina ; all point it out, too clearly to be mistaken ; and many of these symptoms, together with those of general irritation and exhau>tion, increase with the period to which labour is allowed to extend. This state may be anticipated, when the pelvis is ascertained to be deformed. We know that if the pelvis measure, in its diameter, only three inches and a half from one parietal protuberance to another, even that part must be compressed more or less in order to pass.* But the distance from one zygoma to the other, marking the traverse diameter of the firm and resisting base ofthe skull, is often more, even four inches, and this portion is so firm and unyielding, that a * The head can bear much more pressure before the child is born, than after it has breathed. Respiration is more under the influence of the brain, than the action ofthe heart is; and the action of the latter, after birth, ceases when the brain is injured or compressed, not so much because it is directly affected, as because respiration, with which it is associated, ceases. 423 small diminution of the pelvic space, requires a great and protracted force to push it through. The more that the brim is reduced below its natural dimensions, the longer and more painful must the labour be, until we come to such a degree of contraction, as will either render expulsion altogether impossible, or delay it until great danger have been induced. It is difficult to draw the line of distinction betwixt that degree of contraction, which will render it impossible for delivery to take place naturally, and that which will only render it extremely difficult. It has been proposed to ascertain this, by a rule founded on the dimensions ofthe pelvis. But this method cannot be brought to a sufficient degree of perfection, for the result of cases is much influenced by the size of the child, the pliability of its head, the vigour of the uterus, and other causes. Besides, it i« difficult, if not impossible, to determine, with minute precision, the dimensions of the pelvis in the living subject; and they are apt to vary, according as the soft parts within the pelvis are more or less swelled. There is another cause of protracted labour requiring instrumental aid, when the head is not impacted ; the pelvis may even be of ample size. It is much more frequent in its occurrence, and is known under the name of the case of arrest, or by the French writers la Ute arrelce a.u passage. The head is not fixed or jammed, the finger can more readily be passed round it, the scalp may be swelled, but it is to a less degree and firmer. The bones are nearer the perinaeum, and are never so squeezed or misplaced, and the retardation appears to ariie rather from the nature of the pains, or the unyielding state of the soft parts at the outlet ofthe pelvis, than from any great obstruction offered by the pelvis to the delivery; but I have already noticed, tjjat a very small obstacle often decidedly impairs the actual force of the uterus; though, perhaps, not the degree of pain. Further, the head descends lower than in a case of impaction. The ear is more easily felt, not only from there being more room for the finger, but also from being farther down. It can be felt by introducing two fingers ; whereas, in greater con- traction, the hand sometimes must be introduced into the vagina to feel the ear fully. It is a mere case of tedious labour, but a case protracted to the utmost limits of prudence, in spite of the employment of those means which have been pointed out in the last chapter. It may arise from some 424 slight disproportion between the size of the head, and the capacity ofthe pelvis, or more frequently from variations and irregularities of the uterine action, which have already been fully considered, and it is much more frequent in its occurrence than the locked head. The case of impaction is clearly marked by the symptoms formerly detailed; that of arrest is ascertained by the simple condition of the head being stationary, but not jammed in the pelvis. There are many cases, then, of arrest, which are safely terminated by nature, and which are placed under the class of tedious labour; but there are many others, where it becomes prudent to accelerate delivery by artificial force, and the question for deliberation is, at what period we shall thus interfere, or, when further delay is hazardous ? I have fully, and I hope practically, detailed and considered the causes which render labour tedious, and have pointed out the impropriety of permitting the first stage to be protracted, for thereby the uterus becomes enfeebled, and less able to accomplish the second. But when this advice has not been acted on, or when the treatment proper for the particular cases already described, has not been successful in effecting delivery, what is the consequence ultimately of delay ? The uterus, by continued, by inefficient action, or unavailing contraction, becomes gradually debilitated ; and when at last delivery is effected, it cannot contract with vigour and regularity, whereby haemorrhage is occasioned, or the same event is produced by spasmodic action of the uterus.—Here, then, is one very serious evil which may be anticipated. Next, there is a strong disposition given to puerperal disease, not merely to those troublesome, though less dangerous complaints, known under the name of vyeeds, or irregular febrile paroxysms; but also to more formidable affections, of an inflammatory nature, especially of the womb or peritonaeum. Accordingly, we find that a much larger proportion of women die after protracted, than after natural labour. Here, then, is another class of evils to be apprehended. Again, although the same local mischief is not so apt to take place, that we meet with in locked head ; yet, the patient is not exempted from risk even of that; by continuation of labour, the soft parts at last inflame and swell, which adds not only to the difficulty of delivery, but also greatly to the danger ofthe case. If it be necessary to enumerate other hazards, I may set down the consequence of protracted irritation and exertion, marked by the induction of a state of fever, and at last of great exhaustion, 425 insomuch that the patient may actually die undelivered, but this event, as well as rupture ofthe uterus, is less apt to occur than in locked head. Besides all these hazards to the mother, the child is in danger of perishing, not from compression of the brain, but from the continued pressure ofthe uterus, after the evacuation of the water, interfering with the regular performance of the function of circulation. These are surely no trivial evils resulting from protracted labour ; and the utmost that I feel at liberty to concede in favour of delay, is, that it may be permitted longer in cases of arrest, than of impaction. Many eminent men have placed an undue confidence in the power of nature, and have been hostile to the use of instruments. For a long time I was influenced by the high authority and plausible arguments, as well as bold assertions of these practitioners, but experience has compelled me to adopt the opinion, I am now, with a firm and solemn belief of its correctness and importance, to maintain in this chapter. From the strength ofthe recommendations of the partisans of nature, we should suppose, that whenever the childcould actually be born without aid, no hazard occurred, and, on the other band, that instruments must of necessity prove not only very painful in their application, but dangerous in their effects. Now, the first supposition is notoriously wrong, for innumerable instances are met with, where the mother does bear her child, without artificial aid, and much, doubtless, to the temporary exultation of the practitioner, but, nevertheless, death takes place, or, at the best, a tedious and bad recovery is the consequence. The second supposition is just as positively untrue ; for in the majority of cases, if the practitioner be humane and gentle, the introduction of the instrument gives little or no pain; in so much so, that in many books we meet with strong and just reprehension ofthe clandestine and unnecessary use of instruments, which could never possibly take place, if their application were attended in such cases with much pain. Then, as to the pain occasioned by extraction, that may be greater than the patient was just before suffering, and yet not be greater than is often experienced in a natural labour; or even granting it to be uniformly greater, a concession I make for the sake of argument, it is but for a short time, and, on the whole, the suffering of the patient is less than if nature had been allowed at length to expel the child. These positions are perfectly correct in all cases of arrest, when the practitioner is well instructed and cautious. Next, as to the danger to be 3 F 426 apprehended, I cannot in cases of arrest see any source whence it can arise. The mere introduction ofthe forceps, if gently accomplished, can scarcely be more hazardous than the introduction of the finger, for no force is, or ought to be, exerted. If there be hazard, it must be in the process of extraction, and this, it is evident, can arise only, either from pressure of the instrument on the soft parts, or from the head and instrument lacerating the perinaeum. The last event must, in general, be the consequence of want of caution, and the first can never be carried to any dangerous degree in a case of arrest, if the operator know how to direct his efforts. In such cases, then, we may experience much evil, from trusting too long to nature, but add little to the sufferings ofthe patient, and nothing to her hazard by instrumental aid. When, however, we turn our attention to the cases of impaction, the matter is different. There is greater difficulty in introducing and fixing accurately the instrument, and doubtless more pain even in this stage is given than in cases of arrest. When again we come to act with it, the suffering or pain must be increased, even in the hands of a gentle operator, in proportion to the resistance to be overcome. The soft parts have already been pressed on, during labour, by the head, they must still be pressed to a greater degree; and even if the maxim, that time is equivalent to force, were acted on to a certain extent, it would be vain to denv that there must be both greater suffering and greater danger than in natural labour, or than in cases of arrest. These sufferings, and this danger, must be in a certain degree proportioned to the tenderness which has already taken place in the soft parts, and therefore may be greatly lessened, but cannot be increased by an early application. Their production depends on the obstacle afforded. When the head has arrived at a station rendering the application ofthe short forceps practicable, no good can arise from delay ; we only add unprofitably to the suffering in the mean time, or lay the foundation of a state, which is to render the later application of the instrument more painful and more hazardous. When mischief arises from the application of the forceps, it always is owing either to harsh and unskilful conduct, or to the state induced by delaying their use too long. If it require strong efforts to extract the child, could that child ever have been born by the power of nature, or could the uterus and abdominal muscles, after long action, retain vigour sufficient to exert a force equal to that which is often required to extract an impacted head .? 427 Indeed, our best writers, however fond they may have been of delay in cases of arrest, are disposed to deliver whenever the head has been locked. Nothing can be expected from delay except sloughing, and the alternative of speedy death, or a miserable existence; and in all cases of decided impaction, the question, I apprehend, is not whether we shall immediately deliver, but whether we may succeed with the forceps, or shall be obliged to use the crotchet. Holding the opinion I have been laying down, it is not without astonishment and regret, that I find Dr. Osborn stating, that in a case requiring 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 sink together, under the influence of such continued but unavailing struggles, unless rescued from it by means of art." If such a state be allowed to take place, even in a case of arrest, but more especially of impaction, it is much to be dreaded that the interference of art shall prove as unavailing as the struggles of nature. Were this the opinion only of Dr. Osborn, I should pass it in silence; but unfortunately it is the prevailing doctrine of the day ; and the modern disciples ofthe school of patience, men of talent and observation, carry their fears of the mischief resulting from the use of the forceps to an extravagant length, and place a mistaken confidence in the efficacy and safety of a continued action ofthe expulsive powers. I have much pleasure, however, in strengthening my opinion with the authority of Dr. Hamilton, the present excellent Professor of Midwifery in Edinburgh, who has long seen the hurtful effect of the temporizing system, and of Dr. Osiander, the active and experienced Professor in Gottingen.* To place the argument in a yet stronger light, I shall * In Dr. Smellie's time, he calculated that the forceps were required once in 125 cases of labour ; since then there has been rather a deterioration in practice so far as delay is concerned, for the more modern calculations are 1 in from 158 to J88. One gentleman, for whom I have great respect, states, that the forceps were not necessary in the hospital practice, above once in 728 cases, and in private practice, above once in 1000. Dr. Merriman's practice comes nearer the line of safety, for it exhibits 1 in 93. Dr. Nagele has employed them once in about 53 cases, which corresponds very much with my own list; but I must qualify this, by saying, that I include, with the result of my general practice, those cases where I have been called in consultation, which, I admit, increases beyond the due proportion the number of instrumental deliveries. In former editions of this work, I expressed an opinion, which I still adhere to, that of two evils, it is infinitely safer, for the mother, to interfere too soon, than to procrastinate. 423 examine the result of delay, as deduced from the table*, published by Dr. Breen, of the cases occuring in the Dublin Hospital, because these are the latest I have beside me, and were published without reference to any particular opinion. In the course of 57 years, 7S,001 women were delivered, of whom one out of every 92 died, and one child out of every 18 was stillborn. If, however, we were to exclude cases of tedious labour, and attend to the rest of cases of natural labour, or the consequences of a correct and healthy process of parturition, we would find the proportion of deaths to be altogether trifling; I am willing, however, to adopt this average. Let us now see the result of tedious labour. In women, who were in labour of their first child, from between 30 to 40 hours, one in 34 died, and one child in 5 was stillborn. Here then is a prodigious difference, between even the average result of all labour, good and bad, and a protracted labour. During the same period of labour, amongst women, who had previously borne children, and therefore, if requiring instruments, might be supposed to have a more permanent obstacle, or contracted pelvis, though this is not stated, about one in every eleven died, and one child in every six was stillborn. When labour was protracted between 40 and 50 hours in women who had not previously borne children, one in 13 died, and the proportion of stillborn children was as one in 3J. If labour were protracted other ten hours, that is, between 50 and 60, one eleventh of the women died, and when we * proceed to the period of between 60 and 70 hours, one eighth died, and nearly one half of the children. It is observable, however, that only one twelfth died in the next ten hours, but this variation must arise from accidental circumstances. It is impossible to give any comparison of these results, with those afforded in the same hospital by the use of instru- ments ; for artificial aid, it is evident, was always long delayed, unless in cases where dangerous symptoms not essential to labour occurred. Instruments were used, on account of tedious labour, in 44 cases, and of these 18 died. Now, taking the proportion of deaths in the parturient state to be, including all disasters whatever, as 1 in 92, it is most important to observe the progressive fatality arising from delay. Suffering above 30 hours destroys 1 in 34; in other 10 hours the danger more than doubles, for 1 in 13 die ; then 1 in 11, and next 1 in 8, to say nothing ofthe children. To deliver a system of rules precisely applicable to every 429 case, is quite impossible, for much must be left to the judgment of the practitioner, who is to be guided by general principles; I can therefore only offer for his consideration, the following observations : First, It is important in every case of parturition, but more especially if there be reason to anticipate a tedious labour, to prevent the first stage from being protracted. Whenever the uterus is in a state of unsuspended action, that is to say, the pains decidedly parturient, and continuing without long in- tervals, but producing a slow effect on the os uteri, the means formerly pointed out for effecting its dilatation, within a limited time, generally twelve hours, ought to be resorted to. Second, Whenever the os uteri is completely dilated, but not sooner, the forceps can be applied, if the case admit of relief by the use of that instrument. But the lowerthat the head has descended, the easier is the application, with the exception of those instances in which the head is very firmly impacted in the pelvis ; for in such it may be necessary to press the head up a little, in order to be able to introduce the blades. Third, It is ascertained that the head, at the full time, cannot, consistently with safety, bear to have its transverse diameter reduced, by pressure, to less than three inches. Forceps, therefore, are, or ought to be, so constructed, that when joined, the blades at their most curved part, which is t6 contain the parietal bones, cannot come nearer to each other than three inches. The pelvis then must, after making an allowance for the soft parts, measure at least that space in its conjugate diameter, in every case where the forceps are applicable. It would, in a smaller pelvis, be dangerous, always difficult, and often impossible, to introduce the blades, and, when introduced, they never could be brought through it, and indeed could only be locked by being carried above the brim. This fact, then, fixes the limits of that deformity, which permits the application of the forceps. The blades might doubtless be made to approach nearer, and to squeeze the head more, but as the child would perish, it is better to employ another method safer for the mother. But whilst it is a rule, that the pelvis must measure fully three inches, to permit of delivery by the forceps, it does not follow, that in all cases where this is so, the forceps can be safely used, even if they could be introduced. In all cases of impaction, owing to great contraction, we must not be san- guine in our hopes, nor obstinate in our trials, for decided im- paction oftener calls for the crotchet than admits of the forceps. 430 Fourth, The forceps are merely small hands, and, therefore, when the finger of the operator can be extended over the side ofthe head, one blade can be passed along that side, in whatever part the head is situated. This, it is indisputable, may be done, when very little, or even no part at all, of it has entered the brim of the pelvis. The possibility, however, of applying the corresponding blade, must depend on the dimen- sions ofthe conjugate diameter; and, if possible, it would be useless, unless there were space to deliver a living child, or to bring out the locked forceps enclosing the head. We shall presently see that, in this high situation, the forceps cannot be applied without great care and dexterity; and that no small danger attends the attempt. Fifth, The lower that the head has descended, the more easy and the safer is the use of the instrument. In almost every case where the forceps are beneficial, the head has so far entered the pelvis, as to have the ear corresponding to the inner surface of the pubis, and the cranial bones touching the perinaeum. Until this descent have taken place, the common or short forceps cannot be employed ; and it is to this instru- ment that I confine my remarks, leaving the use of the long forceps to be specially considered. When the finger, without the introduction of the hand into the vagina, can easily touch the ear, and when the cranium is in contact with, although not protruding the perinaeum, the forceps are applicable. Sixth, It has been laid down as a rule, that the head should have rested on the perinaeum for six hours previous to the use ofthe forceps; but this is quite unsatisfactory, for it may, in many cases be allowed to rest there longer, and in others, especially when the head is impacted, it would be both unnecessary and dangerous, to permit it to remain so long. It is confessedly in every instance, allowing the labour, whether with or without propriety, to be continued for six hours after the delivery has become practicable. Seventh, Whenever the pelvis is ascertained to be con- tracted, we are to take care that the first stage of labour be not prolonged, and the vigour of the uterus diminished. As soon as the head has come within reach of the ordinary or short forceps, unless it be descending farther, and the labour going on briskly, we ought to deliver, and whenever the head becomes impacted, we are warranted, and imperatively called on, to interfere. In cases, then, where the pelvis is dispro- portionate to the head, we do not wait any definite time, and pay no regard to duration, farther than becoming, every hour 431 that labour is prolonged, more solicitous that the head may come within reach of the short, and save the necessity of trying the long forceps, or resorting to the perforator. The safest rule is, to deliver as early as delivery is easily practicable; but it may even be necessary to interfere before the head has come within reach of the common forceps, and when con- siderable difficulty attends the application ofthe instrument. This is the case when the head has partly entered the brim, but has not for some hours yielded farther to the pains ; and at the same time its deformity is not so great as absolutely to require the crotchet. Eighth, Neither are we, in cases of arrest, to proceed strictly on a rule founded altogether on time, unless we vary that according to the strength of the constitution, and the actual efforts made by the uterus. We cannot, with reference to the present question, consider a patient to have been decidedly 30 or 40 hours in labour, who has had slight pains at first; then a suspension of these for a number of hours, and again, perhaps, a return of trifling pains, with long intervals scarcely affecting the os uteri. These can scarcely be called the pains of labour ; and whether they should be checked or let alone, must depend on considerations formerly brought forward. We date our time from the commencement of evident and progressive effects on the os uteri, and are also in part regulated by the state of the pains in the second stage. The patient may have the os uteri fully dilated, and yet the next stage may be suspended for some hours ; there may be a pause in the uterine action, occupied in sleep or passed in ease. It is quite different when there has, from the first, been continued uterine action, which has brought the head into the pelvis; but, whether from weak, or restrained, or irregular action, has not been sufficient for its expulsion. In this case, presuming that the rule has been acted on, of having the first stage accomplished within a certain number of hours of actual labour, that pains producing little or no effect on the uterus or its mouth have been either stopped or rendered inefficient, I am inclined to lay it down as a principle, that the second stage should be accomplished within a little longer period of time, than was allowed for the first. But to prevent all mistake, in a rule which is connected with time, I must again expressly state to the reader, that as I formerly spoke of the first stage being accomplished within a certain period of actual labour, and dated from the commencement not of mere pain, which may not even have been truly uterine, 432 but of pain affecting the os uteri ; so the second stage is to be considered also as a state of uterine pain, and is not to have included in its duration, the hours of suspension, which may have been passed in sleep or tranquillity. When I come to lay down a rule as to the time of interference, I would say, and that from reflection and experience, that few cases ought to be trusted to nature for 36 hours, and in general it is safe and proper to interfere within 30. There may be cases where particular symptoms shall justify and call for aid, even within 24 hours, and an impacted head may demand it within that time ; but, in an ordinary state of health and strength, a mere case of arrest may be safely trusted till between 24 and 36 hours, and the point of interference in this range of 12 hours must be regulated by the efforts which have been made, the uninterrupted continuance of labour, the obstinacy ofirregular action, the situation of the head, or length of time it has remained in a situation rendering the forceps applicable, and, last of all, the general vigour of the patient. Finally, the longer that the first stage has been protracted, and the more painful or severe that it has been, the shorter should we wait in the second, and vice versa: this remark, however, is only applicable to cases of arrest, and not of impaction. Ninth, In cases where we anticipate the necessity of using the forceps, and find considerable fever or excitement ofthe vascular system, with or without local tumefaction, we should have recourse to the lancet before delivery. This renders delivery safer, or may, in certain cases, happily supersede the necessity of instruments. We must not, however, mistake mere frequency of pulse, from long continued efforts, and excitement, for synochal fever; a state tending to exhaustion, for one requiring depletion. The doctrine I have now been supporting rests on this principle, that it is safer«to extract the child with the forceps, than to allow the uterus to remain long in a state of action, whether that be regular or spasmodic, and whether it lead directly to exhaustion, or ultimately to disease arising from irritation. If I have been tedious in my argument, or been betrayed into repetion, I plead that the great importance of the question to society has led me to trespass. 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 433 reconciled to the use of instruments. The result of a labour is often uncertain : on this account, as well as from motives of humanity, no hint ought, in the early part of the process, to be given, ofthe probability of instruments being required. But as their necessity becomes more apparent, and the time of their application draws nearer, it will be proper to prepare the mind ofthe relations for what may be necessary, if the delivery be not naturally accomplished. With regard to the patient herself, we must proceed according to her disposition. If she be, from what we have already learned, strongly prepossessed against interference, it will be necessary to give such prudent hints, and such explanations of the practice as relating to others, though not to herself, as will prepare her for her consent. But if we can perceive that she is disposed to agree readily to whatever fnay be necessary, nothing ought to be said till very near the time, as the anticipation of evil is often as distressing as the enduring of it. When we are to deliver, it is useful to explain shortly and delicately what we mean to do, which has a great effect in calming the mind. When the child could not be born by the efforts of nature, it was anciently the practice to apply strong forceps, which destroyed the child, or to open the head, and pull it out with a hook. To give the child a chance of living, it was next proposed, and soon became a general practice, to turn the child and deliver by the feet, as thereby much force could be exerted. If the resistance were great, however, death was invariably the consequence; nay, in many instances, the body was pulled away from the head, which was left in utero. This gave rise to many inventions for the extraction of the head under this circumstance. Fillets or bands of cloth were also applied over the head, to enable the practitioner to pull it out. These were preferred by Daventer, who informs us at the same time, that single or double hooks might also be employed, and these sometimes even brought out a living child. I have been in possession of these instruments, which consist of two blades, like the forceps, and lock like them. The bladetf are narrow, and end in a hook which is fixed at the ear. The danger of this instrument arises from its hook, which in all cases of contracted pelvis, must have sunk through the cranium. In cases of arrest, it might sometimes only go through the integuments, and these are the cases where living children were born. It is surprising that it did not at once occur to practitioners, that by taking away the hook, this danger might be avoided, 3G 134 and still the head remain fixed between the blades. It only illustrates, what I have often shown inniy lectures on surgery, that men come frequently within a single step of a great improvement, without taking that step, and often rest satisfied with imperfect knowledge, and hazardous, if not almost fatal practice, rather than exert the faculties of reflection and investigation. That it is owing to this cause, and not to any superior degree ofthe inventive faculty, in the man who actually does make the discovery, is evident from this, that no sooner is the fact published that an improvement has been made, than skilful men discover it, in spite of every endeavour to conceal it. Dr. Chamberlain, in 1672, published a trans- lation ofthe treatise of Mauriceau, in the preface to which he mentions, that his father, himself, and his brother, possessed a secret by which they could deliver women, without destroying the child, although the pelvis were small. Previous to this publication, however, he had gone over to Paris, in hopes of selling his nostrum; but rashly boasting that he could thereby deliver a woman, whom Mauriceau had declared could not be delivered otherwise than by the Caesarean opera- tion ; and failing to effect what he promised, he was obliged to return with empty pockets and little reputation. Next he went to Holland, where he sold at least part of his secret to Roger Roonhuysen, from whom it passed to the celebrated Ruisch, as thorough a quack as any of them ; nor was it made public till 1753, when De Vischer and Van de Pole purchased the information, and divulged it. The instrument so revealed, is known under the name of the lever, but it is now ascer- tained that Chamberlain also employed the forceps. Whether he only sold one half of his secret to Roonhuysen, or whether the latter preferred the lever, or only made others acquainted with it, preserving the forceps to himself, may, like the lithotomy of Raw, be important in the history of quackery, but is of little consequence to us. Of late, the original instruments of Chamberlain have been discovered, which, it is supposed, he had manufactured himself; ona of them is a lever, the other two are forceps; one of which is a little more improved than the other. Soon after this, other practi- tioners in Britain seem to have devised similar instruments, which they also kept secret, and, perhaps, the first public description is to be found by Mr. Butler, in the Edinburgh Medical Essays, for 1733. In the same volume, Chapman is severely reprimanded for concealing the instrument, which he gives intimation of in his treatise. This fault he made 435 reparation for in his next edition. Dr. Smeliie, in 1752, published his system, containing, amongst other useful instruc- tions, a full account of the mode of using the forceps, the construction of which he improved; and nearly about the same time, Levret, in Paris, performed a similar service to his countrymen. I do not conceive it necessary to detail the various alterations which have been made on the forceps and lever,* but shall proceed to explain the manner of applying and using those instruments. It is, perhaps, not sufficiently attended to, in considering this point, that the lever, unlike the forceps, acts only on one side ofthe head, and even when employed as a tractor, must press the opposite side of the head against the back part of the brim ofthe pelvis; and, further, in proportion as the head is high, we must, whilst we depress the anterior sides, tend to turn up the opposite one, or render the head more oblique. The same force, therefore, exerted with the lever, ought to be less efficacious than that employed with the forceps. I have long been of opinion, that although practice may enable a man to use either the lever or the forceps with dexterity, yet a young practitioner shall be less apt to injure his patient, and less likely to be foiled in his attempt, with the latter, than with the former ; and, therefore, I give a decided preference to the forceps. It has been said, that we may operate with the lever earlier than with the forceps, but that can scarcely be the case, if the long forceps be used; and next, it has been maintained, that the lever might be fixed on the head, when both blades ofthe forceps could not be applied. I have never known such a case, but I am not prepared alto- gether to refute the assertion, and therefore conceive that the * 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 Vecticum Obstetricorum. I do not think it necessary to describe the forceps, nor do I con- sider the slight variations made by different practitioners as of great importance. A particular kind of forceps, with three blades, was employed by Dr. Leak, but it is never used. M. Asalini has altered the forceps somewhat, and I understand, makes the junction at the extremity of the part which is held by the operator, and not at the union ofthe blade and hands as we do. Some have made one ofthe handles to screw off, others to fold by a joint, at the commence- ment of the blade. Dr. Davis proposes forceps with blades of different curves, lengths, and breadths, all made to adjust to each other. The small blade is used as an antagonist to the long one, when one of the full length cannot be introduced. They are also made so as to act when locked, one on a point farther forward, and the other on one farther backward than the other, so as to turn the head. 436 former instrument may, with propriety, be in the possession of every accoucheur.84 When the lever is to be employed, we are to apply the extremity of the instrument on the mastoid process of the temporal bone,* or side of the occiput, at the very base of the skull. The patient ought to be placed on her left side, in the usual posture; and we then, with the fore finger of the right hand, feel for that ear which is next the pubis, nnd take it as our guide in passing the lever, which is to be carried quite beyond it to the very base of the skull, so as to embrace as fully as possible the most bulging and resisting part within its curve. Three directions must be particularly attended to. The first is, to keep the point of the instrument, during the introduction and operation, close to the head of the child, lest the bladder or urethra be injured. The second is, that the concavity of the instrument be kept in contact with the curvature of the head, by which it will be much more easily introduced, than if it be separated to an angle from the head. It will, therefore, be necessary to keep the handle back towards the perinaeum, in the beginning ofthe 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 shall be applied with difficulty. It is a general remark, that within a certain range, the greater the curvature, the more is the difficulty of introducing it, but the greater is its power over the head. The third is, to attend to the axis of that part of the pelvis in which the head is placed, and pass the instrument in that course. In the 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 perinaeum. 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 further forward. When we act with the instrument, we must not make any part ofthe mother a fulcrum ; and, indeed, whatever fulcrum be employed, we ought not to raise the handle much, or sud- denly, in order to wrench down the head. Instead, at first, of raising the handle considerably, we rather attempt to draw * This process is very indistinct in the fcetus, but the direction may still be retained, as it refers to a well known spot. 437 down the head, as Mr. Gifford 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, we press it firmly against the head, which both prevents it from slipping, whilst we draw down with the right hand grasping the handle, and also serves as a defence to the urethra, should the handle be a little too much raised like a lever. At first, we should pull or act with the instrument gently, to see that it is well fixed, or adapted to the head. Afterwards we act with more force, but not rashly or un- steadily. These attcmps will renew the pains if they had gone off, and then they ought only to be made during the continuance of a pain ; for every practitioner knows, that the co-operation of pains adds prodigiously to the utility of the instrument. The head being brought fully into the pelvis, and the face turned into the hollow of the sacrum, we must act in the direction ofthe outlet; and for this purpose, it will be useful to withdraw the instrument, and apply it cautiously over the chin, which, as less force is now necessary, will not suffer by the operation. Or the forceps may now successfully be applied, and should be used whenever there is necessity for a speedy delivery. Sometimes the natural pains will, without any further assistance, finish the delivery. We must be care- ful ofthe perinaeum. The forcepswith a single curve85 may, I believe, be very safely and easily employed; but it is usual to prefer those which have the blades curved laterally also. In this case they must be so introduced, that the convex edge of the blades shall be next the face. It is therefore necessary, to determine which blade shall be placed next the pubis, before we begin; and this we do by ascertaining to which side the face lies, by examining the position ofthe ear, as well as the general shape of the presentation. Were the forceps with a single curve employed, it would be a matter of indifference which blade were first inserted. The instrument is to be gently heated, by placing it in tepid water, and the blade first to be used is to be placed so as to prevent mistake. The bladder being emptied, the patient is now to lie on her left side, in the usual posture, but with the pelvis near the edge of the bed ; a female assistant is to go to the opposite side, to allow the patient to hold by her, if she wish it; whilst another may be required to sdpport and hold up the knee and thigh, when the second blade is introducing. All things being prepared, and the head being supposed 438 to be placed in the same position as in natural labour, the operator gently introduces two fingers between the head and the pubis, in the same way as he would do in an examination; he feels for the ear, that he may know the part of the head on which he has his fingers ; then taking up the blade, he carries the extremity of it along the hollow of the hand, cautiously and gently, into the vagina, sliding it between the two fingers and the head. In this introduction, but more especially in its passage over that part of the head which it first touches, it is, owing to the curve ofthe blade, necessary to have the handle directed backwards, and almost parallel with the perinaeum ; but as the blade advances, the handle will come more downward and forward. The point of the blade ii gently to be insinuated between the head and the pelvis, with a slight wriggling motion ; and when the fingers are no longer useful, in guiding the point, they are to be so far withdrawn as not to occupy the room. When the extremity gets opposite to the ear, it in general slips very easily inward ; and the full introduction is sometimes succeeded by a gush of water, which may be foetid, and tinged with meconium, although the child be alive. When the blade is fully inserted, the handle is in a line nearly parallel with the inner surface ofthe symphysis pubis, but not always perfectly corresponding ito the axis of the brim of the pelvis, for it is often, as we shall soon observe, carried on a little too far. The blade itself passes over the lateral part of the head, in a line, running from midway between the two fontanelles, over the ear, which lies in the open part ofthe blade. If the blade be not straight but have the lateral curve, the anterior edge ofthe rim at its icurving part passes just behind the angle of the jaw, the extremity ofthe blade rests on the lower and anterior part of the occipital bone, whilst the end of the open portion, or fe- nestra, exposes that part where the mastoid process forms. I am not satisfied, however, that any material advantage be- longs to the curved over the straight forceps, although from habit I use the former. If straight forceps be employed, the extremity of the blade, of course, will not extend so far back- ward. A fault of some of the present forceps is, that the blades for three fingers' breadth, from the beginning of the open part, are a little too wide, so that the grasp is chiefly made by the ends; in this part, too, ofthe forceps, the ante- rior rim, in particular, is too wide, so that the posterior acts more than it. The anterior, or convex rim, acts too little on the parietal bone, near the stock of the blade, and too much at 439 Ihe last two fingers' breadth ofthe curve, about the angle of the jaw. Whether the forceps be straight or curved, I believe both rims ought to be equidistant from each other ; if curved, the very extremity might be bent a little more than it is. In most cases, the blades also might be somewhat shorter, so that when locked, the jointing would be nearer the child's head, and a nearer resemblance would be obtained to the firm grasp ofthe head by a slender hand. But a cautious and dexterous operator may use any form of forceps. In this introduction and application of the blade, however, we do not very nicely manoeuvre to describe any given line ; but are sure, if we introduce it directly behind the pubis, and fairly over the ear, onwards, till it rest, and the handle be brought forward, that it has gone, almost sua sponte, in a right direction. If we carry too much to either side of the pelvis, we have an insecure and bad hold ofthe head. If too far forward on the ear, and the blade traverse a line nearer the face than that described when introduced as directed, it slips. If too far back, it presses on the bulging part of the head, only with its anterior edge, and injures it ; or holds so unsteadily, that it slips, as in the former case. If applied in the diagonal line from the vertex to the chin, the jaw is too much pressed, but indeed it would not be easy at first to get it in this direction. If the blades be not introduced far enough beyond the ear, to get their extremities over the base of the skull, so as to embrace fully the head in their grasp, it is impossible to act with them. The extremities going only as far as the ears, or a little beyond them, may indeed catch the head between their points, but can do no more, and they slip the moment we begin to pull. The first blade being applied, it seldom requires to be supported, but remains sufficiently fixed, between the head and the pubis : and the operator proceeds to introduce the second, exactly in a reversed manner. When the first was inserted into the vagina, its handle was placed almost directly backwards; when the second is inserted, its handle is directed forward ; and, therefore, at this time, the thigh ofthe patient must be raised from the other, by an assistant. The extre- mity is to be guided past the root ofthe first blade, into the passage, by the finger ; and directed, by it, between the perinaeum and the head. By moving the handle backward, and carrying, in the same degree, the extremity ofthe blade up along the sacrum, it traverses the head, in a line corres- 440 ponding to the blade, on the opposite side. It glides easily between the head and vagina, along the curve of the sacrum; and in doing so, comes sometimes very readily, and at once, to meet the lock of the other blade, and join correctly. But, more frequently, it requires a little address to lock the instru- ment so, and it may be necessary to withdraw the one or the other a little, generally the first, which has been pushed too far on, in order to make them meet. If this be not sufficient, it will generally be found that the difficulty arises from the blades not being correctly placed on parallel lines, on the opposite sides of the head, but the one a little nearer the face, or occiput, than the other; so that when we attempt to join them they do not lock, but the handles cross or pass each other. This is rectified by moving the one which seems wrong placed gently to a correct position ; or, if this cannot be done, it must be withdrawn and re-introduced. To attempt, by force, to thrust the handles together, to make them unite, would give pain; and, most likely, the instrument would slip, when we began to act; and if a young practitioner, who tried the forceps for the first time, were foolishly to attempt to pull with the blades, without locking them, he would only pull them out,'without bringing away the head. In joining the instrument, care must be taken, that neither the nympha, nor any other part of the mother, be included in the lock. The finger is therefore passed round the point of junction, before the handles be pressed together, or correctly locked. As the blades are fixed along the sides ofthe head, which is lying in the axis of the brim of the pelvis, it is evident that when they are joined, the handles will be situated in the same line or axis, and therefore will be directed downward, and backward, the lock resting on the margin of the perinaeum. I have directed the first blade to be introduced in front between the head and the pubis, but this is by no means necessary. We may reverse the direction, and sometimes find it much easier to introduce the posterior blade first, and in that case should do so. 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 contracted as to make it just practicable to introduce the forceps or lever, that part of the head which is above the pubis sometimes projects a little over it, so that we cannot pass the 441 blade until we press backward a little with the finger, on that part which we can reach, or when the head is impacted, we may find it necessary to endeavour to raise it a little, in absence of a pain, before we can insinuate the forceps, so far as to facilitate the introduction of the blade. All attempts to overcome the resistance by force, every trial which gives much pain, must be reprobated. But, on the other hand, so long as his conduct is gentle and prudent, the young practitioner must not be 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 have been well ascertained that neither the lever nor forceps could be used. The instrument being joined, we pull it downward, and move it a little, to ascertain that it is well applied. We then begin to extract, taking advantage of the first pain. If the pains still continue, we pull the instrument downward, and backward in the direction ofthe axis of the brim. Then we move the handle a little forward, toward the pubis ; and again, after halting a second, move it slowly back again, still pulling down. We must not carry the instrument rapidly or strongly forward or backward, against the pubis or perinaeum, but the chief direction of our force should be downward, in the direction ofthe axis ofthe brim. The motion ofthe pendu- lum 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, we must be circumspect, and imitate the steps of nature. We must act and cease to act alternately, and examine, as we go on, the progress we are making, and also ascertain that the instrument be still properly adapted to the head ; for it sometimes slips, or shifts ; and this is particularly the case, if it have not been, at first, very correctly applied. The instrument is sure to slip, if the blades have not been introduced far enough to embrace fully the head, or if they be too near the face or the occiput, or be not quite parallel to each other, and however correctly they may at first have been applied, the efforts for extraction may make them shift a little. In this event, we must stop and rectify the error; and, in every instance, must ascertain that the head be descending 3H 442 along witb the instrument, otherwise the forceps may come suddenly away. 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 round on their axis ; and when the face is thrown fully into the hollow, the handles must be turned more forward and upward, being placed in the axis of the outlet. The pendulum kind of motion must now be very little, and is to be directed from one ischium toward another. As the head passes out, the handles turn up over the symphysis pubis. In this stage we must proceed circumspectly, otherwise the perinaeum may be torn. This is more apt to happen, if we be not attentive to the correct position of the forceps on the head. The blades are apt to slip a little, and not embrace the head properly, but when it has descended, and is just about to turn, the blades press much on the perinaeum, and when the head does turn, the convex edge is apt to act so much on the perinaeum, as readily to tear it. If the forceps or lever be injudiciously introduced, the bladder or uterus may be perforated ; or if the head be allowed 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.86 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 neces- sary, the catheter. The parts ought also to be kept very clean, and may be frequently bathed with decoction of camo- mile flowers. If the fonlanelle present, the blades of the forceps are to be placed directly over the ears, and we endeavour, as the head advances, to make the vertex, rather than the face, descend, raising as much as possible the forehead. Indeed, if this can be effected before the forceps be applied, it will be so much the better, that we may have a natural presentation to act on. If the lever be used, its point will rest on, or near, one of the mastoid processes. If the face present, the lever will rest on the back part of the temporal bone, or on the occipital bone, and may be used with advantage.87 The forceps are applied over the ears, and if we can with the hand so far change the position as to make the forehead descend, and the chin rise toward the breast, it will be an advantage. Dr. Davis proposes to bring down the occiput by fixing, on it a vectis, having sharp projections 443 on its concavity,, to fix it on the scalp, but this advice does not appear to have been„adopted. I,have mentioned that a defect of some forceps is* that the blades, for three fingers' breadth from the beginning of the fenestra, are too wide, so that the grasp is made more by the ends, and the convex rims being nearer each other than the concave, in the curved forceps, toward the extremities of the blades, they act chiefly, if not solely, in face cases, and it may generally be said, that in whatever way the forceps be placed, whether with the junction toward the chin or toward the upper part of the face, the instrument, if of this construction, revolves on the head, and the junction, or locking of the blades, becomes opposite to the forehead where the hair begins. The ears are apt to be bent forward in forceps cases. If the forehead be the lowest end of the face, the blade is passed over the temple and the ear, and if curved the convex rim runs over the ear, and the concave rim above it, whilst the extremity winds on the occiput at its upper part. If the.chin be lowest, and cannot be pressed up, the junction of the blades is lower, often between the chin and the nose. The connexion of the blades is regulated by the position of the presentation, and the elevatjpn or depression of the forehead. Turning. th,er child in face presentations, with some little contraction ofthe pelvis, is not to be approved of; for setting aside the pain, and sometimes danger, of turning, there is great risk to the child, owing to the difficulty of bringing the head through the contracted pelvis. It is much better, when it can be done, to change the position of the head with the hand. The power required to be exerted in bringing down the head, must evidently be proportioned to the resistance, and is sometimes very considerable. But much pain to the mother, and fatigue to the operator, are sometimes produced, by not pulling or acting in the proper direction. Having offered these practical directions for the use ofthe forceps, in cases where the head has descended considerably in the pelvis, I am next to state, that sometimes it remains long very high, or is absolutely prevented, by the contraction of the brim, from making any great progress. When it is altogether above the brim, or only a small part, after many pains, has entered, and the conjugate diameter is evidently only three inches, the forceps, even if the blades could be applied, could not, when joined, be brought through, if they do not approach nearer to each other than is compatible with 444 the safety of the child; and therefore the head must be lessened. The blades of the forceps may be made with little curvature, so that, when joined, they shall not be above two inches and a half from each other; and, when applied, they may be, by force, brought perhaps to this proximity. But can the head be expected in general to bear this degree of pressure? But, if no such deformity exist, we may contem- plate the application of long forceps, in a high situation of the head. There are two causes which may keep the head high. The first is, such a degree of contraction of the brim, as renders it difficult for the uterus to force the head so low, as in ordinary forceps cases, and dangerous to wait until time ascertain, practically and experimentally, the impossibility of accomplishing this. The more yielding parts ofthe cranium have entered, the scalp probably is swollen, but all the more solid and resisting part of the head is still above the brim. The finger must be carried high, to feel the ear, and ascertain the position, and the common forceps are too short, as part of their handles would be buried perhaps in the vagina. The second cause is, spasmodic action ofthe uterus, compli- cated with some degree of contraction in the brim, but not so much as to prevent regular and efficient action from forcing down the head; for 1 have known this state occur in those who have formerly borne living children without aid. When spasm in such instances takes place, and is not speedily removed, this very formidable state may be met with ; and so far from the head being forced lower by the pains, it is some- times rather raised a little, during the pain. Long delay, in this state, is dangerous ; and whatever practice is to be adopted, must be resorted to promptly. Inflammation is a frequent consequence, and may begin previous to delivery. It long ago was, and still with some is, the practice, in this state, to turn the child; but the force required to pull the head through a contracted pelvis, can scarcely fail to be fatal to the child, to say nothing of the difficulty and danger of turning in an uterus much contracted. Lessening the head implies, to a certainty, the death ofthe child, which is barely possible to be avoided by the other practice ; but it does not necessarily endanger the mother. A third practice, and that which comes before us now for consideration, is the application of long forceps. It is vain to propose this, when the head possesses its usual firmness, and is of the ordinary size, if the pelvis do not, with the soft lining, measure fully three inches ; for if this be not the case, the forceps, when joined, could not 445 be brought through the pelvis, unless they were so shaped, as to permit of squeezing the head to a degree most probably incompatible with life. Can the blades be introduced when the conjugate diameter does measure three inches? They possibly may; but it is one thing to introduce them, and quite another thing to apply them over corresponding parts of the head, so as to be able to lock them, and obtain a secure fixture. The blade, at the pubis, may be applied in a proper direction, but the projection of the sacrum may turn the other blade more easily aside than an unexperienced man would suppose; and those who have most frequently tried it, will best know the difficulty of adjusting the blades. I have seen much want of dexterity in introducing the common forceps, and the practitioner repeatedly baffled, by the instru- ment slipping. The application of the long forceps requires more dexterity and experience ; and as great danger may arise from the fruitless irritation which is given in those unsuc- cessful attempts, which, besides, end at last in the use ofthe perforator, and often in the loss of the mother, I cannot conscientiously advise any practitioner, until he have become well acquainted, practically, with the application of the common, to attempt the use of the long forceps, which, even in the hand of the most experienced, are but of very limited utility. It is easy to say, let such a man send for another who has more dexterity. Such a person may not perhaps be in his vicinity; and he must, therefore, act according to the best of his skill; and certainly ought not to make a painful and rash attempt to apply the long forceps, but had better lose the child, than to destroy both parent and child. A sensible man will make cautious, and possibly successful, attempts to apply the forceps, without danger to the parent; he will satisfy himself whether he can succeed in this way. He will try early, and before the parts be in such a state as to be irritated by his trial; and if, after a well con- ducted attempt, he fail, he has not injured his patient, and can still use the crotchet successfully. It is not so with the man of inexperience, for too often his attempts only add to the danger; and it is still worse for the patient, if two such practitioners meet; for both must try their skill, and double suffering be inflicted. My opinion, then, on this question, is, that a well instructed practitioner is warranted to make a cautious, steady, but gentle attempt, to apply and employ the forceps, when the crotchet is not decidedly necessary, and the head is higher than it is in ordinary cases admitting the use 446 of the short forceps. But when it is altogether above the brim, the success will bear a small proportion to the disappointment, and I must strongly urge that the operator never make reiterated trials and efforts, which can only end in the pro- duction of fatal inflammation.* I must also say, that I do so from actual observation, that the long forceps may fail in a first labour, where the pelvis is not so. much contracted as to prevent, if the child be only of an average size, the application even of the short forceps in a subsequent parturition. I cannot say that I have known the lever prove successful, when the forceps failed, although, a priori, a superiority might have been expected, as only one blade requires to be introduced.88 When we are going to use the long forceps, in the ordinary position of the head, it is seldom sufficient to introduce two fingers, to guide the blade ; but generally it is necessary, or useful, to introduce the hand into the vagina, as thereby the blade can be more safely and readily conducted over the head. The manner of application is the same as with the short forceps. De Leurie indeed advises the blades to be applied over the face and occiput, but Baudelocque well remarks, that although this may be the easiest way of intro- ducing them, it is the most dangerous for the child. Dr. Davis has also proposed this, and that the blade applied over the face, should have a soft cushion on its concavity to defend the features. The blades being fixed and locked, we next pull a little, and with gradually increasing strength, to see that the hold is secure; being satisfied of this, we endeavour to bring down the head, by drawing, as has formerly been described, in the proper direction, that is, downward and backward. If the head be of full size, and firm, and the blades made to approach considerably nearer each other, than three inches, at their greatest curvature, the handles at first cannot touch each other, nor come quite in contact, till so much pressure have been applied, as shall diminish the size of the head sufficiently. This strong pressure it is always pos- sible to employ, but not always safe; and therefore, if the blades be made to approach near each other, we never ought to make more pressure than is necessary. If it be often * Smeliie andPadecomb first used the forceps in this high situation. Levret does not even notice such a case ; succeeding writers have held various opinions. Baudelocque prefers turning, when that is practicable ; Capuron joins with him, when the conformation ofthe pelvis is good ; but when [it is a little con. tracted he prefers the forceps. In greater degrees, ho looks on the instrument as murderous. Flamant and Gardien prefer it to turning. Dr. Hamilton and Dr. Osiander both use it. Saxtorph and Plenk, again, positively forbid it. 447 difficult to extract the head when it is impacted, within reach of the short, it must be still more so, to bring it down with the long forceps, for less has entered the brim, and the resistance is greater. In this attempt, it is not the child only, that is at stake, but the mother is in jeopardy, from the pressure on the soft parts, and this pressure must, in spite of all our caution, and all the time we can take, often be great, but it never ought to be unprofitable. For instance, if the forceps be completely closed, showing that they cannot be made less, and if by the finger, we find that the blades are in a manner jammed in the conjugate diameter, and that the most curved part has scarcely passed, is it not evident, that farther attempts must be fruitless, and inexpressibly danger- ous ? Is it not physically impossible, indeed, to deliver, unless the pelvis give way, or the blades be not tempered, but yield, and come closer together ? This danger may be avoided, it may be replied, by diminishing the curve, or distance of the blades. True: it is possible to crush the head, into a very small size ; but is it not better, as this must destroy the child, to open the head, and deliver with safety at least to the mother ? ORDER SECOND. It unfortunately happens, that sometimes the pelvis is so greatly deformed, as not to permit the head to pass, until it have been lessened by being opened. It is universally agreed, that a living child at the full time cannot pass through a pelvis whose conjugate diameter is only two inches and a half. It has been even stated, by high authority, that if the dimensions were "certainly under three inches, a living child could not be born." This opinion is decidedly correct, and the few exceptions which may per- chance occur, depend on the original size and peculiar consti- tution of the child ; together with the pliability ofthe cranium, or the peculiar shape ofthe pelvis : and the force and activity ofthe uterus, as well as the general strength ofthe woman. The resisting part.of the base of the skull, often measures above three inches and a half, -sometimes near four inches; and, in this case, with all the effort made by the fo*«eps, even supposing that they could be applied, it must top in every instance laborious, and, in many, next to impossible, with safety to the mother, leaving the child altogether out of the question, to bring down the head. There have,' indeed, been instances, where, even by the efforts of nature, living children 448 have been expelled through a pelvis measuring only three inches ; and there are similar examples ofthe delivery being, under the same conformation, accomplished by instrumental aid.* Every one knows, that even at the full time, the child is sometimes very small, or the head, when not very diminutive, may be either small at the base, or more than usually pliant. But in making up our judgment in a case of deformity, we are not justified in calculating on the happy coincidence of such a state; but ought, unless the finger can inform us to the contrary, to reason on the ordinary size and firmness of the cranium. We are not warranted, therefore, instantly to open the head, merely because we estimate that the pelvis does not, in its conjugate diameter, measure fully three inches; but because we have ascertained, by a sufficient but not a dangerous trial, that the uterine action cannot force down the head, so that the forceps or vectis may be applied or acted with effectively. In all cases where the dimensions and cir- cumstances ofthe 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, far less in a dangerous manner, but deliberately and attentively, to introduce and act with the vectis or forceps. To ascertain the dimensions of the pelvis, the hand in general will require to be introduced into the vagina, unless the fingers be very long. We may, however, if the dimensions be under three inches, be assured, that delivery, at the full time, cannot be accomplished without the destruction of the child. But as it is a matter of great nicety to determine, within a fraction of an inch, the capacity of the pelvis, a practice founded alto- gether on arithmetical directions must be unsafe. In every case, therefore, we ought to allow some time for the pains to produce an effect; and this time should be longer or shorter according as, in our estimation, the dimensions diminish below three inches. When this is the case, even in a small degree, we have no reason to expect that the head can pass, unless it be unusually soft and small, or burst,t or be artificially * M. Baudelocque relates a most interesting case, where there were decided marks of the fcetus being dead in utero, and yet these were delusive ! for, by the forceps, the woman was delivered of a living child, although the pelvis measured only about three inches. L'Art. des Accouch. last edition, sect. 1917.—Cases in point may also be seen in Dr. Alexander Hamilton's Letters, pp. 94, 102, 13.— Similar instances hate come within my own knowledge. t So far as I can judge, the sutures yield sooner than the scalp, and the brain is effused, or pushed out like a bag. When the integuments open first, it is owing, I apprehend, to sloughing from pressure and injury. A very distinct case of spontaneous bursting ofthe cranium may be found in Dr. Hamilton's Cases, p. 17. 449 opened; and therefore it should, for the advantage of the mother, be perforated as soon as the os uteri is properly dilated ; and this ought always to be effected in, at the farthest, the time formerly specified ; but until the os uteri be fully opened, no attempt to introduce the perforator can be sanc- tioned. One circumstance, however, must be attended to in our consideration, namely, that the promontory of the sacrum may be directed somewhat obliquely, in which case, although the conjugate diameter measured, from that to the front, do not extend to three inches, yet toward the side, the diameter may be greater. The thickest part of the head may find its way down there, whilst a narrower or more compressible portion may pass at the smaller part. In cases at all doubtful, it is imperative to wait for some time to ascertain what can be effected ; not that delay is less injurious in crotchet than in forceps cases, but because interference in the latter may be productive of much benefit, without purchasing that at the certainty of mischief; whilst in the former, the greater safety, or abridged suffering, ofthe mother, arising from the perforation, necessarily implies the destruction of the child. Some eminent men on the Continent seem to think, that the long forceps may in most cases supersede the necessity ofthe crotchet; but I must dissent from this opinion, and whilst I endeavour to prevent the unnecessary loss of the child, I cannot place out of consideration the danger, if not the destruction of the mother, which may follow from improper and injudicious delay. But although it be thus laid down as a general rule, that the pelvis which measures fully three inches in its conjugate diameter, may possibly admit a living child to pass, either by the application 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 considerably above three inches. This may become necessary, owing to the great size of the child and firmness of the cranium, or a hydrocephalic 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 delivery,t or spasmodic action of the uterus may * I have seen a cranium so enlarged with water, that when it was inflated after delivery, so as to resume its former size, it measured twenty-two inohea in eircumfesence. t Baudelocque, l'Art des Accouch. sect. 1705.-«-Sea also a 6as* ha p»iat i* Dr. A. Hamilton's Letters, p. 83.—Every attentive practitioner must, item his own experience, admit the fact. 31 150 so retard the descent of the head, as to prevent it from coming within reach of the forceps, within a time safe for the mother, or of avail to the child. The parts may also be so tender, as to render even a common examination painful, and to prevent the application of the forceps, or their effective action, in a case merely equivocal. I have seen in a first labour, from the tardiness of the process, and slow descent ofthe head, the long forceps fail in the hands of a very judicious operator, now dead, although the conjugate diameter of the pelvis measured three inches and a half, and, in that case, even the use ofthe crotchet required exertion. 1 know some will be ready to say, the operator failed when he ought to have succeeded ; but I was most attentive to the steps, and quite satisfied of the correctness of the opinion I give of the impracticability of delivering with the forceps in this particular case. Alarming convulsions may likewise induce us to perforate the head in a case of deformity, where it is perhaps possible that the vectis or long forceps might succeed, after a greater delay or length of time than is compatible with the safety of the mother; but this combination of evils must be rare. No practitioner, I believe, in this city, has met with such a case. At one period, however, the crotchet was employed in cases of convulsions, where the vectis or forceps would now be used. . By the rash and unwarrantable use of the crotchet, living children have been drawn through the pelvis with the skull opened, and have survived in this shocking state for a day or two.* To prevent all risk of bringing a living mutilated child to the world, and to avoid, at the same time, killing or giving pain to the child,+ even in those cases which clearly demanded the use ofthe perforator, some have delayed operating until the child appeared to have been destroyed by the expulsive efforts, or other causes, and have therefore been anxious to ascertain the signs by which the death of the child might be known.J It was still more desirable to know these, at a time • Vide Mauriceau, obs. 584—La Motle, case cxc—Hamilton's Letters, p. 153.—Peu La Pratique, p. 346.— Crantz de Ee Instrument, &c. sect. 38.— Mr. Hammond relates a case where the child lived 46 hours. It was able to cry, and was supposed to die more immediately from loss of blood than injury ofthe brain. The cerebellum was not hurt. Med. &. Chir. Trans, vol. XII part 2d. t It has been disputed, whether the child in utero was capable of sensation • but both facts and reasoning are'in favour of its sensibility. X The signs of a dead child have been described to be a feeling of weight or »«n»ation of rolling in the uteri*, want of motion ofthe child, pallid countenance 451 when the forceps were undiscovered. But the signs are in general extremely equivocal, nor is this much to be regretted, for we do not operate because the child is dead, but because it is impossible for the woman to be otherwise delivered. The steps of the operation are very simple: the rectum, but especially the bladder, being properly emptied, we place the fore-finger of one hand on the head ofthe child, and with the other hand convey the perforator to the spot on which the fingers rest. 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 perforator, being placed on the head, must have its handle in the axis of the brim, which may require the perinaeum to be stretched back. These points being attended to, the scalp is then to be pierced, and the point ofthe instrument rests on the bone, through which it directly, or after a momentary pause, is to be pushed, either by a steady thrust, or a boring motion.89 It is to be carried on, till checked by the stops. The blades are then to be opened, so as to tear up the cranium ; and in order to enlarge the opening, they may be closed, and turned at right angles to their former position, and again opened, so as to make a crucial aperture. If the liquor amnii have been well evacuated, and a portion of the cranium have entered the pelvis, the perforation can be made without any assistance ; but if the whole of the head be above the brim, it may be and sunk eye, coldness ofthe abdomen, with diminution of size, flaccid breasts which contain no milk, foetor of the discharge from the vagina, liquor amnii coloured apparently with meconium, although the head presents, puffy feeling of the head, want of firm tumour formed by the scalp when the head is pressed in a narrow pelvis, no pulsation in the cord, &c. Most of the cases requiring the crotchet cannot be benefited by any marks characterizing the death of the child in the progress of gestation; and we well know, that the child may die during labour, without testifying this for a length of time by any sensible signs ; and that those enumerated above are deceitful, I believe every attentive and unprejudiced practitioner will join with me in maintaining. Nothing but un- equivocal marks of putrefaction of the child itself can make us certain, and these cannot be discovered for some time. Foetor 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 recovery prove bad. I may notice here, that in order to get rid of the crotchet, small forceps have been applied over the collapsed head, or a kind of crutch or tire-tete has been inserted within the cranium. Some have employed a trephine in place perforator. 452 necessary to have it kept steady, by 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 car. It is scarcely necessary to break the brain down, by turning the perforator round within the head. If part of the cranium have entered the pelvis, some ofthe brain will come out with a squirt, whenever the bones are opened ; and at all times we have more or less haemorrhage from the vessels of the brain. Sometimes the blood flows very copiously. We have been advised always to delay a considerable time after opening the head before we apply the crotchet, and doubtless, if the perforation have been made early, we may leave the case for a little to the operation ofthe uterine efforts, which, although they may not effect delivery, yet may force the yielding head down, and render the action ofthe crotchet less severe. But when the labour has been already long protracted, the ropriety of this direction is to be disputed, on grounds I ave formerly explained, relating to instrumental aid. If there be reason to believe that the crotchet can at once be easily used, what advantage is there in delay ? In greater deformity there may, on the other hand, be advantage in delaying for some time. Dr. Osborn, in his Essays, advises, that the head should be opened early, and that we should then delay to extract for thirty hours. In cases of deformity, decidedly re- quiring the use of the crotchet, the first direction is important; but the delay ofthe specific number of thirty hours is, in most cases, if not in every instance, much too long ; and I question if it be sufficient to produce, in any case where the child was alive when the skull was perforated, such a degree of putre- faction 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 further assistance. But this is not a general occurrence, for the base ofthe skull does not readily yield, and it is better at once to use the crotchet. But in all cases, if the deformity be greater, or the pains weak, only the pliable part of the cranium will descend, and the face and basis of the skull remain above the brim of the pelvis, until artificial force be used. When this aid is required, which is generally the case £ 453 the crotchet is to be introduced through the aperture of the cranium, and fixed upon the petrous bone, or such projection of the sphenoid bone, or occiput, as seems to afford a firm fixture, or on the outside of the base of the skull, at the pubis. This will be generally near the mastoid process, and is often found to be a good situation. We then pull gently, to try the hold ofthe instrument ; and this being found secure, we proceed to extract in the direction ofthe axis ofthe brim, by steady, cautious, and repeated efforts, exerting, however, as much strength as may be necessary to overcome the difficulty. In doing this, we must always keep a hand, or some of the fingers, in the vagina and on the cranium, to save the soft parts, should the instrument slip. If the force be steadily and cautiously exerted, we may always feel the instrument slipping or tearing the bone, and have warning before it come away. We should, in extracting, cooperate as much as possible with the pains. Sometimes an extractor, in the form of pincers, is used in place ofthe crotchet, or different tire-tetes have been proposed. The craniotomy forceps, at present used, are considered safer than these, and preferable to the crotchet: one blade goes within the bone and scalp, and the other without. A kind of double crotchet, one blade going within, and another with prongs going without, has been'proposed by Dr. Davis. In cautious hands, however, I think the crotchet may be safely trusted. It is quite a mistake to suppose that because the head is opened, therefore, the delivery must be easy. The force requisite to bring down the base ofthe skull, even when the pelvis is barely so small as to prevent the application of the forceps, is often much greater than is generally used in forceps cases. The reason is to be found in the remarks I have made on the action ofthe vectis, part of the force being spent unprofitably. It is not very easy to fix the crotchet, so as to make its action on the head be direct, without inclining it in any degree obliquely, with regard to the axis of the pelvis, or making it press unprofitably, or even hurtfully, on some part. Small forceps, whose blades could come considerably within three inches of each other, may, in this particular degree of contraction, on the principle I have formerly noticed, act better and require less exertion. But it may happen, 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 facili- tated by the softening of the head, which takes place some time after death, rather by pressure than putrefaction. If the 454 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 been much squeezed, or the child have been dead, before labour began, the parietal and squamous bones come easily away, and the frontal bones separate from the face, bringing their orbitary process with them. We have then only the face and basis of the skull left, and if the pelvis will allow these remains to pass, then the crotchet can be used. I have carefully measured these parts, placed in 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 ofthe nose to the chin. For, in my experiments, after the frontal bones were completely removed, this did not in general exceed an inch and a half. It is therefore of great advantage, to convert the case into a face presentation, with the root of the nose directed to the pubis. The size ofthe crotchet, which ought to be passed over the root ofthe nose, and fixed on the sphenoid bone, must, however, be added to this measurement. I never have yet been so unfortunate as to meet with what maybe considered as the smallest pelvis, admitting of delivery pervias naturales ;* but I would conclude, that whenever the pelvis, with the soft parts, measures fully an inch and three quarters,t or, if the head be unusually small, the child not being at the full time, an inch and a half, the crotchet may be employed, provided the lateral diameter of the aperture in the pelvis be three inches, or within a fraction of that, perhaps two inches and three quarters, if the head be small or very soft; and the operation will be easy, as we extend the diameter ofthe pelvis beyond what may be considered as the minimum. It is scarcely necessary to add, that if the outlet be much contracted, it will make the case more unfavourable ; and where we have any hesitation, owing to the shape and dimensions of the brim, will determine us against this operation. It ought not to be forgotten, that it is one thing to extract, and another to extract safely, in extreme deformity. Gardien mentions, that * 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 Caesarean operation, has occurred in this city, since the year 1775, when Mr. Whyte performed the latter operation. X M. Baudelocque considers the crotchet as inadmissible, when the pelvis measures only an inch and two thirds. Dr. Davis says, that by means of bone nippers, or what he calls an osteotomist, he has so broken the cranium as to bring it through a machine with an aperture of only one inch diameter. 455 Boyer and other judicious practitioners, have witnessed re- peatedly the mutilation and extraction of the child by eminent men, but the mother sunk immediately. In two of these cases the uterus was ruptured. 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 instrument in the foramen magnum, then, as we have the chin thrown down on the throat, we must have both the neck and face passing at once, or a body equal to two inches and three quarters. If, on the other hand, we fix the instrument on the petrous bone, which is certainly preferable to the foramen magnum, and bring the head sideways, we must have both that bone and the vertebrae passing at once, or a substance equal to two inches and a half in diameter; and if the head pass more obliquely, then it is evident that the size must be a little more. Although, therefore, Dr. Osborn be correct, in saying, that the base of the cranium, turned sideways, does not measure more than an inch and a half; yet we must not forget, that when the opposite side comes to pass, the neck passes with it, which increases the size. The head being brought down and delivered, we ihen fix a cloth about it, and pull the body through ; or, if this cannot be done, we open the thorax, and fix the crotchet on it, endeavouring to bringdown first a shoulder, and then the arm. In operating with the crotchet, we must always bring the head through the widest part of the pelvis; but where the deformity is considerable, no small force is requisite. This is productive of pain during the operation, and of danger of inflammation afterwards, which may end in the destruction of some 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. Much advantage is also derived in this kind of pain, from applying a compress on the sacro-sciatic notch, and binding it on with a roller, wound firmly round the pelvis, and all the upper part ofthe thigh. 456 In considering the necessity of using the crotchet, 1 have not, more than in the observations on the forceps, made any special remarks on those instances where the capacity ofthe pelvis is diminished by an enlarged ovarium, or other tumours, as the practice is the same, or when a different course is proper, that has been pointed out in the commencement of this work. To avoid the destruction of the child, and the severity of the operation of extracting it, the induction of premature labour has been proposed ;* and the practice is defensible, on the principle of utility as well as of safety. We know that the head of a child, in the beginning of the seventh month, does not measure more than two inches and a half in its lateral diameter; two and three quarters in the end of that month; and from three to three and a half in the end of the eighth month. We know, further, that there is no reason to expect that a full grown fcetus can be expelled alive, and very seldom, even after a severe labour, dead, through a pelvis whose dimensions are only three inches ; and, lastly, we have many instances where children born in the seventh month have lived to old age. Whenever, then, we have, by former experience, ascertained beyond a doubt, that the head, at the full time, must be perforated, it is no longer a matter of choice, whether, in succeeding pregnancies, premature labour ought to be induced.90 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.t All the principles of morality, as well as of science, justify the operation ; they do more, they demand the operation. Two methods have been pro- posed for exciting expulsive action; First, by insinuating a finger within the os uteri, and gently dilating it, and detaching * This practice was first adopted about the middle ofthe last century, by Dr. Macauly in London, and was afterwards followed out by others. About twenty years after this, it was proposed on the Continent by M. Roussel de Vauzeme ; and lately Mr. Barlow, in the eighth vol. of Med. Facts, &c. has given several cases of its success.—See also Med. and Phys. Journal, vols. XIX. XX. and XXI. It may not be improper for me to mention as a caution, that I have been called to consider the expediency of evacuating the liquor amnii, where there was no deformity of the pelvis, but merely a collection of indurated faeces in the rectum. Dr. Merriman has a very sensible paper on this subject, in Med. Chir. Trans, vol. III. p. 123. where he states that, out of 47 cases of premature labour, induced on account of distorted pelvis, 19 children have been born alive, and capable of sucking. He very properly advises that, before puncturing th« membranes, it should be ascertained that the presentation is natural. If it be not, it may become so in a day or two. + It has been proposed, by low diet, to restrain the growth of the child; but this is a very uncertain and precarious practice. It is romantic. 157 a part of the membranes, from the portion of the cervix in its immediate vicinity. This may also be done, by conducting within the os uteri a pair of ball forceps, by slightly opening which, we gently and slowly dilate it, so as freely to admit the finger. This is better than the finger alone, and gives less unprofitable irritation. It ought to give no pain referrible to the os uteri, but is productive of sensation not amounting to pain in the back. If we have not thought it prudent to dilate at once the os uteri, so as to admit the finger freely to touch the membranes, we may repeat the dilatation gently at the end of twelve hours, and then detach cautiously the membranes as far as the finger can reach. If this be not followed by indications of labour within three or four days, we must have recourse to the second proposal, namely, evacuating the liquor amnii, by piercing the membranes with a long narrow-pointed probe, conducted by the finger, or a canula, with a concealed stylet, the point of which is, after the canula is guided by the finger within the os uteri, to be barely pushed so far on as to pierce the membranes. Could the first always be depended on, it would be preferable to the second, as evacuation ofthe water is sometimes succeeded by spasmodic or partial con- traction of the uterine fibres. It ought, therefore, always to be first tried. The period at which the labour should be excited must depend upon the degree of deformity; and where that is very great, it must be 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 singular, where the bones gradually yield, and become so distorted, as at last to prevent even the crotchet from being used. Now, granting a succession of pregnancies to take place in this situation, it follows, as a rule of conduct, that if the deformity be progressive, we should regularly shorten the term of gesta- tion, exciting abortion, even in the third month, if necessity require 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 abortion, destroy many children to save one woman ? This objection is more specious than solid. Those who make it, would not, in all probability, scruple to employ the crotchet frequently; and where is the difference to the 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 3K 458 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 them. The interval which elapses between the use of the means for promoting labour and its accession, varies from two to five or six days ; the fourth day is not an unusual time. If shiver- ing come on before pain, an opiate is the best remedy. CHAP. VII. Of Impracticable Labour. It may be urged against the reasoning in the conclusion of the last chapter, that the Caesarean operation ought to be per- formed; and, doubtless, in cases of extreme deformity, if the proper time for inducing labour be neglected, it must be per- formed. But the danger is so very great to the mother, that this never can be a matter of choice, but of necessity. In balancing the Caesarean operation against the use of the crotchet, or the induction of abortion, we must form a com- parative estimate of the value of the life of the mother and her child. By most men, the life of the mother has been considered as of the greatest importance, and therefore, as the Caesarean operation is full of danger to her, no British prac- titioner will perform it, when delivery can, by the destruction of the child, be procured per vias naturales. As, in many instances, the woman labours under a disease found to be hitherto incurable, it may be supposed, that the estimate will rather be formed in favour of the child. But, in the first place, we cannot always be certain that the child is alive, and that the operation is to be successful with respect to it; and, in the second place, it ought to be considered how far it is allowable, in order to make an attempt to save the child, to perform an operation, which, in the circumstances we are now talking of, must, according to our experience, doom the mother to a fate, for which, perhaps, she is very ill prepared. There are, I think, histories of twenty-three cases, where this operation has been performed in Britain ; out of these only one woman has been saved,* but eleven children have been preserved. On the Continent, however, where the ♦ Vide a case by Mr. Barlow, in Med. Records and Researches, p. 154. 459 operation is performed more frequently, and often in more favourable circumstances, the number of fatal cases is much less.* If we confine our view to the success of the operation in this island, we must consider it as almost uniformly fatal to the mother. This mortality is owing, not only to the injury done to the cavity of the abdomen, and the consequent risk of inflammation, even under the most favourable circumstances, and with the best management; but also to the morbid con- dition ofthe system, at the time when the operation was per- formed, many of the women being affected with malacosteon, which would in no very longtime have of itself proved fatal. These dangers have, probably, sometimes been increased by delaying the operation, until much irritation had been excited. From this unfavourable view, it may perhaps arise as a ques- tion, whether nature, if not interfered with, might not, as in extra-uterine pregnancy, remove by abscess the child from the uterus ? It has been said, that this event has taken place ; but I do not recollect one satisfactory case upon record. Whenever this has happened, the uterus has either been ruptured, and the child expelled into the cavity of the abdomen; or, in a very great majority of the instances, the child has, evidently from the first, been extra-uterine. We are therefore led to conclude, that the mother who cannot be delivered by the crotchet, must submit to the Caesarean operation, or must inevitably perish, together with the .fruit of her womb. It has been asserted by Dr. Osborn, that this operation can seldom if ever be necessary; never where there is the space of an inch and a half from pubis to sacrum, or on either side : and that he himself has, in a case where the widest side ofthe pelvis was only an inch and three quarters broad, and not more than two inches long, delivered the woman, by breaking down the cranium, and turning the basis ofthe skull • According to Dr. Hull, we had, when he published, at home and abroad, records of 231 cases of this operation, 139 of which proved successful.—Vide Translation of M. Baudelocque's Memoir, p. 233. A greater number now exist. See also Sprengel, Hist, de Med.—In a case fatal to both mother and child, the operation was, on the 3d day of labour, lately performed at Pavia, by Dr. Omboni. The pelvis measured three inches and a line, but the os uteri could not be dilated by the finger. The occiput lay to the pubis. She was bled without advantage. The practice in such a case I apprehend ought to be, after free venesection, to introduce the hand into the vagina, and gradually dilate the os uteri, and then use the perforator. If the os uteri, from disease, could not be dilated, it should be cut. In a case related by Vanderfuhr, the woman was only 3 feet 8 inches high, and the sacro-pubic diameter under two inches. The operation was performed in the linea alba, and the mother was able to nurse her child. 460 sideways. As the patient recovered, and afterwards, I think, died in the country, where she could not be examined, we cannot say to a certainty what the dimensions of the pelvis were. Dr. Osborn must only speak according to the best of his judgment. I have the highest respect for his character and for his works, and nothing but irresistible arguments could make me doubt his accuracy. But from the statement which I have already given of the dimensions of the head, when broken down at the full time, as well as from the experiments of Dr. Hull, and the arguments of Dr. Alexander Hamilton and Dr. Johnson, I am convinced that there must be some mistake in Sherwood's case. Had the child been brought by the face, there might have been room for it to pass, so far as the short diameter of the passage is concerned; but the lateral diameter is too small for the head, if of the usual size, to pass, in that which I consider as the most favourable position. In the cases related by Dr. Clarke,* who was a practitioner ofthe highest authority, we are informed, that the short diameter of the passage did not exceed an inch and a half, but we are not informed of the lateral extent. As the women both recovered, the precise dimensions and construction of the pelvis cannot be determined. It is like- wise much to be regretted, that the diameter ofthe cranium, or cranium and neck, in the state in which they may have been supposed to come through the passage, was not taken after delivery. Where, and only where, it can be ascertained, that the head placed in the position in which it was drawn through the pelvis, does not form, in any part, a substance measuring more than an inch and a half by two inches or three inches, it is allowable to infer, that the cavity through which it passed may have been as small as that. Finally, this is a question, on which, although we may lay down a general rule, we must admit of some exceptions ; for a premature, or a very small child, may be brought through a pelvis which will not permit, by any means, an ordinary sized foetus to pass. But it behooves us, in our reasoning, to judge every child to be at the full time, unless we know the contrary, and to make an estimate on the average magnitude ; and until the contrary be proved, by dissection ofthe mother, or careful and rigid measurement ofthe child after delivery, I roust hold to the position formerly laid down, that the crochet cannot be used when the child is of the full size, * Vide Dr. Osbom's Essays, p. 203, and London Med. Journal, vol. VII. p. 40. 4G1 unless we have a passage through the pelvis, measuring fully an inch and three quarters in the short diameter, and three inches in length; or, if the child be premature and soft, an inch and a half broad, and two inches and three quarters long.* It is in this extreme deformity even questionable whether extrac- tion be not as dangerous as the Caesarean operation, and we always ought to consider well, before we give the preference to mutilation in such cases. The operation itself, although dangerous in its consequences, and formidable in its appearance, is by no means difficult to perform. Some advise the incision to be made perpendi- cularly in the linea alba,91 others transversely, in the direction ofthe fibres ofthe transversahs muscle. Perhaps the precise situation and direction ofthe wound must be regulated by the circumstances of the case, and the shape of the abdomen; but, in general, I apprehend that the transverse wound will be most eligible. The length of the incision, through the skin and muscles, ought to be about six inches ; and if a vessel bleed, so as to require the ligature, it will be proper to take it up before proceeding further. The uterus is next to be opened by a corresponding incision ; and as the fundus, owing to the pendulous shape of the abdomen, is the most prominent part, the incision will in general be made there, unless the external wound be made lower than usual. The child is next to be extracted, and immediately afterward the placenta. One assistant is to take the management of the child, whilst another takes care to prevent the protrusion of the bowels. In this part ofthe operation, although pretty large vessels are divided, yet the haemorrhage is seldom great; it has, however, proved fatal. The external wound is now to be cleaned, its sides brought together, and kept in contact by a sufficient * I believe few will dispute, that the precise deformity requiring the Caesarean operation, must, to a certain extent, be modified by the dexterity of the operator. I shall suppose that a surgeon in a remote part of the country, far from assistance, is called to a patient, whose child is evidently alive, and whose pelvis measures just as much as would render it barely possible to use the crotchet, were he dex- terous ; but he has not a belief that he could accomplish the delivery with that instrument. Would that man be wrong in performing the Caesarean operation 1 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 more experienced can be had, within such time as can be safely granted, the surgeon ought, after taking the best advice he can procure, to perform the Caesarean operation, by which he will save one life at least. By the opposite conduct, there is ground to fear that both would be lost. In a case related in the Jour, de Med. for 1780, a woman in the village of Son, had the child turned, and even the limbs separated without delivery being accom- plished ; four days afterwards, the Caesarean operation was performed, and the woman died. 462 number of stitches passed through the skin alone, or the skin and muscles, avoiding the peritonaeum. Adhesive plasters are to be placed carefully in the intervals; and, a bandage with a soft compress being applied, the patient is to be laid to rest. An anodyne should be given, to diminish the shock to the system ; and our future practice must, upon the general principles of surgery, be directed to the prevention or removal of abdominal irritation or inflammation. The patient may die although there be very little inflammation of the peri- tonaeum. It has been proposed by Dr. Hull, to whose work I refer for more particular information, to operate as soon as the os uteri is dilated, and before the membranes burst, in order that the wound of the uterus may contract into a smaller size. When the mother dies in the end of pregnancy, and there is reason to think that the child is alive, there is an imperative call to perform the operation. The uterus may live longer than the body, and after the mother has been quite dead the child still continue its functions. An instance is lately related by Dr. Ebel, where the uterus expelled a child after the interment of the mother, and the fact was discovered by raisin" the body for examination owing to a suspicion of murder. A woman died of dysentery of two months' duration in the end of pregnancy, and by the operation performed about twelve minutes after death, a living child was extracted. Dr. Jackson restored to animation a child extracted half an hour after the mother's death. In order to supersede the Caesarean operation, and even to avoid the use of the crotchet, it was many years ago proposed to divide the symphysis pubis, in expectation of thus increas- ing the capacity of the pelvis. This proposal was founded on an opinion, that the bones ofthe pelvis, either always or fre- quently, did spontaneously separate, or their joinings relax, during gestation and parturition, in order to make the delivery more easy. In deformity of the pelvis, the symphysis was first divided by a knife during labour, by M. Sigault, in 1777, assisted by the ingenious M. Alphonse Le Roy. The operation was afterwards repeated on the Continent, with various effects, according to the degree of deformity and extent of the separation.92 It has only once* been adopted in this country, because it is not only dangerous in itself to the * Vide case by Mr. Welchman, in London Med. Jour, for 1790, p. 46. 463 mother, but also of limited benefit to the child. We have already seen, that there is a certain degree of deformity of the pelvis, which must prevent a child, at the full time, and of the average size, from passing alive, or with the head entire. Now, in a case where it is barely impracticable to use the lever or forceps, and where it just becomes necessary to open the head, the division may perhaps save the child, and with less danger to the mother than would result from the Caesarean operation, which is the only other chance of saving the infant. If we increase the contraction of the pelvis beyond this degree, then the chance of saving the child is greatly diminished; and the extent to which the bones must be separated to accomplish delivery, would in all probability be attended with fatal effects. In such a case, the crotchet can be employed with safety to the mother, and continues to be eligible, until we find the space so small as to require the Caesarean operation ; and in this case, the division can do no good. It cannot even make the crotchet eligible, owing to the shape of the pelvis in malacosteon, and the great mischief which would be done to the parts after the division, by the necessary steps ofthe instrumental delivery. There is only one degree of disproportion, then, betwixt the head and the pelvis, which will admit of the division ; but the smallest deviation from this destroys the advantage of the operation. Now, as this disproportion is so nice, we cannot, in practice, ascertain it; for although we could determine, within a hundredth part of an inch, the capacity of the pelvis, yet we cannot determine the precise dimensions of the head, and thus establish the relation of the two. On this account the division of the symphysis pubis cannot be adopted with advantage, either to the mother or child. CHAP. VIII. Of Complicated Labour. ORDER FIRST. During labour, there is always a slight discharge of bloody slime, when the membranes begin to protrude : for the small vessels ofthe decidua, near the cervix uteri, are opened. In some cases, a very considerable quantity of watery fluid, tinged 464 with blood, flows from the womb, but this is attended with no inconvenience. It may happen, however, that pure blood is discharged, and that in no small quantity. If this take place in the commencement of labour, it differs in nothing from those haemorrhages which I have formerly considered. But occasionally the flooding does not begin, till the first stage of labour be nearly or altogether completed. If the membranes be still entire, it proceeds certainly from the detachment of part of the placenta or decidua, and often is connected with unusual distention of the uterus, from excessive quantity of liquor amnii, or with ossification ofthe placenta. If the mem- branes have broken, then we must consider the possibility of its proceeding from rupture of the uterus, and must inquire into the attending symptoms. Sometimes it will be found to proceed from tedious and exhausting labour, from improper exertion, or rude attempts to dilate the os uteri, or alter the presentation ; or it may be caused by rupture ofthe umbilical cord. Now, in this order of labours, the practice is very simple, and admits of little difference of opinion. For every experienced practitioner must admit, that when the haemor- rhage is considerable, and is increasing or continuing, the only safety consists in emptying the uterus. If the pains be smart, frequent, and effective, the labour advancing regularly, and there be reason to suppose that it will be finished before the hsemorrhage have continued so long as to produce injurious effects we may safely trust to nature. We must keep the patient very cool, and in a state of perfect rest. But if the pains be weak, ineffective,and rather declining than increasing, whilst the haemorrhage is rather increasing than diminishing, we must deliver the woman, either by turning the child, or applying instruments, according to the circumstances of the case, and the situation of the head. Opiates are useful. ORDER SECOND. When haemorrhage takes place from the lungs or stomach during parturition, we ought to have recourse, in the first place, to blood-letting, or such other means as we would employ were the patient not in labour. If the haemorrhage continue violent, or be increased by the pains of parturition, we must consider whether artificial delivery, or a continuance ofthe natural process, will be attended with least exertion and irritation, and consequently with least danger, and we must act accordingly. In general, these cases can seldom be trusted to nature, and prompt delivery is requisite. It is scarcely 465 necessary to add, that a complication of labour, with other diseases than haemorrhage, but which may be increased by it to a dangerous or fatal degree, will equally justify interference. Of this complication, pleurisy affords an example. I may also observe, that if this disease occur in the course of pregnancy, and require bleeding, foe. to a great degree, the patient usually has premature labour. ORDER THIRD. Syncope may proceed from various causes, such as haemor- rhage, or rupture of the uterus ; but these cases have been already, or will be considered. It may proceed from a delicate nervous constitution, from long continued labour, from parti- cular states ofthe heart or stomach, from passions ofthe mind, and from an unhealthy state of the spinal cord, in which case it is generally preceded for some time by a distressing feeling of sinking. Syncope, probably from this cause, has proved fatal, without any explanation being given on dissection. A simple paroxysm of fainting, unless it proceed from causes which would otherwise incline us to deliver, such as tedious labour, flooding, foe. is not to be considered as a reason for delivering the woman. We are to employ the usual remedies, and particularly, keep the person in a recumbent posture. Ammoniated tincture of valerian, or tincture of opium, are useful. But if the paroxysms be repeated, whatever their cause may be, we ought to deliver the woman, if the state ofthe os uteri will permit. We must be very careful to prevent haemor- rhage, after the expulsion ofthe child. ORDER FOURTH. Convulsions may occur, either during pregnancy or labour, and are of different kinds, requiring opposite treatment. One species is the consequence of great exhaustion, from excessive fatigue, tedious labour, or profuse haemorrhage. This makes its attack without much warning, and generally alternates with deliquium, or great feeling of depression and debility ; the muscles about the face and chest are chiefly affected, and the pulse is small, compressible, and frequent, the face pale, the eye sunk, the extremities cold. The fits succeed each other pretty quickly, and very soon terminate in a fatal syncope. This species naturally requires that we should, first of all, check the farther operation ofthe exciting cause, by restraining haemorrhage, or preventing every kind of exertion, and then 466 husband the strength which remains, or recruit it by cordials. Opiates are of great service. Delivery is usually necessary. Hysterical convulsions are more common during pregnancy than labour, and have already been noticed. I have only to say here, that the muscles of the trunk and extremities are affected to a greater degree than those of the face; there is an appearance of globus, often considerable palpitation, and occasionally a kind of crowing or screaming during the fit. At the termination of it there is usually wind discharged from the stomach, and often as the struggling is about to end, the bowels seem to be much inflated, and suddenly subside. Part of this, however, is a deception, for the spine is in such cases frequently bent back, so as to render the abdomen apparently more prominent. In the interval there is a tendency to laugh or cry, or sometimes a childish appearance. This kind of convulsion is rare in the parturient state. If the face be flushed, or there be headach, and suffusion of the eyes, vene- section should be premised; and if this be not sufficient, then we give antispasmodics. If, on the other hand, there be no undue vascular action or determination to the head, we may at once give antispasmodics, such as tincture of valerian, or assafoetida; a smart clyster is also of great service. If these means fail, and the labour be far advanced, it will be proper to employ the forceps, but in general artificial delivery is not required. The most frequent species of puerperal convulsions, how- ever, is of the nature of eclampsia, or of tetanus, which occurs a hundred times for once that the others appear. Convulsions may affect the patient suddenly and severely. She rises to go to stool, and falls down convulsed; or, sitting in her chair, conversing with her attendants, her countenance suddenly alters, and she is seized with a fit; or she has been lying in a sleep, and the nurse is all at once alarmed by the shaking of the bed, and the strong agitation of her patient. Imme- diately all is confusion and dismay, and the screams of the females announce that something very terrible has happened. Presently the convulsion ends in a short stupor, from which the woman awakes, unconscious of having been ill; and thus, for a time, the apprehensions ofthe attendants are calmed. But in a short time the same scene is generally repeated ; or, perhaps, although the convulsion have gone off, the stupor remains ; and it is always more unfavourable when the patient continues insensible in the interval ofthe fits. It is, however 467 not unusual for the fit to be preceded by some symptoms, which, to an attentive observer, indicate its approach. These may even exist to a degree which cannot be neglected. They are, headach, which is sometimes dreadful ; ringing in the ears; dazzling ofthe eyes, or appearance of substances floating before them, either opaque, or, more frequently, of a fiery brightness. Or there may be more fixed and constant pain felt in some part of the spine, and always confined to that, without any pain in the head. In other cases, the first indi- cation is violent pain in the stomach, with insupportable sick- ness, for sometimes the stomach is the first part which suffers from irritation of the origin of the nerves, and the patient may die before convulsions take place. The pulse usually is slow ; the patient sometimes sighs deeply or has violent rigors, which, in the second stage of labour, are always hazardous. There is great drowsiness during the pains. It is neither uncommon nor dangerous for the woman to be drowsy between the pains; but here, even during them, she falls into a deep sleep. When the attack comes on, which very often is soon after these preludes appear, the muscles are most violently convulsed ; the whole frame shakes strongly ; the head is jerked quickly and strongly backward or obliquely to one side by the extensor muscles, and the face is dreadfully distorted,* and often swollen. The tongue is much agitated, and is very apt to be greatly injured by the teeth ; foam issues from the mouth, and the convulsive inspiration often draws this in with a "hissing noise;" or she snores deeply, and cannot be roused during the fit. The skin becomes, during the convul- sion, livid or purple. The pulse, during the whole of the disease, is often slow, but sometimes it does at last become frequent, small, and irregular. This attack may end at once in fatal apoplexy, but generally the patient recovers, and is quite insensible of having been ill. There may be only one fit ; and without any interference, I have known the disease go off, and no return take place; but in general the attacks are repeated, and if they do not prove soon fatal, or are not averted by art, they recur with the regularity of labour pains, becoming more and more frequent as they continue; and if the patient have been sensible in the interval ofthe first two orthree convulsions, she soon becomes quite insensible, lying in a state of stupor like apoplexy, agitated at intervals with * Mr. Fynney gives a case, where the lower jaw was luxated during convul. sions, which came on in the birth of a second child, or twin. Med. Comment, vol. IX. p. 380. 468 convulsions increasing in violence ; she appears to have no labour pains, yet the os uteri is affected, and sometimes the child is expelled, or if the patient become sensible in the intervals, and feel a pain coming on, it appears to be speedily carried off by a supervening convulsion. The fit may last only a few seconds, or may continue, with very little remission, for half an hour. In some instances the patient lies for hours insensible after the child is born, and is afterwards long of recollecting her delivery. Convulsions may occur in any period of labour, or before it have begun, or after the delivery of the child; and in this last case, are sometimes preceded by great sickness or oppression at the stomach. Dr. Leak relates the case of a patient who had ten or eleven of these fits ; the abdomen was swelled and tense, and she vomited phlegm mixed with blood, which probably came from the tongue. She recovered by means of blood-letting and clysters. Puerperal convulsions are quite different from epilepsy, for they recur at no future time, except perhaps in a subsequent pregnancy. They take place in greater number in a given time than epilepsy does in general, and belong to the genus Eclampsia of Sauvages, " artuum vel musculorum plurimorum spasmus chronicus acutus,cum sensuum obscuratione." This differs from his definition of epilepsy, by the absence of the character " periodicus;" and on the same principle Vogel simply defines it " epilepsia acuta." The principal difference, and one of a highly important nature in practice, is, that whilst the symptoms are the same in both diseases, they arise, in epilepsy, from some organic affection of the brain, or direct irritation of that organ ; whilst, in eclampsia, they rather depend on some sympathetic and temporary cause—very often the uterine irritation acting on the spinal cord, and thence on the brain. Sometimes the effect on the cord is the most prominent, and the patient may truly be said to have tetanus. Hence, eclampsia may be produced by worms, by costiveness, indigestion, &c.; and occasionally not only by the parturient condition of the uterus, but also by other affections of the same organ, in the virgin state. I have seen distinct cases of eclampsia, where the fits were very severe, and repeated, and accompanied, in the interval, with coma, or delirium, caused altogether by menstrual irritation, attended with severe pain in the hypogastrium and bearing-down sensation. In such cages, venesection and purgatives give relief, and a blister on the head perfects the cure. Fomentations, or the hot-bath, 469 are also useful, but opiates are not to be given, at least at first. To return from this digression, puerperal convulsions often recur exactly like labour pains, or are frequently accom- panied or preceded by them ; though, when the convulsion comes on, the feeling of pain is suspended, and often, but not always, the uterine contraction is stopped or diminished.93 The same observation applies to excessive rigors, which are indeed a species of convulsions, but are not attended with distortion of the face, nor insensibility. If the patient be in a state of stupor, she frequently has the countenance distorted at intervals, accompanied with some uterine action. They are never preceded by aura, and the patient usually recovers sensibility much sooner, and more completely during the intervals, than in epilepsy; at the same time, there have been instances of the patient remaining in a state of stupor for two days. The organs of sense, particularly the ear, are often preternaturally sensible. Sometimes the child is unexpectedly born during a fit. Convulsions, of the kind I am considering, evidently are connected with gestation or parturition ; they occur at no other time, and are more frequent in a first labour. They arise particularly from uterine irritation, but also seem fre- quently to be connected with a neglected state ofthe bowels, a fact to which I wish to call the attention of practitioners. It is a general opinion, that pregnancy produces plethora, and I do not mean here to dispute the fact, but distinctly to assert, that we often confound the effects of excitement with those of fulness ; for in many instances, a powerful stimulus will produce the same consequences, in a spare and bloodless, that a smaller one would have done in a plethoric habit. Is apoplexy confined entirely to the latter ? There are, per- haps, few subjects more deserving of inquiry, than the effects of irritation of the extremities of the nerves supplying the abdominal viscera, on the basis of the encephalon and the spinal marrow. There is nothing either more difficult, or more mysterious, in the etiology of puerperal convulsion, than of chorea, or stupor, or apoplexy, or insupportable feeling of fulness in the head, from stomachic or intestinal irritation, connected with costiveness, worms, bile, or unhealthy action of the alimentary canal. If practical observers know that these causes do pro- duce often such effects, where is the ground of surprise, that uterine irritation, especially when associated with irritation of the bowels, arising from long neglect, should produce 470 tetanic, spasmodic, or even apoplectic affections, during labour? This sympathetic irritation is almost invariably accompanied by an affection of the vascular system, productive of great determination to the head, either directly or indirectly through the medium ofthe spinal nerves, which aggravates the evil, and becomes, indeed, the chief source of danger.* I am inclined to think, that, in a majority of instances, the spinal cord is first affected by the state of the uterine nerves, and immediately afterwards, the head suffers, as described in a future chapter, on spinal and cerebral disease. A strong pre- disposition is given to this condition of the nervous system, by a bad state ofthe bowels, and labour seems to bring the matter to a serious crisis. I shall not, however, enter farther into the theory, but state the practice, which is of more consequence. The first object is, to prevent the patient fioni injuring the tongue, by inserting a piece of cork or wood into the mouth ; this occupies no time. Next, we bleed the patient, and must not spare the lancet. All our best practitioners are agreed in this, whatever their sentiments may be with regard to the nature of the disease, or to other circumstances. We must bleed once and again, whether the convulsions occur during gestation or pregnancy.t There is more danger from taking too little blood, than from copious evacuation. Often, in a short time, several pounds of blood have been taken away with ultimate advantage. Blood-letting also tends to relax the os uteri. The quantity to be taken away must depend on the severity and obstinacy ofthe symptoms. We never ought to take away more than is required for relief; nor, on the other hand, are we to stop prematurely. It is desirable to procure the discharge as speedily, and in as full stream as possible; but it is not essential, that it be taken from the jugular vein, nor is that often safe and practicable.94 I have, when treating of the diseases of pregnancy, observed, that in many cases, affections, arising evidently by sympathy from a state of irritation of some of the abdominal viscera, might require venesection for their removal; or, if this were * It has been supposed by Mr. Power, that convulsions depend on a transla- tion of, what he calls, the parturient energy, from the uterus to the brain, or that there is a metastasis of action. f La Motte mentions a case, 522, where a woman, in the last five months of pregnancy, was bled eighty-six times. Sometimes 2 oz. would relieve her.—By modern practitioners, from 40 to 80 oz. have been taken with advantage, in a case of puerperal convulsions. Puzos insists on the necessity of copious blood-letting and speedy delivery. This practice is adopted by the most judicious ofthe pre- «ent day. 471 neglected, and the disease treated merely by purgatives' pro- tracted illness, or immediate danger, might result. Nothing can illustrate this principle better than the present disease, which requires instant, and generally a copious loss of blood ; the mere removal of the irritation, which excited the inordinate action of the nervous and sanguiferous system, not being sufficient for the cure. Next we administer a smart clyster, which, if given early in the precursory stage, is of itself sometimes sufficient to arrest the progress ofthe disease. A smart dose of calomel, or solution of salts, may also be given with advantage, when the person can swallow, especially if the convulsions have occurred during pregnancy, with little tendency to labour. We must also attend to the bladder, that it be emptied, for its distention alone has sometimes brought on convulsions.* One part of practice, then, and a most important and essential one, too, consists in depletion, by which the risk of fatal oppression of the brain, or extravasation of blood within the skull, is diminished, and the convulsions mitigated. But this is not all; for the patient is suffering from a disease connected with the state of the uterus, and the state is got rid of by terminating the labour. Even when convulsions take place very early in labour, the os uteri is generally opened to a certain degree, and the detraction of blood, which has been resorted to on the first attack ofthe disease, renders the os uteri usually lax and dilatable. In this case, although we have no distinct labour pains, we must introduce the hand, and slowly dilate it, and deliver the child. I entirely agree with those who are against forcibly opening the os uteri ;f but I also agree with those who advise the woman to be delivered as soon as we possibly can do it without violence.J * La Motte, 223, 224.—Leak relates a case where it produced subsultus ten- dinum, and excessive pain at the pubis. Vol. II. p. 344. t Dr. Bland is rather against delivery, and for trusting to nature. Dr. Garthshore, Jour. vol. VIII. says, more women have recovered of this, who wore not delivered, than of 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.—Baudelocque says, that we ought not to be in haste to deliver, and never to do it when nature seems to be disposed to do it herself. Dr. Hull, Obs. &c. p. 245, says, that we should trust to the usual remedies, till the os uteri be easily dilatable, or be dilated, and then deliver. He informs me, that in every case which proved fatal, there was no dilatation of the os uteri. Gardien is disposed to limit the propriety of delivery to those cases, where there is great sensibility of the os uteri, with pain at the external parts. Traits, tome II. p. 424. X 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 4? 2 There is, I am convinced, no rule of practice more plain or beneficial,* when evacuations fail to check the convulsions. It not only removes an original cause, but also tends to put a stop to that renewed aggravation of symptoms, which attends on every pain or effort, whether it be called parturient or con- vulsive. Delivery does not, indeed, always save the patient, or even prevent the occurrence of the fits, but it does not thence follow that it ought not to be adopted. 1 look upon it as indispensable, if the convulsions be not checked by vene- section. In no case, however, ought we to deliver till we have freely detracted blood, as we otherwise might add to the excite- ment of the brain or spinal nerves. When the os uteri is rigid, the hipbath and emollient vaginal injections have been recommended, but they are useless as well as troublesome. The applicaction of extract of belladonna has been proposed for removing rigidity, but of this I have no experience, and believe that if venesection do not produce relaxation, nothing else can. Chaussier applies it to the os uteri by diluting the extract, and putting it, when of a soft consistence, into a small syringe, which is to be guided to the os uteri, and a little forced out there. In obstinate rigidity the os uteri has been cut with advantage ; but this is an example not to be rashly followed, and I must say, no case requiring it has ever come within my notice. In almost every instance, the forceps are applicable, and turning is rarely required. Indeed, if the water have been evacuated, it is very questionable how far the irritation attending it would be safe. But if the water be still retained, and the head not within reach of the forceps, we may with propriety turn. Internal remedies have been advised, such as opium, and musk, and camphor; but experience does not establish the utility of the two last, and the first is highly dangerous, tending to convert the disease into fatal apoplexy. If in any case it be admissible, copious venesection must precede it, and the bowels must have been opened. In general it is to be strictly avoided, as the most fatal agent which can be employed, and is only admissible when there is acute and obstinate pain indispensable duty to effect it in the quickest possible manner.—Dr. J. Hamilton, Annals, V. 318. et seq. says, that when convulsions oecur during labour, delivery is to be accomplished as soon as possible.—Dr. Leak, that when they seem to proceed from the uterus, speedy delivery is useful; but when from "any cause independent of the state of pregnancy," delivery would be hurtful, II. 348. * Even evacuating the liquor amnii has, M. Baudelocque admits, been of service, § 1118. In one case the os uteri was hard and callous, it was divided, the child speedily born, and the woman immediately became calm, 1130. 473 in the head or stomach, which has resisted the lancet, and the application of a sinapism to the part. Ergot has been tried, with the effect, we are told, of aggravating the disease. Blisters to the head can never be trusted to, for they are long of operating* and even the preparatory step of shaving the head is troublesome. If stupor remain after delivery, the head ought to be shaved, and a sinapism applied to it, which often contributes greatly to recovery. If it do not, then a blister should be applied. Bathing the head with cold water has been proposed, but previous to delivery it is liable to the objection of requiring the hair to be cut off, and it is really not of so much utility as to make us, in general, resort to that step in this stage ofthe disease. The practice, then, which may be deduced from the view I entertain of the nature and causes of puerperal convulsions, and which, independently of all theory, comes recommended by experience, is, first to detract blood ; second, to remove intestinal irritation by clysters, and afterwards by purgatives, which, although they may not immediately, yet will ultimately produce beneficial effects ; third, to get rid of the uterine action, by accomplishing delivery, when that can be done, without much irritation ; fourth, to avoid every thing which can excite the nervous and vascular system, such as cordials and opium. If the fits have been only apprehended, but have not taken place, then we may use remedies as preventives. The most beneficial treatment is, to empty the vessels and the bowels. When there are evident symptoms of disordered stomach, a gentle emetic has been advised; but I have never seen it administered myself, and am, from its effects on the head, not partial to its exhibition. When a violent pain in the stomach takes place, we should bleed, and if it shall continue after that, give an opiate. I wish it to be carefully remembered, that when we have headach, or any other symptoms indicating a tendency to convulsions, the lancet is necessary. Blood- letting can seldom do harm ; it may do much good; it may be the only means of preserving life; and if this book serve only to impress that fact on the mind of one reader, I will not regret having written it. When one spot of the spine is very painful, and pressing on it produces spasms, it is desirable, if possible, to take blood from it by cupping, if venesection have not relieved it. When symptoms of nervous irritation exist, without any determination to the head, or fulness of vessels, then, after 3M 474 bleeding, opiates may be of advantage,* but I have very great hesitation in employing them, I ought rather to say in sanc- tioning them, for I have seldom, if ever, used them myself, and in the ordinary puerperal convulsions should expect nothing but mischief from them. Camphor has been strongly recommended by Dr. Hamilton,95as the most powerful internal remedy which can be prescribed; but I cannot, from my own observations, say much respecting its virtues as a preventive. But when convulsions have continued after delivery, or when the recovery was not complete, I have found it of service, and recommend it to be always tried, but would not trust to it alone. The head, as I have already said, ought to be shaved, and have a sinapism or blister applied. Sometimes forty drops of laudanum given in a clyster have done good when the convulsions continued after delivery. If convulsions take place after the delivery ofthe child, for the first time, then the placenta, if it have not come away, is immediately to be extracted; and if the pulse do not expressly forbid it, a vein is to be opened, and afterwards, the bowels purged. If the practice be prompt and vigorous, the generality of patients recover from puerperal convulsions. Those who have had convulsions during labour, ought in a succeeding pregnancy to pay the utmost attention to the bowels, avoid a regimen which induces plethora, and lose blood once or twice ; when labour commences, a clyster should be given, and the patient bled on the slighest feeling of uneasiness in the head. Apoplexy may take place, at the commencement of labour, or during gestation, without convulsions. In the latter term, the os uteri is rarely affected ; but, in a few instances, if death did not take place immediately, it has been found to dilate a little. The practice, in either case, is much the same, and differs in nothing from that to be followed at other times The chief resource is the lancet. The child claims our attention m this disease. If it occur during labour, and death be evidently approaching, the delivery ought to be promoted as soon as possible, by turning or the forceps, in order to preserve the child. If it occur in the end of pregnancy, the Caesarean operation should be performed them. Annals of Med. vol V^PeUt i^STfth « H** 475 immediately after death, or, with a better chance, somewhat before it, for the mother cannot suffer in such circumstances, being moribund. ORDER FIFTH. The uterus may be lacerated during labour, under different circumstances, and from various causes. Any part of it may be torn, but generally the rupture takes place in the cervix, and the wound is transverse. Sometimes the uterus is entire, and the vagina alone is torn. It may happen during any stage'of labour, and even before the membranes burst,* but this is uncommon. It may take place when the head has fully entered the pelvis, or in the moment when the child is delivered.t The uterus may be ruptured, by attempts rashly made to turn the child ;J or, after the water has been long evacuated, some projecting part of the child may so affect a portion of the uterus, as to make it tear. A certain set of fibres may also be suddenly and spasmodically contracted, and laceration may thus take place. In these cases, there is often very little warning, and the accident may happen when we are just in expectation of a happy termination of the labour.96 In a case detailed by Dr. Douglas, (p. 50.) the head of the child was resting on the perinaeum, when the lady, who had been sub- ject to cramp, uttered a violent cry, and the head receded. The child was delivered, but the patient died. Mr. Goldson's patient complained of cramp in the leg, in the intervals of the labour pains ; and in the instant when the rupture happened she exclaimed, "the cramp!" Dr. Munro's patient (Works, p. 677.) was sitting in a chair, when she suddenly screamed, and the uterus was lacerated; she was not delivered, but lived from Tuesday till Friday. Rigidity ofthe os uteri may also be a cause of laceration.^ It dilates very slowly, requires great exertion of the uterine fibres, and the patient suffers much pain. The uterus may at last be torn, even * Vide Mem. of Med. Soc. vol. II. p. 118. + In a case which I saw, the placenta was retained by a spasmodic stricture, though the child was expelled; every allowable attempt was made to extract it, but in vain. The uterus acted from the os uteri towards 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 caso in Med. Facts, vol. VIII. p. 146. . X A fatal case of this kind is related by Mr. Dease.—One more fortunate in the issue, is inserted in Mem. of Med. Soc. vol. IV. p. 253. § Perfect's Cases, vol. II. p. 439.—Hamilton's Cases, p. 138. 476 although the head have partly descended into the pelvis, and the pelvis be large. In this case the liquor amnii has been discharged before the rupture takes placm. The most frequent cause, however, of this accident, is a disproportion between the size of the head and the capacity ofthe pelvis, by which a portion ofthe cervix uteri is pinched between the head and the pelvis, and fixed so, that the action of the uterus is directed against this spot rather than the os uteri.* The woman feels very severe pain, either in the back or at the pubis, which, during the action of the uterus, augments to an extraordinary degree, and then the part gives way. Another way in which the cervix may be lacerated, is by the linea iliopectinea being so sharp,t that when the uterus is pressed against it, the parts are either cut through, or so much acted on, that they are in a manner killed, and give way, having a sphacelated appearance.f In some cases the rectum, but much more frequently the bladder, is opened. Preternatural presentations, from the obstacle afforded to delivery, becomes also a cause of rupture. 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 ofthe womb indurated. Scholzius relates a case, where it was produced by scirrhus of the fundus; and Friedius one, where it was owing to a cameo-cartilaginous state of the os uteri.97 Sometimes the uterus seems to be predisposed to this accident, by a fall or bruise. Reidlinus relates one instance of this. Behling, Steidle, and Perfect, furnish us each with another. Salmuthus considers a thinness of the uterus as a predisposing cause of rupture ; and Dr. Ross§ 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 * It has been calculated, that in three fourths of the cases of rupture, the Child has been a male. The head ofthe male is a little larger than that of the female foetus. t 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 X Mr. jscott, of Norwich, has sent me a case which he published in the 11th vol. of the Med. Chir. Trans., where the lower part of the uterus, including its mouth, came away. The patient was, after the laceration, delivered with the lever, and recovered. § Annals of Med. vol. III. p. 277. 477 great exacerbation, and attended with a very acute or tearing sensation. The pains are 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 alarming, if the liquor amnii have been fully evacuated. The treatment to be followed must depend on the apparent cause; rigidity is to be overcome by venesection ; spasmodic action, by an opiate clyster; change of structure of the os uteri may demand consideration, how far incision may be proper ; malposition of the child must be rectified ; and, finally, when the pelvis is contracted, and there is any symptom, indicating the risk of laceration taking place, the forceps are instantly to be em- ployed; or, when such symptoms exist, in any case where the forceps are applicable, it would be criminal to delay. When this accident does happen, the woman feels some- thing give way within her, and usually suffers, at that time, an increase ofthe pain. The presentation disappears more or less speedily, unless the head have fully entered the pelvis, or the uterus contract spasmodically on part of the child, as happened in Behling's patient.* The pains go off as soon as the child passes through the rent into the abdomen ; or, if the presentation be fixed in the pelvis, they become irregular, and gradually decline. The passage of the child into the abdo- minal cavity is attended with a sensation of strong motion of the bell}', and is sometimes productive 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 frequently the patient cannot lie down. Sometimes the intestine pro- trudes through the wound in the uterus, and has even been strangulated in it. These symptoms do not all appear in every case, nor come on always with the same rapidity. In Dr. Ross's patient, although the child escaped through a rent in the vagina into the cavity ofthe abdomen, and though the nature of the case was ascertained, yet no haemorrhage, fainting, nor bad symptoms took place; and, the child being delivered, the woman recovered.98 If the patient be not speedily relieved, she becomes very restless, tosses in the bed, and vomits frequently ; complains of a pain in the belly, which becomes swelled, the pulse is * Haller's Disput. Tom. III. p. 477. 478 rapid, the extremities become cold, and the strength sinks. In every case that I have seen, the intestines were chiefly affected, being much inflamed. The interval which elapses between the accident and death, is various; but generally, whether the patient be delivered or not, she dies within twenty-four hours, often in a much shorter time. Steidle, however, relates a case where the patient lived till the twelfth day; Dr.Garthshore's patient lived till the twcnty-rixth day; and in the Coll. Soc. Ilavn. vol. II. p. 326, there 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 Caesarean operation, some delivering per vias naturales, and others leaving the case to nature. We have instances of all these methods being successful ; but the delivery, by turning the child, has advantages over the other modes, and certainly 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 difficulty, be introduced, it is to be passed through the os uteri, and the rent in the uterus, into the abdominal cavity, in search of the child's feet, which are to be brought down, and the case managed in the same way as in presentation of the feet. When the placenta is extracted, we are to introduce the hand again, to ascertain that no part of the intestines have pro- truded through the wound. This process is usually easv, when the rent is in the cervix uteri or the vagina. When it is higher, there is often great difficulty, owing to the contraction of the uterus ; which may be affected spasmodically, or may have universally contracted, and the rent become very small. It sometimes happens, that when attempts are made to carry the hand through the cavity of the uterus to the rent, the fibres contract over the hand, and the contraction may be felt sweeping toward the rent, so as to carry, as it were, the uterus off the hand. It would be both cruel and useless to attempt delivery in such a case. When the os uteri is rigid and very little dilated before the accident happens, and cannot be opened without extreme irritation, which is, indeed, rather a state which may be sup- posed, than actually met with ; or when the uterus is spas- modically and violently contracted between the rent and the os uteri, which I know is apt to happen, if the fundus be lacerated, I consider attempts to deliver as adding to the danger. These cases are only rare, because the rupture is 479 generally in the cervix, for when the body or fundus is torn, the contraction is often strong; and, although there be doubtless instances of delivery being accomplished with facility some hours after the rupture, yet, in most cases, such con- traction soon takes place, as must altogether prevent it, or render it highly dangerous. It may also happen,'that deformity ofthe pelvis prevents delivery. In such circumstances, we must either perform the Caesarean 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 incision.* If many hours, how- ever, have elapsed, then such irritation is often produced, as renders it doubtful if the additional injury of the operation could be sustained. On the other hand, if little irritation be yet excited, and the woman be tolerably well, there is room, it may be said, to hope, that a natural cure may be accomplished, as in extra-uterine pregnancy; and therefore, as the child cannot be saved now, it may be argued that it is more prudent to trust to nature.t Even in this case, I a in inclined to extract by a small incision, which I conceive to be less dangerous than by the rent, when such a time has elapsed, as must have rendered the uterus very tender and easily irritated. Another risk arises from the extravasation of blood into the abdomen, early exciting inflammation ; and it has been proposed by M.- Deneux and others to evacuate the blood by an aperture. * 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. 370, is a case most incredible, were both the uterus and abdominal integuments were torn during labour. The child escaped, and the woman recovered. A case is related lately in one of the French Journals, where the Caesarean operation was per- formed twelve hours after the rupture with success. t 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 complaired only of a 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 20 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. Bromfield's patient did not get rid of the child, but she lived for many years, and after her death the rent was visible. Phil. Trans, vol. XLI. p. 696. In Dr. Sym's patient, the process for expel- ling 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 placenta ^as expelled; on the 16th a tumour appeared at the linea alba, which was opened, and a child extracted; the woman recovered. Obs. tom. II. ob. 92. 480 The cases which admit most easily of delivery, are those where the rent is situated in the cervix uteri or vagina; and laceration ofthe vagina is less dangerous than rupture ofthe uterus,* provided the bladder be not injured. I do not think it necessary to make any further remarks on the laceration of the vagina, as distinct from that of the womb, except to say, that delivery may be practised after a greater lapse of time, that when the uterus is torn ; for the vagina does not contract. When the head is engaged in the pelvis, and cannot recede after the womb is torn, we have other symptoms, indicating rupture of the uterus, or at least the necessity of using instru- ments. The strength sinks, the pains become useless or go off, the patient vomits, foe. When, from precursory symptoms, we expect that laceration * 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. Douglas relates the successful case of Mrs. Manning, in his Observations, p. 6. Dr. A. Hamilton gives a fortunate case, where delivery saved the mother. Outlines, p. 384; and Dr. J. Hamilton relates one, in his Cases, p. 138, where the rent had contracted so much, as to give some difficulty to the delivery. The case is instructive. In the case of E. Dwyer, related by Dr. Labat, (Dub. Trans.) recovery took place, but, in the next pregnancy, the same accident occurred and proved fatal. In the 2d vol. ofthe Trans, of the Coll. of Phys. in Dublin, p. 15, Dr. Frizel gives the ease of Bridget Fagan, who had the uterus ruptured in consequence ofthe child presenting the arm. With great difficulty, and aided by the crotchet fixed in the foot of the child, he succeeded in turning and delivering it, when he found the uterus extensively ruptured at its cervix, and the intestines protruding. He replaced the bowels, and thinks he prevented a rcprotrusion by making one edge of the rent overlap the other. She recovered. In the 3d vol. of the Trans, of the Association, &c. is a case by Dr. M'Keever, which he sent me, of a ruptured vagina, accompanied with protrusion of a yard and a half of intestine. It could not be reduced, and sloughed off. The patient recovered, but voided stools by the vagina, but after a time they came by the anus. In the 12th vol. of the Med. Chir. Trans, is a case by Mr. Powel, where the cervix was lace- rated, and although during the extraction of the child, which was effected by turning and then perforating the head, the patient required to be supported by brandy, yet she recovered. 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; but in one case the woman recovered, although the hand could be introduced into the bladder. The woman had incontinence of urine afterwards. In his eighth case, the child lay transversely, and the vagina was torn and filled with clots; but the peri- toneeum was still entire, and therefore the wound did not enter the abdomen. The uterus was supported with a napkin until the child was turned. Dangerous symptoms supervened, but the woman recovered. He gives fifteen cases, and of these six recovered. Several were produced by attempts to reduce the arm ofthe child. 481 is about to take place, we must accelerate labour, generally by the use of instruments. This is more necessary if the patient have formerly had the uterus torn. Turning must be dangerous, in such circumstances, after the water has been evacuated, and before that, there can seldom be any indi- cation of danger. It has been calculated that rupture takes place once in 940 cases. ORDER SIXTH. Suppression of urine may take place during labour, ill Con- sequence of the head ofthe child being locked in the pelvis; or from a kind of paralytic state of the bladder, produced by long retention of the urine ; or by a small stone, or quantity of lymph, obstructing the urethra. It produces tenderrless, and great pain, in the hypogastric region, which is also swelled. The pain is constant, but is increased during every effort of the abdominal muscles to bear down, because then the bladder is pressed. It is injurious in so far as it tends to impair the uterine action, and it is dangerous on account of the risk of the distended bladder being ruptured by the con- traction of the abdominal muscles, or its giving way by a gangrenous rent. The bad symptoms consequent to this event do not always come on instantaneously, and sometimes the bladder still retains a little urine. In a case related by Mr. Hey, in the fourth volume of Medical Observations and Inquiries, they did not take place till the second day. The patient was thirsty, vomited, had a frequent desire to void the urine, which she did very suddenly, but not more than a teacupful at once. The pulse was quick, the belly swelled, and pressure gave her pain. She died about the eight day, and the bladder was found to be ruptured at its upper part. When the urine cannot be passed by the voluntary efforts of the woman, aided sometimes by pressing up the head of the child, the catheter must be introduced. The perforations ofthe instrument, however, ought to be large, as a slimy, tough mucus in the urethra, sometimes fills completely those ofthe ordinary size. If the head should be so jammed in the pelvis, as to prevent the introduction ofthe catheter, which is rare, the woman must be delivered." I have never known such a case. In some cases, although no water be 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 j and although, of itself, it cannot deter- 3N 482 mine us to accelerate delivery, yet, should it be attended with other bad symptoms in tedious labour, it may form an addi- tional argument for interfering, as then the functions are becoming impaired, and effusion may take place into some of the cavities. There are some other complications, which might perhaps be made the subject of distinct orders ; such as the existence of aneurism, hernia, foe. foe., but these may more properly be referred to the head of cases requiring the use of instru- mental aid. It ought to be a general rule, and it is a very clear one, that whenever a disease exists, which may be much or dangerously aggravated by a continuance of the efforts of labour, that process ought to be shortened as much as possible. BOOK III, OF THE PUERPERAL STATE. CHAP. I. Of the Treatment after Delivery. Immediately after the placenta is expelled, thefinger ought to be introduced into the vagina, to ascertain that the peri- naeum or recto-vaginal septum be not torn, and that the uterus be not inverted. Then, if the patient be not much fatigued, she is to turn slowly on her back, and a broad bandage is to be slipped under her, which is to be spread evenly, and pinned so tightly round the abdomen, as to give a feeling of agreeable support. This bandage is made of linen or cotton cloth ; and it is usual to place a compress over the uterus, to assist contraction. In some, if not in many cases, this might be dispensed with, as we see in a state of nature ; but, in civilized life, it is useful. if not absolutely necessary. For the abdominal muscles do not readily contract, so as to afford a support to the parts within, and syncope, breathlessness, or other unpleasant effects, may be the consequence. 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 topband, and is introduced and pinned like the bandage. A warm napkin is then to be applied to the vulva, and the patient laid in an easy posture, having just so many bedclothes as to 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 ascer- tain that the bandage be felt agreeably tight, that there be no considerable haemorrhage, and that the after-pains be 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 avoided. 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 this purpose, to raise her to an erect posture. Now this prac- 184 tice may not always be followed by bad consequences, but it is very reprehensible ; for the patient is thus much fatigued, and if she sit up even for a short time, haemorrhage or syncope may be produced. The pretext for this is generally to make the patient comfortable ; and, indeed, if the clothes be wet with perspiration or discharge, there may be some inducement to shift them. But this ought to be done slowly, without raising her, and if she have been fatigued, not until she have rested for a little. Another bad practice is, the administration of stimulants, such as brandy, wine, or cordial waters. I do not deny, that these, in certain cases of exhaustion, are salu- tary; but I certainly maintain, that generally they are both unnecessary and hurtful, tending to prevent sleep, to promote haemorrhage, and excite fever and inflammation. A third practice, no less injurious, is, keeping the room warm w ith a fire, drawingthe bed-curtains close, increasing the bed-clothes, andgiying every thing warm to promote perspiration. This is apt to produce debility, and many hysterical affections, as well as a troublesome species of fever, which it is often difficult to remove. It also renders the patient very susceptible of cold, and. a shivering fit is very readily excited. On the other hand, exposure to cold, or the application of cold in any way, is to be avoided, being very apt to produce local inflammation. Lastly, gossiping and noise of every kind is hurtful, by pre- venting rest, occasioning headach or palpitation, as well as other bad symptoms. At our next visit, which ought to be within twelve hours after delivery, we should inquire whether the patient have slept, and ascertain that the pulse be not frequent, that the after-pains have not been severe, nor the discharge copious. We should also particularly inquire if she have made water; and if she have not, but have a desire to do so without the power, a cloth dipped in warm water, and wrung pretty dry, should be applied to the pubis. If this fail, the urine will often be voided if the uterus be gently raised a little with the finger, or the catheter may be introduced. There are two states in which we are very solicitous that the urine be voided ; the first is, when the patient has much pain in the lower belly, with a desire to void urine; the second is, after severe or in- strumental labour. A stool should be procured within twenty-four or thirty-six hours after delivery, either by means of a clyster, or a gentle laxative. If the patient usually have the milk-fever smartly, or the breasts be disposed to be painful and tense, a mild dose 4«5 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 sauguineous fluid from the uterus for some days, which then becomes greenish, and lastly pale, and decreases in quantity, disappearing altogether within a month, and often in a shorter time. This is called the lochial discharge. During this time, it is necessary that the vaginal and external parts be daily washed with tepid milk and water. During the latter end of gestation, milk is generally secreted in a small quantity in the breasts, and sometimes it even runs from the nipples. After delivery the secretion increases, and about the third day the breasts will be found considerably distended. Many women, indeed, complain at this time of much tension and uneasiness, and there is usually some acce- leration 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 be not to give suck, liquids should be avoided, the food must be of the dry kind, and thirst should be quenched rather with fruit than with drink. If they be 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 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 supper ; 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 returned to. The time at which the patient should be allowed to rise, 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, 180 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 are rendered profuse, and the strength impaired. If there be, or have for- merly been, the smallest tendency to prolapsus, it is absolutely necessary to keep the patient very much for some time in a recumbent posture, on a sofa, avoiding, however, that degree of heat which relaxes the system. It is also necessary in this case to stimulate the uterine lymphatics to absorption by a smart purgative once in three or four days, to bathe the external parts with rose water, having a third part of spirits added to it, and at the end of a fortnight begin a tonic, mixed with a mild diuretic. CHAP. II. Of Uterine Hemorrhage. In natural labour, after the expulsion of the child, the uterus contracts so much as to loosen the attachment of the placenta and membranes to its surface, and afterwards to expel them.* This process is always accompanied by the discharge of blood, but the quantity in general is small.- .If, however, the uterine fibres should not duly contract after the delivery of the child, so as to diminish the diameter of the vessels, and at the same time accommodate the size of the womb to the substance which still remains within it, then, provided the placenta and membranes be wholly or in part separated, the vessels which passed from the uterus to the ovum shall be open and unsupported, and will pour out blood with an impetuosity proportioned to their size and the force ofthe circulation. This flow will contine until syncope check it, a state too often only the prelude to death. So Ion"- as the placenta and membranes adhere, we have little or no haemorrhage, although the uterus be relaxed. But as soon * 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 solid mass; but when torpid, it is not so distinctly felt, for it is softer, being destitute of tonic contraction. 487 as partial detachment takes place, the blood flows, and many of our worst cases occur after the placenta is expelled. The contraction of the uterus, by acting on the vessels, tends to prevent haemorrhage. But, whilst we assign the due value to this contraction, and hold its absence as a cause of haemorrhage, still we must attribute somewhat to the state of the vessels themselves, as affected by the nerves ofthe uterus. The fibres contract much more powerfully during a strong pain before delivery than afterwards ; and yet we have no evidence, that during a pain the circulation is suspended in the uterine vessels. But, it may be said, that after delivery the fibres come nearer to each other, and a slight tonic con- traction will constringe the arteries. It is, however, certain that this contraction is not strong, and that the circulation goes on freely in the vessels after delivery, and their orifices are, at least, as large as those which bleed freely in wounds and operations. Whilst, then, I admit the absence of con- traction to be an indisputable cause of haemorrhage, I do not look on it as the only one. Many facts prove the influ- ence ofthe nerves on the vascular system. And if we admit the uterus to have been dependant on its nerves for its action, as other organs are, we can scarcely deny, that a great and immediate effect will be produced on those nerves, by the complete removal of the ovum, which the uterus was destined to support. The activity of circulation must be diminished in those vessels going not to the proper substance of the uterus, but to the ovum, and coagulation take place in their orifices. But if any circumstance shall keep up an excite- ment of the nerves of the uterus, the whole vascular system is also kept active, and should this be conjoined with relaxa- tion of great part of the fibres, as happens, particularly when part is thrown into spasmodic action, the effect in producing haemorrhage must be decided. In a great majority of instances of flooding, either before or after the expulsion ofthe placenta, we find spasmodic contraction of the fibres of the cervix uteri, which seems sufficient to excite the vessels, perhaps also retard the return through certain veins ; and also, if not the cause, is, at least, generally the concomitant of a relaxed state ofthe rest ofthe fibres, and these two opposite states are both apt to be produced, if the labour have been tedious, or the child expelled suddenly, by a strong, but perhaps only momentary contraction. Even independent, however, of the state of muscular contraction, haemorrhage may take place from that of the vessels, and sometimes has been prevented 188 in those liable to it from these causes, by detracting blood during labour, or in the end of pregnancy. But this seems useful, not so much, as Dr. Gooch supposes, by lessening general plethora, or unusual arterial action, as by its local influence on the origin of the uterine nerves. Uterine haemorrhage appears very soon after delivery, and often before the placenta has come away. It is profuse, and produces the usual effects of haemorrhage on the system, and these effects are greater and more speedy than those which follow from haemorrhage before delivery, for the loss is instant and extensive. The first gush indeed does not produce great debility, because it consists chiefly of blood, which formerly circulated in the uterus, and is not taken directly from the general system ; and the separation ofthe 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 ofthe child.* »If flooding occur after delivery, the woman says there is surWy an unusual discharge; and, on examining, it is found to be really so; but at first the pulse is pretty good, and the countenance is not much altered. In a minute, perhaps, the pulse sinks, the face becomes pale, the hands cold, the respi- ration is performed with a sigh, or after lying quiet for a little, a long sigh is fetched, and the patient seems as if trying to * 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 of the heart, such as ossification of the valves or arteries, dilatation ofthe cavities ofthe heart, or aneurism ofthe aorta. The effect of any sudden change in the system, in these cases, must be known to every practitioner. Whenever we suspect such disease, the most perfect rest must be observed after delivery. Should there be any inequality in the size of the two ventricles, the right being larger, for instance, than the left, then any cause capable of hurrying the circulation, may make both sides contract to their utmost, the consequence of which is, that all the blood in the right side is thrown out, but it cannot be received into the left; rupture of the pulmorary vessels must take place, and I have known many instances where the patient was imme- diately suffocated. Speedy death may also arise from the brain becoming affected in a way similar to that which takes place in puerperal convulsion. In this case, the first symptom often is pain of the stomach, and the patient may die before any farther effect is produced. If a slight hemorrhage accompany this state, the sinking effect is great, and from the combined causes the patient may die, although there be little loss of blood. Great difficulty of breathing, and most alarming, if not fatal syncope, may take place, from the mere emptying of the uterus, if an adequate support have not been given, as.we also sometimes see after tapping for dropsy. In this case, even when due attention was paid to the application of a bandage, I have*een gasping and alarming weakness produadd. The best remedy is an opiate, with a little1 warm wine or brandy: 489 awake from a slumber. She exclaims she is sick, and imme- diately vomits; she throws out her arms, turns off the bed- clothes, and seems anxious for breath ; she complains of cold, or perhaps is listless, and begs not to be disturbed ; or lies in a state approaching to syncope, or gazes wildly around her, and is extremely restless, breathes with difficulty, and quickly expires. The danger of flooding is universally known, and the consternation excited by it is in many cases great. One exclaims the patient is dead, another she is 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 inertness ofthe uterus is sometimes so universal, that when the hand is introduced, it passes almost up to the stomach. But generally a circular band of fibres contracts spas- modically about the upper part of the cervix uteri, enclosing the placenta above it, whilst the rest of the fibres become relaxed. This has been called, though not very aptly, the hour-glass uterus ; and if I did not know the hazard of estab- lishing a general rule, I would say, that in almost every instance this contraction takes place. I have scarcely ever introduced the hand into the uterus in a case of flooding, without meeting with it, whether the placenta had or had not been expelled. When it is not present or recognised, I must suspect that it is owing to an almost moribund state of the womb, and must be a very ..bad symptom. From this view it is evident, that flooding is to be prevented by preserving the muscular action ofthe uterus, and avoiding whatever can increase the force ofthe circulation. A powerful mean of keeping up the action ofthe womb, consists in pre- venting it from emptying itself very suddenly. It frequently happens, when the child is instantaneously expelled by a single contraction, being in a manner projected from the uterus, or when the body is speedily pulled out, whenever the head is born, that haemorrhage takes place. Delivery, therefore, is not to be hurried; the steps of expulsion should be gradual ; instead of pulling out the body ofthe 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. On the other hand, severe and protracted labour is no less apt to be 3 O 490 followed by irregular contraction of the uterus, and haemor- rhage. 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 lessening the quantity of bed-clothes, by a state of perfect rest, and by avoiding the exhibition of stimulants. If these direc- tions, which are few and simple, be attended to. we shall seldom meet with haemorrhage after the delivery of the 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 haemorrhage, we should give her a full dose of laudanum immediately after delivery, excite the action of the uterus by external pressure or friction ; and, on the first appearance of discharge, perhaps in some instances whenever the child is born, we ought to introduce the hand into the uterus. We are not to meddle with the placenta, or endea- vour 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 important consequences to the future health or comfort of our patient. I need scarcely, I think, add, that in every case, more espe- cially in those where the labour has been tedious, or the woman has been subject to haemorrhage, we ought not. to leave the bed-side, but should examine frequently, to ascertain that there is no unusual discharge. The instant a woman is seized with haemorrhage after delivery, we ought to take steps for exciting the contraction of the uterus, upon which alone we place our hopes of safety, for it is a fatal error to wait till dangerous symptoms appear. Some powerful means are at all times within our reach ; fric- tion, the application of cold, and the introduction ofthe hand * During pregnancy, there is sometimes a scorbutic or hemorrhagic diathesis induced, marked by vibices, spongy gums, bleeding from these or from the nose, or from a small wound, or after extraction of a tooth. If this be not corrected by strengthening diet, the free use of fruit and vegetables, and attention to the bowels, uterine haemorrhage of an obstinate description may take place after delivery. Dry diet and laxatives have been proposed, for those who were liable to haemorrhage ; but the most effectual preventive, is due regulation of the labour, and exciting the uterine contraction after delivery. 491 into the cavity ofthe uterus. These are aided by the instant exhibition of fifty drops of laudanum. The retention of the placenta is not in general the cause of the haemorrhage, but a joint effect, together with it, of the state of the uterus. Our primary object, therefore, is not to ex- tract the placenta, but to excite the uterus to brisker action.100 How improper and dangerous, then, must it be to thrust the hand into the uterus, grasp the placenta, and bring it instantly 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 haemorrhages By the second, we either tear the cord or invert the uterus. Yet, although this be correct, I must not carry the rule too far. The placenta is retained, because the uterus does not act vigorously ; but, in consider- able torpor, I am inclined to think, that it may sometimes act injuriously, by preventing the uterus from collapsing, whilst it does not, on the other hand, make any stimulating pressure against its surface, as can be done by the hand. The mere removal of the placenta, after the womb has been excited by the introduction of the hand to lay hold of it, allows the sides of the now empty cavity to fall together, and this of itself stimulates to contraction, as the discharge of the water does during labour. Hence the manual abstraction of coagula, if haemorrhage take place after the expulsion of the placenta, is of signal benefit, often of more advantage than retaining the hand longer in the uterus. When we introduce the hand, we conduct it to the placenta, 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 detached, and lying loose in the cavity ofthe womb, we move the hand gently to stimulate the uterus, but do not withdraw it, nor extract the placenta, until we have, by gentle motion or pres- sure, excited the uterus, and feel it contracting, or until we be satisfied that the pressure of the hand is not effecting this purpose. In this case, on the principle just noticed, we ought to remove both the hand and the placenta at once, and several coagula are often propelled along with these, the uterus contracting so as to put an immediate end to all farther anxiety. Friction is of evident advantage, in exciting the uterus. It is effected by placing the hand firmly on the abdominal parietes, and moving these briskly, but not rudely, over the 492 uterus, and occasionally grasping that viscus gently. I his* remedy has been often employed with success, and is yery properly recommended strongly by Gardien and Power. The hand may also be so applied, as to make considerable pressure on the flaccid uterus, as well as to excite to contraction, and thus impede so far its distention. The contraction of the uterus is sometimes powerfully assisted by the application of cold. The quantity of clothes should be lessened so far, as to prevent the surface being heated, and the circulation excited; but our principal object is to apply cold as a topical remedy ; which should be done if the other means fail, but only in that case. Cloths dipped in cold water should be laid suddenly upon the belly, or cold water may be thrown upon it. In obstinate cases, it has been found useful to project it forcibly with a syringe. In desperate cases, it has been advised to dip a sponge or a piece of cloth in cold water, and carry it in the hollow of the hand into the uterus. Nay, ice itself has 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, when requisite, and have never known any bad consequence result from it.101 The uterus, in such cases, generally contracts spasmodically, at the upper part of the cervix, either before or after the expul- sion ofthe placenta.t This spasm ofthe uterus is an almost invariable attendant on haemorrhage, and is accompanied with pain in the back, sometimes severe; great depression of strength, an a very feeble pulse, sickness and paleness, and, last of all, uterine haemorrhage, which occurs early, and is often profuse; but it is not the sole cause of the sinking and * Saxtorph uses injections of vinegar and cold water. Pasta has the hardi- hood to use alcohol and acids, to cauterize, as it were, the mouths ofthe uterine vessels, which cannot fail to cause inflammation. Others introduce a sponge dipped in cold water, or a sow's bladder, which they afterwards blow up with air, to press on the uterine surface, or fill it with cold water, at the same time that they apply external pressure. Others use the cold bath itself. Le Roy rubs the abdomen with spirits, and Lapira praises the external application of a strong solution of carbonate of ammonia. Gardien supposes it may sometimes be so active as to require the lancet. Others plug the os uteri, and compress the abdomen. I do not think it necessary to comment on these proposals. t Some have denied that the placenta was retained by spasm, but imagined that the cyst, in which it lay, was produced by the torpor of the part, whilst all the rest contracted ; or from the uterus contracting round the placenta. Dr. Douglas conceives that the spasm is always produced by mismanagement, par- ticularly, irritating the vagina or pulling at the cord. For the peace of mind of many attentive and careful practitioners, I am happy in differing from the opinion of the respectable writer. See Med. Trans, vol. 6th. 493 debility, for these often precede even internal hsemorrhage, though they are speedily increased by it to an alarming degree. They depend greatly on the spasm, and, as I shall hereafter notice, sometimes arise directly from affection ofthe spinal nerves. If a patient feel sick or weak, or the pulse sink, or she become pale soon after delivery, whether there be or be not haemorrhage, we may be sure that this spasm has taken place, or that she has had formerly an affection of the spinal eord, which is now operating in a dangerous way, and that in either case nothing but prompt measures can preserve life. This effect of spasm, in causing debility, inde- pendently of the actual quantity of blood lost, or altogether disproportionate to it, is analogous to the effect of spasm ofthe stomach. We are immediately to give a full dose of laudanum. We must also, without loss of time, introduce the hand into the uterus, and slowly and cautiously dilate the stricture, so as to get the hand into the upper cyst of the uterus, thus stimulating to universal and regular contraction ; and, in doing so, we shall be greatly assisted, should the ordinary means fail, by applying cold water tothe abdomen, or dashing water smartly on it from a cloth. If the placenta be still retained, it is to be slowly detached, and after keeping it and the hand, for some time, iu the under part of the womb, both may be withdrawn. No remedy whatever can, in my opinion, be depended on so certainly as the introduction of the hand, and in no case ought it ever to be neglected. I will not go the length of saying, that it is infallible in its effects; but I can say, that if it fail, I believe nothing could succeed. I have met with most obstinate and alarming cases, but I never yet have lost a patient, from uterine haemorrhage after delivery, when I attended from the first; and I attribute this entirely to the prompt introduction ofthe hand. 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 danger in being deliberate. It is too much the practice with some midwives, to trust more to their fingers than to the contrac- tion of the uterine fibres; the consequence of which is, that they tear the placenta and irritate the womb. Yet it is cer- tain, on the other hand, that gentle attempts to separate it are sometimes necessary ; but these should be so cautiously and deliberately made, as not to lacerate the placenta. The fingers should be very slowly and gently insinuated betwixt the uterus and the placenta, so as to overcome the adhesion, 494 which is seldom extensive. I haveknownthe placenta retained, for four days, by an adhesion not larger than a shilling. This case proved fatal by loss of blood, which continued to take place, I understand, in variable quantity, during the whole time. No attempts were made to relieve the woman until she was dying. We can in general save the patient in flooding, if we are on the spot when it happens ; but if much blood have been lost before we arrive, the strength may be irreparably sunk. In those cases where great weakness has been produced, we must not only endeavour to excite the uterine contraction, in order to prevent further injury, but we must also husband well the power which remains. The hand is to be immediately introduced into the womb, and must be kept there, moving it gently, until the fibres contract ; and until this take place, neither the hand nor the placenta should be withdrawn. But the moment that we find the uterus beginning to con- tract, the placenta is to be removed, even if the hand should require to be reintroduced, as emptying the uterus under these circumstances promotes farther contraction. A cloth moistened with cold water is to be applied suddenly on the abdomen, pressure, along with friction, is to be made by the hand on the region of the uterus, and the whole belly firmly supported with a bandage, provided that can be applied with- out moving the patient much. But, as every exertion is dangerous, motion must be avoided ; and upon no account is the patient to be shifted or disturbed for some time. By imprudent attempts to raise the patient, or " to make her more comfortable," she has sometimes suddenly expired.102 The state of the stomach is to be watched, preventing, as for 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. Cor- dials, as, for instance, brandy, 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 decreased; for if persisted in to the same extent, fever or inflammation may be excited. Opiates are of greater service in all cases of uterine haemorrhage 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 proportioned to the urgency, varying from fifty to sixty drops. In some 495 instances, when the debility was great, a hundred drops ofthe tincture, or when the stomach was very irritable, five grains of solid opium, have been given at once, and afterwards three grains every three hours, till the patient was out of danger. But I do not consider such large doses of laudanum to be necessary, and as for the solid opium, it ought to be given in doses only of a grain, to allay the irritability ofthe stomach, after the pressing danger is past, for in no dose can it act instantly, or be depended on in urgency. Moderate doses of laudanum by the stomach or in clysters, never prevent the contraction of the uterus, or produce afterwards any bad effect. Opiates supply the place of wine, and are infinitely safer. Aromatics have been given, such as tincture of canella, with good effect. Iced water has also been recommended, but of this I have no experience. 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 alwTays unfavourable, for it sometimes excites more powerfully the contraction of the womb. The rising ofthe pulse, and relief of the patient after it, are 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 these effects do not follow from vomiting, the case is very bad. Solid opium is the most effectual remedy against repeated vomiting. It must be given in the dose of from one to two grains. When the haemorrhage has produced complete syncope, the state of the patient is very alarming. Yet the danger is not the same in every case, for some women faint from slighter causes than others. La Motte relates one case where the patient fainted no less than twenty times, in the course of the night. She is to be preserved in a state of the most perfect rest, the face is to be smartly sprinkled with cold water, and a little wine or brandy, or spiritus ammonia? aromaticus given, after the opiate already exhibited, to rouse the system. After- wards, warm spiced wine may be given in small quantity and warm cloths applied to the feet. Friction on the region ofthe stomach, with some stimulating embrocation, as harts- horn 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, we must obstinately fight against death. It may appear to some that 496 stimulants, and other means to remove syncope, must renew the haemorrhage, and that the syncope itself is useful, by checking the circulation. But no man of observation can suppose syncope to be safe, in haemorrhage after delivery, or hesitate, by opium and brandy, or wine, to recall his patient to animation, or prevent a renewal of the fainting fits. The transfusion of blood has been proposed in this desperate case. It was at one time the practice to prevent the patient from sleeping, or indulging that propensity to drowsiness which often follows haemorrhage. But we can surely, at short intervals, 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 of the child, or suddenly taken away upon the accession of haemorrhage, then we find that the uterus does not contract properly, and the vessels pour out blood plenti- fully. This in part escapes by the vagina, but much of it remains in the cavity of the uterus, where it coagulates, and hinders the free discharge of the fluid by the vagina. But blood may be still poured out into the cavity of the womb, which becomes distended, and that often to a great size. Thus it appears, that after delivery the haemorrhage may be sometimes apparent, sometimes concealed. When it flows from the vagina, it is always discovered by the patient ; but when it is confined in the uterus, it is known only by its effects; the pulse sinks, the countenance becomes pale, the strength departs, and a fainting fit precedes the fatal catastrophe. Even when the placenta has not been rapidly extracted haemorrhage may come on, and most frequently it, in this case, proceeds from rash exertion, or much motion. In an uncivilized state of society, we find that almost immediately after delivery, the parent is able to walk about ; but women brought up in the European modes of life, cannot use the same freedom. Motion not only disorders the action of the uterus, and impairs its contraction, but also powerfully excites the circulation. The continued application of a great degree of heat, mental agitation, and the use of stimulants, may also contribute to the production or renewal of haemorrhage. A partial or complete inversion of the uterus is another 497 cause of haemorrhage, and which can only be discovered by examination. Sometimes a partial or irregular contraction ofthe uterine fibres takes place, and the person is tormented by grinding pains, accompanied by repeated haemorrhage.* The retention of a small portion ofthe placenta, which has firmly adhered to the uterus, is also a cause of haemorrhage, 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- 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 haemorrhage. These symptoms very much resemble those produced by the retention of part of the pla- centa, and cannot easily be, with certainty, distinguished from them. We have, however, less ofthe 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 ofthe uterine cavity. Lastly, we find, that if exertion have been used before the uterus have been perfectly restored, there may be excited a draining of blood, which does not come, in general, very rapidly ; but, from its constant continuance, amounts ulti- mately io a considerable quantity, and impairs the health and vigour of the woman. This has been called menorrhagia Jochialis. When haemorrhage, whether external or internal, takes place in very moderate quantity, immediately after the expul- sion of the placenta, and when the system does not seem to suffer, we may be satisfied with firmly supporting the uterus by external pressure, and applying a dry cloth closely to the * 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 arc obstructed ; sometimes, on the contrary, pretty copious haemorrhage is produced. Relief is obtained by slackening the bandage ; by giving an anodyne and, if there be no haemorrhage, by fomenting the belly. t This, at first, is owing to muscular contraction ; afterwards, absorption forms part of the process. But if these operations shall be interrupted, or injured, then the vessels, which are still large, not being duly supported, will b« very apt to pour out blood. 3 P 498 orifice ofthe 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 ; but in giving this advice, I beg most distinctly to be under- stood as affording no sanction to the use of the plug, in any important haemorrhage after delivery. After-pains are soon to be expected, but the fear of haemorrhage is removed. In some instances, when we have had no external haemorrhage, 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 intro- ducing the finger into the vagina, and raising up the uterus. If it should not, the catheter must be employed. But whenever haemorrhage takes place to any considerable extent, we do not wait till it endanger the patient, and produce the effects I have already mentioned, but must interfere more actively : and I need not attempt to prove, that the only security consists in uterine contraction. This is to be excited by the application of cold, and by the introduction of the hand, not simply to extract the coagula, but to stimulate the uterus, and rather make it expel them. It in general will be found that the uterus is affected with spasm. Nothing is so useful as retaining the hand for some time in the lower part ofthe uterus, and occasionally gently dilating the contracted spot above, at the same time that we rub externally. The extraction of coagula from the cavity is of signal benefit, and, if necessary, this must be done oftener than once. Gardien has made a practical remark, which perfectly agrees with my experience, that the successive emptying ofthe uterus is the best remedy, yet this must not be done too rapidly. What good cart accrue from allowing coagula to remain ? It cannot prevent the farther flow, for no vessels of such size as the uterine can be stopped in this way. No harm can arise from their removal; for if the womb do not contract, and the flow continue, we re-introduce the hand, and are at least as well as we were before. We must also proceed with opiates, cordials, and nourishment, upon the rules formerly stated for recovery; and we shall do well, not to be in a hurry to quit our patient, for the haemorrhage may be renewed, and she may be lost before we can see her. When the haemorrhage proceeds from irregular action of the uterus, and is attended with grinding pain, a full dose of 499 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 haemorrhage is often very obstinate. Both clotted and fluid blood will be discharged repeatedly. The clot has the shape of the uterus, and is expelled with fluid blood like an abortion. 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, or even weeks; and this expulsion is often attended with severe attack of haemorrhage. By examination, the os uteri will be found soft, open, and irregular. If, by the introduction of the finger, we can feel any thing within the uterus, it should be cautiously extracted ; but we are not to use force or much irritation, either in our examina- tions or attempts to extract, lest we inflame the womb. It is more advisable to plug the vagina, and even the os uteri, so as to confine the blood, and excite the uterine contraction. We may also inject some cold and astringent fluid for the same 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 gentle 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. When the haemorrhage proceeds from an interruption of the process of restoration, our principal resource consists in exciting the contraction ofthe womb by the use of clysters— by friction on the abdomen—by injecting cold and astringent fluids into the womb—by the exhibition of a gentle emetic— and by clapping, if other means fail, a cloth wet with cold water suddenly upon the abdomen, when the womb is expel- ling the coagulum. We also check the haemorrhage, and save blood, by the prompt application of the plug, and diminish the action ofthe vessels themselves, by allaying or removing every iritation, and avoiding the frequent use of stimulants, or attempts to fill the vessels too quickly. The feeling of sinking, sickness, tendency to syncope, foe. are to be obviated by the means already pointed out. Lastly:—The menorrhagia lochialis is to be cured by rest, cool air, the use of tincture of kino, sulphuric acid, or other tonics, bathing the pubis or back with cold water, and inject* 500 ing an astringent fluid three or four times a day into the uterus. Sometimes, whenever the discharge stops, the patient complains much of stomachic affection. This is to be allayed by laxatives and aromatics, or rubefacients applied to the epigastrium. When it alternates with diarrhoea, confectio catechu is useful, along with some bitter tincture. If the pulse be frequent, the exhibition of 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.103 The distressing palpitation, beating in the head, and headach, with anomalous nervous affections which often follow haemor- rhage, are best relieved by the regular and steady use of laxatives, which may be conjoined with asafcetida or tonics, according to circumstances. In a former part of this work, the student will find remarks on the effects of great haemorrhage. CHAP. III. Of Inversion of the Uterus. Inversion of the uterus implies, that the inside is turned out, and down into the vagina. It may take place in different degrees, and it has been divided, accordingly, into the simple depression ; the incomplete inversion, when the fundus is merely engaged in the orifice; and the complete, when it pro- truded out of the vagina, and exactly resembled the uterus after delivery, only the mouth turned upward. The vagina is, in this case, also partly reversed or inverted, so that the tumour is of considerable length. When it is partial, the tumour is retained altogether, or chiefly ,within the vagina, and the fundus only protrudes to a certain degree through the os uteri, forming a firm substance, something like a child's head.* * Mr. White of Paisley describes it very well, as resembling a printer's ball. Med. Com. vol. XX. p. 147. Sometimes it does not pass through the os uteri. Denman, vol. II. p. 35l. Mangetus, lib. IV. p. 1019, relates a fatal case, where the tumour was taken for the head of a second child. It was at first partially, and then completely, inverted, with excruciating pain. Mr. Smith relates a ca>02 any fault ofthe attendant. Dr. Merriman (Synopsis, p. 149,) mentions an instance, where it took place when the hand of the operator was introduced for the purpose of effecting the separation ofthe placenta. It is in this way that we are to account for those cases which have apparently recurred many days after delivery, and where, either with or without hemor- rhage, the uterus has suddenly come down. It would appear, however, that this depression ofthe fundus, ending at last in complete inversion, may take place some time after delivery. There is one case of this kind recorded, when, on account of haemorrhage, the hand had been introduced, and the uterus was not found unusual in its figure. On the 12th day inver- sion took place. Even in this instance, however, it is by no means certain that there was no depression early; for the prac- titioner, Ane, might not have attended minutely to this circum- stance, not expecting it. An incomplete inversion may remain for life, and occasion incurable fluor albus and haemorrhage Some, however, speculate on a cure being effected by preg- nancy, which doubtless would be the case, if that could take place. It has been supposed possible, that inversion might take place in the virgin state, if the womb had been distended by blood c«r other fluid. Inversion may terminate in different ways. It may prove rapidly fatal by haemorrhage ; or it may excite fatal syncope, or convulsions; or it may operate more slowly, by inducing inflammation, or distention of the bladder ; or after severe pains and expulsive efforts, the patient may get the better of the immediate injury, the uterus may diminish to its natural size by slow degrees, and give little inconvenience;* or it may discharge foetid matter, and give rise to frequent debilitating haemorrhage, with copious mucous discharge in the intervals; or hectic comes on, and the patient sinks in a miserable manner. It has also been said, that after a lapse of many years, the inversion might be spontaneously cured, which Dailliez explains, by supposing that the tubes pull up the inverted part. There are two examples of this termination recorded, and one of them (Mad. Bourchalatte) on the authority of the justly * La Motte, 383, mentions a woman who had inversion for above thirty vears. Dr. Cleghorn, Med. Commun. II. 226, relates a case where the uterus slowly returned to its natural size. This woman still menstruates, and, enjoys tolerable health; it has been of twenty years' standing. The womb is smooth, moist, and gives little pain. Menstruation also continued in Dr. Hamilton's case, Com. XVI. p. 315. 503 celebrated Baudelocque.* In this case, the restoration took place, after a lapse of eight years. If this be physically pos- sible, it must at least be exceedingly rare. If inversion be discovered early, the uterus may be replaced. If it have protruded out of the vagina, it is first of all to be returned within it; if it have not, we proceed directly to en- deavour to return it within the os uteri, by cautiously grasp- ing the tumour in the hand, and pushing it upwards, within the os uteri. This may be facilitated by pressing up the most prominent part of the fundus in the direction of the axis of the uterus, so as gradually to undo the inversion, or re-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 compressing the tumour, we some- times bring on violent bearing-down pains. These are occa- sionally attended with increase, or renewal, of flooding, and in all cases on pressing the uterus, small vessels spout like arteries in an operation. If we succeed, we should carry the hand within the uterus, and keep it there for some time, to excite its contraction. If the placenta still adhere, we should not remove it until we have reduced the uterus ; after which, we excite the contraction of the womb to make it throw it off.t It is sometimes long before the pulse becomes steadily to be felt.i; 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.|| If inversion have not been discovered early, it is more dif- ficult, nay, sometimes impossible, to reduce it, owing chiefly to contraction of the os uteri.105 Dr. Denman says, that he has found it impossible to reduce it, even four hours after it took place; and in a chronic inversion, he never once succeeded. In such cases, it is not prudent to make very violent efforts to reduce the uterus, as these may excite convulsions, foe. Soon after becoming inverted, the uterus is apt to swell and inflame. If this have happened, no attempt should be made to reduce, * Gardien Traits, Tom. III. p. 335. t In a case related in Memoirs of Med. Soc. vol. V. p. 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. Dr. Merriman, in one instance, followed the advice of Puzos, to remove the placenta, but although he did it without detriment, yet he acknowledges he would not follow the same course in future. X Case by Dr. Duffield, in Trans, of Coll. at Phil. 167. $ Case by Dr. Albers, Annals of Med. vol. V. 390. U Mr. White's Case, Med. Comment, vol. XX. 247. 504 till, by bleeding, and rest, and mild fomentations, this state have been allayed. We must in every instance alleviate urgent symptoms, such as syncope, retention of urine, or inflamma- tion, by suitable means. I may further observe, that when a patient, after delivery, complains of obstinate pain or bearing- down, or suppression of urine, or is very weak, we should always examine per vaginam. If the uterus be inverted, we may feel the tumour, and we may find the hard womb to be absent in the belly, or lower down than it should be. If this 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, we should at least return it into the vagina. We must palliate symptoms, apply gentle astringent lotions, keep the patient easy and quiet, attend to the state ofthe bladder, support the strength, allay irritation by anodynes, and the troublesome bearing-down by a proper pessary ; the bad effects of neglecting or removing this are to be seen in La Motte's 385th case. A spring ban- dage is also useful. If inflammation come on, as is usually the case, we must prescribe blood-letting, laxatives, foe. In this way the uterus contracts to its natural size, and the woman menstruates as usual, but generally the health is delicate. Sometimes the uterus becomes scirrhous, or grangrenous sloughs take place.* If the uterus discharge foetid matter, and haemorrhage take place, the strength is apt to sink, and the patient dies hectic. Astringent applications, with attention to cleanliness, good diet, and the occasional use of opiates, may give relief; but if they do not, we are warranted to prefer extirpation of the uterus to certain death. This operation has been repeatedly successful,t and is performed by applying a ligature high up, * Schmucker's Surgical Essays, art. xvii.— A case is given, Med. Journ. VI. 367, where appearance of gangrene, from strangulation, took place. The womb was scarified, and the swelling quickly disappeared. The patient recovered. t The inverted uterus has been torn off with the crotchet, being mistaken for the child's head. Jour, de Med. tom. XLI. p. 40. A case of successful extirpation is inserted in the same work for August, 1786. Wrisberg 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. Another by Mr. Baxter, Med. Phys. Jour. vol. XXV. and by Mr. Chevalier, related in Dr. Merriman's Synopsis, p. 286. Petit of Dijon says, a surgeon, by mistake, applied the ligature and cured the woman. The surgeon's son denies that the cure was wrought by mistake. Osiander relates a case where the 505 and cutting of 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 polypus,* 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 ofthe os uteri; from the second, by attending to the history, and by careful examination. In complete inversion, there may be a rugous state or corruga- midwife pulled down the uterus and placenta, and cut them both away. The patient recovered, and afterwards was exhibited during every course of lectures. Mr. Hunter, of Dumbarton, gives a successful case, in Annals of Med. vol. IV. p. 366. I have particularly examined this woman, several years after the operation. She was delivered without any violence, after having been twenty. four hours in labour. In about an hour the 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 was reduced to a state of great weakness. A ligature was applied, which, she says, gave her a good deal of pain, and the tumour was cut off. Her account differs in some respects from Mr. Hunter's, probably owing to her speaking from memory alone, some years after the event; and she does not notice the previous extraction of any lumps from the uterus, which Mr. Hunter mentions, for most likely she did not know of that. About two years ago, she had for a length of time a discharge of thick white matter. At present, the vagina is of the usual length ; and at the top, a transverse aperture is felt, the posterior lip or edge of which is longer and more tendinous to the feel, than the anterior. It admits the tip of the finger, and feels softer than the os uteri, in a natural state. There is no cervix uteri. The mammae are firm, and of good size, and she has not lost the sexual desire. She is subject to dyspepsia. From the pre- paration in the possession of Dr. Jeffray, there can be little doubt that part of the uterus was extirpated. Mr. Newnham, in his Treatise on Inversion, p. 31, relates the case of Mrs. Glassock, who had a ligature applied to the inverted uterus, but on account of pain, it was removed in some hours. As she was evidently losing ground, it was re-applied on the 13th of April. It produced much pain, which came at intervals, like that of labour. This was allayed by opiates, and the ligature gradually tightened. She was very irritable, and suffered much from spasmodic pain; but, on the 6th of May, the tumour dropped off, and she got well. As the finger could be passed within the os uteri, and around the tumour, the inver- sion must have been incomplete. The inverted uterus, when touched with the finger, appeared to be nearly insensible, and had never caused pain. The uterus has also been successfully extirpated, partly by the ligature, partly by the scissors, by Mr. Windsore. Med. Chir. Trans, vol. X. p. 358. 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, button the third day the patient died. In the cavity of the portion were found the ovaria and ligaments.—Gouland's patient died on the 18th day. Mem. of Acad, de Sciences, 17'vl. * In a case related in Recueil des Actes de la Soriete de Sante de Lyon, the uterus was taken for polypus, and the ligature applied. The mistake being dis- covered, it was instantly withdrawn, but the woman died in a few days. 3Q ,v>* tion at the top, but can be no distinct orifice, as in polypus. A polypus is more moveable, especially more capable of being rolled. It is generally of a different shape, being more bulging at the extremity and having a smaller pedicle, and the finger can be carried as far as it can reach within the os uteri, which embraces it more like a ring than a mouth with projecting lips. It is quite insensible, yet we must remember, that pressing it may press the uterus and cause sensation ; but scratching or irritating it does not give pain. Still there may be cases where some doubt remains.* An incomplete inversion is more apt to be mistaken, for the finger can be passed within the os uteri, and along what appears to be the stalk or pedicle of a polypus ; but this root is thicker than in the polypus, and the os uteri is somewhat thickened and projecting. The tumour itself is not very sensible, but nevertheless may be distinguished from polypus by scratching it gently with a sharp probe, which will cause some sensation, whilst in the polypus it causes none, unless we move it, and thereby move the womb.106 CHAP. IV. Of After-pains. Few women proceed through the early part ofthe puer- peral state, without feeling attacks of pain in the belly, which are called after-pains. These are generally least severe after a first labour. They proceed from the contraction of the uterus in an irregular manner, excited by the presence of coagula, or othef causes, and each severe pain is 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 applies the child to the breast. They are distinguished from inflammation of the uterus or peritonaeum, 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 frequent. When the pulse is frequent, then we must always be on our guard ; for if this be the case * 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. >o; before the accession of the milk-fever, the patient is not out of danger, and if any other bad symptom appear, we must be prompt in our practice. After-pains may also be caused by flatulence and costiveness, which we know by the usual symp- toms ; but a combination of this state with uterine after-pains is often attended with a frequency of the pulse, and may give rise to a fear that inflammation is about to come on, but other symptoms are absent. Uterine after-pains are relieved by opiates,107 friction, and fomentations, and these are the usual remedies ; but if protracted, or very severe, the spasmodic action which causes them is more readily and effectually removed by a purgative than by opium. This fact I first learned by accident. If the pulse be frequent, this is indis- pensable. A severe constant pain in the hypogastric 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 colic pains for puerperal inflammation; for in such cases there is often retching and sensibility of the muscles, which renders pressure painful. But there is less heat of the skin, the tongue is moist, the pulse, though it may be frequent, is soft, the feet are often cold, the pain has great remissions if it do not go off completely, there is little fulness of the belly, and the patient is troubled with flatulence. It requires laxatives, anti- spasmodics, anodyne clysters, and friction with camphorated spirits. Oil of turpentine acts both as a laxative and antispas- modic. In doses of half an ounce, it often relieves spasmodic pain in the stomach or bowels; but in this case, it is better to combine it with castor oil, giving two drachms of the former and four of the latter ; but from the disagreeable irritation it pro- duces, and the effect sometimes induced on the orifice ofthe bladder, it is not to be used in slight cases. 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. The external application of oil of turpentine is also useful. 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 viscera: or in some cases it is fejt near the groin, and may be the fore- runner of swelled leg; ©r about the hip, ending in a kind of rheumatic lameness ; or, in consequence of the application of 508 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. 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 shifting and aching, or gnawing, though sometimes it is pretty sharp, like a stitch. It is relieved by friction, with laudanum, by sinapisms, and by mild diaphoretics, bark, and the usual treat- ment. When speaking of rheumatic pain, it may not be improper to mention, that chronic rheumatism, especially of the extremities, is very troublesome when it occurs after par- turition. 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 of the crotchet. CHAP. V. Of Hysteralgia. By hysteralgia, I understand uterine pain proceeding from spasm, and not from inflammation. This may occur soon after delivery, and is marked by severe pain in the back and lower belly, frequent feeble pulse, sickness and faintness. This is sometimes accompanied with discharge, or succeeded by expul- sion of a coagulum. In other cases, although attended with severe bearing-down, we have no expulsion of coagulum, no retention of urine, no inversion of the uterus. It is mere pain and irritation, perhaps from some bad position of the uterus. Dr. Baird, of this city, has favoured me with a paper on the malposition of the uterus, productive of great pain, and also tenderness on pressure. This, he says, is relieved by pressing the uterus from its situation, generally one of the sides of the belly. Hysteralgia requires a purgative clyster immediately, and afterwards an opiate ; or, if it occur very early after delivery, we may reverse the practice, and give instantly an anodyne clyster, to be followed by a purgative medicine, if the stomach will bear it. Another modification of this comes on later, but always within three or four days after delivery, and attacks in general very suddenly. Perhaps 509 the patient had 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 paiifful on pressure. After some hours, the severity abates, and presently by proper means the health is restored. As the lochial discharge is usually obstructed, this obstruc- tion has been considered as the cause of the pain and other symptoms ; but it is merely an effect, and sometimes does not exist. The cause appears to consist in a deranged state of action in the uterus, which is productive of spasm 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 exposed 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 becoming speedily more severe than it does at the same period of inflam- mation ; and frequently it greatly remits, or goes almost entirely away for a short time. It is possible, however, for this state, especially if it be neglected, to excite inflammation, which is marked by constant pain, more or less severe accord- ing to the part affected, and an obstinate continuance of the fever. The first thing to be done is to administer a turpentine clyster to open the bowels. Then the belly is to be fomented, and if speedy relief be not obtained by these means, an anodyne njection 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, I strongly advise the detraction of blood. Purgatives are useful, and a cloth soaked in oil of turpentine must be applied to the pained part ofthe belly, to prevent inflammation. •HO CHAP. VI. Of Retention of part of the Placenta. If either the whole, or a considerable portion of the pla- centa, be left in utero for some time, the patient is exposed to great danger. Haemorrhage is not the only risk, for in many cases severe headach, hysterical affections, sickness, nausea, prostration of strength, and fever, have taken place, and con- tinued until the placenta have been expelled, after which the patient has began 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 afterwards gradually increased, and carried off the patient.* Sometimes the symptoms run so high, or the portions ofthe placenta are so obstinately retained, that the patient sinks under the dis- ease, 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 haemorrhage. These symptoms have a very indefinite duration, for some- times the patient dies in a very few days ; in other instances they are protracted for two or three weeks.t Sometimes no haemorrhage takes place during the whole course ofthe dis- ease, but occasionally, repeated haemorrhages do occur, adding greatly to the debility ofthe patient. In several cases, inflam- mation 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 inspecting the uterus, it has either been found black, as if it had been gangrenous, or in a state of high inflammation, or of suppura- tion, whilst the parts in the vicinity were in various stages and degrees of inflammation. Now, when these symptoms have taken place, our object 0ught to be to remove the cause, and support the patient under * In a case related by Mr. Whyte, the secundines, after a clyster, came away in a putrid state on the fifth day. On the sixth, the patient was much oppressed, had foetid breath, &c.; on the twelfth, an eruption appeared, and she died on tho twenty-second. + 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 subsultus lenrfinum. Vol. II. p. 390.__ in an other case, the placenta was retained till the thirteenth day, and the woman died on the twentieth, p. 381. M I the disease. 1 am aware that some have attributed these symp- toms,not to the placenta,but to concomitant circumstances, such as injury done with the hand in endeavouring to take it away. But we find that they take place when the whole ofthe pla- centa has been left without any attempt having been made to remove it. They are produced when any substance is left to corrupt in utero.* They continue as long as it remains, and they usually cease when it is expelled. At the same time, it must not be denied, that the rash extraction ofthe placenta, by the injury done, renders the effect of retention'of part of it, or of the membranes, much more serious, and more apt to produce a degree of local inflammation, marked by more or less pain or tenderness on pressure. 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 ofthe 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 not use vio- lence ; but this condition is rarely conjoined with retention of the entire placenta. When a portion of the placenta is retained, we may derive advantage from injecting, frequently, warm water, or warm infusion of camomile flowers, or weak solution of chloride of lime. A strong decoction of oak bark has been proposed, to tan the retained substance. These injections may be made, by fixing a female catheter to an elastic gum-bottle; or a syringe with a long pipe may be employed. Sometimes natural or artificial vomiting assists the expulsion. The patient should be allowed the free use of fruit and vegetable acids, and light mild diet should be given in small quantity at a time. The bowels ought to be kept open, and opiates should occasionally be given to allay irritation. Vomiting and nausea may be checked or mitigated when * Similar symptoms have been produced by the head of the child being left in utero. Perfect, vol. II. p. 80. 512 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 of the vulva is tender and of a deep red colour. This is productive of very distressing strangury, which is occasionally accompanied with a considerable degree of fever. It is long of being removed, but yields at last to a course of gentle laxatives, opiates and fomentations. Anodyne clysters are of service. An inability to void the urine requires the regular and speedy use ofthe catheter. CHAP. VIII. Of Pneumonia. It is unnecessary to detail the symptoms of inflammation ofthe 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 ofthe lungs during pregnancy, as tends toward phthisis, that disease is exceedingly apt to be rapidly induced after delivery. Pleurisy requires, on the first attack, copious blood-letting, laxatives, and blisters, which are never to be omitted. If the early stage have passed over, the use of the lancet is doubtful, and it is better to trust to digitalis given freely, and the appli- cation of blisters. Laxatives are also not to be neglected. 513 CHAP. IX, Of Spasmodic and Nervous Diseases. Palpitation is not an uncommon disease after delivery. It usually attacks the patient suddenly, and often after a slight alarm. She feels a violent beating in the breast, and some- times has a sense of suffocation ; she has also a knocking 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 languid. Some- times it issucceeded 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 dangerous disease, unless it proceed from uterine disease, marked by pain and swelling of the belly. It is to be relieved by giving, during the paroxysm, a liberal dose of ether and laudanum; and during the inter- vals, antispasmodics, laxatives, and tonics, are to be employed. As soon as possible, the patient should remove to the country. Hysteric fits, hiccup, syncope, and dyspnoea, are to be treated upon general principles, by full doses of opium, and other antispasmodics, and clearing out the bowels with pur- gatives. When a patient is known to be subject to syncope,, it will be proper to give her, the instant the child is born, a draught containing spiritus ammoniaearomaticus, and lauda- num, and to have the abdomen firmly supported by a bandage. There is a species of dyspnoea, that depends upon exertion ofthe 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 little the compress round the belly, and giving thirty drops of laud- anum. 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 stomach, 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 pain 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 3H 514 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 frequent, but is sharp. Dyspnoea is also occasionally produced by the roller being too tight. Colic may occur within a few days after delivery. It attacks suddenly, and generally in the evening. It is not preceded by shivering, but is sometimes accompanied with sickness. The pulse may at first be either slow or of the natural fre- quency, but soon becomes frequent. The pain is subject to exacerbation and remission, but sometimes does not entirely go off for several hours. The chief risk of this disease, is the induction of inflammation, if the excitement be not soon removed. A good remedy is, from two drachms to half an ounce of oil of turpentine, with some other laxative, such as half an ounce of castor oil, or tincture of senna. I was led to employ this remedy in painful affections ofthe stomach and bowels, not dependant on inflammation, from witnessing its excellent effects in the hands of veterinary practitioners, and from observing its safe and purgative quality in the human bowels, when given as a cure for tenia. If the turpentine fail, a large dose of laudanum is to be given in a clyster, and fomentations are to be used at the same time. It is generally beneficial to precede the anodyne by a saline clyster. If the symptoms do not go entirely off, the saline julap with laudanum is of service. If there be much flatulence, tincture of assafoetida and hyos- cyamus are proper. Cramp in the stomach is very dangerous, when it occurs within three weeks after delivery. It requires the immediate exhibition of at least sixty or eighty drops of laudanum, with a drachm of sulphuric ether, or two drachms of spiritus ainmoniae aromaticus in a suitable quantity of water; a sinapism is also to be applied to the region of the stomach. Pain in the region of the kidney sometimes proves very troublesome for two or three days after delivery. It comes in paroxysms, which are relieved by sinapisms, fomentations, clysters, purges, and opiates. Those females who have suffered from that formidable dis- ease of the spinal cord, described in the 5th chapter of the next book, are in great hazard after delivery. They often. 615 within half an hour after the placenta has been expelled, or at a longer interval, feel great debility and sinking, with or without sickness; and although the discharge have not been more than usual, yet they insist they are flooding or going to faint from loss of blood. The pulse is sometimes feeble, but often it is much stronger than the feelings of the patient would lead one to expect. The hand placed on the abdomen ascer- tains that the uterus is not distended with coagula, and that there is no concealed haemorrhage. The clothes are not wetter than usual; there is no pain indicating spasm of the uterus; and even if the hand be introduced into the vagina, no spas- modic stricture of the uterus is discovered. The practice I have found best is to give thirty drops of laudanum, and after- wards small doses of wine or brandy, or aromatic spirit of hartshorn, or ammoniated tincture of valerian, till the deadly feeling of sinking be abated. But we should never carry the stimulant plan too far, for we are apt to have too much excite- ment afterwards. On the other hand, if we give nothing, the patient may speedily die, and this I believe to be the cause of sudden death after delivery, which can in no other way be accounted for. The previous disease is often obscure. If the patient do not recover completely from this state, we find that next day, or within three days at farthest, she complains of headach, and great noise in her head, as if hail were rattling on a cupola; her eyes are red, the skin hot, the pulse frequent, and she is extremely restless. These symptoms may abate, or may end in puerperal mania, but, if neglected, they are more likely to end in the patient continuing to complain of her head, her neck, weight over the eyes, great pain in the arms and legs, then painful sense of sleeping or numbness, then complete paralysis ; the pulse becomes slow, the breathing difficult, as from the pressure of a weight on the chest, and the patient in a few days expires, apparently from the mere failure of the functions of respiration and circulation. The mind remains clear till the very last. In some cases, the patient merely complains of giddiness, or confusion of the head, with very rapid pulse, then the abdomen becomes tumid without pain, and, lastly, fatal stupor takes place. The only useful practice is to bleed freely from the arm, the moment that the state of excitement appears marked by heat of skin, and frequency of pulse, and beating in the head. Leeches applied to the head may also be useful after venesection, but cannot be trusted to alone. The bowels are to be freely opened; and if these means do not check or cure the disease, a blister 5lo should be applied to the nape of the neck, if the arms or breathing be much affected ; or to the back of the head, if the eyes or fifth pair of nerves be more affected. Sudden death may also take place from strong emotions of the mind, but instances of this are comparatively rare. CHAP. X. 0/ Ephemeral Fever or Weed, and Remittent Fever. 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 ofthe breasts, the bowels, or the uterus. The first of these symptomatic fevers, is generally pretty easily recognised by the sensibility of the breast; the others, particularly that connected with the state of the womb, are often more ambiguous, the local symptoms being in many cases insidious. The ephemera, or weed, as it has been called, is a fever usually of short duration ; the paroxysm being completed generally within twenty-four, and always within forty-eight hours; for if it continue longer, it becomes a fever of a dif- ferent description. It proceeds from great susceptibility of the nervous system, by which slight exposure to cold, mental agitation, or some local cause, 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. Without entering into the consideration of a general system of pathology, it may be useful to offer a few remarks illus- trative of puerperal disease. Such disease may take place in two ways; by the application of causes directly to the part, and which act on the extremities of its nerves, or by causes acting immediately on the origin of its nerves, and then on their extremities. Hence, local inflammation maybe produced in two ways, by direct application of causes to the part, or by the state of the origin of its nerves. An affection of the extre- mities ofthe nerves may either excite, or render more inactive 517 their origin, according to circumstances ; and either state is apt to extend itself farther to neighbouring portions of the brain, or medulla spinalis, and thus involve the origins of nerves going in a different direction, and to distant organs, which then come to be disordered, and an extensive chain of evil may thus be produced. An affection of the extremities ofthe uterine nerves may thus influence those going to the stomach or intestines, and vice versa, and slight disease in one of those organs, may induce fatal disease in the others. The affection of the origin of a particular nerve, in consequence of irritation or excitement of its extremity, may also react on that extremity, and increase the disease there. Further, as it is probable that different portions of the same trunks of nerves, and assuredly different individual nerves, have distinct destinations in an organ, as, for instance, producing sensation, secretion, muscular contraction, changes ofthe circulation, foe. we may have various modifications of disease, produced accord- ing to the nervous fibrillae, principally affected. Another effect, of the excitement of the extremities, on their origins, is not the induction of marked disease in any one distinct organ, but. of general disorder ofthe system marked by fever. Ap- plying this view to the puerperal state, I would go on to say, that one ofthe simplest effects is the ephemeral fever, arising evidently from excitement of those nerves which influence the heart, and the secretion of heat. It may, doubtless, be produced by some causes acting directly on the origin of those nerves, and which may, or may not, depend on the state of the uterus. But, in many instances, it is caused by the condition ofthe extremities ofthe uterine nerves, in the same way as temporary fever is caused in children by irritation of the stomachic or intestinal nerves. The wonder is not, that the uterus after delivery should have this effect, but rather that it should not always produce it. One single attack may be produced, or when the effect on the spinal cord, or sympa- thetic nerve, has been greater, the consequence is a prolonged fever ofthe remittent kind, which may last without any pro- minent local symptom being induced, though, doubtless, very ■apt to end in more marked disease of some important part. But sometimes from causes we cannot always explain, whether from a difference in the original irritation of the nervous extremities ofthe uterine system for instance, or from different integral parts of the nerves being affected at their origins, we have superinduced, various and formidable local affections, in- flammation of the abdominal cavity, as in peritonitis, or of 51* the extremity, as in swelled legs, &c. The production of a sudden sensation of cold in any part of the system, is very apt to induce this disease, and if the sensation have been long continued, the effect is likely to continue long. This disease generally makes its attack within a week ufter delivery, but it may come on at any time during lactation, or a coin- plaint essentially the same may occur in any female. It may be occasioned by irregularities of diet, or irritation of the visceral nerves, arising either from the state ofthe bowels, or some condition of the uterus or its appendages, not acute enough to produce pain, or any permanent local symptom, or by causes acting directly on the base of the brain, or medula spinalis. No cause is more frequent than the applica- tion of cold to the surface, so as to produce sensation. Some when nursing cannot touch any thing cold, without having an attack. Fatigue, exhaustion, passions ofthe mind, or want of rest, if not exciting causes, give a strong predisposition. The attack is sometimes directly ushered in with a fit of palpitation, or is preceded 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 of the symptoms. The head is usually pained, often intensely, especially over the eyes, in the two first stages. The pulse is extremely rapid, until the third stage have con- tinued for some time ; it is also subject to very great irregu- larities, and is very changeable in its degree of frequency. The thirst is considerable, the tongue furred, the stomach generally filled with flatus, and the belly bound. The mind often is weakened, and the patient is much afraid of dying. In some instances, she is slightly delirious; in others, she has shifting pains in the abdomen. If the paroxysm be repeated, the secretion of milk is diminished. The paroxysm continues for some hours, and then may completely go off, not to return again. But in other cases, it recurs daily for a length of time, being always preceded by a cold fit, and often with a pain in the back ; and sometimes the fit begins regularly one or two hours sooner every suc- ceeding day. It is more favourable when the fit postpones. In other cases, after one or two distinct paroxysms, the fever assumes a more continued form, or the exacerbations are not 519 preceded by distinct chills. When this disease is not com- bined with any local injury, it is less dangerous than most fevers occurring in childbed; but if it recur very frequently, and be attended with much debility, the danger increases in proportion to the continuance of the disease. Local derange- ment may manifest itself very suddenly in the course of this ailment; the breasts are peculiarly liable to become inflamed; generally, these local affections are rather causes than effects of the febrile state; and in all cases, where the paroxysms are repeated, it is necessary to examine carefully into the state of every organ, especially of the breasts and pelvic region. In prolonged cases, sometimes, the coxal nerves become very painful, or even paralysis of the extremities may take place. Very protracted cases will always, I believe, be found to be of a more formidable nature than a mere remittent weed: the fever is of the nature of hectic, and dependant on a local disease attended with suppuration. Other continued and obstinate cases are marked by pervigilium, and a tendency to puerperal delirium, or to serious affections of the brain, or may be considered as the intestinal fever, soon to be noticed. A fatal termination in acute cases is usually preceded by coma, or vomiting of dark-coloured matter, which is most apt to take place, if the origin ofthe nerves have been affected. Delicate women, and those who have suffered much in par- turition, are chiefly affected with thisdisease, but all are more or less liable to it, especially if the bowels be neglected. It is distinguished from symptomatic fever arising from local inflammation, by the absence of the particular pain, and other specific symptoms, which attend these fevers, whilst in them the pulse is usually at first not so rapid as in the ephe- meral fever. In the cold stage, we give small quantities of warm fluid, and apply a bladder filled with warm water to the stomach, or a warm flannel to the back, on the commencement of the chilness ; or, if the patient be sick, and have a foul tongue, a gentle emetic of ipecacuanha will be useful. If this be not required, we give a smart dose of calomel and jalap, or some other laxative, amongst the first acts of our practice. Having hastened on the hot stage, we lessen \e\y cautiously the number ofthe bedclothes, and give saline julap with diluents, to bring on the sweating stage. When this is done, we are careful not to encourage perspiration too much, which increases the weakness, or brings out a miliary eruption, and renders the disease more obstinate. On the other hand, if the per- 520 spiration be too soon checked, the fever continues, or recurs more severely; a gentle sweat may be kept up for five or s'u 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. In the whole paroxysm, we must watch against the sudden application of cold, which, in the two last stages, renews the shivering. If there be any local pains, or where the pulse is very frequent and full, and there is no contra-indication, a little blood should be taken away. In the first case it is necessary, in the second it is, if the patient be strong, always safe, and often useful in preventing a repetition of the attack, especially if the bowels be immediately opened. When the fits recur we may sometimes check them, by giving an opiate, with ether, just before the expected accession, and applying heat to the back and stomach, the moment the chilness is felt, or we rub the whole back well, daily, with a stimulating embrocation, such as camphor dissolved in the oil of rosemary. It is of great consequence to keep the bowels open, by such medicine as agrees best with the patient, for the paroxysms often are repeated,or continued fever pro- duced, from intestinal irritation alone. For a time no par- ticular appearance may be observed, but soon hard and offensive stools are obtained, and from that day improvement begins. Tonic medicines, such as infusion of bark, sulphuric acid, or sulphate of quinine, are afterwards useful; and in some cases valerian may be joined to these with advantage. Sleep is to be procured by opiates, if they do not produce confusion of mind. During the whole time, the strength must be supported by suitable diet, with a little wine ; 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. In very protracted cases the disease has been miti- gated by sponging with cold water and vinegar, after the cold stage had quite gone oft", and that without regard to the pre- sence or absence of perspiration. Any temporary chill thus produced, is removed by a little warm wine and water. This is more especially useful in the hectic form ofthe disease. If derangement of any organ should appear during this disease, it must be treated on general principles. Occasionally suppuration takes place within the pelvis, particularly after the application of cold, or from allowing the fire in the apartment to go out. This is not always preceded by much ril pain and often in its course is attended with little or none, till the progress have advanced far beyond any control. Even when the uterus has been implicated, so as to form adhe- sions to the sides of the pubis, as appears after death, there may be no pain felt on pressing it from the vagina. The fever in this case is long continued, and ofthe hectic kind, and the disease ofthe nature of lumbar abscess. The matter points at last about the groin or buttock, and must be let out. 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 satis- factorily. 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, preceded by shivering, and going off with a perspiration. This attack, if properly managed, seldom continues for twenty-four hours ; and during this time, the breasts are full, hard, and painful, which distinguishes this from more dangerous fevers. Some- times, during the hot fit, there is a slight delirium. A smart purge generally cures this disease, and is often used, in ple- thoric habits, on the third day after delivery, 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, languor, sometimes amounting to syncope, and frequency of pulse, with heat ofthe 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 bef6re the eruption appears, often for four or six days. Previous 3 S 522 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 suppressed. Before the eruption is seen, the skin feels rough like the cutis anserina. Presently a number of small red pustules appear like millet seeds, which are felt with the finger to be promi- nent. In a few. hours, small vesicles form on their tops, con- taining a fluid, first straw coloured, and then white or yellow. In twojjor three days small scabs form, which fall off like scales. The pustules are generally distinct, but sometimes they form clusters. They appear first about the forehead, neck, and breast, and then spread to the trunk and extremities, but very rarely affect the face. Different crops of pustules may come out in the same fever. Burserius, and others, divide the pus- tules into several varieties ; but most writers are satisfied with two, taken from the general appearance, the red and the white, and the first is attended with a milder disease than the second. This disease is peculiary apt to attack those who are weak- ened by fatigue, evacuations, or other causes ; and hence we can easily explain why women in childbed should be subject to it. Some have considered the eruption as altogether dependant on the perspiration. Others consider it as in many cases idiopathic ; and both, perhaps, at times are right. We can only consider the disease as idiopathic, when the eruption mitigates the symptoms, when the fever goes off as the pus- tules arrive at maturity, and there is no other puerperal dis- ease present, acting as an exciting cause. It does not appear to be contagious, unless connected with a fever which is so of itself, such as typhus. Miliary eruption also occurs during childbed, as a symptom connected with puerperal diseases. It often accompanies the milk-fever, or the protracted weed, when the perspiration is injudiciously encouraged ; and this is by far the most frequent form, under which the febris miliaris appears. It never alle- viates the symptoms. It may also accompany fevers connected with a morbid state of the peritonaeum or brain, which gene- rally prove fatal; death being preceded by vomiting of dark co- loured fluid. Women, much reduced, have also partial miliary 523 eruptions, generally of the white kind, without fever, which require no particular treatment. Whether the miliary fever be idiopathic, or symptomatic, the treatment is the same. We endeavour, at first, to check or remove the fever, by means which I have pointed out in a former chapter. When profuse perspiration, with or without eruption, takes place, we must cautiously abate it, by prudently lessening the quantity of bedclothes, or making the bed-room cooler. The rest of the treatment consists chiefly in removing irrita- tion from the intestines by the use of laxatives, and support- ing 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 renew the perspi- ration, apply blisters, and give musk and cordials, especially when convulsions are threatened. This dangerous retroces- sion, however, I have not met with, and apprehend that it very rarely occurs. CHAP. XIII. Of Intestinal Fever. We shall presently have an opportunity of observing, that the state of the bowels frequently produces in children a very troublesome species of fever, which, though proceeding from a cause which has been some time in existence, makes its appearance suddenly. The same holds true with regard to women in childbed, who, either from previous torpor or cos- tiveness of the bowels during the end of gestation, or some error in diet after delivery, are seized, within eight or nine days, generally earlier, with fever, which passes for weed; and most cases of what is called protracted weed, without any appearance of local disease, will be found to be fevers of this description. 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 521 very hot, especially in the hands and feet ;—she has no appetite,—is thirsty,—has a white slimy tongue,—is sick,— and occasionally vomits phlegm or bile, and is troubled with flatulence. The pulse is quick; she does not sleep, but rather slumbers, and is tormented with dreams and visions, and talks during her slumbers. Generally she complains of throbbing, often of confusion, but seldom of continued pain in the head, though for a short time headach may be severe. 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 fcetid and dark coloured, ; and, frequently, laxatives operate both early and powerfully. The lochial discharge is not necessarily obstructed, nor does the secretion of milk, in many instances, suffer for several days. The eye and the countenance 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 symp- toms may be complicated with others, proceeding from nervous irritation, such as palpitation, starting, foe., or in the course ofthe disease, new ones arising from injury of the function of the womb may supervene, and are marked first by pain, and afterwards by tumefaction ofthe lower part ofthe belly, and pain in making water, or in passing the faeces. The duration of this fever varies from a few days to a fortnight.* On the first appearance of this fever, a gentle emetic of ipecacuanha should be administered; and afterwards, when the operation is over, we determine to the surface, by giving • the saline julap with tepid drink. Then, in a few hours, we administer a dose of rhubarb and magnesia to remove offen- sive matter from the bowels; or, if necessary, we give a suit- able dose of castor oil, or calomel. After this, if there be considerable griping, or a tendency to much purging, we give * Since the publication of this work, the fever I have called intestinal, has been described by Dr. Granville, in his Report, p. 160. He notices that it is sometimes, when there is much inflation ofthe bowels, mistaken for puerperal fever; but the tumefaction in the intestinal fever precedes pain in the bowels, and the symptoms are decidedly relieved by purgatives. More recently still, Dr. M. Hall appears to have described this fever under the name of " a serious puerperal affection," and enumerates the various com- plications which may take place, but which do not seem essential to the disorder such as, vertigo, palpitation, feeling of sinking, &c, and divides the disease itself into two varieties, that which takes place acutely, and that which comes on more slowly; the former being preceded by more distinct shivering, and attended with more severe affections ofthe brain or abdominal viscera, than tha latter. 525 an opiate-clyster, and repeat this every night till the bowels dre less irritable, taking care, if they become costive, or the stools foetid, to interpose, occasionally, gentle laxatives. The great principle indeed on which we proceed, is the early and prompt evacuation of the offensive matter, whether bilious or feculent, from the bowels, and the prevention of re-accumula- tion, and this must be done by such doses as are required. The diet must be very light, such as beef-tea, calves' feet jelly, arrow root, foe., and if there be no diarrhoea, ripe fruit may be given. Ginger wine and water forms an excellent drink, and in a few days, such a quantity of Madeira wine may be given, as is found to impart a comfortable feeling, without inducing heat or restlessness. When the tongue becomes clean, small doses of colomba, or other bitters, will be useful. If there be much nervous irritation or palpitation, or ten- dency to delirium, the camphorated julap is proper. CHAP. XIV. Of Inflammation of the 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 describe them separately. The first begins within the ninth 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 establish- ment 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 continues, and the secretion of milk is not checked. The pain", at first, and usually during the whole course ofthe disease, is slight; it is generally felt near the pubis, but it may also extend a little to one side, or toward the groin. Sometimes there is pain in the back, but frequently there is none, unless when the 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. 526 There is no hardness to be felt, and the belly is not tender, but becomes a little full; the lochial discharge gradually diminishes, but does not of necessity stop, and the milk some- times continues plentiful. There is considerable thirst, no appetite, and the sleep is disturbed. The pulse, which at first is very frequent, falls in a day or two to 100, or varies from 90 to 108. The head is confused rather than painful, slight wandering pains may be felt in the belly or sides. The bowels are generally affected, being at first rather bound, afterwards loose or irregular, and the faeces, 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 circumstances are preceded or accompanied with a slight discharge 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 yield- ing completely to the treatment ; or they may be removed in so far as that all fever and pain go off; but when the patient comes to rise, she feels a pressure like prolapsus uteri, which 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 distinguish this state from prolapsus, except by exa- mination. The uterus is felt in its proper altitude, but often the os uteri is turned a little to one side, and sometimes is tender to the touch, 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 be in tolerable health, until a little purulent mat- ter, or still more frequently, a little blood, like the menses, be discharged, and then she is almost instantly cured. The treatment of this species of uterine inflammation con- sists in exciting early a free and ptetty copious perspiration, fomenting the belly, and opening the bowels with a smart purge. If the pain be more permanent, blisters may be necessary, and blood-letting, early employed, is useful, but most cases of this partial nature recover without the use of the lancet, merely by cuticular and intestinal evacuation. Nevertheless, I believe that venesection, to a moderate extent, is generally proper, and more effectually prevents chronic dis- ease afterwards. The more serious and extensive inflammation of the uterus may be excited in consequence of rude management, or other causes. The disease usually begins between the second and third day after delivery, but it may take place at a later period, 527 and sometimes even earlier. It is pointed out by a pain in the lower part of the belly, which gradually increases in violence, and continues without intermission, though it is subject to occasional aggravations, like very severe after-pains. These aggravations, at first, seem to proceed from contractions or spasms of the inflamed fibres. The uterine region is very painful when it is pressed, and it is^a little swelled. There is, however, little general swelling of the abdomen with ten- sion, unless the peritonaeum have become affected. But the parietes are rather slack, and we can feel distinctly the uterus through them, to be harder than usual, and it is very sensible. There is also pain felt in the back, which shoots to one or both groins, accompanied with sensation of weight; and there is usually a difficulty in voiding the urine, or a complete sup- pression, or distressing degree of strangury. The situation ofthe 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 red lochial discharge is very early suppressed ; if renewed, it is sero-purulent, 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, is sick, vomits bilious fluid, and often has headach. The pulse very early becomes frequent, and somewhat hard, and the skin is felt to be hot. The tongue is first white and dry, and then red and fiery, 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 peritonaeum come to partake extensively ofthe disease, then we have early swelling, and tenderness ofthe abdomen, and the danger is greatly increased. Sometimes the internal or mucous mem- brane is chiefly affected, and, succeeding to pain, fever, and suppression ofthe lochia, we have a puriform discharge. If the inflammation do not extend along the peritonaeum, 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 bloody dis- charge ; which last is the most frequent and complete crisis. If the pain abate, the pulse come down, and the lochia and secretion 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 becomes more frequent, but is full for a day or two, after which it 52* becomes small, the tongue is redder, but dry, the pain does not abate, and in some days, shiverings take place, and the pain becomes of the throbbing kind. The face is pale, unless when the cheeks have a hectic flush ; the urine, which was formerly high coloured, now deposits a pink-coloured sedi- ment, in great abundance. The nights are spent without sleep, and the patient is wet with perspiration. After some time, matter is discharged from the vagina, or by the bladder or rectum, but oftenest from the rectum. The hectic symp- toms continue for many weeks, and may at last prove fatal. Sometimes the disease early proves fatal, the pulse increasing in frequency, the tongue becoming very red, and the strength sinking; but, even in this case, it will generally be found that suppuration has taken place. No reliance is to be placed on the abatement of pain, and the apparent improvement of the pulse, if the patient continue to vomit, and the tongue remain dry and fiery, or aphthae appear. Pus is contained often in the ovaria and tubes, and sinuses of the uterus. Mortification is an extremely rare termination. This is a fact of which my dissections convince me, and it is farther confirmed by the opinion of Dr. Clarke. Little or no serous effusion takes place into the abdomen, if the inflammation be confined to the uterus. In some cases the veins participate Very extensively in the disease, and become inflamed to a great distance. Thus inflammation may spread toward the heart or liver, or down along the veins of one or both thighs. This is attended with great and debilitating fever, and much pain in the course of the affected veins, which, after death, are found inflamed, thickened, or filled with pus. The treat- ment of this complication must be conducted on the antiphlo- gistic plan, and a knowledge of the nature of the disease will call for early attention to local pain attended with fever. In one case, but the circumstance may have been accidental, the patient complained of very severe pains in the outside of the arm she had been bled from. This was accompanied with some degree of tumour and swelling, and gave her more dis- tress than the uterine pain. Inflammation of the uterus may arise without any very perceptible predisposing or exciting cause, but frequently it is distinctly attributable to previous exertion during tedious labour, or to rash manual interference, or hurried extraction ofthe placenta, or the application of cold in any way. It, as well as peritonaeal inflammation, is also peculiarly apt to affect those who have suffered from uterine haemorrhage. This disease calls for the early and free use ofthe lancet, 529 which is the principal remedy; and the number of times that we repeat the evacuation must depend on the constitution of the patient, the effects produced, and the period of the dis- ease.* If three or four days have passed over, the pulse may be full and frequent; but this is an indication that suppura- tion is going on, which will be ascertained by throbbing pain, fo,c. In this case the lancet is hurtful. Mild laxatives are also highly proper. Fomentations, or a cloth soaked in oil of turpentine, arc useful. A blister applied to the hypogastrium is often highly beneficial, more especially when the disease seems to be in what may be called a hesitating state. Dia- phoretics ought to be administered, such as the saline julap, with the addition of antimonial wine and laudanum. This is the best internal remedy 1 think we can employ. Emollient elysters, or sometimes anodyne clysters, give relief. In the suppurative stage, we must keep the bowels open, give light nourishment, apply fomentations, and allay pain w ith 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 patient complains of pain and tenderness at the groin, increased by pressure. The lower part ofthe belly is, after a little, swelled and uneasy. Fever attends this disease, and sometimes the stomach becomes irritable. It is often caused by hasty extrac- tion ofthe placenta. It requires the early use of laxatives; and if the symptoms are violent, it is proper to take blood from the arm, and apply leeches to the groin, which should seldom be omitted. Afterwards we employ fomentations and blisters. If neglected, the disease may end in suppuration, or in a painful swelling at the ring ofthe oblique muscle, which lasts a long time. This is sometimes removed by issues. Anodynes should be given to allay irritation, and the strength must be supported under the fever, which resembles hectic. In some cases, the internal membrane of the uterus is chiefly affected. The pain is not constant, but the uterus is always tender when pressed, and there are paroxysms like severe after-pains, with wander- ing pains about the abdomen or thorax. The discharge is foetid and sero-purulent. The skin is hot, and sometimes moist. The pulse is of moderate frequency. The sleep is disturbed, and the head pained. Sometimes the bowels be- come for a short time inflated, and the breathing, at the same time, more or less oppressed. The treatment consists in taking • The French writers erroneously do not consider the lancet as requisite, unless the symptoms be very acute, but trust rather to leeches, applied to the vulva. Gardien, tom. III. p. 4-17. 3T :>.*o first a little blood, if the local symptoms or fever be considera ble, opening the bowels, and applying warm fomentations to the belly; afterwards, opiates, alternated with laxatives, are useful; and great attention must be paid to remove the foetid discharge. CHAP. XV. Of Peritonaial Inflammation. The peritonaeal lining of the abdomen, or the covering of the intestines, may be inflamed alone; or thisdisease may be combined with inflammation ofthe uterus. Peritonaeal inflammation may be caused by violence during delivery, or the application of cold, or the injudicious use of stimulants. Those who have suffered from uterine haemor- rhage after delivery, are most liable to this disease, as well as to inflammation ofthe uterus. It may not come on for three weeks after delivery, but it usually appears on the second day; 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 universal; though, in other cases, it is at first confined to one spot. The abdomen very soon becomes swelled and tense, and the tension rapidly increases. The pulse is frequent, small, and sharp, the skin hot, the tongue either clean, or white and dry, the patient thirsty; she vomits frequently, and the milk and lochia are obstructed. These symptoms often come on very acutely, but it ought to be deeply impressed on the mind of the student, that they may also approach insidiously. Wandering pain is felt in the belly, neither acute nor altogether constant. It passes for after-pains, but it is attended with frequency of pulse, and some fulness of the belly, and a little sickness. But whether the early symptoms come on rapidly or slowly, they soon increase, the belly becomes as large as before deli- very, and is often so tender that the weight of the bedclothes can scarcely be endured; tho patient also feels much pain when she turns. The respiration becomes difficult, and some- times a cough comes on, which aggravates the distress; or it appears from the first, attended with pain in the side as a prominent symptom. Sometimes the patient has a great inclination to belch, which always gives pain. The bowels are either costive, or the patient purges bilious or dark coloured 531 faeces. These symptoms are more or less acute, according to the extent to which the peritonaeum is affected. They are, at first, milder, and more protracted, in those cases where the inflammation begins in the uterus; and in such, the pain is often not very great, nor very extensive, for some time. If the disease be to prove fatal, the swelling and tension of the belly increase, so that the abdomen becomes round and pro- minent, the vomiting continues, the pulse becomes very fre-^. quent and irregular, the fauces are aphthous, death is marked in the countenance, the extremities cold, and the pain usually ceases rather suddenly. The patient has unrefreshing slum- ber, and sometimes has delirium mite, but she may also remain sensible till the last. The disease usually proves fatal within five days, but may be protracted for eight or ten days, or even longer. If the patient be to recover, the swelling does not proceed to a great degree; the pain gradually abates, the vomit- ing 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 suppu- ration, 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 peritonaeum is found in a state of high inflammation, but it is rare to find it mortified. A consider- able effusion of serous fluid, mixed with curdy substance, is found in the belly. The patient is only to be saved by vigorous means, and great attention. If the pulse continue above a hundred in the minute, for twenty-four hours after delivery, there is reason to apprehend that some serious mischief is about to happen ; and therefore, unless the frequency depend decidedly on debility, produced by great haemorrhage, foe. we ought to open the bowels freely, and give a diaphoretic. We must carefully examine the belly, and if it be full, or painful on pressure, or if the patient be inclined to vomit, we ought instantly to open a vein, and use purgatives. One copious bleeding, on the very invasion of the disease, is more useful than ten afterwards; and the delay of two hours may be the loss of the patient, where danger, even under the most active practice, is extreme. I know that many are unwilling to bleed women in the puer- peral stale, and the condition ofthe pulse may seem to young 5;32 practitioners to forbid it. But in cases of peritonaeal inflam- mation, 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 constitution of the patient. If she have borne it ill, and not been relieved, when it was used first, I apprehend that the case has not been simple peritonaeal inflammation, but malignant puerperal fever. If •.•she bear it well, and the pulse become slower and fuller, and the pain abate, we are encouraged to repeat it. I wish to impress on the mind ofthe student, in the most earnest manner, the fatal consequence of neglecting blood-letting in this disease. How many women fall a sacrifice to the timidity or inattention of their attendant! The lancet is the anchor of hope ; it may indeed be pushed too far; it may be used by young practi- tioners in cases of spasm, mistaken for peritonitis; but the error is safer than the contrary extreme, for of two evils debility is more easily removed than inflammation. When I say this, however, I do not mean to urge the senseless and extravagant use of the lancet. A prudent practitioner will bleed early and freely, so long as he is thereby abating inflam- mation; but he will stop in time, and observe whether he be really gaining advantage by evacuation, or, on the contrary, sinking the patient, and destroying that vigour which is neces- sary for an effort to recover. He will never bleed late in the disease, unless it be to subdue an exacerbation, and unless the beneficial result of his practice confirm its propriety. Whilst some have been dilatory and too timid, others, 1 fear, have sunk their patients as effectually by inordinate evacuation, as if they had left the inflammation quite uncontrolled. After the lancet has been freely used, if pain continue, leeches, or the scarificator, should be applied to the most painful part. A large dose of opium, that is, three grains, are to be admi- nistered after the bleeding, and repeated according to circum- stances, in smaller doses. The bowels are at the very first to be opened freely with calomel, or some other purgative, which we require to give in a large dose, particularly calomel, for ordinary doses do no good. Dr. Armstrong, who is also a powerful advocate for the use of opium, gives half a drachm of calomel, and afterwards a purgative draught of senna and salts to work it off, and I think the principle safe, provided we regulate the dose of the medicine by the constitution and habits of the patient. In an advanced state of the disease, after effusion has taken place, we must employ purees alone, rather than blood-letting. Sinapisms and blisters are also proper. Digitalis has been given, either to abate inflamma- 533 tion, or promote absorption, after effusion has taken place ; but I have never in one single instance 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 administered. There are one or two cases recorded, where the fluid had been either spontaneously discharged by an opening taking.place in the intestines, or artificially by paracentesis, and with a good effect. Peritonaeal inflammation may take place during pregnancy, and not prove fatal. After delivery, the pulse continues quick, the face is flushed, the belly is swelled, and fluctuation is per- ceived. The patient dies of rapid hectic, and, on inspection, the intestines are found inflamed, and pushed aside with much pus. If the disease be not checked by bleeding in the com- mencement, I believe nothing can do good in the hectic stage. Paracentesis may be proposed, but its effects are not to be much depended on. Chronic, or slow inflammation of the peritonaeum, is not very unfrequent, and may last for some weeks. It is attended 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 ofthe disease. It requires at first blood-letting, and then the frequent use of laxatives, with repeated blisters. When upon this subject, it may not be improper to men- tion, that a young practitioner may mistake spasmodic affec- tions, or colic pains, for puerperal inflammation? for in such cases there is often retching and sensibility of the muscles, which renders pressure painful. But there is less heat ofthe skin, the tongue is moist, the pulse, though it may be fre- quent, is soft, the feet are too often cold, the pain has great remissions if it do not go off completely, there is little ful- ness of the belly, and the patient is troubled with flatulence. It requites laxatives, antispasmodics, anodyne clysters, and friction with camphorated spirits. If these means do not give speedy relief, then we use the lancet. 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. Inflammation of the mucous coat of the intestines is not an uncommon disease during pregnancy, and is marked by dysenteric symptoms, and great emaciation, if it be protracted. 534 After delivery, the purging generally increases, the stools are liquid and often slimy, and usually without pain, at least except at the moment of discharge, which is perhaps very rapid. There is seldom pain on pressure, or if there be, it seems rather at the epigastrium from vomiting than from any other cause. The pulse is frequent, the appetite lost, consi- derable thirst, occasional vomiting of bilious fluid, extreme emaciation, and oedematous extremities. In many cases, the inflammation seems to be concentrated into spots, here and there, and the vicinity is only in a state of irritation or excite- ment. In the early stage of the disease, bleeding may be necessary. Mild laxatives should be given to remove acrid or indurated faeces, and the diet should be light. Afterwards, opiates must be exhibited to allay the irritation, and the best form is that of pills. In the more advanced stage, clysters, with laudanum, or suppositories of three or four grains of opium, must be given, and in extreme cases, brandy is useful in supporting the strength. I have not known astringents do good, neither have I derived so much advantage from external irritation as I expected. CHAP. XVI. Of Puerperal Fever. Puerperal fever begins sometimes in an insidious manner, without that shivering which usually gives intimation ofthe approach of a serious malady. In other cases, the shivering is perceived, and varies considerably in degree, being either slight or pretty severe. The first symptoms, independent of the shivering, are frequency of pulse, oppression, nausea, or retching, pain in the head, particularly over the eye-brows. The night is passed with little sleep, much confusion, and occasionally some delirium. It must not, however, be unno- ticed, that in many instances, there is no headach in any stage ofthe disease, nor any sickness or vomiting in the beginning. In some, the temper is, from the first, uncommonly irritable ; in others, there is much timidity, or listlessness, or apathy. Hysterical symptoms not unfrequently supervene ; or parti- cular nerves become more sensible ; or organs of sense are affected : thus, some imagine they hear the performance of a piece of music. From the beginning of the attack, or very soon afterwards, pain is felt in the belly, at first slight, but 535 it presently increases; and in some instances the abdomen becomes so tender, that even the weight of the bedclothes is productive of distress. A general fulness ofthe belly precedes this, or, at least, accompanies it from the first, and this usually increases 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 ; indeed, in every instance, the respiration is more or less affected, the free action ofthe abdominal muscles, which are concerned in that function, being productive of pain. The degree of pain, its seat, and period of accession, vary in dif- ferent cases. In some, it evidently begins in the uterus, never going entirely off, yet being subject to severe exacerbation, accompanied w ith sense of bearing down. The uterine region is painful, particularly toward one side. The os uteri, if examined, is not much more sensible than usual. There is generally pain in the back. In other cases, it is first felt about the lower ribs, on one side, and is accompanied by cough, the belly is tumid, and tender when pressed, but, excepting then, or when the patient turns, she complains little of it. Sometimes severe pain, like spasm, attacks the iliac region, and extends down the thigh, and toward the bladder and pubis. The face is sometimes flushed at first, or the cheeks are suffused, but the countenance, in general, is pale and ghastly, the eyes are without animation, and the lips and angles of the eyes are white. When the face is flushed, the cheeks are generally covered with a broad patch of deep red, whilst the brow and other parts are cadaverous, or covered with perspiration. The whole features indicate anxiety, if not terror, and great debility. Vomiting occasionally occurs at the very commencement, and in that case it is bilious. In the course ofthe disease, it sometimes becomes so frequent, that nothing will stay in the stomach; and towards the con- clusion of the fever, the fluid thrown up is dark coloured, and frequently foetid. This is a symptom, which, so far as I have observed, always, if it do not proceed from a morbid structure, indicates, in whatever disease it occurs, an entire loss of tone of that organ. But to proceed with the history. There is a great dejection of mind, languor, with general debility of the muscular fibres, and the patient lies chiefly on her back; or there is so much Iistlessness, that she sometimes makes little complaint. The skin is not very hot, but is rather clammy and relaxed. The tongue is pale or white at first, but presently becomes brown, and uniformly aphthae appear in the throat, and extend down the oesophagus, and 536 over all the inside ofthe mouth. From the irritability of the stomach and bowels, it is probable that these organs parti- cipate in the tender state ; and from the cough which is excited, the upper part ofthe larynx seems also to be affected. It has already been mentioned, that from the first the pulse is very frequent, and is, at that period, fuller than in simple peritonaea! 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 after- wards, especially about the third day, they usually become loose, and the stools are dark, foetid, and often frothy. This evacuation seems to give relief. It is, indeed, peculiarly deserving of remark, that often, in this disease, either from spontaneous or artificial evacuation, or, sometimes, without any perceptible cause, there is a delusive calm, and the patient is supposed to be better; but in such cases, I cannot say I ever remember to have found a corresponding improvement in the pulse, and therefore I placed no reliance on the apparent relief. The urine is dark coloured, has a brown sediment, and is passed frequently, and with pain. The lochial dis- charge is diminished, and has a bad smell, or is changed in appearance, or gradually ceases ; and it is observable, that the re-appearance of the lochia, if they had been suppressed, is not critical. The secretion of milk stops, and the patient inquires very seldom about the child. In some cases, I have met with pleuritic symptoms. As the disease advances, the pulse becomes more frequent and weaker, or tremulous. In bad cases, the swelling of the belly increases rapidly ; but the pain does not always keep pace with the swelling, being sometimes least when the swelling is greatest, and in the end, it generally goes entirely off. The breathing becomes labo- rious, in proportion as the belly enlarges. The strength sinks ; the pulse, always frequent, becomes weak and tremulous ; the throat and mouth become sloughy ; perhaps the stools are passed involuntarily; hiccup sometimes takes place ; and the patient usually dies about the fifth day of the disease, but in some cases not until the fourteenth; in others so early as the second day. In some instances, death is preceded by low delirium, or stupor. In others, the mind continues unin- paired till within a few minutes of dissolution, and the patient is carried off after a fit of a convulsive kind. This fever attacks generally on the second, or sometimes on the third day after delivery, but is has also occurred so late as after a week. The earlier it attacks, the greater is the 537 danger, and few women recover who have the belly much swelled. On dissection, there is found in the abdomen a consider- able quantity of fluid, similar to that met with in peritonitis. The omentum and peritonaeum are inflamed in a variable degree ; sometimes considerably, sometimes very slightly, and gangrene is unusual. The swelling is neither proportioned to the inflammation nor effusion, nor in every instance dependant on these, but on that inflation of the bowels which results from the relaxation ofthe muscular fibres of the bowels, which is so common in the puerperal state, particularly in puerperal disease. The uterus, although sometimes the first seat of the pain, and occasionally found considerably inflamed, yet in general is not more affected than the intestines. In some cases, the thoracic viscera are inflamed. It is most frequent, and most fatal, in hospitals. In private practice it is less malignant, though still very dangerous. It is sometimes epidemic, but I do not know that it has above twice been a very prevailing epidemic, in this city. In some instances it was easy to trace the contagion from one woman to another. In hospitals, it has conspicuously appeared as a contagious disease. There has been much dispute whether the contagion was one sui generis, or that of typhus or erysi- pelas, 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 peritonaeum, conjoined with the opera- tion of some debilitating poison, more or less contagious. It is not connected with the state of the labour, except in so far as that haemorrhage seems to predispose to it; but when epi- demic, it occurs after a rapid and easy, as well as after a more painful labour. It is also, I think, established, that not only different individuals may have more or less violently symptoms of inflammation, but also that particular epidemics have the peritonitic state more or less prominent and acute, and in some there is much swelling with little pain. I have formerly stated that inflammation and other local disease may take place, as well by causes acting on the origin of the nerves, as by those applied to the part itself. In this disease, I am inclined to attribute the effect to the first mode, but have not, as yet, satisfied myself of the existence of increased vascularity, &c. ofthe spinal sheath. It is important to distinguish this disease from simple peri- tonitis, which may generally be done by attention. In puer- 3 U 538 peral fever, the abdominal pain is seldom at first the most prominent symptom, unless it begin like severe after-pains, with distinct remissions. There is more despondency, debility, and headach; less heat ofthe skin, less thirst, and less flushing of the face. In the peritonaeal inflammation, the pain in the belly usually increases rapidly after it begins, and the swelling increases along with it. Pressure gives very great pain. The fever is inflammatory. Inflammation of the uterus has its proper symptoms. This disease is dangerous, in proportion to the 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 * Dr. Denman, vol. II. p. 493, considers puerperal fever as contagious. He strongly advises early bleeding, giving an emetic or antimonial, so as to vomit, purge, or cause perspiration; and if this do good, he repeats the dose, and uses clysters, fomentations, leeches, and blisters. He gives an opiate at night and a laxative in the morning; or, if there be great diarrhoea, he employs emollient clysters. The strength is to be supported by spt. ether nit. or other cordials. Dr. Leak, vol. II. trusts much to blood-letting ; if the patient be sick, he gives a gentle vomit; if not, laxatives, and then antimonials ; applies blisters, and in the end restrains purging with opiates, and prescribes bark. Dr. Gordon, p. 77. et seq. depends on early and copious blood-letting, taking at first from 20 to 24 ounces, and purges with calomel and jalap. He is regu- lated rather by the period of the disease than the state of the pulse—bleeding, 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 employs Dr. Denman's antimonial, which is two grains of tartar emetic, mixed with 3ij. of crabs'eyes, and the dose is from three to ten grains. Dr. Walsh forbids venesection, and advises emetics, followed by opiates, and cordials. Dr. Hulm 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, com- bined with camphor. Mr. Whyte is against blood-letting. He gives at first a gentle emetic, followed by a laxative and diaphoretics. Then he gives bark, with vitriolic acid, and supports the strength. Dr. Joseph Clarke 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 purging, the bark is to be omitted, till some rhubarb be given, or a vomit, if there be little pain in the belly. Dr. Kirkland bleeds only if the patient have had little uterine discharge, and tiie pulse indicate il. He employs laxatives, and in the end bark and cam'i.hor. 539 partly depends on giving the name of puerperal fever to dif- ferent disorders. 1 am sorry that I find it much easier to say, what remedies have failed, than what have done good. I have stated, that in peritonaeal inflammation, blood-letting Dr Hull considers this disease as simple peritonaml inflammation, which may affect three classes, the robust, the feeble, and those who are in an intermediate state. In the first he bleeds and purges, in the second he begins with emetics and ends with bark, and in the third he bleeds with great caution. Dr. Hamilton has advised puerperal to be treated as putrid fever. Guinot, Allan, and others, recommend carbonate of potash, in doses of ten or fifteen grains. M. Vigarous joins with those who consider this as not a fever 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 hypo- gastrium. He advises first ipecacuanha, which he trusts to chiefly, and then clysters, laxatives, and saline julap. 2d, The putrid bilious. This is occasioned by bleeding, or neglecting evacuants in the former species ; or even without improper treatment, the fever may from the first be so violent, that bilious matter is absorbed. It is marked by great debility, small or intermitting pulse, tumour of the hypogastrium, with sharp pain and putrid symptoms, aphtha?, vomiting, foetid stools, &c. He advises vomits, laxatives, and bark in great doses, with mineral acids, and clysters containing camphor. 3d, The pituitous fever, attended with vomiting of pituita. The surface is pale, the pulse has not the force or frequency it has in the former species, the heat in general not increased, anxiety, weight, and vertigo, rather than pain of head, often miliary spots, and the usual symptoms of pain in the belly, and subsidence of the breasts. He gives vomits, and afterwards three or four grains of ipecacuanha every three hours. If he use 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, suppres. sion 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 blisters, are to be used, if pleuritic symptoms occur. 5th, Sporadic fever, proceeding from cold, passions of the mind, &,c. Puerperal fever, he considers as apt to terminate in milky deposits in the brain, chest, legs, &c. Dr. Armstrong considers this fever as decidedly inflammatory, and trusts to the early use ofthe lancet, followed by a large dose of calomel, from one scruple to half a drachm, with the subsequent assistance of infusion of senna with salts. Of late, he seems, from meeting with other constitutions, to trust more to bleeding, followed by the use of full doses of opium. Dr. Brenan has published a pamphlet, recommending, in the place of blood- letting, the free use ofthe oil of turpentine internally, and the external applica- tion to the belly of a cloth soaked in it. Mr. Hey is decided as to the inflammatory nature of the disease, and trusts entirely to the early and free use of the lancet, and the administration of jalap and calomel, with other cathartics, so as to maintain a purging for two or three days, or longer, if necessary. Hufeland applies cold poultices to the abdomen. Gardien admits 6 species. 1st, Puerperal fever, complicated with la fievre angiotenique, or synochia, marked by the ardent symptoms of that fever. u is more strictly inflammatory, but is the least frequent species. It is to be treated by strict antiphlogistic regimen. Venesection is only allowable in the 540 and laxatives are the principal remedies; but in this disease blood-letting must be employed with greater caution. It must be resorted to very early, and ought not to be pushed very far, but the exact extent to which we may prudently go must most robust and plethoric. A dozen of leeches applied to the vulva or anus are safer. Lactation is the best remedy, and the surest preventive. 2d, With la fievre adenomening^e, or mucous fever. This is met with often, and is more slow and insidious; the mouth is slimy, and the abdominal pain is obtuse. It is to be treated with bitters and tonics. 3d, With la fievre meningo-gastrique, or bilious state, marked by yellow-tinge, epigastric pain, nausea, bad taste, iVc. In this case, the violent abdominal pain is not always from inflammation. It is to be treated by emetics or purgatives, according as the stomach or bowels seem most affected. 4th, With la fievre adynamique, or putrid fever. This is the most fatal, but most rare species, and is marked by great weakness, small pulse, dry mouth, paleness, and foetid diarrhoea. The pain is less acute, and the swelling is from gas. We should neither use the lancet, nor active tonics, such as bark, but rather a kind of negative plan, giving lemonade and cream of tartar, or perhaps camphor. 5th, With la fievre antaxique, or nervous symptoms, as hic- cup, convulsions, &c. 6th, With other local phlegmasia?, as of the brain, lungs, &c. Dr. Campbell and Dr. Macintosh have both published on puerperal fever, and look on it as inflammatory, non-contagious, and to be cured only by active deple- tion. Their treatment consists in bleeding freely from the arm, fomenting the ab- domen, and applying to it and the pudendum from 60 to 100 leeches, conjoining also the use of purges, such as calomel, with antimony and clysters. Dr. Douglas, in the 8th vol. of Dublin Hospital Reports, divides the disease into three species, the synochal, gastrobilious and epidemical or contagious. In the first he advises venesection freely, purges, &c. In the second, venesection more moderately, and calomel in the dose of ten grains, with castor oil. In the third, the same dose of calomel, with opium and a clyster. Then from two to four dozen of leeches to the abdomen, and pure oil of turpentine to be exhibited in the dose of three drachms. In the Edinburgh Journal for July, 1824, is an account of the report made on the disease as it appeared at Vienna, and an abstract of the opinion of Boer. There appeared marks of vascularity or turgescence in all the cavities, and in most instances, peritonaea! inflammation existed. The uterus was little con- tracted, its substance flabby and tender, and its internal surface gangrenous— a condition in every case more strongly prevalent at the os uteri. It was con- sidered not to be contagious. The treatment consisted chiefly in venesection, the application of leeches, clysters, blisters, and then diffusible stimuli, but seldom with good effect. The disease has of late been epidemic in this city, and more especially in the suburbs, particularly toward the east side of the city. I have made particular inquiry into the treatment, and fear it has not been so successful as the attendants could have wished, although the utmost care and promptitude were exercised. In a few instances, the lancet was neglected, and the tonic plan used, but with- out effect. The universal opinion I find to be in favour of the lancet, at the same time that its too general failure is fully admitted. Mr. J. Watson informs me, that in most of the cases he met with, the disease seemed to begin at the hysteritis, and spread to the peritonaeum. Copious bleeding, blistering, and large doses of opium, were the remedies used by him, and only in one case did he think tur- pentine of service. Mr. S. Clark expressly says, in a statement he gave me, that all the cases he saw cured, and his practice was very extensive in the disease, where by means of very copious depletion, both by venesection and purgatives. " After copious bleeding, 541 depend on the nature of the epidemic, and the constitution of the patient, as well as the special symptoms of her particular case. I am quite convinced that, in simple peritonitis, the lancet is the anchor of hope, if hope may be indulged ; but in contagious or puerperal fever, it must be used with more cir- cumspection, and is still less to be depended on. I am fully aware, from experience, of the good effects of bleeding early in typhus or contagious fever ; and, therefore, I have no pre- judice against that remedy in this contagious disease. I have, on the contrary, used it freely myself, and have known it done so by others; and to this free trial I have been led, by the respectable testimony to its advantage, as well as the fatal issue of the disease under other treatment. I am, however, from observation, convinced, that if this remedy be useful, it is in the very early stage, and that it cannot be too soon em- ployed. If the disease have gained any progress, I never have found it useful. Like other remedies, particularly purging, it has been followed by an apparent relief, but the pulse did not come down, nor was the patient cured. My conviction, therefore, is, and, if an opinion given in an elementary work is to influence the conduct of those who read it, I cannot state it without a feeling of awful responsibility, that the lancet is only admissible in the very commencement ofthe disease, and if decided benefit be not derived then, we ought not to repeat the evacuation. It is my duty to say, and I do it, considering the opposite sentiments of good judges, with a sense of defer- ence, that I have never known any patient recover, who had been largely and repeatedly bled, and that all my successful cases have been amongst those who either were not bled at all, or bled early, not above once, and that not abundantly. At the same time I am willing to admit, that much must depend on the constitution of the patient as well as the pecu- liarity of the epidemic and particular circumstances. If bleed- ing be indicated, let us bleed early, and be guided by its effects. The most of my private patients were delicate females, and they were less able to bear copious bleeding than the more robust; yet in consultation I have also attended the more large dosps of calomel were useful in the epidemic which prevailed lately at Kilsyth, but none recovered there, nor in the country around, without bleeding." He at first tried the tonic plan, but with universal failure, whereas he says a third part recovered by the other, if used early and boldly in constitutions pre- viously sound. Dr. Baird, another intelligent practitioner, seems to think that, in every instamce, the disease arises from some malposition of the uterus, and may be cured, if we early remedy that, by pressing with the hand externally, as I have stated at hysteralgia. 542 robust, as well as the delicate, and have too often seen the lancet fail—but what succeeds ? Were full and free depletion the proper and indispensable remedy in this disease, and were no mistake committed by its advocates, in looking on hysteritis or peritonitis as puerperal fever, the lancet ought to be more uni- formly beneficial. It ought not, indeed, to be more useful than in simple peritonitis or enteritis, but if early and vigor- ously employed, it should not be much less so. Is this the case ? Many cases of hysteritis and simple peritonitis I have seen alone, and in consultation, and ofthe benefit of the lancet in these never entertained a doubt; but there is a malignancy in puerperal fever which seems, as yet, in most cases, to baffle every remedy.108 On the appearance ofthe disease, it will be proper imme- diately to give a smart dose of some purgative medicine, such as infusion of senna, with the addition of Epsom salts; or calomel, succeeded by Epsom salts; afterwards we begin the use of bark, giving it as liberally as the stomach will bear, or administering it in the form of a clyster ; at the same time we repeat occa- sionally the aperient medicine. Opiates given after purgatives, 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 restrained, unless it evidently give relief, and the faeces be very foetid. In this case, calomel and diluents should be employed. If there be tenesmus, anodyne clysters should be given after the use of the calomel. In all cases, we are to attend much to the bowels, using brisk purgatives and clysters, where there is no diarrhoea; milder doses alternated with opiate clysters, where there is. Vomiting is to be restrained by solid opium, and by an opium plaster applied to the region of the stomach: sometimes saline draughts are of service. Nausea has been supposed to indicate the necessity of an emetic ; but if no 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. Anodyne, or rubifacient embrocations, sometimes abate the pain in the abdomen. The repeated appli- cation 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. Cloths, wet with oil of turpentine, applied to the belly, produce less constitutional irritation, and are at least as effectual, if not more so, in reliev- ing the internal pain. They are generally more advantageous than fomentations. The strength should be supported by light 543 nourishment, and ultimately by 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. Some'have drawn off the fluid by paracentesis. Emetics and antimonials, I am afraid, do more harm in general than good. Most authors have laid down distinct and formal indications to be fulfilled ; but it is much to be doubted, if the means pro- posed be adequate to the effect intended to be produced ; or if all the parade of science has done more than show, that, with the addition of remedies for removing particular symp- toms, one class of practitioners have trusted to the lancet as the chief engine of cure, and another to the use of bark and cor- dials. Peritonitis is much more frequent than puerperal fe- CHAP. XVII. Of Swelled Leg. The swelling of the inferior extremity, in puerperal women, is usually preceded by marks of uterine irritation, and a tender state ofthe parts within the pelvis, not unfrequently by symp- toms of inflammation higher in the abdominal cavity, and even in the diaphragm. About a fortnight after delivery, some- times a little earlier, or even so late as the fifth week, the patient complains of pain in the lower belly, increased by pres- sure, 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 ofthe 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 sartorius muscle, and is most acute in the course of that muscle; it also darts down to the heel; or along the distribution of the nervous saphenus. Within twenty-four hours after the pain is felt, the limb swells, and becomes tense: it is hot but not red ; it is rather pale and somewhat shining. The swelling sometimes proceeds from the groin downwards; in most cases, it is first perceptible about 514 the calf of the leg, and proceeds upwards. It generally pro- cures an abatement ofthe pain, but does not remove it. On the contrary, the patient cannot move the leg, and it is tender to the touch. The inability to move it, however, does not depend altogether on the pain, but also on a want of command over the muscles. The pulse is very frequent, being often 140 in the minute, and generally is small and feeble, but sharp; the tongue is white and moist, the countenance has a pale chlorotic appearance, the thirst is considerable, the appetite is lost; the bowels are either bound, and the stools clay- coloured, or they are loose, and the stools very foetid or bilious. The urine is muddy; the lochial discharge sometimes stops, or becomes foetid ; in other cases it is not at all affected. The nights are spent without sleep, and the patient perspires pro- fusely. All the parts within the pelvis are tender, and the os uteri is open, but not more painful when touched, than the sides ofthe vagina or the internal muscles. The period at which the swelling reaches the acme is various, but often it is accomplished in twenty-four or forty-eight hours. It seldom makes the limb above double its usual size. Gen- erally in ten days, sometimes in even two or three, the febrile symptoms, swelling, &c. abate; but they may be more pro- tracted, and they rarely go off entirely, for a length of time. When they go off, the patient is left feeble, and the limb stiff, weak, and often, for a time, powerless. In the course ofthe cure, we frequently feel hard bumps in different parts ofthe limb, especially on its back and inside. These are not glands; some consider them as indurated lymph, others as muscular contractions. At the top of the thigh, the inguinal glands are often felt swelled, even at the beginning of the complaint; but in some cases, I have found them not at all affected. If the skin be punctured, no serum is effused, at least not in the same way as in anasarca, and the swelling is not increased in a depending posture. Not unfrequently the patient is attacked with inflammation of some part connected with the abdominal cavity, as, for instance, the diaphragm or diaphragmatic pleura, and when wc hope that this disease is subdued by bleeding and blistering, we have the mortification of finding a new train of symptoms, those peculiar to the swelled leg, appear. Sometimes the disease begins like rheumatism, affecting the backand hip joint.110 Then the upper part of the thigh becomes painful and swelled, and next the calf of the leg suffers ; some- times the limb at first feels colder than the other. Occasion- 545 ally the disease is very mild, and attended with little swelling. This is more apt to be the case when it is late of occurring, and is vigorously attacked at first. In some cases the patient has been sensible of the pain which expelled the child, rushing violently down the leg. After a short time it has abated, but about the usual period this disease has appeared. In one or two instances, suppuration has taken place ; mor- tification has also happened. Amputation has been required. If the disease run its usual course, it is always a length of time before the patient recover, for the swelling does not go soon entirely away, and the strength is long of returning. In some instances, the limb remains permanently swelled and feeble. After one leg has been affected, and even before the com- plaint has completed its course there, the other may become diseased ; and this has no influence on the progress of the first. The second attack is sometimes the worst of the two, owing, perhaps, to the previous debility. A coldness is often felt in the second leg, before the paroxysm come on, and pain in the belly precedes the attack. The first leg may be a second time attacked. In one instance, both of the inferior and of the superior extremities, were successively attacked. The affection of the arm was preceded by pain, feeling of weight, and swelling of the lateral part of the thorax and back. In this case, the lady, after severe uterine haemorrhage, had a smart attack of hysteritis, which required, but yielded com- pletely to, the usual depleting plan. In a day or two after- wards this disease took place. « This is not generally a fatal disease, but it is tedious, and is often accompanied with hectic symptoms. Death, however, may be caused by suppuration or gangrene; or by exhaustion, proceeding from the violence of the constitutional disease ; or by exertion made by the patient, which has sometimes proved suddenly fatal. The production of this disease does not seem to depend on the circumstances of the labour, for it appears both after easy and difficult deliveries. Those who give suck, and those who do not, the strong and the weak, are affected by it. But if it be late of occurring, it is generally in those who have suffered from mammary abscess. It has succeeded an abortion, or suppression of urine, and a slight degree of it has followed abdominal pain, attendant on menstruation, and been repeated for one or two periods. 3 X 546 We cannot always detect any apparent exciting cause, but, when we can, it is generally cold ; standing, for instance, on a cold or damp floor. I am inclined to consider the cause to be an irritated or inflamed state ofthe parts within the pelvis, which sometimes produces merely a stiffness and swelling at the passage ofthe round ligament, sometimes an irritation of the nerves which pass to the leg. The same effect is also very apt to follow from inflammation ofthe diaphragm, particularly when it extends along its crura and downwards. Puzos and Levret consider the disease as proceeding from a depot of the milk. Some modern writers attribute it to an affection of the lymphatics, which are ruptured, or have their circulation inter- rupted by swelling of the inguinal glands. Dr. Hull considers the disease as an inflammatory affection, suddenly succeeded by effusion. I refer, for a view of the different opinions, to his Treatise on Phlegmasia Dolens. If any part of the skin, of the leg for instance, be pricked with a rough substance so as to irritate considerably the nervous fibrillae, we often find that the whole leg swells, becomes tense and painful. It is glossy, firm, and elastic, as if a fluid were contained below the fascia, although none exist there. At first, the swelling is so firm that it receives with difficulty the impression of the finger, but presently it pits more readily, and finally the effused fluid is absorbed, and the limb returns, though perhaps very slowly, to a state of health. This is a peculiar modification of inflammation, probably connected with, if not dependant on, injury of a nervous filament, and it is extended over a great portion of subcutaneous substance. It rarely suppurates. This must be familiar to surgeons, and accoucheurs may at once recognise a strong resemblance to phlegmatia dolens, which seems to be a, similar kind of inflam- mation, dependant, however, more frequently on irritation of the trunk, or origins of the nerves, than their extremities. It will be difficult to prove that cases of this disease, in the puer- peral state, ever arise without previous inflammation, or, at least, much irritation, of some part within, or about, the abdomen ; and this, on the principle alluded to in the chapter on ephemeral and remittent fever, may cause general fever, and remote local effects, varying according to circumstances. If we admit that the origins of the nerves can be thus affected by some obscure affection of the uterus itself, or any other local disease, we may the more easily understand how the disease under consideration may become very extensive, and must, in most cases, be accompanied by extreme frequency of 547 pulse. The local disease thus produced is undoubtedly inflam- matory, but so modified as very rarely to terminate in suppu- ration, whilst it speedily produces a secretion, into the cells, of coagulable lymph. The inflammation of lymphatic vessels, or of veins, I look on rather as an accidental participation of these partsinthe surrounding disease, than asaeauscor essen- tial part of the complaint. Dr. Davis is of opinion, that a violent inflammation of one or more ofthe large veins within the pelvis, or in its neighbourhood, so as to diminish the diameter ofthe vessels, or obstruct the return of blood from the contributory branches, is the chief cause. Dr. Caspar, on the other hand, found the vessels without disease, but the orifice of the uterus and the vagina in a highly inflamed state. The disease seems to consist in that species of inflammation which, affecting the cellular texture, is connected with nervous irri- tation, and it is less apt to end in suppuration than in effusion of serum, or albumcnous fluid. The state ofthe nerves also produces early a powerless condition ofthe limb, independent ofthe inability to move it from pain. The treatment naturally divides itself into that ofthe limb, and that ofthe constitution. Our first object is to check the disease within the pelvis. For this purpose, leeches ought to be applied to the groin, and we should immediately open the bowels with a purgative. A small blister should then be applied to the groin, or sinapisms may be applied to the groin, inside ofthe thigh, and near the knee on the leg, and afterwards cloths, wet with tepid solu- tion of acetate of lead, or with warm vinegar.111 These means may prevent the swelling, or render it milder. If the disease have already taken place in the limb, gentle friction, w ith warm oil, anodyne balsam, or camphorated oil, will be useful, and should be frequently repeated. Fomentations sometimes give relief, but also, in other cases, are rather disagreeable. The bowels should still be kept regular, but the patient is not to be purged. Opiates are useful, to allay irritation. When the acute symptoms are over, we endeavour to remove the swelling, and restore the tone of the part, by friction with camphorated spirits, and the use of the flesh brush, and a roller applied round the limb. The liberal use of solution of cream of tartar, is also in many cases of service. If the dis* ease threaten to be lingering, small blisters may be applied to the groin, and different parts ofthe limb. If much weak- ness of the limb remain, the cold bath is proper, or sometimes a bath of warm sea-water. 548 Besides these means, we must also employ remedies for abating the fever, and constitutional affection. We never derive advantage from venesection in this disease, although we may have occasion to use it freely for that which some- times precedes it. In the disease itself it not only is useless, but even detrimental, sinking the strength and retarding the recovery. At first we may use saline draughts, but these are not to be often repeated, and must not be given so as to pro- cure much perspiration. In a short time they should be exchanged for bark, sulphuric acid, and opiates, which tend to diminish the irritability. In the last stage, we give a moderate quantity of wine. When the pain shifts like rheumatism, bark, and small doses of calomel are useful. In every stage, the bowels should be kept regular. If the uterine discharge be foetid, it is proper to inject tepid water, or infu- sion of camomile 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 supporting 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 ten- dency. The diet should be light and nutritious.112 CHAP. XVIII. Of Paralysis. Some women, after delivery, lose for a time the power of the inferior extremities, although they may have had a very easy labour. This paralysis may exist in different degrees, and in some cases the muscles are painful. Sometimes it is attended with retention of urine. It is not accompanied with any cephalic symptoms. In general, the disease wears off in a few weeks. Friction, the shower-bath, tonics, and gentle exercise on crutches, are the means of cure. The bowels are also to be kept open. After a severe or instrumental delivery, the woman may complain of excessive pain about the loins and back, attended with lameness, or even palsy. This is sometimes a very te- dious complaint, but usually it is at last removed. A roller firmly applied, and anodyne embrocations, relieve the pain ; at a more advanced period, sea-bathing is proper.113 *49 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 take place, blood is found extravasated in the brain. CHAP. XIX. Of Puerperal Mania and Phreniiis. 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 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 usually appears rather suddenly, the patient awakening, perhaps, terrified from a slumber; or it seems to be excited by some casual alarm. She is sometimes extremely voluble, talking incessantly, and generally about one object, supposing, for example, that her child is killed, or stolen ; or, although 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 incoherence, but there is oftener a tendency to raving than melancholy. She always recognises surrounding objects, and either answers any question put to her, or becomes more exasperated by it. She can by dint of perseverance, or by proper 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 much nervous irritation, or bodily exertion, is frequent, but it is not in general per- manently so, though it is liable to accelerations; the skin is sometimes rather hot, the tongue white; the secretion of milk is often, but not always, diminished; and the bowels are usually costive. There is seldom permanent headach; but this symptom is sometimes produced pretty severely by attempts to go to stool, if accompanied by tenesmus, or by efforts to void urine in strangury. In some instances the patient recovers in a few hours, in others the mania remains for several weeks, or even 550 some months ; but I believe it never becomes permanent, nor does it prove fatal, unless dependant on phrenitis. Venesec- tion has been advised in this disease; and its propriety will depend on the presence of symptoms of determination to the head, indicated by pain or heaviness, and by the state of the vascular system, with regard to increased action, and the evolution of heat. Where there is little febrile affection, I agree with those who consider it as hurtful, or at least as useless.* In every case we may apply leeches to the temples, open the bowels with a smart purgative, preserve them after- wards open by suitable laxatives, keep the surface gently moist, by means of saline julap, and afterwards allay irritation with liberal doses of camphor. Blisters have by some, for whose opinion I have much regard, been considered as useless, or detrimental; but I am confident I have seen them do good, after they had discharged freely. Opium is a very doubtful remedy; it oftener makes the patient restless than procures sleep; but in the wane of the disease, it does in some cases agree with the patient, and is productive of great benefit. A good, although I will not say the only good form, is Batt- ley's liquor opii. There is sometimes considerable difficulty in keeping the patient in bed, and making her take either food or medicine. It is therefore in such instances of great ad- vantage to have early recourse to the straight waistcoat, which not only commands the patient, but tends to make her exer- cise self-control. In the whole course of the disease, the greatest attention must be paid to procure and preserve proper alvine evacuation. This is of essential importance. Often the patient voids both urine and faeces without telling, not from being unable to retain them, but from inattention or perversity. The mind is not at first the subject of manage- * M. Esquirol says, puerperal mania is generally attended by suppression of the lochia and milk. He thinks venesection should be employed, only with great caution, and that leeches applied to the thigh and pudenda are more useful. Sinapisms he also uses, laid on the nape of the neck, or legs and thighs. Blisters he has not found serviceable at first, but thinks them so in the sequel. Clysters are to be given. M. Georget proposes clysters of milk and water, the use ofthe tepid bath, and in congestion, local bleeding, adding that venesection has been much abused. Dr. Gooch, in the 6th vol. of Med. Trans, of Coll. says that venesection is sel. dom safe, but if the pulse be full and strong, and not brought right by purging and applying cold to the head, blood may be taken from the scalp or neck by cupping or leeches. When the pulse is only frequent, without evidence of deter. mination to the head, he forbids even topical bleeding. The best soporific, he says, is the tepid bath, with camphor and extract of hyoscyamus, each in the dose of ten grains. 551 ment, but in the progress of the complaint, it may by prudent efforts be aided in convalescence, by cheerful conversation, light reading, music, and afterwards by daily walking and change of scene.'14 Some are peculiarly liable to this disease after delivery,* in consequence ofthe irritable state ofthe nervous system at that time. In such cases, the patient ought to be bled occa- sionally during pregnancy, and particularly toward its con- clusion ; unremitting attention should especially be paid to the state ofthe alvine discharge, which 1 am disposed to con- sider as of the utmost importance. She must be carefully watched after parturition. Every irritation must be removed, every source of alarm or agitation obviated, and the cam- phorated julap with laxatives will be proper remedies, these being the most powerful means of diminishing the excessive irritability ofthe nervous system. It is impossible to be too vigilant ofthe state ofthe bowels, either in a prophylactic or curative view. The diet is also to be regulated. If the patient do not sleep well, hyoscyamus should be given. It is often of service to get the patient up as soon as can be done with safety, and have the mind occupied with such amusements and pursuits as keep it equally exercised, without risking irri- tation. There is a variety of this disease, in which we find the patient, very soon after delivery, complains of restlessness, or rather inability to sleep. The head is slightly pained, there is a feeling of unusual muscular weakness, the pulse very little quicker than it ought to be. Then, rather rapidly, the symp- toms become more marked, the pulse becomes very frequent, the skin hot, the face flushed, the hearing acute, the eyes suf- fused and sensible to light, the eyelids heavy. There is a sense of tightness in the throat, or suffocation ; the feeling of mus- cular weakness is converted into a degree of paralytic debility; the head is acknowledged to be pained, but sometimes only a very indistinct and varying account can be got of the sensa- tion. There is thirst, the bowels are costive, and the secretion of milk goes on. There is often no apparent mental derange- ment, only the patient is generally dull or still, though some- times irritable, and in some cases, decided insanity takes place. * Gardien denies that this disease depends on the puerperal state, but says it is to be attributed to moral causes, as jealousy, fright, &c. He advises a blister to be applied to the neck ; or, if the lochia be obstructed, leeches to be applied to the vulva. A scruple of colocynth mixed with some bland substance, as lard, has been recommended, to be rubbed on the abdomen three times a day, to little purpose, I fear. 552 If the disease be not attacked vigorously, the paralytic symp- toms increase; the pulse becomes very slow, and in many instances even death might follow. I look on this disease as intimately connected with a particular state of excitement in some part ofthe spinal cord. By instant venesection, to a considerable extent, all the febrile symptoms subside, the skin becomes cooler, the flushing goes off, the pulse falls from per- haps 130 to 80 or lower, and the patient says that she can now open her eyes freely, and feels relieved from weight in her head, which she remembers to have had, although before bleeding she perhaps would not admit its existence. In a few cases, by full purging, and blistering the head, she is restored at once to health. But more frequently the recovery is partial. She complains still of muscular weakness, some- times of her head, and often of extreme acuteness of hearing, or sensibility to light; and the mind is affected in so far, that she doubts the identity of her child ; or becomes suspicious of her friends ; or impressed with the idea of approaching evil; or indifferent about every thing. The appetite is generally keen. This state, by attention to the bowels, regulation of the mind, change of scene, or inducement to moderate but renewed exertion, goes off, although sometimes not for many months. Melancholy usually comes on later than furious delirium. The disease differs nothing in appearance and symptoms from melancholy madness occurring at other times. It is obstinate, 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 possible. In some instances, both kinds of madness seem to be dependant on a morbid irritation, such as inflammation of the mamma, foe. Here our attention must be directed to the cause. Inflammation ofthe brain usually appears still earlier than delirium from irritation. It may be caused by determination of blood to the head, or preternatural irritability of the senso- rium, or may occur in consequence of a constitutional ten- dency to mania. It must be distinguished from puerperal delirium, which is seldom dangerous, whilst this is a most fatal disease. It generally appears within the third day after par- turition, but it may also take place later. The pulse usually continues frequent from the time of delivery. The patient does not sleep soundly, and indeed is watchful. She soon complains of pain or throbbing within the head, or in the throat or ears ; then of confusion, hears acutely, dislikes the 553 light, and speaks in a hurried manner, and often is unusually interested about some trifle. There is at first little delirium, but only a kind of confusion of thought, and she is able to describe her feelings. The bodily sensations here are the first symptoms, whereas in mania the mind is more apt to be affected before, or, at least, as early as, the corporeal feelings are noticed. It is more difficult to distinguish phrenitis from the sympathetic effects produced* on the brain by inflammation, or high excitement ofthe spinal cord or its coverings. But this is the less to be regretted, as at first the practice in both is the same, namely, early and free venesection. Afterwards, the state of particular nerves, or the sensibility of one or more portions ofthe spine to pressure, may assist the diagnosis, and direct where to apply blisters or issues. Soon, all at once, furious delirium comes on ; she talks rapidly and vociferously, the eyes move rapidly, are wild and sparkling, and very sen- sible to the light. This state may continue, with little inter- ruption, till symptoms of compression appear, or there may be a snort interval of reason, but presently the furor returns, and alternates perhaps with sullenness. The case is, in these respects, modified according to the inflammation ; for some- times it comes on rapidly and to a great extent; at other times it proceeds more slowly. The lochia are not suppressed, nor are the bowels bound, but the secretion of milk ceases. In three or four days, she becomes paralytic in one side, and then sinks into a low comatose state; the extremities become cold, the breathing laborious, and sometimes convulsions precede death. This disease requires the prompt and early use of the antiphlogistic treatment, general and local blood-letting, the use of purgatives, and the application of a blister to the scalp. The inflammatory symptoms being subdued, the delirium abates, or goes off, by the use of remedies formerly pointed out. CHAP. XX, Of Bronchocele. Swelling ofthe thyroid gland takes place, so much more frequently after parturition, than under other circumstances, that it may with propriety be noticed here. It appears within a few davs after delivery, and is often attributed to exposure 3 Y 554 to cold. In other cases, the woman feels, during labour, 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 diffi- culty of swallowing. In other instances, it augments in size, and becomes dangerous from its pressure on the neighbouring parts ; or it inflames, forms a large abscess, and bursts. En- largement ofthe left lobe is more dangerous than that ofthe right.115 Various remedies have been employed, such as burned sponge, calomel, muriate of lime, foe., but these have seldom much effect. The immediate application of leeches, followed next day by the use of cold water, to the part, repeated blis- ters, and long continued friction, are useful. The tincture of iodine, and friction with a mixture of iodine and lard, have been lately extolled, and the evidence in favour ofthe utility ofthe plan is such as certainly to demand for it a full and a fair trial, always remembering, however, that the effect of the iodine must be watched, as it is a dangerous and active agent. If the tumour threaten to enlarge, which it often does*after every succeeding pregnancy, or even independent of gestation, it has been proposed to extirpate the tumour, or to tie the arteries going to it. If there be a tendency to suppuration, it ought to be encouraged, and treated on general principles. CHAP. XXI. Of Diarrhoea. If the patient have been costive before delivery, large masses of faeces may come down afterwards, producing violent pains in the belly, piles, tenesmus, or uterine haemorrhage; or the same cause may excite diarrhoea with the passage of scybalae. Both states require the use of gentle laxatives. Diarrhoea may also occur without previous costiveness ; the stools are then foetid or bilious. In this case the diet is to be strictly regulated ; gentle laxatives are to be first given to evacuate the offensive matter, and then opiates are to be imme- diately resorted to. If neglected, great weakness, uterine haemorrhage, 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. 555 f vo mited, be given in the form of clysters, or suppositories. [ hare already noticed that dangerous form of this disease which depends on chronic inflammation of the mucous coat of the bowels. CHAP. XXII. Of Inflammation of the Mamma, and Excoriation of the Nipples. The mamma is enclosed, as it were, in a fascia. A thin layer passes under and between it and the pectoral muscle, whilst a stronger one, a continuation of the fascia, which shuts up the axilla, is extended over it, and lost in the neigh- bouring parts. This is of much importance. In cancer, it is soon diseased, and if any part be left adhering to the skin, a relapse takes place after the operation. It is also one source of communication of disease to the axilla, and down the arm. Inflammationof the mamma may be divided into three species, according to its seat—the subcutaneous cellular substance, the fascia, and the subfascial cellular substance, with the glands embedded in it. It may take place at any period of nursing, but is most readily excited within a month after delivery. It may be caused by the direct application of cold, engorgement from milk, the irritation of excoriated nipples, mental agita- tion, foe. Some have the breast prodigiously distended when the milk first comes, and the hardness extends even to the axillae. If in these cases the nipple be flat, or the milk do not run freely, the fascia, partially, in some habits, rapidly inflames. Others are more prone to have the deep cellular substance, or the glands themselves, inflamed. The subcutaneous inflammation, if circumscribed, differs in nothing from a common phlegmon, and requires the same treatment. It is not easy to resolve it, but a tepid poultice will do this, if it can be done ; if not, it brings it forward. When it bursts, the poultice should be exchanged in a day or two for mild dressings. The inflammation of the fascia, if slight, is marked by some little tension ofthe breast, with erythema of the skin over the affected portion. There is considerable fever, but not much pain, and the disease is likely to yield to tepid fomentations, and a purgative, if the milk can be drawn off freely. If the 556 fascia be more extensively or severely inflamed, the breast swells quickly, and this distension adds to the disease, which, indeed, is often caused at first by tension of the fascia. The pain is great, and the fever considerable. The inflammation never is confined to the fascia, but is communicated either to the subcutaneous cellular substance, or the parts within, usually to the latter, and often, at the same time, to the former. When the deeper parts are affected, the glands inflame, and the milk is not secreted by those glands which have suffered; matter fotms, and spreads under the fascia with much destruc- tion ; and when, at last, after long suffering, the abscess gives way, much matter is discharged, with masses of slough, chiefly consisting of portions of fascia. Usually, there is a consider-' able degree of fever attending the complaint, and the pain is often severe, especially when the breast is extensively affected. It is a very difficult thing to prevent this inflammation from ending in suppuration. It is to be attempted, however, by purgatives, and the application of a tepid poultice of bread and milk* or cloths moistened with tepid water. Cold solu- tion of acetate of lead, alone, or preceded by leeches, has been recommended, but I have long been obliged to abandon this practice, from the little success which attended it.llc If it be ever useful, it is only in slight cases, where it is adopted early, and the disease is chiefly in the cellular substance near the surface. If there 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 accumulation in the vessels. The breast is also to be carefully supported, and indeed the patient will be easiest in bed* When the pain becomes throbbing, a warm bread and hiilk poultice is proper to assist the suppurating process. After the induration has abated, and matter is formed, it ought to be freely let out, by an opening of sufficient size, provided there be nonappearance of the abscess bursting soon of its own accord. This is never the case where the fascia is strong, and if we delay long, we not only protract the suffering of the patient, but add greatly to the destruction 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 onC instance I knew the haemorrhage prove fatal. After the abscess bursts, or is opened, there is for sometime a discharge 557 of purulent matter, which frequently is mixed with milk; then the surrounding hardness gradually abates. The poultice may be continued for several days, as it promotes the absorp- tion ofthe 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 oyer this a cloth spread with spermaceti ointment: great attention is to be paid to the evacuation ofthe matter, and the preven- tion of sinuses. Fungus at the orifice ofthe sinuses requires escharotics. 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 upon one breast. It may even be requisite, if the fever and pain be great, and the secretion of milk much injured, to give up nursing alto- gether. It sometimes happens* if the constitution be scrofulous, the mind much harassed, or the treatment not at first vigilant, that a very protracted and even fatal disease may result. The patient has repeated, and almost daily shivering fits, followed by heat and perspiration, and accompanied with induration or sinuses in the breast* She loses her appetite, and is constantly sick. Suppuration slowly forms, and per- haps the abscess bursts, after which the symptoms abate, but are soon renewed, and resist all internal and general remedies. On inspecting the breast, at some point distant from the original opening, a degree of oedema may be discovered, a never-failingsign ofthe existence of deep seated matter there, and, by pressure, fluctuation may be ascertained. This may become distinct very rapidly, and therefore the breast should be examined carefully, at least once a day. Poultices bring forward the abscess, but too slowly to save the strength, and, therefore, the new abscess, and every sinus which may have already formed or existed, must be, at one and the same time, freely and completely laid open ; and so soon as a new gland suppurates, the same operation is to be performed. If this be neglected, numerous sinuses form, slowly discharging foetid matter, and both breasts are often thus affected. There are daily shiverhigs, sick fits, and vomiting of bile, or absolute loathing at food, diarrhoea, and either perspiration, or a dry, scaly, or leprous state of the skin, and sometimes the internal glands seem to participate in the disease, as those of the mesentery, or the uterus is affected, and matter is discharged 558 from the vagina. The pulse is frequent, and becomes gra- dually feebler; till, after a protracted suffering of some months, the patient sinks. It is observable, that often in these cases, which seem to depend on a constitutional cause, and when there is great debility, the sinuses heal rapidly, after being laid open, but a new gland instantly begins to suppu- rate. Internal remedies cannot be depended on here, for they cannot be retained. If they can be taken, they are those of a tonic nature that we would employ, with opiates to abate diarrhoea. The diet must be as nourishing as possible, and a liberal allowance of that kind of wine which agrees best with the stomach must be given. Our prognosis, indeed, will be more or less favourable, according to the nourishment which can be taken. The main security, however, ofthe patient rests on an early stop being, if possible, put to the disease, by opening the abscesses or sinuses freely, and before the constitution have been injured, or undermined by repeated paroxysms of fever. It ought to be impressed on the mind of every practi- tioner, and every patient, that unremitting attention should be paid early to the state of the breast, and no deep-seated col- lection of matter ever be allowed to remain unopened; for we do not know where the mischief, if allowed to continue, may end. This is urgently necessary, in proportion to the severity ofthe constitutional symptoms. There are indolent cases, where sinuses form and give little or no trouble, except by the dressing or attention they require. Timid patients will not submit to have these opened; but the cure is hastened, if that be agreed to. In the former state it was, from the affection of the general health and the state of the patient, imperative. In this indolent state, where the patient is in pretty good health, and walking about, it is proper, but nevertheless, more optional. Superficial sinuses should be laid open. Those which are very deep, should either have a counter opening made, or a seton introduced. Induration, with sinuses, yields to laying the sinuses open, and then employing gentle friction. This even holds true often with regard to simple induration occurring after an operation for cancer. In the case under consideration, I have never known bad effects, but quite the contrary, follow from free incisions, even into the substance ofthe breast. Sometimes, although the abscess heal readily, and have been small, an induration remains, which either may continue long indolent, and cause apprehension respecting future con- 559 sequences, or it may occasion a relapse. It is to be removed by gentle friction with camphorated spirits three times a-day, and the application, in the intervals, of cloths wet with cam- phorated spirits of wine, with the addition of a tenth part of acetum Ivthargyri, or a bread and milk, or cicuta, poultice may be applied. 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, especially if the patient be not nursing, the tumour is some- times pretty deep or indolent ; is for a long time hard to the feel; and gradually extends more through the breast, forming a pretty large substance, not unlike a scirrhous or scrofulous gland. But, during this time, suppuration is slowly going on, though there may be little pain. At last a more active change takes place, the pain increases, becomes throbbing, the skin grows red, and, finally, the abscess bursts. This state requires the application of warm poultices and hot fomentations. Excoriation ofthe nipple is a very frequent affection, and often excites that disease we have ju.st been considering. The ulcer may be extensive, but superficial; or it may be more circumscribed, but so deep as almost to divide the nipple. When the child sucks, the pain is severe, and sometimes a considerable quantity of blood flows from the part. In some instances, an aphthous state ofthe child's mouth excites this affection : in others, excoriation ofthe nipple affects 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.117 When excoriation takes place, six grains of sulphate of zinc, dissolved in four ounces of rose water, form a very useful wash, which should be applied frequently. Solutions of sul- phate of alumine, acetate of lead, sulphate of copper, nitrate of silver, foe., 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, or solution of borax, before applying 560 the child. When chops take place, dressing the part with lint spread with spermaceti ointment, is sometimes of use. A combination of white wax, with fresh butter or melted marrow, with or without vegetable additions, form popular applications. Stimulating ointments, such as ung. hvd. nit. diluted with axunge, are sometimes of service ; or the parts may be touched with burned alum.118 It is often useful to apply a tin case over the nipple, to defend it, or broad rings of lead or ivory. It is also proper to make the child suck through a cow's teat, or an artificial nip- ple, that the irritation of its tongue or mouth may be avoided. This often is of great service, but it does not always succeed; and some children cannot suck through it. The artificial nipple is preferable to the cow's teat. It is made of elastic gum ; but a small polished case or nipple, made of wood, covered with any soft substance to defend the gum, will serve the purpose. 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 possible, 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 ulcerations of the nipple or areola, accompanied with swelled glands in the axilla, and a diseased state of the child's mouth, require a course of mercury. It may be proper, before concluding this chapter, to add some remarks on causes disqualifying a woman from nursing, If the nipple be very flat, and cannot by suction be drawn out, so that the child can get hold of it, the woman cannot nurse. A glass pipe, however, frequently used, sometimes remedies this defect. A deficiency of retentive power, so that the milk runs constantly out, is another disqualification, and it is not easy to find a remedy. When the milk disagrees with the child, having some bad quality, we are also under the necessity of employing another nurse. If the mother 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 chlo- rotic or phthisical symptoms are induced. In this case, we must take off the child. Opiates are useful, at bedtime, to procure sleep, and the bowels are to be kept open. Many 561 women, after delivery, are subject to disorders ofthe alimen^ tary canal, especially diarrhoea and worms. These impair the health, and diminish the secretion of milk. They are to be treated with the usual remedies. Anasarca, jaundice, erysipelas, ing 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 ofthe 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 pulsation have stopped in the cord, and the child do not recover, the cord is to be divided, for connexion with the placenta is useless after the circulation stops. The cord is not to be tied, but only a loose ligature put round it; then it is to be divided, and the child removed to the fire, or its body immersed in warm water, and the artificial respiration sedulously continued. An injection is also to be administered, and could a stream of electricity 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 per- mitted to proceed, to the extent of two or three teaspoonsfull; but if it do not manifestly produce a good effect soon, it is to 56* be stopped with a ligature, that it may not throw the child back into a state of inaction. Even when it is of service, it must be kept within bounds, otherwise dangerous debility will be the consequence.* It will be chiefly useful when the breathing does commence, but is slow and oppressed, with stupor, indicating affection ofthe brain. If the shape ofthe 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 1 cannot speak from my own experience. In footling cases, it has been supposed, that extension ofthe spine was a cause of death, but this, I apprehend, is seldom the case. It often is desirable to know, whether a child have been born alive, and destroyed afterwards ; but the signs are not without ambiguity. When, therefore, the life of the mother is at stake, we must be very circumspect in forming our opinion. If the lungs be solid and sink in water, the child certainly has not breathed ; and although respiration may, from the first, be prevented by the midwife, it cannot by the mother. If the head be much misshapen, there is additional ground for believing the child to have been stillborn, and if clothes have been made for the infant, it is to be presumed, that the mother intended to have preserved it.t When, on the other hand, * It is occasionally of service, in weakly performed respiration, to give some gentle cordials or stimulants. t If the child have not breathed, the lungs are dense, and so contracted, as to leave the greater part of the heart exposed. If respiration have been established, they are paler in colour, redder, they cause the diaphragm to descend lower, and they cover in a great degree the heart. Respiration expands the lungs gradually, and it has been maintained that not only one portion of lung becomes rilled with air before the rest, but one lung expands or fills with air before the other. Considering the efficient cause of respiration, it must be evident, I think, that as both sides ofthe thorax, if well constructed, ought to expand alike, so, unless there be an obstruction in the bronchiae, both lungs ought to dilate alike. The time required for the complete expansion of the air cells is various, and differs in individuals. This fact does not militate against the opinion I have just given, for it is dependant on the degree to which the thorax dilates. If it do not dilate fully, the lungs cannot be expanded; if there be any obstacle to the free and immediate expansion of the lungs, the thorax is restrained and does not dilate fully. Dr. Brent says we may determine the question by this, that the foramen ovale, if the child has not breathed, is exactly at the bottom ofthe fossa ovalis, but is turned to the right as soon as it has respired. If the child have the cord soft and spongy, and the stomach contain only a little mucus, or bloody fluid, and the great intestine be filled with meconium, whilst the body have lost its firmness, the cuticle peels off, and leaves the skin below purple or blackish, and the head be flat and flaccid, whilst the cellular, texture is infiltrated with red serum, and the viscera of a deep red colour, there is evidence that the child has died in utero. When the cord is shrivelled, and 569 the child has a healthy look, and has been recently born, the lungs swim in water, and their air-cells universally contain some air, giving a frothy appearance to the mucus squeezed out of them, there is no doubt that the child has breathed. But we cannot from these circumstances say, that it has been intentionally deprived of life. Some corroborating facts must be necessary to fix this point, such as the birth having been concealed, and no preparation made for preserving the infant; the cord being untied, by which it has been allowed to bleed to death, which, I believe, must always happen if a ligature be not applied ; 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 exculpatory evidence. Physicians are much divided in opinion as to the import- ance to be attached to the circumstance of the lungs, with the heart attached, swimming or sinking in cold water.— Dr. Hunter, amongst other objections, states, that the child may, when the head alone has been born, breathe, but may die before the body be delivered. M. Marc, on the other hand, contends that the thorax, being compressed within the pelvis, cannot expand, and the air can only enter the trachea without fully inflating the lungs. In this, I think him wrong. Again, it has been stated, that although the child were born dead, yet artificial attempts having been made to inflate the lungs, they will swim, even if the child have never breathed. But, in reply to this, it is with great justice urged, that although air may be forced into the lungs, yet it is more par- tially than in respiration, and the blood-vessels will be found empty, or with very little blood, compared to the rest of the sanguiferous system. Putrefaction, it is also argued, will make the lungs swim, although the child have never breathed. But Camper, Marc, and other excellent observers, agree that the lungs putrefy later in the stillborn child than most other parts of the body, and maintain that this process does not, even in summer, take place in less than six days, and in its attachment surrounded with a circle bearing marks of inflammation, the child must have been born alive, and lived for some time before this inflammation could take place. We must, however, be careful not to confound redness ofthe skin, exhibited after the cuticle has peeled off, for inflammation. When the child has lived for some time, the great gut is nearly free from meconium, and if the child have not been starved, there may be remains of aliment found in the stomach. If lie child have a full eye, be stiff, and the skin of natural colour, it has died very recently. We cannot depend on the conclusion drawn from the skin being free from the white spennaceti coating it usually is covered with at birth, for some children have little or none of it. 4 A 570 winter, in less than as many weeks. On the whole, I am inclined to place very considerable reliance on this test, and am happy to find that my opinion is confirmed by that ofthe latest writer on medical jurisprudence, M. Fodere, who ob- serves, " La supernation du cceur avec les poumons est une preuve que la respiration a ete tres prononcee." If the lungs have been fully inflated by respiration, they require, when the heart has been detached, to have a weight equal to from two to four ounces affixed to them, to cause their fully sinking. Ploucquet, from considering that the lungs in the foetus contain much less blood than after respiration, concludes, that it will be possibleto determine whether the child have respired, by comparing the weight of the lungs with that of the rest ofthe body, by means of an accurate balance. The blood flowing into the lungs, by respiration, doubles their former weight. Thus, before respiration, the weight ofthe lungs to that ofthe body is found to be as one to seventy, whilst after respiration it is as two to seventy. Others, as Haartmann, give a different proportion, making it as one to fifty-nine before, and one to forty-eight after respiration. Lecieux, again, states, from a multitude of experiments, that there is no constant relation. The lungs of a full grown fcetus before respiration, are found to weigh nearly eight hundred grains. The absolute, as well as the relative weight ofthe lungs, may, with propriety, be attended to. By calling in the aid of all these tests, we can seldom be at a loss to decide, and our opinion will be confirmed, if we observe signs of injury** SECTION SECOND. 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 substance, which generally covers the skin, is to be gently and delicately removed by ablution with tepid water, and the use of a sponge, and sometimes of a little soap. It is not necessary to remove every part of this, nor make such attempts as will fret the skin ; but in every instance, and especially if there be reason to suspect that the mother has had gonorrhoea or chancre, the surface should be washed. It is also customary, with many nurses, to bathe the body, or at least the head, with spirits, » Thefe are some tery good papers on infanticide by Mr. Hutcheson, in the Ivfedi and Phys. Journ. No. 254. et seq. See also La Medicine Legale of capuron>and a veryuseful view of the subJect in the Edin' Med-Jour-vo1- XdU.449.™ 571 a practice which can serve no useful purpose, but may be at- tended with mischief. The child being dried, it is usual to wrap a bit of soft rag round the remains of the navel string, and retain this by means of a bandage brought round the belly. It is alleged, that this is necessary to prevent umbilical hernia ; but hernia does not take place because the child is not bandaged, but because the umbilicus is unusually wide; and in those countries where no compress is used, hernia is not a frequent complaint. A tight bandage produces pain, difficulty of breathing, and other deleterious effects. The only purpose to be derived from a bandage, is to retain the rag, which is for the sake of cleanliness, applied round the cord. It was at one time the practice to wrap the child very tightly round the whole body, and to stretch both the arms and legs, whilst the head was secured by tapes, passing from the cap to the body. A more easy method is now adopted, and it seems to be agreed upon, that the more simple and loose the dress is, the more comfortable will the child be. Nurses are pecu- liarly afraid ofthe head being cold, and therefore are apt to keep it too warm. In summer one cotton cap, I believe, is sufficient to preserve the heat, but in winter an under cap may be added, but neither of these ought to be secured by pins. Soft tapes are preferable, for this and every other part of a child's dress. The rest of the clothing consists of a short shift, and a wrapper of fine flannel, which is better for a week or two than the separate pieces of dress employed by many, and which add to the time and trouble of shifting the child. All children cry when shifted and dressed ; therefore the shorter and simpler that the process can be made, the better. Last of all, a cloth is to be applied, to receive the faeces or urine, and this is to be removed the moment it is soiled. By atten- tion, a child may very early be taught to give indication when he wishes to void urine or faeces, and can then be held over a pot or basin. It is proper to encourage the child to use these at regular intervals. Children should have their bottom and thighs washed and wiped dry, always after soiling themselves. The whole body ought likewise to be regularly washed, morn- ing and evening, with a sponge and water, at first rather tepid, but soon brought to be cold, at least ofthe temperature that cold water has in summer. But although this is ageneral prac- tice, yet some children do not agree with it, being languid, cold, and pale, after being washed, and these ought to have the water warmed a little. Plunging the child into cold water is, perhaps, in this country, for some weeks, rather too violent 572 a shock, but about the third month, it will be proper to do so daily. The temperature in which children are kept, should be such as neither to increase nor diminish the natural heat ofthe sur- face. The child in utero is placed in a temperature of about 96 or 98 degrees ; but its power of generating heat is proba- bly much less than after birth. The heat ofthe room, and the quantity of bedclothes, should be nearly such as would be agreeable to a healthy adult. Depressing heat is to be avoided on the one hand, and exposure to cold on the other. The apartment should be well ventilated, but the infant ought not to be exposed to the open air, for nearly a month in winter, as it is apt to produce convulsions, or catarrh, with fever, or bowel complaints. SECTION THIRD. It is customary to give some food before the child be ap" plied to the breast, and very frequently medicine also, such as salt, magnesia, or manna, to purge off the meconium. The absolute necessity of either of these practices may perhaps be questioned, especially if the mother be able to suckle at the usual time. A little milk and water is at all events sufficient; and with respect to laxatives, I believe that they are seldom necessary. If, however, the meconium do not come freely away, and the child have no stool in twelve or sixteen hours, or seems to be oppressed, or troubled with pains, a little manna may be given with much advantage ;121 but generally the milk which is first secreted, called colostrum, is sufficiently powerful. When the bowels begin to act, and the bile is plentifully secreted, it is usual for the child, in consequence of absorption of bile, or perhaps of meconium, to have a yellow tinge on the skin which is called the gum. This is sometimes attended with a drowsy state. If it require any medicine at all, it is a gentle laxative. All children are intended to be brought up on the breast, and they ought to be applied early, generally betwixt twelve and twenty-four hours after birth. Some mothers, however, cannot, and others will not, suckle* their children, but employ another nurse,f or bring the child up on the spoon. If the * Van Helmot, and after him, Browzet and others, have advised, that children should not be brought up on the broast, but fed on asses' and goat's milk, or a nanado made of bread boiled in small beer, and sweetened with honey. + In choosing a nurse, it is necessary to be satisfied that she enjoys good health, and has an adequate supply of milk. Certain rules have been laid down to enable us to ascertain the quality of the milk by its appearance ; but it is suffi- cient that it be not too thick, and have a good taste. With regard to the quantity, 573 latter mode is to be adopted, it is necessary to determine the proper diet, and the best mode of giving it. It is evident that the diet which will be most suitable for an infant, is that which most neaily resembles the mother's milk. It is not sufficient that we merely give it milk, it must be milk similar to that of the human female. It is certain, that the lacteal secretion of each species is best fitted for the young of that species ; and we know that there is a great diversity both in the flavour and proportion ofthe component parts of different milk. Yet, in many cases, the milk of one animal will agree with the young of a very different species. Thus, a leveret has been suckled by a cat. Milk consists of cream, curd, and whey ; and the whey, the greatest portion of which is water, is the only part that becomes sour. The quantity of cream is greatest in ewe's milk, next in that of woman, the goat, the cow ; and then the ass and the mare. The proportion of whey is greater in the milk of mares and women, than of the cow or the sheep. With regard to the caseous part, it is greatest in the milk of sheep, the goat, the cow, the ass,the mare, in the order in which they stand; and it is little in that of women. Sugar again is most abundant in the milk ofthe mare and woman, and less so in that ofthe goat, the sheep, and the cow. Woman's milk contains more cream than cow's milk, yet no butter can be made from it. It contains much whey, and yet it scarcely ever becomes sour by exposure to air, and does not pass either to the vinous or 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 passionate disposition, should not be employed as a nurse. The milk, during menstruation, is apt to disagree with the child, and produce vomiting or purging, but this is not uniformly the case. Violent passions ofthe mind affect the milk still more ; it often becomes thin, and yellowish, and causes colic or even fits. Those who labour under hereditary disease should, at least for prudential motives, be rejected. The woman's child, if alive, should be in- spected 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 ; the quantity of curd increases. 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 accustomed to. It is also proper that she be employed in some little duty in the family, otherwise she becomes indolent and overgrown. When a nurse becomes preg- nant, the milk often diminishes in quantity, but does not become hurtful; on the contrary, the quantity of phosphate of lime it contains, appears in the course of gestation to increase. 574 putrefactive fermentations. Acids do not coagulate human milk. From these remarks it follows, that if a child be not suckled, the best food will be milk, resembling that of women, and the nearest is asses'; but as this cannot always be procured, we must change that of cows, so as to diminish the proportion of curd, and increase that of sugar and cream, which is done by adding an equal quantity of new made whey, a sixth part of fresh cream, or less if it be rich, and a little sugar.122 Some dilute the milk with water gruel; or a little water may be mixed with it, and so small a quantity of salt as shall not give it a taste. It may then be sweetened with a little sugar. This is to be mixed just as it is required, for, by standing, it acquires bad properties. It is not to be given with the spoon, but the child is to suck it, of a proper heat, out of a pot which is made for the purpose, and which has a piece of soft cloth tied over the perforated mouth. This diet may be occasionally alter- nated with a little weak veal or beaf soup. Panado made with crumbs of bread is not proper ; and meat made with unbaked flour is still worse. In the third month, we may, besides the milk-mixture and light soup, give occasionally a little spoon meat, such as panado made with the crust of fine bread, and a little salt, which is better than sugar, care being taken to break down the lumps completely. This is to be mixed with milk. Arrow-root, calves'-feet jelly, foe, are also very proper; and as the child advances in life, eggs, in the form of light custard, foe. are allowable. Some have proposed a panado made with the flour of wheat malt. By attention, a child may be taught to eat at pretty regular hours,* espe- cially after he is a few months old ; and great care should be taken, that he do not eat too much at a time. If the child be not suckled, we ascertain that the artificial diet is agreeing with him, if he be lively and easy, and the bowels be correct. But when it does not suit, as is too often the case, he is either dull and heavy, or cries much, and often the bowels are either bound or too loose; and in both states the stools are foetid, and have a bad appearance. If this condition of the bowels cannot be corrected by medicines, the child in all probability will be lost, if a nurse be not procured ; convulsions, or diarrhoea, will carry him off. When a child is brought up on the breast, there is no » It is also of advantage, that when a child is brought up on the breast, he be not applied at all hours indiscriminately; and no child should be allowed to suck whilst the nurse is asleep, as he is apt to surfeit himself. 575 ♦vccasion, if the supply be abundant, to give him any other nourishment for three or four months. After this time, how- ever, it will be proper to give a little food ofthe kinds men- tioned above, and the proportion ought to be gradually increased, as we proceed to the time of weaning, by which theorgans of digestion areenabled to accommodate themselves better to the change of diet which then takes place. With regard to the age at which a child should be weaned, it is not possible to give any absolute rule. In general, the longer it is delayed, if we do not go beyond a year, the better does the child thrive, provided the milk be good. When a child is nursed beyond a year, and receives little other food, or when the milk becomes earlier altered, he is apt to be injured. At all times, delicate should be nursed longer than robust chil- dren ; and, if possible, weaning should not be made to interfere with the developement of teeth, nor be attempted in the pros- pect of, or soon after the cure of, any debilitating disease. If the mother's health permit, children may be suckled from nine to twelve months. After the child is weaned, the diet must be carefully attended to, and should consist of light soup, eggs, bread and milk. In Ireland, potatoes form a principal part ofthe diet. In Scotland, oatmeal porridge is a common diet, and with many agrees very well; but it is, notwithstand- ing, apt to be heavy and binding, unless it have an admixture of barleymeal, which corrects it. But it may be as well to substitute some other aliment, such as ground biscuit, boiled with milk and water, arrow root, foe. As soon as teeth suffi- cient to masticate appear, a little animal food may be given once a day. The dress of children, as they grow up, must be regulated, in some respect, by the custom of the country, and the season of the year. It ought always to be easy and warm. Mr« Locke advises, that a child should wear thin shoes, and get wet feet, that he may become hardy; but experience proves, that the children of the poor, who are exposed to many privations and hardships, are not improved thereby. Clean- liness is essential to health, and the whole surface should be washed once a-day at least, and the hair daily combed, and brushed, which may prevent scald-head. The exercise should be proportioned to the age. Infants sleep much, and can take no exercise, if we except that given by their nurses; but when they are about two months old, they may be placed on the carpet, and encouraged to creep. When they are able to walk, they should be allowed to run about freely ; and it will 576 be of great advantage, where circumstances permit, that the first years of life be spent in the country. CHAP. II. Of Congenite and Surgical Diseases. SECTION FIRST. When a child is born, it is necessary to ascertain that it have no congenite imperfection, or have met with no accident during birth. I can here only make a few short remarks on some ofthe most frequent and important imperfections. The first I shall notice, is the hare-lip, which may exist in different degrees, and be accompanied with a vacancy in the palate. Sometimes an operation has been performed soon after birth, but it often fails, and occasionally the child dies. It is better to delay it for ten or twelve months, or even longer. In the mean time, the child must be brought upon the spoon, unless the defect be so trifling, as to permit him to suck a large nipple. SECTION SECOND. Imperforated anus may exist in different degrees. There may be an appearance of anus, but an obliteration a little higher up. This is discovered, by introducing a bit of oiled paper rolled up, which ought always to be done when the child is long of voiding the meconium. If the paper be soiled with faeces, we may be sure that the rectum is pervious. A blunt probe, cautiously introduced, will also ascertain the state ofthe gut, or even the little finger previously oiled, can be, without much effort, introduced, to ascertain the state ofthe gut above. Sometimes the anus is covered with a thin mem- brane only. In other cases, a great part of the rectum is wanting, or it terminates in the bladder of the male, or vagina ofthe female, which last is not a fatal deviation. It is proper always to make an incision at the anus, or at the spot where it ought to open, if there be no mark of it ; and this is to be carried about half an inch, or an inch deep. If no intestine be found, a trocar or lancet may be passed a little deeper in the proper course ofthe rectum. If, by any of these means, the bowel be opened, a tent should be employed to keep the o< i aperture from closing.* But if it be not thus found, we are not to prosecute the dissection farther, but must form an artificial anus.t This may be done by opening the caecum, by making an incision immediately above, and parallel to, the posterior part ofthe crest ofthe ilium, on the right side. The incision is to be deepened in the same direction, or rather downward than upward, that we may not come on the end of the kidney. The caecum, is thus exposed, at a part exterior to the peri- tonaeum. It is to be laid hold of by a pair of dissecting forceps, and opened. It has been proposed to operate in the same way on the left side, and open the colon as it is tied down under the kidney, and get at it behind the peritonaeum. But this does not succeed. We have to go deep, are apt to expose the kidney, and often find the colon quite included in peritonaeum, forming a short but distinct mesocolon. It is better to open the continuation of the colon in the left iliac region, by cutting just above, and parallel to, Poupart's liga- ment, near the spine of the ilium. We thus expose the colon, which lies just behind the parites, on the iliac muscle. An artificial anus must then be made, and preserved according to the rules of surgery. It is not possible, owing to the curve of the colon, to pass with safety any flexible instrument, from the opening along the tube to the rectum ; otherwise, we might, by introducing the little finger into the anus, or into the incision supposed previously to be made in that region, feel the end of the bougie, and cut the part. Death does not always follow from refraining from an operation. In the Revue Med. for Dec. 1823, there is an account of a man, then alive, and aged 70, who had both the anus and urethra imperforate. He voided the excrement by vomiting. Imperforated urethra is rare, for generally the canal opens in supposed cases of imperforation, about midway between the scrotum and glans penis. There is seldom occasion to do any thing instantly, but, in due time, an operation may be performed to carry on the urethra to the point. Retention of urine, not dependant on malformation, is readily removed, by introducing a probe into the bladder. Deviations in the * In a case operated on by M. Cervenon, where the incision was obliged to be carried an inch high, it was necessary to use a bougie for a year. The child was enabled to retain the fasces, but the anus appeared as if it were sunk an inch deeper than usual. Recueil Period., tom. I. p. 36. t Vide Observations on this subject, by Dumas and Allan, in the Recueil Period., tom. III. p. 46 and 123, and a case in point by Duret, in tom. IV. p. 45. 4 B 578 structure of the vagina and hymen have already been con- sidered. Imperforated meatus auditorius is very rare, and can seldom be remedied, except there be merely a membrane stretched across the canal. Adhesion of the eyelid is often complicated with a defect in the eyeball itself; but when this is not the case, an operation will be advisable. SECTION THIRD. Sometimes the umbilicus is peculiarly large, and hernia takes place soon after birth, but still more frequently betwixt the second and fourth months. Two modes of treatment may be adopted. The first is compression, carefully maintained, which should be always tried. This, in some instances, pro- duces a radical cure, the umbilical opening contracting, which it never does in adults. The second mode is, reducing the intestine, and tying the sac with a single or double ligature. It has also been proposed to open the sac, and close the umbilical aperture by pins or stitches; but this has no advan- tage over the double ligature. Sometimes, a very great por- tion of the intestines is found protruded at birth, into the sheath of the cord. This may be complicated with an imper- fect or transparent state of part of the abdominal parietes ; but whether it be or not, the child generally dies within forty-eight hours. The abdomen is too small to receive back the intestine quickly ; and even although it could be reduced, the child, if we may judge from experience, has no great probability of existing. In one case, Mr. Hey found the tumour burst during labour. Other species of hernia, are to be treated on general princi- ples. The bowels are to be kept open, and violent exertion avoided. The propriety of endeavouring to retain the bowel with a bandage, must depend on our being able to do it effectually; for if the bowel protrude, it is pinched by the pad. This produces pain and local inflammation, and not unfrequently convulsions. SECTION FOURTH. Spina bifida is an imperfection of the vertebral canal and the spinal marrow. The bone is deficient generally about the lumbar vertebrae ; a tumour is formed externally, which con- tains a fluid, and the skin is usually livid. The marrow stops- at the commencement of the tumour, but sometimes begins again below it ; or small nervous twigs arise from the inner 579 surface of the sac, and pass out to form the nerves of the inferior part ofthe body. This is a fatal disease, and death is generally preceded by inflammation or gangrene of the tumour. In some instances the sac is open at the time of birth. The tumour may either be, or not be, connected with hydro- cephalus internus. »If the head be enlarged, there can be no doubt ofthe existence ofthe latter disease, and nothing ought to be done to the tumour ofthe spine. If the urine or faeces be expelled involuntarily, or the inferior extremities be para- lytic, or the tumour have burst, or sloughed, no attempt need be made for relief. Where these unfavourable circumstances are absent, then two modes of treatment offer for considera- tion, palliative and radical. The first consists in treating the tumour as a hernia, that is, gradually getting the contents to retire within the vertebral sheath, if they are not so great as to produce compression ofthe parts, and then a compress or truss is applied. Or, if the tumour be larger than to permit of this, then a hollow compress, or hollow piece of plaster of Paris, may be applied, at least in the first instance. This plan is only palliative, and never cures the complaint, but it prevents increase. The second exposes the patient to great danger from constitutional irritation, but if it succeed, the cure is radical. It consists in repeatedly puncturing the tumour with a needle, and drawing off the water. At last, adhesion of the sides ofthe sac is produced, and the opening from the spine is closed, the skin hanging shrivelled over it, or becoming puckered at the part.*123 SECTION FIFTH. Marks and blemishes are very frequent, and may be placed on any part of the body. They are of two kinds : First, simple discoloured patches, generally of a red colour, and not elevated. These are not dangerous, but rarely admit of cure, for if we destroy them with caustic, the cicatrix is almost as bad as the original blemish. Second, elevated discoloured marks, which are of a purple or red colour, and very vascular. These are apt to increase, and at last bursting, great haemor- rhages may take place. They may be seated on the face, or in the lip, eyelid, foe. or on the spine, resembling spina bifida, but are more solid or spongy, and the bone is not de- ficient. These are to be extirpated as soon as they begin in the smallest degree to increase, and even if situated on the ' Vide case by Sir A.Cooper, in Med. Chir. Trans, vol. II. p. 324. 5H0 gums, or within the mouth, however small they be, they ought to be removed. When on the palate, and extending to the velum or tonsils, the case is most hazardous. Small marks have occasionally been removed, by laising the skin with a blister, and then applying mild escharotics, or by means of caustic. But in almost every instance the knife is better. The application of cold, or pressure, can seldom be depended on, neither can we trust to tying the main artery ofthe part. SECTION SIXTH. Children may, especially after tedious labour, be born with a circumscribed swelling on the head. This seems to contain a fluid, and has so well defined hard edges, that one, who, for the first time saw a case of it, would suppose that the bone was deficient. It requires no particular treatment. By applying cloths dipped in brandy, the effused fluid is soon absorbed. This, which is called hematocele, is generally on the parietal bone. Encephalocele, as Naigel remarks, is oftenest at the posterior fontanelle or occiput. SECTION SEVENTH. Distortions of the feet are not uncommon. They are called vari, when the foot is turned inwards ; valgi, when outwards. These, and similar deviations, are to be cured by pressure, applied with proper bandages adapted to the nature of the case. They must operate constantly, but gradually, and ought to be applied as early as possible. It is a bad case, indeed, which cannot thus be cured by a good mechanic* SECTION EIGHTH. When the frenum linguae is too short, or attached far forward, the child can neither suck well, nor speak distinctly. It is very rare in its occurrence. I have not seen two children where it was really necessary to perform any operation ; for in all the rest the child sucked the finger,124 or a good nipple, very readily. The operation consists in dividing to a suffi- cient extent, the frenum, with a pair of blunt-pointed scissors. If the artery be imprudently cut, the haemorrhage is to be checked by compression or cautery. SECTION NINTH. Imperfection or malformation of the heart is a very fre- * For the anatomy of the club-foot, vide Scalpa. 581 quent occurrence; or the foetal structure may continue long after birth. If the imperfection be great, the symptoms come on almost immediately after birth ; but if slight, or consisting merely in a continuation of the foetal structure, they may not come on till the child begin to walk, or get teeth, or even later. The child is dark-coloured, or the skin has a dirty appearance, the nails and lips are livid, the breathing is more or less difficult, and he is subject to attacks of asthma, or a kind of suffocating cough, like that in peripneumonia, or hooping-cough ; and whenever this attacks an infant, I augur very ill. I have no remedy to propose. Comparative ease may be obtained, by keeping the child as quiet as possible, avoiding a loaded stomach, or costive state of the bowels. For an account ofthe different kinds of malformation, I refer to my brother's excellent work on the Diseases of the Heart. SECTION TENTH. Children have sometimes a swelling of the breasts after birth. This is chiefly owing to secretion of a milky fluid, and much injury is often done by attempting to squeeze it out. Gentle friction with warm oil is of service ; but if in- flammation come on from rude treatment, a tepid poultice must be employed. Hydrocele generally goes off, by applying compresses dipped in solution of muriate of ammonia. A puncture is rarely necessary. Phymosis requires astringent lotions. Prolapsus ani is to be cured, by keeping the bowels easy,. using the cold bath, and returning the gut whenever it pro- trudes. The child should also be prevented from remaining long at stool. If the prolapsus prove obstinate, injecting a little decoction of oak bark may be proper. Serous discharge from the navel sometimes takes place, after the separation of the cord ; and, in general, it will be found to arise from a small fungus not larger than a cherry stone. This is removed by a little powdered alum, or if that fail, by a little red precipitate, or by a ligature. Excoriation of the navel is different; for there is no fungus,. but rather inflammation and superficial ulceration.. It is to be removed by opening the bowels, keeping the part very clean, and bathing it occasionally with Port wine; after which it is to be dressed with cerussa ointment. If neglected, or the bowels be not attended to, swelling of the nature of furun- cuius may take place, or the inflammation may become erysipelatous, and end in gangrene. If this be threatened,. 582 gentle laxatives, a good nurse, and mild dressings, poultices, or the application of cloths wet with weak solution of chloride of lime, if there be much smell, constitute the practice. Sometimes, a day or two after the cord separates, or at the time of separation, haemorrhage takes place from the navel. This may yield very readily to compression, or astringents ; but, nevertheless, may also prove obstinate and fatal. The actual cautery has been proposed, or nitrate of silver, or cut- ting at the navel and applying a ligature on the end ofthe vein, which is supposed to bleed oftener than the arteries. I know, from experience, that no compress can at all times be depended on, except the point of the finger, and that cannot well be steadily applied for hours or days in succession ; yet, in obstinate cases, I know no safer nor better plan, the assistant being relieved at proper intervals, for some time, both night and day. I give this opinion, from finding other means, apparently more powerful, fail. Strong astringents, or escha- rotics, caustic applied so as to form an eschar, a ligature carried, by means of a needle, round the umbilical aperture, and tied tightly, the twisted suture made by crossing two needles, and working the whole navel over tightly with'thread, have all failed, and appeared, by propagating inflammation to the peritonaeum, to hasten death. It has been proposed to apply a bit of cloth, wet with solution of caoutchouc in ether, over the navel, applying the same frequently with a pencil, till a firm coating or plaster were made to cover the part. If it should be necessary to tie the vessel, the umbilical vein is exposed by cutting directly upward from the naval, so as to divide the skin and aponeu- rosis, taking care not to open the peritonaeum. If the finger be placed in the wound, a rope may be felt, consisting ofthe vessel, which is rendered tense and more distinct by pulling the remains of the cord, or the navel. It is to be laid hold of with forceps, and a ligature cautiously put round it. The arteries, should they bleed, are exposed by cutting directly down from the umbilicus. Discharges of blood, but much more frequently of mucus or muco-purulent matter, from the vagina, occur in infancy, but still oftener in childhood, and sometimes are very pro- tracted ; they are not, however, hazardous. The bowels are to be kept regular, by the administration of rhubarb and mag- nesia, and sometimes small doses of calomel. Tincture of steel is also useful in childhood. The cold bath should be 583 employed. The discharge is carefully to be removed by fre- quent ablution ; and if these means fail, some mild astringent solution is to be injected frequently into the vagina. Incontinence of urine, during the night, often depends on a bad habit, and is to be treated accordingly. When it con- tinues long, the cold bath is proper. Scalds and burns are best cured, by applying instantly cloths wet with cold water or vinegar. This is the proper practice, whatever part is injured ; but when the face or neck is scalded or burned, it is of the utmost importance to pre- vent a mark, and nothing does so more effectually than the instant application of vinegar, alone or diluted. This, if the injury be slight, prevents the part from blistering, or only a very slight vesication takes place. The part "should then be covered with dry cotton wool, and, indeed, without the pre- vious use of vinegar, it is a good application. It is to be allowed to remain on the part till it come off as a mask, entire or in part, unless the discharge be such as to wet it, in which case it must be daily renewed, taking away only the wettest portions, and replacing those with dry wool. In scalds and superficial burns on other parts, the cotton is also a good application. It sometimes succeeds well when the cutis itself is considerably disorganized, but it is not so certain as in more superficial cases : still we may use it. The old remedy of linseed oil and lime water often is useful, or the parts may be covered with a cloth dipped in a liniment composed by adding to melted lard as much of a mixture of equal parts of rose water and acet. lyth. as it can incorporate with, or we dress with cerussa ointment, or anoint the spot with this, and then make it dry with cerussa or chalk. The part is to be washed at least once a-day, to remove any irritating matter which might fret it. A weak solution of chloride of lime forms a good wash. If vesications have formed, they are to be opened with a very small puncture, to let out the fluid, and then the cotton is to be laid on ; or if the liniment be used, and give much pain, it may be diluted with oil.125 In more extensive and severe burns, if the surface be nearly torrefied, it may be wet with oil of turpentine, applied with a soft brush, or dressed with ung. resinosum, mixed with a fourth part of oil of turpentine; but in all cases where the cutis is not disorganized, this would be too severe, and the best application is cold water for a time, if it do not produce shivering or depression, and then the old formula of equal 5r4 parts of lime water and linseed oil. Afterwards, simple oint- ment thickened with chalk may be used, and in some time longer, the sore may be covered with powdered chalk, which is to be continued till it heal. It represses fungus, and forms an artificial scab. Cotton applied after suppuration has taken place, sometimes agrees Very well with the sore. In all eases pain is to be allayed by opiates, and the bowels are to be kept open. Stupor is very apt to follow a severe burn, and if not relieved by a blister to the head, and purgatives or clysters, soon proves fatal. Inflammation of internal organs is also apt to succeed a burn or scald. Infants are easily sunk by burns. When boiling water, tea, the same time that we, if the stools be very bad, give small 591 doses of calomel at proper intervals, to bring the bowels into a better state. The greatest number of children who die durino- dentition, perish in consequence of obstinate or neg- lected diarrhoea. Sickness, loathing at food, and ill-smelled breath, require a gentle emetic. Spasmodic and convulsive affections require the warm bath and purgatives. It ought not to be forgotten, that as the irritation of the third branch ofthe fifth pair, causes more or less excitement ofthe base of the encephalon, we should, if the symptoms be acute, detract blood, and apply a blister to the back of the head, nor are we to be rash in healing that blister. Opiates are not to be given without much circumspection. They are always hurtful, when there is much vascular excitement, and are only admis- sible when this is absent, and there is, at the same time, great irritation ofthe nervous system, or pain ofthe bowels. They ought, in general to be combined either with oil of anise or assafoetida, or with both. It is not easy to describe the different symptoms which occur during dentition, or may be connected with it; but one general rule must be laid down, namely, to treat them, as we would do in any other circumstance, with the additional practice of cutting the gum. Delicate and slender children suffer chiefly from bowel complaints, and sj*asmodic affections ; stout or plethoric children are more apt to suffer from acute fever, with determination to the head. Third, We support the strength directly by the breast milk, anow-root, beef tea, or, if necessary, by clysters of veal soup, or calves'-feet jelly; and indirectly by restraining immoderate evacuations. If the child have been recently weaned, it is often of service to apply him again to the breast. CHAP. IV. Of Cutaneous Diseases. Jn the following short account of cutaneous diseases, I may perhaps have committed some errors respecting the names of eruptions.* Nosological writers, unfortunately, do not agree * I adopt the terms of Dr. Willan, not that I think his arrangement free from many objections, but because it is now best known. If any of my readers have leisure and opportunity to form a more correct division, I would suggest the practical utility of introducing, as part of their improvement, an arrangement of those mixed diseases, where there is a resemblance in character to two different, genera; and the nomenclature, in this case, might be similar to that of th« ehemiit exhibiting the composition. 592 in giving uniformly the same name to the same disease, and perhaps it is not always easy to give a perfect definition by words alone. I have, however, endeavoured to detail faith- fully, so far as I am able, the symptoms characterizing the eruptions which I describe, by whatever name they may be called, and also to point out the mode of treatment commonly employed. SECTION FIRST. The first eruption which I shall mention, is well known under the name of red gum, and is described very accurately by Dr. Willan as his first variety of strophulus, a papulous eruption. The strophulus intertrinctus, or red gum, consists of a number of acuminated elevations of the skin, of a vivid red colour, not, in general, confluent, and sometimes even pretty distant from each other. The papulae are surrounded with a red base. This redness is often the most evident part ofthe eruption, in very young infants, and the disease then resembles measles. It covers a great part of the trunk, and keeps almost entirely off the face. In the centre of the spot, we may observe a very minute elevation, or papula, with a clear top. There is no fever, nor has the child catarrhal symptoms. The eruption comes out irregularly, and is either more durable, more fugacious, or more partial, than the measles. On the feet the papulae are still more distinct. The papulae of strophulus are often intermixed with small red specks not elevated above the surface. They are hard, and contain no fluid, or only a very small quantity under the cuticle at the apex, giving it a glistening appearance; but they seldom discharge any fluid, and scarcely ever form pus. This eruption appears generally on the face and superior extremi- ties, but sometimes it spreads universally over the body. On the back part of the hand, the papulae occasionally contain a little yellow serum, but this is presently absorbed, and the cuticle is thrown off like a slight scurf. This variety of stro- phulus generally appears during the first ten weeks* of life, and is not productive of any inconvenience. It seems to be connected with the state of the stomach and bowels ; and any uneasiness the child may suffer, during the continuance of the eruption, or previous to its appearance, seems referrible to this source. The particular connexion existing betwixt the chylopoetic viscera, and the surface, I do not pretend here to * Sometimes a few spots of this kind may be observed on the forehead of ehildren, *t the time of birth. 593 explain or investigate. I hold the fact to be established, and from no circumstances more decidedly than these, viz. that, in adults, certain kinds of food do, with individuals, invariably produce an eruption on the surface ; and that, in children, where all the system is much more irritable, trifling irritation of the bowels is followed by cutaneous erupiion, whilst the sudden disappearance of the eruption, on the other hand, is succeeded generally by sickness and visceral disorder. I am inclined to attribute to a cause within the abdomen, all those eruptions which are not produced by the direct application of irritations to the surface.* The affection at present under consideration requires no particular remedies. It is sufficient to avoid the application of cold, which might suddenly repel the eruption ; and filth or other irritation, which might increase it, or superinduce another affection. Should the stomach or bowels be affected, or the child be oppressed, a very gentle laxative may be occasionally administered ; or should the bowels be too open, and the child flabby, a little tincture of myrrh, or myrrh with lime water, may be given, and, if necessary, an opiate. If the eruption be repelled, and the child thereafter be disordered, the warm bath, with a gentle laxative, will be proper. SECTION SECOND. The next variety is the strophulus albidus, which is an eruption consisting of minute whitish specks, hard, and a little elevated ; sometimes, but not always, surrounded by a very slight and narrow border of redness. No fluid is contained in the papulae, which appear chiefly on the face, neck, and breast. This generally is met with after the period at which children are subject to red gum ; it remains rather longer, but requires no peculiarity of treatment. Sometimes children, at a more advanced period, have this kind of eruption on the neck, which is exposed to the sun in warm weather. It has sometimes been mistaken for the itch. SECTION THIRD. The strophulus confertus is a very frequent affection during dentition, but seldom appears before that period, though it may occur after it. It consists of papulae, often set extremely • Dr. Underwood is inclined to think, that when children are subject to repeated eruptions, the milk does not agree with the stomaeh, and ought to be changed. I am very much disposed to adopt his opinion.—See also Turner on the Diseases ofthe Skin, p. 69. 4D 594 close together, forming patches, varying from the size of a sixpence to a dollar. Such, at least, is the appearance on the face and arms, to which parts it is often confined, especially to the former. But it sometimes appears on the trunk, and there the papulae are larger, flatter, and surrounded with more inflammation, than those on the face or arms, looking at a distance like measles. This eruption not only varies a little, according as it appears on the trunk or extremities, but also according to the age of the child. For after the seventh month we find, especially on the arms, the papulae pretty large ; and either red, with scarcely any appearance of lymph at the top, or of a light yellow colour, but the base surrounded with a halo or inflamed rim. These papula? may on some parts, be distinct "from each other, whilst elsewhere they form clusters so close, that the redness surrounding one communi- cates with that of another, forming altogether a large inflamed ground-work. In some cases, the red patch is the prominent feature; it may be as large as a dollar, with innumerable little dots within it, like pin heads, with clear or watery-looking tops, or larger red hard papulae. This eruption is sometimes preceded by sickness, and in certain circumstances, has been mistaken for measles ; but it is attended with little or no fever, and has none ofthe catarrhal symptoms met with in measles. By not attending to the characters of the two diseases, they may be confounded ; and not unfrequently, when young chil- dren take measles, the strophulus confertus appears on the arms, previous to the proper eruption, or even along with it. Dr. Underwood says, this eruption does not dry off like measles ; but, as Dr. Willan remarks, it often does terminate with a slight exfoliation of the cuticle. A variety of this disease appears like red patches on different parts ofthe body, particularly on the arm, and often coming out in succession. They are as large as a split pea, and a very little raised toward the centre. By near examination, several small papulae may be discovered, which are something like vesicular points. In three or four days, the patches become yellowish or brown, and covered with small scurf. This is denominated by Dr. Willan, strophulus volaticus, and is said not to be very com- mon, but I think it is frequently met with. It is seldom necessary to give any medicine for this complaint. If, however, it be troublesome, it is usual to prescribe gentle laxatives, and testaceous powder.-. Some advise emetics, and the use of the bark ; but neither, I believe, are in general necessary. 595 SECTION FOURTH. Slrophulous candidus consists of papulae having a smooth, shining surface, which appears of a paler colour than the rest ofthe skin, and the base is not surrounded by any inflamma- tion. It is described by Dr. Underwood as resembling itch, but is neither red nor itchy. It generally either attends den- tition, or succeeds some acute disease of children, and is justly considered as a very favourable symptom. It is most fre- quently met with on the trunk ofthe body, the arms, or fore- head. In a few days the papulae die away. No particular treatment is necessary. SECTION FIFTH. A different eruption from any of the foregoing is the lichen, a term restricted by Dr. Willan, in his elaborate work, to a papulous eruption, chiefly affecting adults. It may, however, appear also in children ; and I have seen it succeed some of their febiile diseases, as, for instance, measles. It consists of numerous distinct papulae, some of which are pale at the top, but very slightly red at the base; these are generally small like pin hea^s. Others are larger and flatter, and more inflamed, but have always at first a clear apex, and do not end in ulceration, but die away in slight scurf. Some- times on the body, there are small shining or silvery-looking patches, from exfoliation of the cuticle ; or the skin may peel oft' more extensively, as if it had been blistered. They resemble often the papulae in strophulus, but seldom form in clusters, and have not, in general, any diffused redness con- necting one papula to another. There is, however, sometimes about the joints or fore-arm, a considerable degree of red efflorescence, covered with scurf. This eruption may be pro- duced by exposure to heat, and by drinking cold water when heated, or other less obvious causes. It is frequent in warm weather, and a species of this is known under the name of prickly heat. It is preceded often by febrile symptoms, and the eruption itself may last for more than a fortnight, but in a few cases it goes off in a day or two. These papulae, at different stages, bear a resemblance totwo very dissimilar dis- eases, the itch and the measles; but it is not pustular like the itch, neither does it ulcerate; it is not very itchy, and if scratched so as to take off the top, it does not yield matter, but a little bloody scab is formed; It differs from the measles in being papulous, and having on the spots, before they form 596 slight scurf, a clear looking top ; it in general lasts longer than the measels, and is not attended with catarrh. Further, it is sometimes accompanied, with a broad scurfy efflorescence about the elbow joint, or other flexures. A suitable dose of calomel is the best remedy, or, should the patient be oppressed, an emetic and saline mixture may be given. When there is no febrile affection, it will be sufficient to keep the surface clean, by means of the tepid bath. A variety of this, named lichen urticatus, by Dr. Bateman, resembles the bites of bugs, and appears in irregular wheals, which are very itchy. This ends in small elevated papulae, and the whole body may be successively covered with these papulae. The itching is in- tolerable at night. It seems to be relieved by small doses of sulphur, and, if the child be weak, by tonics and chalybeates. No external application is useful, if we, perhaps, except tepid oil. SECTION SIXTHi Intertrigo is a kind of erythematic affection of those parts of the body where the skin forms folds or sinuosities, as, for instance, the joints of fat children. It also is very common about the nates and inside of the thigh" in consequence of the urine fretting these parts. The inflamed surface ought to be washed occasionally with tepid milk and water, and the child should never be allowed to remain wet, but ought to be bathed, and gently dried after making water, when the thighs are affected. Afterward the parts are to be dusted w ith some cool powder, such as tutty, white lead, levigated flowers of zinc, foe. It is not usual for intertrigo to end in gangrene or suppuration, but sometimes the form of the disease changes, and the cellular substance inflames ; either of these termina- tions may then take place, and will require the usual treatment. SFCTION SEVENTH. During dentition, or in consequence of affections of the bowels, different anomalous eruptions may appear, which are not distinctly referrible to any well defined species. Sometimes we find upon the arm, one, two, or three inflamed portions of the skin, something like small-pox, but rather larger, with a small acuminated speck of lymph beneath the cuticle at the apex, or sometimes the top is flattened and shrivelled. Occa- sionally, a greater number of pustules appear on the body, pretty large, hard, and inflamed round the base, with a white top. This kind of eruption is not attended with fever, and 597 is neither painful nor itchy ; it goes off in a few days without any medicine. Infants, who are supplied with deficient nourishment, or bad milk, are subject to troublesome and successive crops of ecthymata, or inflamed pustules, which slowly suppurate, burst, and form brown scabs, which presently fall off. They affect every part ofthe body, and sometimes are combined with one or two pustules, so large and hard that they may be called boils. The colour is dependant on the constitution, the exhausted having the pustules lurid or purple ; the stronger having them of a mere arterial colour. This eruption, named ecthyma infantile, requires a more nutritive diet, or a new nurse, with all the usual means for invigorating the system ; amongst which I particularly mention attention to the bowels, and removal to the country. If necessary, the pustules may be defended with a little mild salve. Young people, after much exertion, or from gross feeding, are sometimes affected with a similar eruption of the pustules. Laxatives, with vegetable tonics, cure this. Ripe fruits, particularly goose- berries, are proper. Another kind of eruption attacks children above two years of age, suddenly covering the greater part of the body. It consists of red elevated spots, at first sight something like a kind of pock. The spots are distinct, and most numerous on the thighs and legs. They are of a dark red colour, pretty flat, with a smooth flatted vesicular-looking top, which does not burst, nor discharge matter, but gradually dries and desquamates. The eruption is scarcely painful or itchy, and is not attended with fever. It may continue for four or five weeks, and is sometimes combined with lichen, or other cuta- neous diseases. The bowels should be kept open, and some advise antimonial wine to be given, with a little tincture of cantharides. There is a small and very itchy pustule, which begins with a black spot on the skin, and contains a sebacious fluid, which can be squeezed out in a worm-like shape ; such pus- tules are not uncommon in youth, and have been called crinones. They are cured by applying ung. hyd. nit. and washing with almond emulsion, containing a little muriate of mercury, or with soap and water. Boils have been divided into the furuncules, or acute boil, and the phyma, which is more tedious. They are hard, usually flat, with an extended base, and of a purple colour. They are sometimes solitary, and very large, but occasionally 598 they are scattered in considerable numbers over the body. They generally proceed from a bad state of health, and, in place of requiring, as some suppose, an abstemious diet, they demand more nourishment, but it must be easily digested, and the bowels should be attended to. A bread and milk poultice is to be applied to the boil, until the top open, which it does by a kind of sloughing. Scarcely any matter comes out, but a kind of ash-coloured, or yellow core, is gradually thrown out, after which the part heals. Resinous ointment is the best application during the process. Those large indolent boils, or small abscesses, which succeed small-pox, or other debilitating diseases, require hot poultices, and then, when they burst, or are opened, and the pus they contain evacuated, stimulating dressings, with moderate pressure, are proper. Good diet, and even wine, may be required. SECTION EIGHTH. Authors describe some other eruptive diseases, which may be noticed here with propriety : one of these called pom- pholyx, consists of a number of vesications of different sizes, appealing on the belly, ribs, and thighs, and containing a sharp lymph ; they may appear during teething, or in bowel complaints, and continue for several days. These vesications are not uncommon in very warm weather; and I think boys are most subject to them, especially about the ankles, if they do not wear stockings. Lory considers this disease as a kind of erysipelatous affection, produced by the heat of the sun. It requires no medicine, but the lymph ought to be let out by a small puncture. A similar appearance, generally attended with fever, and sometimes with aphthae, is more serious. The vesicles, at first small, presently become pretty large and oval, and their contents turgid. They appear soon after birth, generally in emaciated infants, affect both the trunk and extremities, are surrounded with a livid inflamed halo, and when broken, are succeeded by spreading ulceration. Notwithstanding bark and cordials, the fever and irritation generally prove fatal in about a week ; and only those children are saved, who are previously possessed of a tolerable degree of strength. This may be mistaken for syphilis. Some have considered it as pompholyx, under a different modification; others as a dis- tinct disease, under the name of pemphigus. 599 SECTION NINTH. Sennertus describes, under the name of sudamina, an erup- tion like millet seed, fretting the skin, and affecting children about the neck, arms, foe. Plenk defines it in the following terms: Stint vesicula. granis milii magnitudineet similis, subito absque febre eruntpentes. The child should be bathed occa- sionally in tepid water. This eruption often takes place in hot weather. A similar eruption, attended with fever, is also met with, which I find very well described by Dr. Willan, in his reports on the disease of London, under the name of acute miliaris. It does not affect infants, but children old enough to take active amusement. It begins with a febrile attack, attended with headach and pain in the back. The tongue is of a dark red colour at the edges, with the papilla; prominent as in scarlatina: the rest of the tongue is covered with white fur. The pulse is small and frequent. Presently the patient complains of heat and pricking at the surface, is sick at stomach, and perspires freely through the night. At a period varying from the third to the sixth day of the fever, an erup* tion appears, of small pustules like millet seeds. These are of a red colour, but contain at the top a white lymph, and are either diffused over the body, or collected in patches on different parts, especially the back and breast; they may alter- nately appear and disappear, and though the same pustule does not continue long, it may be speedily replaced. They may sometimes be combined with small red efflorescences, and generally vesicles appear on the tongue and fauces, ending in aphthous ulceration. The complaint often terminates in about ten days, but it may be prolonged even to twenty. It is fre- quently the consequence of being overheated, or drinking cold water in that state. It requires first of all an emetic, and then a purgative. During the course of the disease, the patient should be kept moderately cool, and use acidulated drinks freely. SECTION TENTH. Itchy eruptions are frequently met with on children, but these are not always the true itch, nor the consequence of infection. The prurigo mitis, described and delineated very accurately by Dr. Willan, is a disease often met with in spring. It appears without any previous indisposition, and consists of soft smooth elevations of the skin, or papulae, dif- fering in colour very little from the surrounding integuments* 600 When they do become red, it is in consequence of friction. If the top be rubbed off, a clear lymph oozes out, which forms a thin scab, of a dark, or almost black colour. The eruption is itchy, especially on going to bed, and if scratched, it may become pustular and contagious, which it is not in its early stage. At first, it may be removed, by washing fre- quently with tepid water, and a little soap, or lemon juice ; but if neglected, it requires the application of sulphur. A variety of this disease consists of minute red acuminated papulae, with a very small vesicle at the top terminating not in suppuration, but yielding, when scratched, only a little clear serum. Sulphureous preparations give relief, and time, with attention to cleanliness, confirms the cure. Sometimes very little itching attends this eruption, and it disappears by using the tepid bath. SECTION ELEVENTH. The scabies,* or true itch, is contagious, and consists of small pustules, vVhich have a hard hot base, with a watery- looking top. They are attended with an intolerable desire to scratch ; in consequence of which, the tops are rubbed off the pustules, and scabs come to be formed, partly by blood and partly by a kind of matter, furnished by the little ulcers. But if the pustules be not disturbed, but removed by proper applications, they end in a slight desquamation ofthe cuticle, " quae vix furfur aliquod ostendat." The itch first appears betwixt the fingers, on the wrists and hams, but, if neglected, it may spread over the whole trunk and extremities, and, in consequence of the continual irritation, impairs the health, nay, some children die in consequence of it. In neglected cases, the inflammation surrounding one pustule spreads to another, and the part becomes universally red, with pustules or scabs, according to circumstances, scattered over it. This is often the case on the back of the hand, and fore part of the feet. Sometimes small boils, and phymata, appear in the course ofthe disease, on the thighs or body, or about the face. The itch has not always the same appearance, being, in some eases, more vesicular, or more pustular, than in others. Four different varieties have, accordingly, been admitted by Dr. Willan:—1st, The scabies papuliformis, where the erup- tion looks like papula?, but really consists of small pointed * Children in consequence of handling mangy dogs or kittens, are sometimes affected with an obstinate itchy eruption, which is not scabies, but may be cured by the remedies used for the itch. G01 vesicles, which are very itchy; when these break, they are succeeded by scabs. This variety is apt to be confounded with licnen, or prurigo, when there has been much scratching, but these are more distinctly papular. 2d, The scabies lym- phatica, or eruption of vesicles of considerable size, without inflamed base, but extremely itchy. These may heal by scab- bing, but often suppurate, and form small ulcerated blotches, and, in the same part, we have all the intermediate steps, from vesicle to small open ulcer. The disease with which this is most apt to be confounded, is eczema. 3d, Scabies purulenta, or eruption of distinct prominent pustules, about the size of a split pea, filled with yellow matter, and having a slightly inflamed base. These ulcerate in a day or two, and become then more painful. They are not unlike small pox, but are very itchy. The scabs are thin and hard, of a yellow colour, or inclining to brown. They are surrounded by a diffused redness of the skin, which often has a puckered appearance, as if drawn toward the scab. These pustules are most fre- quently situated between the thumb and fore-finger, or about the wrist. 4th, Scabies cachectica combines the character of the former varieties, which it exhibits, at the same time, in different portions ofthe skin. It originates in cachectic chil- dren, without infection. The cure may generally be accom[dished, by frequent ablution, and rubbing the parts affected with sulphur-vivum ointment,* which, in obstinate cases, may be rendered more effectual by the addition of powdered hellebore, or sulphate of zinc or sal-ammoniac. Rosenstein says, that the hands are very soon cleared, by washing them with a strong decoction of juniper-berries; and that, when the eruption isgreat, as for instance, on the feet, he has applied cabbage leaves with advantage. They cause at first a great discharge, but the parts heal afterwards. Sometimes the friction excites an eruption different from itch, and kept up by the remedies intended to cure it. Mf Burdin remarks respecting this, that it consists of small round pustules, " qui se remplissent quelquefois de serosite, et dont la cicatrice laisse le plus souvent une tache d'un rouge brun, le prurit qu'elle occasione est aussi moius fort que celui de la gale." In inveterate cases, the use of Harrowgate water is of great benefit, or a sulphur vapour bath has been * Dr. Joseph Clarke considers it as dangerous to use sulphur ointment with infants lest the eruption be suddenly repelled; and advises rather to boil a piece of stick brimstone in water, in order to make & bath. 4 £ 602 used. In order to avoid the smell of sulphur, other applica- tions* have been employed, such as sulphuric acid, or nitrous acid combined with hog's lard, ointment of nitrated mercury, camphorated ointment, hellebore, or corrosive sublimate, mixed with hog's lard, foe. These often fail,and even when they do remove the eruption, the cure is said frequently not to be permanent. Ointment containing white precipitate is sometimes useful, particularly in the pustular variety. Itch maybe combined with other diseases, such as herpes, syphilis, foe., in which cases, it is more obstinate than usual, and may sometimes require the use of mercury. SECTION TWELFTH. Herpes is a vesicular disease, of short duration. It consists of irregular clusters of small vesicles, which arise in close approximation to each other, from an inflamed surface, and the inflammation surrounds also the base of the cluster, to a small breadth. The vesicles which appear rapidly, contain a pellucid fluid that presently becomes turbid, oozes gently from the opening or declining vesicle, and forms a yellowish or brownish scab on the part. In some instances, however, the vesicle ends in ulceration, and the discharge is copious and thin. If the scab be prematurely rubbed oft', the surfuce below is found raw and glossy. In slight cases, the sensation is that of heat or itching, but, when more extensive or severe the neighbouring parts are pained, and the eruption itself is preceded by some degree of fever. A great number of affections have been comprehended under this name, many of them of very opposite characters, and even our most correct nosologists, who have excluded those which are not vesicular, have admitted, as species, mere vari- eties of the complaint. The first species, for example, of Aliberl, is the herpes furfuraceus, or dartre furfui acee, which is a scaly, and not a vesicular disease, and his other species are also very doubtful in their nature. The subdivisions, again, of Willan and Bateman, are often founded on mere situation, or arrangement of vesicles. The herpes phlyctaenodes, the first species of Willan, and the sixth of Alibert, is, perhaps, the only one to be admitted, all the rest being varieties. This, when well marked, is preceded by slight febrile irritation, for about three days. Then irregular clusters of vesicles appear, * M. Becu advises the following lotion: Take of tobacco leaves two pounds, sal-ammoniac one ounce, ammonia two ounces, water three Paris pints. Infune for two hours. 603 which become opaque in the course of a day. By the fourth day, the surrounding inflammation becomes less, and the areola fades, whilst the vesicles themselves begin to scab, and continue in this state till the end of the week, or sometimes a day or two longer, when the scabs fall, and leave the surface below red. The size of the vesicles vaiies. When small, they are called miliary, and, in this case, the clusters of ten spread over a considerable part ofthe body ; and, as they do not appear all at the same time, the disease may last alto- gether a fortnight. When the vesicles are larger, their clus- ters are not in general numerous, and sometimes are solitary. Within a day or two after the appearance of the vesicles, the slight general indisposition goes off. A slight degree of this complaint is common about the lips, or chin, or side of the nose, and is called by Dr. Willan, herpes labialis. It is not, in general, attended with indispo- sition, but popularly, is attributed to cold, which is then said to strike out. In some cases, however, there is a degree of fever, and successive crops come out, round the mouth, accom- panied with swelling, hardness, and sensation of heat in the lips.* In such case, the fauces may be affected with a similar vesication. Another variety has vesicles, arranged in the form of a ring, the central portion being only very slightly inflamed. As the vesicles break and scab, and the scabs fall off, this central portion throws off the cuticle in form of fine exfolia- tions, like bran. The size of the ring also often increases, by the successive formation of concentric circles of vesicles. Successive circles of this kind appear on different parts, particularly on the face, and upper extremities, so that the disorder is prolonged for, perhaps, three weeks. This is most frequently met with in children, who are also subject to the last variety, the herpes labialis. It forms one kind of ring- worm, of which there are different varieties. It is named by Dr. Willan, herpes circinatus, and is supposed to be infectious; but I believe that every variety of herpes may be inoculated. The herpes circinatus of Alibert is a furfuraceous disease. Another variety, also met with in youth, but not often in infancy, is popularly named the shingles, or, by Dr. Willan, herpes zoster, and by Alibert, herpes zonaeformis. It is pre- ceded, for two or three days, by febrile symptoms, accompa- * Under this name Alibert describes an eruption, to which young girls, near puberty, are subject, and which he makes a variety of his pustular herpes. At a little distance it looks like measles, but is smaller and pustular. C04 nied with shooting pain about the stomach, or lower part of the chest, and smarting sensation in the skin. This sensation is perceived chiefly about the trunk, and is soon attended with an eruption of irregular patches, of a red colour, a little distance from each other, and on which small vesicles soon arise. These run the usual course of herpes. Successive clusters appear, so disposed as ultimately to encircle nearly the part where they are situa'ed, travelling, for instance, like a zone round the waist, but seldom completing the circle. Alibert has selected as a specimen of this, in his superb plates, the disease passing round the thigh. I do not con- sider it as necessary here to describe any other varieties. With regard to the causes of herpes, we are much in the dark. It sometimes appears to follow exposure to cold, or to be consequent to violent exertion ; but, perhaps, it most frequently is connected with some particular condition ofthe abdominal viscera. The treatment of this disease is very simple, consisting in the administration of gentle purgatives, restricting the patient from indigestible diet, and from the use of stimulants. No- thing can, with much advantage, at first be applied to the vesicles, unless it be with a view to prevent their abrasion. If any thing more active be employed, it should only be some weak astringent wash. When crusts are formed, the appli- cation of a little ung. hyd. nit. appears to accelerate their fail, to heal sooner the surface below, and to abate heat and itching. When there is much glutinous discharge, either this or some other milder ointment is useful to prevent the linen from adhering to the part.* The application of nitrate of silver has been useful. » There are two diseases which arc apt to affect females, even when young, but which I have never seen in infancy. They are ofthe mi: ed character, and Cannot strictly be included here. The herpes orbicularis of Alibert appears often on the cheek, as a very superficial excoriation, ending in broad thin 6cabs, or scales. The part is red, and a little itchy, and the scabs are generally thickest at the circumference. It is a very obstinate disease, and lasts for years. T!-.e herpes crustaceus of Alibert appears like a crust of dried honey, on an erysipe- latous ground. It arises from a raw surface, with thickened margins of a purple colour. There is often swelling, and induration of the neighbouring cellular mater, and the crust itself is elevated. On the cheek it forms a thick yellowish crist; on the wing ofthe nose it is still thicker, so that this has been called stalactiform herpes. These diseases are often connected with a scrofulous habit and after remaining long stationary, sometimes end in corroding ulceration, caries, and fatal exhaustion, or hectic. Mercury may do no harm, but never does good, except in a few cases, where very small doses of muriate of mercury have altered the habit. Sarsaparilla, with arsenic, is more useful, and aperient waters containing sulphur, are also employed. Hemlock has not maintained its reputation. Only mild local applications should be prescribed. 605 SECTION THIRTEENTH. Children are sometimes affected with ichthiosis, a disease in which the skin becomes dry, and covered with scales resem- bling in their distribution, and sometimes in their appearance, those of a fish. This disease may come on at any period of life ; it may even be connate, but this is very rare. It is proper to employ the warm bath, and, during its use, to pick off the scales. Their regeneration is to be prevented by friction, and repeated bathing. Sometimes children have this disease conjoined with boils. SECTION FOURTEENTH. The scaly tetter, dry itch, or psoriasis of Dr. Willan, con- sists of red rough spots, which are very soon covered with a laminated scale, sometimes as thick as paper, but generally thin, and very like a bit ofthe dried scale of a herring. They are irregular in their shape and size, occasionally not larger than a coriander-seed; sometimes as large as the nail ofthe little finger, resembling a dried fish scale pasted on the skin ; and frequently they are interspersed with shining silvery-* looking portions ofthe surface. These scales are formed by the exudation of a whitish matter, which is very glutinous, and, as Sylvius observes, stiffens the linen, when it happens to exude in sufficient quantity. In adults, some portions of the surface yield so much fluid, that the parts are quite moist, and scales do not form. The spots on children generally begin like papulae, of small size, and vesicular at the top. These end sometimes in scurf, oftener in thin scales, as has been described. On the back ofthe hand, the vesicles are sometimes pretty large; whilst in the palm of the hand, the eruption is rather pustular, and ends in broad thin rough scabs of a yellow colour. In the early frtage, it is sometimes com- bined with strophulus. The parts are itchy, but when they are srratched, matter does not come out by the removal ofthe scales, but a little blood flows. This eruption often begins on the face or neck, and spreads to the body and extremities. It is very obstinate, and sometimes destroys the nails. When it has continued for some time, the skin, especially about the hands and feet, is found to be universally red, with dark coloured scales interspersed. The skin looks as if it had been scalded, and partly covered with thin scabs, or scales, in differ- ent degrees of adhesion ; and, in some cases, the whole of the extremities, and even the body itself, or the head, become red, 606 partially excoriated, and covered partly with scales and scurf, and partly with scabs, which are yellow, and pretty thickly set, often loose, and easily detached. Sometimes, on different parts ofthe body, particularly on the arms or legs, there are many soft red indolent bumps, more especially if the child have been seized with this disease soon after the small-pox or chicken-pox. The appearance on the head is nearly the same as in pityriasis, but in general it wants the white scurf. It is rare not to find the head affected in this disease. Different species of this have been enumerated by Dr. Willan, which, however, may perhaps be viewed rather as varieties. I do not mean to notice all those here, as it does not consist with the object of this work. 1st, Psoriasis guttata is not uncommon in children, and often spreads rapidly over the whole body, and even the face. It is occasionally preceded by slight constitutional disturbance. The eruption consists of small distinct scaly patches, of an irregular shape, resembling lepra in appearance, but differing from it in wanting the elevated border, inflamed margin, distinct circular or oval shape, and, in the surface below, being more irritable. 2d, Psoriasis diffusa, forming in large patches, which sometimes become confluent, and possess the general character of the disease. A more severe variety is termed inveterata, and others are named from their situation. Excoriation sometimes also takes place about the anus, with a slightly elevated state of the surface ; in consequence of which, and the disease of the skin taking place soon after birth, I have been consulted respecting children given out to nurse, who were apprehended to have syphilis. Dr. Willan remarks the syphilitic appearance of this disease, but justly observes, that all other marks are absent. The syphilitic form of this disease is attended with hoarseness, and the patches are of a livid colour, with a slighter degree of scaliness, and the margin is sometimes higher than the centre. It is not, like the itch, very contagious, nor is it easy to say what occasions it; but we know, that inattention to cleanli- ness is favourable to its production. The application of pre- parations of sulphur, and ointment of nitrated mercury, with the use of the tepid bath, especially made with sea-water, daily, will often cure this disease ; but, in obstinate cases, we must give some sudorific, such as antimonials, or decoction of sarsaparilla, or have recourse to the Harrowgate or Moffat waters, which have great efficacy. They should be used both externally and internally. The internal use of arsenic, as in 607 lepra, will also be proper, if the other means fail. Solutions of soap, or of alkali, or of sulphuret of potash, not so strong as to smart, form very useful baths. Decoctions of hellebore, or solution of muriate of ammonia, or of oxymuriate of mer- cury, are also proper, as external applications. The applica- tion of cloths wet with buttermilk, or of a poultice of butter- milk and oatmeal, sometimes facilitates the cure, and, indeed, when there is much irritatidn, only the mildest application can be borne. Mercury internally does more harm than good; when it is beneficial, it has been in the form of oxy- muriate, in such small doses as have kept the bowels regular. In adult females, whose chylopoetic viscera had been defective in action, I have known the disease very severe and obstinate, and, though mitigated by laxatives, seem to be removed only by time. SECTION FIFTEENTH. The pityriasis is a disease known commonly under the name ofthe dandriff. It consists of a dry, scurfy, and scaly erup- tion on the head, amongst the hairs. Near the forehead, the skin is covered with a thick white scurf, which can be removed in a powdery form ; farther back, larger scales are formed. This is cured by cutting and shaving the hair, and brushing the head daily with a hard brush, washing it with soap and water, and applying ung. hyd. nit. If neglected, ulcers may form, and the disease be converted into the one next to be described. Pityriasis is sometimes infectious. A variety of it appears like small red marks on the scalp. The circum- ference extends, and continues red, whilst the centre becomes pale and scaly. It is accompanied with falling off of the hair. This disease is not confined to the head, but affects oiher parts. That variety named pityriasis rubra by Dr. Willan, is of frequent occurrence at all ages, although said to be most apt to appear at advanced age. It begins with a redness of variable size, and indefinite shape. It may be small, or exten- sively diffused ; the colour becomes deeper and the surface rough ; then it puts on a mealy appearance, from commen- cing exfoliation ofthe cuticle. As this advances, the part is, in a great measure, covered with small branny scales, which, as they in different spots fall off, discover the skin red below. Repeated exfoliation may then take place, and when the sur- face is extensive, the patient's bed is often found covered with small scales. The affected parts are itchy, and sometimes feel 608 stiff. The skin is dry, and no perspiration can be, in general, aturally or artificially procured. There is u great analogy between all scaly diseases, and often the same person exhibits, in different parts, different species. In some, the disorder has more the appearance of psoriasis, and in others there are distinct patches of the nature of lepra. Sometimes it is not very easy to say, whether the disorder belongs most to one species, or to another. It is this pityriasis, and its modifications, which are most fre- quently misnamed herpes farinosus ; an appellation also given to modifications of psoriasis, and, indeed, to every superficial scaly disease. The treatment consists in regulating the bowels, avoiding a saline or irritating diet, the frequent use ofthe tepid bath, gentle friction with ung. hyd. nit., or ointment, containing finely powdered cocculus indicus ; the exhibition of some diaphoretics, such as decoction of sarsapariila, with a little antimonial wine, arsenic, sulphureous waters, internally and externally, SECTION SIXTEENTH. Lepra is a very common disease amongst children, and is vulgarly known under the name of scurvy spots ; others com- monly call it ring-worm, or herpes farinosus. The species %o which young people are subject, is the lepra alphoides. This appears in the form of small patches, of nearly a circular form, seldom exceeding half an inch, but more frequently less, The spots are first red, but soon become covered with small shining scales. The margin is a little elevated, and usually somewhat inflamed. These patches are generally confined to the extremities, particularly the inferior, but they may also appear on the trunk. This, however, is oftener the case with some ofthe other scaly diseases already noticed. They also, much more rarely, become confluent. The causes of this obstinate disease are obscure. The treatment which I have found most useful, consists in the constant application of ung. hyd. nit., frequent ablution, or rather the tepid bath, mild diet, the use of tonic laxatives and the administration of arsenic. A drachm ofthe common solution may be added to four ounces of water, and of this mixture a tea-spoonful may be given in a glass of water, three times a day, to a child three years old. It should always be given after eating, and not when the stomach is empty. If it produce sickness or 609 griping, the quantity is to be diminished, after suspending it altogether for a short time. If it produce no such effect, the dose may be gradually increased to double the quantity pre- scribed, watching, however, the state of the stomach. It requires sometimes to be continued for several weeks, before a salutary effect be produced. SECTION SEVENTEENTH. Impetigo is a term differently applied by writers, and hence uncertain in its meaning. ' Some confine it to a pustular, and others extend it to a vesicular, or herpetic eruption. It appears in clusters of small pustules, which are rather flat, filled with yellow matter, somewhat irregular in their shape, and inflamed at their margin. These are set pretty close to each other, and the whole group seems a very little higher than the sur- rounding skin. They are itchy, and pungent, and soon break, discharging much ichor. The surface has a raw glossy appearance. Then the part becomes covered with scabs of a greenish yellow colour, and, after some weeks, the surface below healing, they fall off, and discover it to be red and scabrous, and easily fretted, so that the discharge and scab- bing may be again renewed. The healing process generally begins in the centre of the patch, and occasionally, as it heals, concentric and enlarging circles of pustules successively appear, as in ring-worm, and this variety has been called impetigenous ring-worm. The pustules are often mixed with distinct vesicles, filled with transparent fluid, which presently becomes dark, or even bloody, and then crusts form, which are rough, of a yellow colour, inclining to brown. There is a good doal of surrounding redness, and radiation of the skin. The vesicles are generally, in this case, the chief por- tion of the eruption, and are more distant or scattered than the pustules. This variety is oftenest met with on the hand, and about the knuckles and fingers. This bears a resemblance to the scabies purulenta, but the pustules are smaller, and more clustered, and it is not infectious ; the discharge is greater, and the skin rougher and redder. This variety is more frequent with children, whilst they are seldom affected with the other kinds. It has been divided into the impetigo figurata, and sparsa ; the former, however, differing only from the latter in the pustules being clustered, whereas, in the sparsa, they are scattered distantly, and especially over the inferior extremities. Other varieties have been enumerated, but do not fall to be noticed here, as they rarely occur in childhood, such as the 4F 610 erysipelatous, beginning like rose, and then in place of blistci * forming, an eruption of psydraceous pustules appears ; the scabida, where the whole limb becomes cased in a crust; the rodens, which is a malignant and spreading sore. The best internal remedy is sulphur ; if that fail, mild diaphoretics and sarsaparilla may be given. Topical stimulants do harm ; mild applications, such as sulphur ointment, or cerussa oint- ment, are better. In very irritable cases, ablution with tepid water, and smearing the parts with cream, or fresh oil, is more useful. In the scabby state', sulphureous waters, as a lotion, and also taken internally, are useful. When cured, the cold bath prevents a relapse. SECTION EIGHTEENTH. Porrigo, or tinea, is a collection of achores, or pustules, containing a yellowish coloured fluid, something like honey, and ending sometimes in the production of a raw and secret- ing surface, but oftener in the formation of scabs, which are generally white or yellow, but sometimes darker, from an admixture of blood. The pustules begin on the face or head, and have their chief seat sometimes in the one, sometimes in the other of these parts, or occasionally both are pretty equally affected. The pustules there are pretty large, and have a red margin. They are not in general painful, but are itchy, especially at night. The matter* discharged is often abundant, and sometimes so irritating, that the absorbent glands about the lower jaw or neck swell and suppurate. Glands on distant parts of the body, or on the mesentery, are sometimes, in unhealthy subjects, enlarged, as a concomitant symptom. Over the body there are also many pustules, which are smaller than those on the head. They have a red base, and lymph- atic top, and are itchy. Presently the straw-coloured fluid they contain exudes, and forms flat ragged crusts, of a bloody or dirty brown colour. The proportion is, however, not always the same between cuticular redness and incrustation; for often, especially about the back of the neck, the whole surface is of a dark-red colour, with only small loose scabs, scattered pretty thickly over it. In other instances it is inter- mixed, in various parts, with furfuraceous patches, and with papulous eruption, like porrigo. When the scabs fall off, the skin below is left red, but no scar remains, unless in very bad cases, where deep ulceration has taken place. Very extensive * An analysis has been published, but it throws little light on the treat- ment. 611 excoriation, yielding much secretion, and having an alarming appearance, leaves no permanent mark, or cicatrix. This disease is infectious, and is generally, if not always, dependant on a scrofulous constitution. This disease has been divided into many species, but no arrangement, that I have seen is free from objection j and I have no wish to add to the number, but will describe what I have met with, under the names employed by Dr. Willan. Neither the names nor the descriptions of different writers agree, and many seem to form distinct species of cases, which, from description, appear to have no dissimilitude. Alibert and Gallot say, that nine tenths of cases are tinea favosa, most of the other tenth tinea granulata, and that the remainder con- sists of rarer species, including the tinea muciflua, which is a mere variety of Dr. Willan's porrigo favosa. 1st. Porrigo larvalis, so named on account of the crusts covering the face like a mask. It is also known under the name of crusta lactea, or milk blotch, ignis sylvestris, or vola- ticus. The tinea muciflua of Alibert may be considered as synonymous, both with this and with the last species of Willan, the porrigo favosa, which is a mere variety, differing in nothing except in the pustules being a little larger. It usually begins on the brow and cheeks, by an eruption o<. clusters of small achores, from an inflamed or red surface ; or of larger and rather sparser mellicerous-looking pustules, called favia, and in that case constituting the porrigo favosa of Willan. The pustules spread on the face, and amongst the hair, over a great part perhaps of the scalp, or they may be more confined round the margin of the scalp,, and about the ears. Numerous pustules are also often scattered over the body and extremities, but these are seldom so large as those on the head. The pustules, which are itchy, soon break, and the viscid fluid they contain hardens into a crust, sometimes thin, sometimes pretty thick,'but generally yellowish, if not tinged with blood. When the scabs are rubbed off, or drop, the surface below is red or purple, but not chopped, and many places are found covered still with little fragments of crust. In other cases the discharge is so profuse, that time is not allowed for scabbing, but the whole surface, except the upper margin, or one or two small patches of crust, is raw and excoriated, and the discharge falls in large drops. In a few instances, where there is greater irritation, or the part has been deeply and hastily scratched, little cup-like ulcers form ; and except in such spots, no cicatrix is ever left by this disease. 612 Even in those cases, the health does not suffer, farther, than from want of rest, and fretting from the itchiness. When the urine acquires a peculiar smell, like that of cats, the dis- ease is supposed to be on the wane. This eruption, if it do not depend on, is at least very prevalent in scrofulous habits. It has been attributed to the richness of the milk, but it is just as frequent in those who are sparingly fed. It seems to be more connected with indigestion, or bad state ofthe bowels, and also is often associated with, if not excited by, the irritation of teething. In the treatment ofthe milder varieties of this complaint, it is sufficient to give regularly some gentle laxative, as rhubarb and magnesia, interposing occasionally gentle doses of calo- mel, or different preparations of sulphur may be given for the same purpose. The diet is to be attended to, and if the child be plethoric, barley-meal, as being less nourishing than some other grains, may be given as food ; a decoction of the viola tricolar, has been advised by Strack and Stoll, but I do not know that any internal medicine is useful, farther than as required by the bowels. Soda or potash, in such doses as keep the bowels open, are useful. As for bark and other tonics, it is difficult to get them administered, and I have seen little cause to have confidence in them. The same may be said of cicuta. Local applications in slight cases are not demanded ; but when they are, on account of the number of the crusts, and the itching, preparations of sulphur and mercury are proper. The sulphur ointment, or sulphur with oil of bays, or charcoal ointment,* or ung. hyd. nit., or cocculus Indicus ointment, may be applied three times a day ; and the red portions which are not defended by crusts, may be washed with lime-water, or water.in which quicklime and sulphur have been boiled, or a weak solution of muriate of mercury, or solution of acetate of lead. When there are few scabs, but much excoriation, and, indeed, wherever there is an irritable surface, mild applications must be employed along with laxa- tives. The salve I have found most useful in such states, is * Powdered charcoal, mixed with as much lard as makes it into a salve or paste, has at least the effect of destroying the bad smell. Some use it, in the proportion of only a fifth part of charcoal, and Alibert prefers that made of pitcoal. Others mix it with sulphur ; both Capuron and Gardien join in testimony to its advan. tage ; but I fear I must say of it, as of other applications, that it cannot be certainly depended on. An opposite prescription, namely, a salve made with manganese, instead of charcoal, has been advised, but I am less disposed to trust to it. Dr. Crompton trusts less to local applications than purgatives, and such remedies as improve the health. Trans, of Irish Col. of Phys. vol. IV. 613 ung. cerussaa, or lard with washed chalk, whilst the parts have been also bathed with a weak solution of sulphate of zinc. Some have proposed to establish a counter-irritation elsewhere, by a small blister or issue, but this is not always safe, in such a state ofthe skin. 2d. Porrigo furfurans is more frequently met with in women than in children. It is confined to the scalp, and the pustules are small, contain little fluid, and soon form thin scales, so that the disease very much resembles ptyriasis, but differs from it in its origin, and also in the occasional re- appearance ofthe pustules, with moisture. The hair becomes thinner and more brittle. The treatment consists in shaving the head, and removing the scabs or scales by ablution with a sponge, and soap and water. Then, if the skin be tender, or irritable, cerussa ointment may be applied, or lard mixed with a fourth part of its weight of cocculus Indicus, or of charcoal. If less tender, some stimulating application may be made, as, for instance, ung. hyd. nit., or decoction of hellebore, which has been recommended by Dr. Heberden. 3d. Porrigo lupinosa, or the tinea granulata and tinea favosa of Alibert, is a tedious and obstinate form of the dis- ease. It is chiefly confined to the scalp, but occasionally small patches appear on the extremities. On the head many separate clusters of achores form, and produce crusts or scabs, about the size of sixpence. These are more elevated at the margin than the centre, which is depressed and powdery in its appearance. The colour is dirty white, unless when tinged with blood, and the appearance like dried mortar. The smell has been compared to rancid butter. These patches are not confluent, but the intervening skin is furfuraceous, or scabby, and if neglected, almost an entire incrustation may cover the head. It is named from a supposed resemblance to the seeds of lupines. It is necessary to have the hair removed, which it has been proposed to effect, in this and all the other species of the disease, by applying a pitch plaster to the scalp, and then forcibly tearing it off, that it might pull out the hair. This barbarous practice is now abandoned. Depilatories, as quick- lime, have also been proposed ; but it is always practicable, by softening the scabs, and repeated clipping and shaving, to get the hair removed. Both for this purpose, and also to expose the diseased surface, it is necessary to apply sapona- ceous lotions, poultices, and mild ointmeat, to soften and loosen the scabs ; afterwards the surface is to be frequently 611 anointed with an ointment consisting of oil of bays, sulphur vivum, and camphor, or axunge with hyd. precip. alb., or ung. hyd. nit., or ointment containing hellebore. Dr. Underwood recommends the lotio saponacea, or decoction of tobacco, but this is dangerous, if the skin be abraded. Mr. Barlow advises the following lotion :—R. Kali sulph. 3iij. ; sap. alb. 3jss. ; aq. calcis Svijss.; spt. vini 3ij. M.—An oiled cap has been advised in porrigo, to retain the applications, and keep the parts warm, but I question if it be of utility. 4th. Porrigo scutulata, or ring-worm of the scalp, seldom occurs before the age of three or four years; but when it docs take place, often continues not only for many months, but in varying degrees, for years, It begins with distinct clusters of very small itchy yellow achores, which break and form thin scabs, covering the original patch, which is somewhat of a circular shape. The base of each little achor is red. The clusters are thickest at the margin, and the pustules fewest toward the centre, where the scabs are thinnest and drop off first. When the scabs or scurfs fall off, the skin is found to be red and shining, and very speedily red pustules appear, with a more extended margin, whilst the centre becomes first a little redder, and then more scurfy. The hair, at the affected part, becomes lighter in colour and more woolly, thinner, and presently at the central parts falls quite off. Many of these rings form over the scalp, so that we have at last, at different parts, numerous patches which are bald, or thinly covered with hair, and exhibiting the disease in all its steps ; some bare and shining, sprinkled with scurf; others, with the exterior circle of yellow achores, and inflamed mar- gins; others, in a state of crust or scab, and so long as the surface retains any unnatural appearance, we may be sure" that the disease is still to return. Similar appearances are observed on other parts ofthe body, or there may be modification of herpes or lepra. This disease may appear without any evident cause, but most frequently it occurs from infection, by using the same comb, or towel, or cap, with one who has already the disease. In this, as in the other species, it is necessary to keep the head shaved ; but this is to be done with as little irritation as possible. Various applications have been proposed, but when there is much tenderness, we mint begin with the mildest, or perhaps be satisfied with frequent ablution, or the use of very weak solution of muriate of mercury in emulsion of almonds, or with solution of chloride of lime, or cerussa ointment, or 616 charcoal ointment. When there is little inflammation or tenderness, and we have the dry scurfy or scaly state most prominent, we must use more stimulating applications, and these are always necessary sooner or later. They must be varied according to their effects, and so must their strength. The mildest, perhaps, is the manganese ointment, already noticed in a note. More acrid are prepared from muriate of mercury, acetate of copper, cantharides, tobacco, capsicum, hellebore, arsenic, gunpowder, nitrous acid, alum, foe. Dr. Hamilton strongly advises the ointment of Banyer* alone, or diluted with lard. Some have employed pyroligneous or diluted muriatic, or sulphuric acid, or strong solution of com- mon salt. All of these, or other stimulating applications, have succeeded ; but not unless prudently employed, the strength never being greater than the part could bear. In too many other cases, as Capuron observes, when speaking of irritants, after having more or less " martyrisee latete," they have failed. The disease at last wears itself out. SECTION NINETEENTH. The bloody scabs which are formed on different parts of the head, especially in the hollow near the neck, in conse- quence of vermin, are cured by combing and washing the hair daily, and rubbing some mercurial preparation on the scabs ; whilst an ointment, composed of oil of bays and staves- acre, should be rubbed over the scalp among the hair, or the powder of stavcsacre may be dusted in among the hair. SECTION TWENTIETH. Children and adults are occasionally affected with baldness without any of the foregoing complaints being evident. Cel- sus terms this area, which consists of two varieties, the alopecia, where the baldness occupies irregular portions of the scalp; and ophiasis, where it spreads from the occiput round the head, in a serpentine direction. Usually the patches are nearly circular, and the skin is quite bare, shining, and smooth, whilst the neighbourhood has the ordinary appearance ofthe scalp, and the hair is healthy. This has been considered as a species of porrigo by Dr. Willan, and is called porrigo decal- vans, but there is no proof that it is either necessarily or fre- quently preceded by the formation of achores. The patches increase in size and number, and at last, perhaps, the whole * R Cerus.lbss.; litharg. aur. 3ij.; alum. ust. gjss.; mer. sublim. cor. ana. 3j"s ; axungite lbij.; terebinth. Vcnet. lbss. M. fiat ung. ad scabiem. 616 head, with the exception of one or two tufts, is bare. Then, without any evident cause, the skin assumes a more natural look, and hair grows. The treatment consists in having the head shaved once a-week, and rubbing the surface twice or thrice daily with some stimulating substance, such as olhe oil, with as much nitrous or muriatic acid as makes it gently pungent, but not acrid. Strong camphorated embrocation or spirits and oil of turpentine, may be used, or some other essential oils, or tincture of cantharides, or blisters, or solution of nitrate of silver so strong as to irritate a little, SECTION TWENTY-FIRST. Purpura, or petechia? sine febre, is a disease not uncom- mon with children, particularly those who live in confined houses, or are fed on poor or improper diet. It consists of an eruption of small purple spots, which are circular, not at all elevated, seldom larger than the diameter of a coriander seed, more frequently of the size of the head of a pin. They are scattered over the whole body, and even over the hairy scalp. They come out suddenly, without any fever or ap- parent indisposition, and go off slowly. They are not in general attended with foul tongue, spongy gums, or foetid breath ; and the faeces do not become unnatural, but they sometimes are so before the disease takes place, and the belly may be very tumid, but these are not essential symptoms. By good diet, the use of acids, and removal to the country, together with moderate exercise in the open air, this disease is easily removed ; or sometimes it goes off without any par- ticular change being made in the mode of treatment. I have never seen this disease affect children till after they were weaned. This eruption is sometimes intermixed with hard papulae, forming a disease described separately, under the name of lichen lividus, by Dr. Willan. These continue for a considerable time, and end by slight exfoliation of tho cuticle, but afterwards may be succeeded by a new crop. No peculiarity of treatment is required. A worse species of this disease affects children as well as adults, and attacks more slowly. For a considerable time before the spots appear, tho patient is languid, and feels uneasy at the stomach. Then red spots, larger than in the former species, appear on the extremities, especially the legs, which are painful before the eruption comes out. The body is next affected, and the spots very soon become livid; sometimes vibices are also observed on the skin. This disease is attended with frequent and 617 daily hsemorrhage from the nose, mouth, alimentary canal, or vagina, and sometimes even from the toes. This species occasionally proves fatal, but it is often cured by the use of bark, wine, acids, good diet, and country air. It is, however, frequently very tedious. In worse cases, and in feeble children, the disease often begins with livid blotches on the scalp, which presently have the skin abraded ; and then we may find some pf them moist, and discharging blood or bloody matter ; others dry, but without any scab or a cuticle ; others covered with a thin black crust. Gangrenous sores form behind the ears; and the gums, especially near the symphysis of the jaws, become foul, and covered with a brown lymph. An eruption of petechias then suddenly appears, and the child generally dips, SECTION TWENTY-SECOND. Erysipelas* sometimes affects children, and even infants very soon after birth.t This disease appears to have been noticed by Avicenna, under the name of undimiam, or humid erysipelas, and afterwards at different times by other writers, but was first accurately described by Drs. Underwood, Garth- shore, and llroomfield. Dr. Underwood conceives, that it rarely makes its attack after the child is two months old, oftener a few days after birth. Dr. Broomfield, however, saw it in a child much older, and I have met with the same cir- cumstance. It makes its attack in general quickly, and the worst kind begins about the pubis, and spreads along the belly and down the thighs. There is not a great swelling, but the parts become hard, purple, and often end in mortifica- tion ; so that the organs of generation drop off. This kind very frequently proves fatal, the peritonaeum and intestines partaking of the disease. It is a variety of the erysipelas gangraenosum of Dr. Willan. A milder kind, which I have met with much oftener, begins about the hands and feet, or not unfrequently the neck or face ; and it is worthy of obser- vation, that this frequently ends in suppuration ; and on the neck especially, a very large collection of matter may be formed. * Erysipelas is attended with fever, and the part affected is red and hot, with (oft diffused swelling. The redness disappears when pressure is made with the finger, but immediately returns when that is removed. There is a tendency to the formation of vesicles, which bursting, form either scabs or troublesome ulcers. + .Dr. Underwood says, he once saw a child born of healthy parents, with ■ublivid inflammatory patches, and ichorous vesications, about the belly and thighs ; but by the use of bark, and especially the mother's milk, it recovered. AG 618 In the milder kind, the redness is more bright, and the bent greater than in that which tends to gangrene ; but if there be much tumefaction or hardness ofthe subjacent cellular sub- stance, it is difficult to prevent the formation of pus. The treatment consists in giving a smart purgative, and keeping the child cool. The hpat of the part is to be abated by the application of cool water, which is better and safer than any more medicated lotions. The part is not to be made cold, nor are we to have it constantly moistened with cold water, which might either produce a dangerous metastasis, or great local debility, ending in mortification. All that I propose is, the moderation ofthe heat by sponging, or bathing more or less frequently, according to circumstances. The usual remedy is flour, which does no good, unless as a medium for the fre- quent application of cold. The prejudice against wetting the skin is quite unfounded. But should the surface be already tolerably cool, and the action rather tending to the weakened form, we must refrain from cooling it farther, and rather apply dry cotton wool. If suppuration take place, a bread and milk poultice is to be applied, and the matter should be early let out, and the parts gently supported with a proper roller, applied over mild dressings, in order to pre- vent the formation of sinuses. If these take place, they must be opened. The strength is to be preserved by means of a good nurse, and giving cordials, as, for instance, white wine whey. In the worst kind, or that which tends to mortification, the colour is, from the first, or at least, very soon becomes, darker, or purple; there is less heat, nay, sometimes the skin speedily feels colder than natural, the subjacent cellular sub- stance is first pretty hard, and then becomes more flaccid, without fluctuation, and the most prominent points become livid or blue. The constitutional debility, and the advance- ment toward mortification, and spreading of that state, keep pace with each other. It is evident, that the local treatment applicable to the former species would be hurtful here, unless in those few cases, where this is preceded by more distinct symptoms of increased arterial action than is usual, such as heat. In general, the best application, from first to last, is camphorated spirit of wine, which was long ago recommended by the late intelligent Dr. Garthshore. But if this smart or give pain, it does harm, and, in that case, a mild application must be substituted, such as a weak solution of sulphate of zinc, or dry cotton. If sloughs form, and the child still 619 ■urvive, a bread and milk poultice will be proper, and the parts may be bathed with weak solution of chloride of lime to destroy the smell, or a poultice made with that and bread, may be applied, which also tends to detach the slough sooner. Ammonia, given early, in doses of from four to six grains every three hours, has been of service; but I have derived more advantage from calomel, in such doses as to act on the bowels, than from any other medicine. Green foetid stools are generally brought away. Bark has also been given, but the precise degree of advantage derived from this medi- cine in infantile diseases, is not yet fully ascertained. Still, when it can be easily given, and agrees with the stomach and bowels, or when it can be administered and retained as a clyster, I am disposed to advise it, and would employ it. The sulphate of quinine has of late been given in doses of half a grain twice or three times a day, and is a very good form for infants. I need not add, that the greatest care must be taken to support the strength by suitable nourishment, and cordials prudently exhibited. The best of these is wine whey; opiates are only useful when there is much irritation, or a diarrhoea. It is an error to give them indiscriminately as part of the cordial plan, for they are of no service except in these two views. Mineral acids are rarely, if ever proper fop infants. Erythema, according to nosologists, differs from erysipelas, in not being attended with the same diffused swelling, nor having the same tendency to form vesications; neither is it preceded nor accompanied by any regular fever, though the system may be occasionally disordered during its appearance. In some cases, the inflamed part seems at first to be rough, as if covered with innumerable papulae, but this appearance presently goes off. The treatment is nearly the same as in erysipelas. Sometimes small, irregular, erythematic patches, accompanied with oedematous swelling, appear about the joints, eyelids, or different parts of children,* with fretfulness or feverishness. They, in general, require only to be kept clean, by being bathed with tepid milk and water, and dusted with some cool absorbent powder, or bathed with vinegar. Calomel is of service, and should be given pretty freely. After the cow-pox, erythematic patches sometimes appear, not only on the arm, where the inoculation was performed, * The erythematic patches produced by the bites of bugs, &c. in those whose ■kin is delicate, ar« distinguished by having a small mark or speck in the middle. 620 but even on more distant parts. This is most apt to take place after the vesicle has arrived at the height, or is on the decline. The inflammation sometimes ends, if not in gan- grene, at least in a livid state ofthe parts, with fatal debility. Spirituous applications are soon necessary. When the part becomes livid, the strength must be carefully supported, and the bowels opened. In the commencement of this affection, saturnine lotions are proper, and often remove the disease. Calomel is useful. Dr. Willan describes this as a species of roseola. There is a species of erythema, erythema nodosum of Dr. Willan, in which the patches are raised toward the centre. This elevation takes place gradually. In a few days, hard and painful tumours are formed, which threaten to suppurate, but they presently subside, soften, and end in desquamation. These are most frequent on the chin, but they may affect any part of the body. Laxatives are proper. SECTION TWENTY-THIRD. Excoriations frequently take place behind the ears, espe- cially during dentition. The skin under the lap of the ear is covered with small pustules, and the inflammation extends from one to another. Sometimes a kind of erythematic inflammation takes place without pustules, and ends in vesi- cations, which discharge thin matter. This complaint is not generally dangerous, but it is sometimes troublesome, and causes swelling of the lymphatic glands about the jaw and neck. Occasionally, however, the parts become first livid, and then gangrenous; and in such cases, the child generally sinks, even although the sloughs begin to separate. In mild cases of sore ears, it is seldom necessary to do more than wash the surface frequently with milk and water, and apply a little lint spread with spermaceti ointment, mixed with the white oxyde of mercury. If the part be very itchy, and not healed by this application, it may be bathed with rose water, containing a little tincture of opium, or weak solution of sulphate of zinc; but astringent lotions, or such applications as teiid to heal the surface speedily, if it have been long abraded or discharging much, are, unless purges be frequently given, justly esteemed dangerous, and apt to excite disease within the cranium, especially in those who are predisposed to convulsions or hydrocephalus. If other applications be necessary, the citrine ointment, or finiments containing acetate of lead, calx of zinc, juice of 621 scrofularia, sulphur, charcoal, cerussa, foe. have been employ- ed. The last of these is often the best. When the parts become livid, or threaten to mortify, cam- phorated spirit of wine should be applied with a small brush, and the part dressed with mild salve ; afterwards, when slough has formed, the fermenting poultice or solution of chloride of lime is to be used. The strength must be care- fully supported. The bowels should be kept regular. SECTION TWENTY-FOURTH. The gums* about the time of dentition, or sometimes when the first set of teeth are shedding, become spongy and ulcer- ated, discharging a quantity of thin foetid matter. This at first may generally be stopped, by applying a mixture of muriatic acid and honey, in such proportions, as to taste pretty sour ; or the parts may be frequently washed with equal parts of lime-water and tincture of myrrh, or with a solution of sulphate of zinc, or of chloride of lime. If neglected, the ulceration becomes either fungous, and is called scorbutic;* or sometimes ofthe kind which resembles sloughing phagedena, that is, a foul, foetid, spreading sore, destroying the gums, and in some cases the jaw-bone and cheek ; so that if the child survive, no teeth are afterwards formed in that part of the jaw. Occasionally, from the very first, this disease assumes a malignant form, beginning with some degree of inflammation of the gum, generally where the incisors should appear. The part is not swelled, but bright, and of a pale red colour, and this extends along the gums a considerable way. This soon festers, forming a line along the gum, marked by a white or brownish slough ; whilst exterior to this, the surface is inflamed, and this inflamed part next festers ; so that inflammation precedes festering, till the mouth and cheeks be affected■, and a large foetid sore formed, which soon injures the bones. This disease has been called the canker. It is attended with considerable discharge of saliva, and the breath is very foetid. Good diet, the use of orange juice and sulphate of quinine, with great attention to cleanli- ness, at the same time that we use solution of chloride of lime as an occasional wash to destroy the smell, are the most likely means of cure. In some families many of the children are subject to a * In this case, some have recommended stimulants and astringent lotions, others compression. M. Berthe advises the part to be cut off; and Capdeville proposes actual cautery. Solution of common salt has also been recommended. 622 spongy and ulcerated state of the gums, which thus expose the teeth down to the jaw, or these become loose. The gums bleed, and sometimes haemorrhage takes place from the nose, and there are livid spots on the skin. This is best remedied by removal to the country, the free use of ripe fruit, and vegetable acids, bark, or sulphate of quinine in half grain doses, laxatives, and nourishing diet. Solution of borax is one of the best local applications. SECTION TWENTY-FIFTH. Another corroding disease begins in the cheek itself, or the lip. It commences wkh some degree of swelling, which is hard, and firm, and shining, It generally begins on the cheek, which becomes larger than the other, and the upper lip becomes rigid, swollen, and glossy. On some part of the tumefied skin, generally on the cheek, we observe presently a livid spot, which ulcerates and spreads, but laterally and downwards. Being generally seated near the mouth, it soon reaches the gums; and even the tongue partakes of this disease, which is of horrible aspect. We often find a great part of the upper or under lip destroyed, perhaps only a flap or por- tion of the prolabium left, all the rest being eaten away. The gums are foul, the teeth loose, the tongue thickened, partly destroyed, and lying so close on other diseased parts, that we cannot say what is tongue or what gum, except by the child moving the tongue ; and the mouth itself is filled with saliva. The sore is foul, shows no granulations, but appears covered with a rough irregular coat of brown lymph. The surround- ing parts are somewhat swelled : near the ulcer, they are hard and red ; farther out on the cheek, they are paler, and have more of an oedematous look. These local appearances arc accompanied with emaciation and fever, and the child is either restless, or lies moaning in a drowsy state. This disease often proves fatal ; sometimes, indeed, the parts cicatrize, or the patient recovers after an exfoliation of part of the jaw-bone. This sore is best managed with stimulants, such 'as solution of chloride of lime or of nitrate of silver, camphorated spirit of wine, tincture of opium, foe. but sometimes it is necessary to give these up for a bread and milk, or a carrot, or a ferment- in"1 poultice, for whatever gives pain, particularly prolonged pain, is hurtful. The bowels are to be kept open, the strength supported by milk, soups, and wine ; and ripe fruit given, if it do not purge. Before ulceration takes place, the best appli- cation is camphorated spirit of wine, provided it do not give 623 pain, or, if the part be swollen and hard but not red, we em- ploy slight friction, with camphorated liniment. A course of gentle laxatives is useful. A nothcr disease, destroying the parts, is called noma, which differs from the former, in destroying rather by grangrene than ulceration. It attacks chiefly the cheeks and labia pudendi of children, and begins with a livid spot without pain, heat, or swelling, or with very little ; and is not preceded by fever. It ends in gangrene, which destroys the part, and the patient often dies in a few days. It is to be treated at first with saturnine applications; afterwards,when sloughing takes place, the nitric acid may be applied to one spot, with a bit of lint or small brush, taking care that it do not spread beyond it; then, we use solution of chloride of lime, or a fermenting poultice, whilst opium and wine are given internally, with or without bark, according as the stomach will bear. The bowels must also be excited to action. Some children more especially those of a scrofulous habit, suffer much from a fretting and inflammation, which often, at the same time affect the nostrils, upper lip, and labia pudendi. The mons veneris and labia are tumefied, red, and very itchy. They sometimes are covered with minute blisters, or little scabs, or yield serous discharge. The internal parts furnish muco-purulent matter, and there is pain in voiding the urine. The child is pale, the bowels in bad order, the pulse frequent, the appetite bad, and the sleep disturbed. I have never found any thing so useful as the application of white lead ointment, or simple ointment, mixed with pre- pared chalk, and bathing the. parts frequently with weak solution of sulphate of zinc, having a small proportion of vinegar added to it. The bowels require also to be carefully attended to. A very formidable affection I have occasionally found to succeed measles or scarlatina, but it may likewise occur with- out any preceding disease of a formed or specific kind, and is decidedly infectious. The labia usually are affected, and sometimes the disease is confined to one side. The exterior surface becomes slightly erysipelatous, and small vesications form, which, in the mildest cases, shrink, and end in small scurf. In worse degrees the inflammation is greater, and the vesications end in livid sores or sloughs. The inside of the labia are of a deep red colour, one or both nymphse swell, but the praeputium clitoridis is chiefly affected, and speedily swells much. Exudation of yellow, or buff coloured lymph, 624 takes place, followed almost immediately by death of more or less of the parts, which form an ash-coloured slough, and when this comes off, the parts below are in a suppurating fiery state, without granulations, If the exterior surface par- ticipate, the sloughs are black. The whole of one labium may be destroyed, or part of both, but the destruction is often comparatively greater in the nympha?, and particularly the praeputium clitoridis. At first there is a copious muco-puru- lent, and then a sanious or bloody discharge, very foetid, From the very commencement there are languor, paleness, and debility, greater or less, according to the severity of the disease. In some, the pulse is not very frequent, nor is there much heat of skin, the tongue is moist, and the appetite is not lost, nor is the pulse much accelerated. In others, the tongue is dry, the skin cold, or of a sharp heat, the pujse frequent, and the eye heavy, and there is no appetite, but rather nausea and thirst. As the disease advances, the debility increases, and the child soon dies. It is a very fatal disorder. It is sometimes conjoined with the affection of the cheek, already described. It requires the use of mild laxatives, sedulous attention to nourishment, and the judicious exhibition of wine, and laudanum to allay irritation. We may also try the sulphate of quinine. The parts must be kept very clean, bathed frequently with weak solution of acetate of lead, and dressed with salves, containing oxyde of lead, or of zinc. When sloughs form, the best wash is a weak solution of chloride of lime, which always for the time destroys the smell. A bread and milk poultice is often the most useful application, or, if the sloughs be deep and extensive, a poul- tice made of solution of chloride of lime and bread is beneficial. The actual cautery has been employed on the Continent, but never in this country. A variety of this disease, differing in no essential symptom, is attended with a fever sui generis.* ' * Mr.Wood describes a very severe variety of this disease, affecting the exter^ nal parts. It is preceded by febrile symptoms, but soon there is pain in making water, and the parts are found to be inflamed and dark coloured. In a few hours afterwards vesication appears, which ends in ulceration, and the surface becomes excessively tender. The fever increases, and along with it the debility. The ul- ceration spreads and becomes deep and foul, but mortification rarely occurs. It is a fatal disease, but by the use of bark, cordials, and laxatives, with tepid satur- nine poultices, and afterwards dressing with mild salves, several recovered after the end of perhaps three weeks. Purulent discharge from the vagina is apt to remain for some time, and contributes to keep up the debility. Med. Chir. Trans. vol VII. p. 84. A similar disease is described by Dr. Hall, in the Edin. Journal for Oct. 1819. M. Cevoule maintains that it is almost always the consequence of a solitary ulceration on the inside of the mouth, or labia, and - not preceded by fever, the constitutional symptoms being merely symptomatie 625 SECTION TWENTY-SIXTH. Aphthae are small white specks or vesicles, appearing on the tongue, inside of the cheeks, and the fauces. They are extremely common, and almost every child has at one period or other an attack. This disease appears under two forms. The mild, in which the eruption on the mouth is slight, and the symptoms comparatively trifling; and the severe, in which the local disease is extensive, and the constitution greatly affected. In the first or milder form, a few scattered spots appear on the mouth, as if little bits of curds were sticking to the surface ofthe tongue, or within the lips. These in a short time become yellowish, and then fall off, but may be renewed for three or four times. They leave the parts below of a red or pink colour. The child, in this complaint, is generally somewhat fretful, the mouth is warmer than usual, and the bowels rather more open, and sometimes griped, which has been attributed to an acid state ofthe saliva. The stools are altered in their appearance, being green, or containing undi- gested milk, or of an offensive smell. There is no fever or general indisposition, except what may proceed merely from irritation of the bowels. It is most frequent within the first month, but may occur later. In the severe or worst form of this disease, a fever,* even of a contagious nature, precedes, or attends, the aphthae ; and the child is sometimes drowsy and oppressed for some hours, or even a day or two before the spots appear, and occasionally is affected with spasms. The fever and oppression are some- times mitigated on the appearance of the aphthae. The eruption is pretty copious in the mouth, and may become confluent, so that almost the whole surface it covered with curdy-looking matter. The stomach and the bowels are very much disordered, and the child vomits and purges. The stools are generally green, sour-smelled, and sometimes acrid, so that the anus is excoriated. The aphthae may not be confined to the mouth, but may descend along the trachea, * Dr. Underwood is of opinion, that fever very rarely attends aphtha?, when it appears as an original disease. Foreign writers have divided this form ofthe disease into four stages :—1st, What they call the incubation, or invasion ofthe aphthae, marked by fever, restlessness, sickness, burning heat ofthe epigastrium, hoarseness, and hot tender state ofthe mouth. 2d, The pullulation or eruption. The membrane of the mouth becomes red, the aphthffi appear, and spread, with cough, difficult deglutition, diarrhoea, &c. 3d, The symptoms increase. 4th, The aphtha? change into crusts, and fall off in fragments. They deny that the cruptionis ever attended with mitigation of the constitutional affection. 4 H 626 producing cough, and great difficulty of breathing; but much oftener they go along the oesophagus to the stomach, which becomes very sensible, is painful to the touch, and the child vomits speedily after sucking. The mouth is likewise tender, so that the child sucks with pain, and with difficulty, if the crusts become hard, the tongue being rigid. After a short time, the aphthae change their colour, and begin to fall off; but they may be renewed, and the abdominal symptoms may increase, so that the child is exhausted, and dies. There are two sources of danger, in bad cases of aphthae: the first proceeds from the disorder ofthe alimentary canal, which always attends the disease ; and the second arises from the particular state of the system, connected with the local disease, as in malignant sore throat, and many other diseases. It behooves us, then, in forming our judgment, to attend to the sensibility ofthe stomach and bowels, and pay attention to the egesta. Frequent vomiting, repeated thin stools with griping, and a tender state ofthe abdomen, with or without tumour, are very unfavourable ; drowsiness, oppressed breath- ing, moaning, spasms, and great languor, with frequent pulse, are likewise dangerous symptoms. With regard to the local disease, we find, that if the spots be few and distinct, and become a little yellow, and then in three or four days fall off, leaving the part below clean and moist, we may expect that the eruption will not be renewed, or will become still more mild. But if the aphthae turn brown or black,* which last is not a common colour, the prospect is not so good, and is worse in proportion to the rapidity with which they change. The longer that the aphthae adhere, the more apt are they to become brown; and the case is worse, than when one crop succeeds another more speedily. If the succeeding crop be more sparing than the former, we augur well, and vice versa. When the aphthae fall off, we expect their renewal, if the parts below are parched and look foul. If however, in this state, the eruption do not take place, and the oppression, weakness, and drowsiness, continue, the danger of the case is increased ; and in such circumstances, it has been observed, if the eruption afterwards appear, the child is relieved. It is also unfavourable, if a new eruption come out before the former one be thrown off. When the aphthae fall off, the mouth becomes very tender, so that the mildest fluids some- times give pain. Occasionally a salivation takes place, and * Sometimes mortification takes place, and even the palate bones have been known to suffer. 627 the inside of the cheek bleeds. Dr. Armstrong remarks, that he has seen the tongue covered with a crust of aphthae, and the cheeks and gums full of angry pustules, and little fungous excrescences. . Now, with regard to the cause, we find that this disease is produced by derangement of the stomach and bowels, excited by improper diet, exposure to cold, &c. and sometimes slight attacks are occasioned by giving spoon-meat too warm. 1 he tongue and mouth sympathize very much with the state ofthe alimentary canal, in every period of life ; but in early infancy, the changes produced in the membrane lining the mouth, by derangement of the function of digestion, are great and sudden. Whenever the diet is deficient, or improper, or the action of the'stomach is deranged, aphthae are produced, espe- cially during the first month ; afterwards, at least, when the infant is considerably older, the tongue merely becomes foul or furred, when the digestion is injured. It is rather with the stomach than the bowels that the mouth at first sympathizes; but the bowels also are generally affected, either from a pro- pagation of diseased action from the stomach to them, or from the operation of causes directly on them, as well as on the stomach. Hence the stools are generally bad, when the mouth is aphthous, and hence, a change of diet, or medicines, which stimulate and invigorate the whole tract ofthe canal, remove the affection of the mouth. If a child be brought up on the spoon, or the milk be bad, one ofthe most early indi- cations of injury is the appearance of aphthae, or white exuda- tions on the tongue. Some particular states of the atmosphere would seem either to excite this disease, or predispose to it, for it is most frequent in damp situations, and in spring and autumn ; and Van Swieten tells us, that it is peculiarly pre- valent in Holland. It would appear also to be produced by sucking an excoriated nipple ; and, on the other hand, an aphthous mouth may infect the nurse. It has been said by Dr. Moss, that a healthy child, sucking a breast immediately after a diseased child, receives the infection ; and I believe it to be the case. In the treatment of aphthae, the cause is often overlooked, and local applications are expected to remove the disease. The first object, however, is to remove the cause, which most frequently is resident in the stomach and bowels. For this purpose strict attention ought to be paid to the ingesta, for many nurses, instead of bringing the child up at first, entirely, or almost entirely on the breast, give spoon meat, and that in 628 too great quantity, and not unfrequently combined with an anodyne, to keep the child quiet. Emetics have been strongly recommended by Arneman and others, in this disease. A little ofthe vinum ipecacuanha may be employed, which is preferable to antimony. This may be given early in the disease, if it require interference with active medicines, or do not yield to mild laxatives ; but if relief be not soon obtained, it should not be repeated ; and, on the whole, I am not very partial to the use of emetics. Gentle laxatives are highly proper, such as manna, cassia fistularis, or a little magnesia ; indeed, Dr. Underwood seems to trust chiefly to absorbents. A small proportion of rhubarb may, together with an aro- matic, be occasionally added to the magnesia. Small doses of calomel may be given with advantage. The remedy I chiefly recommend is laxatives, such as rhubarb, magnesia, or calomel, given so as to evacuate all offensive matter, and excite the action of the whole canal. The operation is to be gentle, but must perhaps be repeated for some days. Emo- lient clysters, made pretty large, and without stimulating ingredients, are likewise useful. Milk or soup may also be injected, to support the strength, when the child does not suck or take food by the mouth. If, however, the child have a purging, then we must proceed according to the directions, which will be given respecting diarrhoea. In the worst species, we must very early give a gentle laxative, or a mild emetic, if the child be much oppressed ; and afterwards the bowels must be regulated, and medicine given according to the appearance ofthe faeces, and the state of sensibility. Nourishment is to be given carefully, or if the child cannot suck, clysters must be administered twice a day. Where the debility is considerable, the strength must be supported by cordials, such as white- wine posset. Bark has been recommended when the debility is great, and especially when the mouth has a sloughy gan- grenous appearance, or tendency thereto. Children, however, cannot take it so as to do good; and, therefore, when it is employed, it should be in the form of clyster mixed with starch* or mucilage, but I cannot speak decidedly as to its benefit. Small doses of calomel, with opiates, are useful. Local applications have been always employed, and in slight cases are trusted to by the nurse, without any internal medi- cine. The most common remedy is borax, in the form of a * From a scruple to a drachm of bark may be given to a young child, mixed with half an ounce of fluid. Sometimes a little laudanum may be added to the clyster, to make it be retained. 629 saturated solution in water, or mixed with honey or sirup; or a little of the powder may be put into the mouth, and it seems to have a better effect than could be expected from its sensible properties. It cannot, however, as Dr. Bisset observes, be expected to remove the aphthae until they be about to separate, when it ought to be employed, and may prevent a renewal. Until this period, a little veal soup, or white of egg beat up with water, may be given. Van Swieten recommends sirup of turnips. Applications which force off the aphtha? prematurely, do harm to the part, and seem to produce a renewal of the exudation. A weak solution ofthe sulphate of zinc, or water acidulated with muriatic acid, has been proposed as lotions, and may occasionally be of service; but it is highly improper to wash the mouth roughly with a cloth dipped in these or any other lotions. SECTION TWENTY-SEVENTH. Aphthae sometimes appear on the tonsils of children and adults, with or without fever; and from an apprehension of the existence of a malignant sore throat, give much alarm. There is, however, very little inflammation, and no lividity of the parts ; the fever is very moderate, the strength not impaired, and the aphthae do not spread, but, becoming brown, presently fall off. This is cured by acid gargles and laxatives. Another kind of sore throat is attended with the usual symptoms of inflammation, accompanied with an exudation of tough yellow mucus. It yields readily to the same treatment. SECTION TWENTY-EIGHTH. A malignant and highly infectious species of aphthae, is one of the most formidable diseases to which children are liable. It constitutes the putrid sore throat, which attacks in different forms, and is always an insidious disease. In some it begius with heat of the skin, and smart fever, and the cheeks, if not flushed, are at least not pallid. The child complains a little of the throat, which is found to be of a dark red colour, and patches of lymphatic exudation appear on the tonsils. At the same time, we find one or more glands under or behind the angle of the jaw, more or less swelled and painful. The tongue is covered with a brown or yellowish coat. The eye is dull, perhaps watery; there is little appetite, not much thirst, seldom much headach ; and, on the whole, the child suffers a little. In three or four days the fever abates, and the pulse becomes nearly of natural fre- •s 630 quency, but other symptoms increase. The throat becomes darker in colour, and the sloughs browner, and when any part separates, some blood is discharged. The nostrils dis- charge ichor, and become excoriated, or bleeding takes place from them and the inside of the eyelid, or even adnata of the eye itself. The cheeks swell and become glossy, and the skin over the nose tumid, then red, and lastly, livid. Dark pitchy stools are voided, either from blood swallowed or dis- charged from the intestines themselves. Bilious, and some- times feculent vomiting takes place. Petechia? appear, the pulse, without becoming more frequent, becomes weaker, and at last imperceptible; but, for some hours, the power of mov- ing, and perfect consciousness, remain. In other cases, the child becomes, first of all, and rather suddenly, sick, listless, and cold; his pulse is quick and feeble ; his eye heavy, and his countenance pale. The throat is seldom complained of, but if inspected, is of a deep red colour, and ash-coloured exudations are visible on the ton- sils. Even at this time, the breath has a bad smell. Soon, the skin becomes hot, and, perhaps, for a short time, the cheeks are flushed, but they soon become either pale or livid, and the heat is never ardent. The pulse is extremely fre- quent and very feeble. The throat is covered with a slough, and filled with viscid phlegm. The tongue is brown or dry and livid. The nostrils discharge acrid ichor. There are in- creased fceter of the breath, hoarse cough, and stridulous breathing, as in croup.* And few, if any, recover, who are thus seized, for it runs the same course as croup; there are the same hoarse cough, the same sonorous breathing, the same fits of suffocation. These symptoms increase, the stools are dark and offensive, the breath putrid, the sloughs spread, the pulse becomes fluttering, and often within forty-eight hours, sometimes in twenty-four, the child dies. Death, however, rather takes place thus speedily, from the intensity of the laryngeal affection, than from the mere debility consequent to the operation of the infectious virus. A variety of this com- plaint seems to be described by Dr. Hamilton, where the peculiarity is extreme slowness of breathing. This I have not met with. Various remedies have been tried. Emetics, nur°-atives, the early application of leeches to the throat, blisters, and calomel, have all failed. Some of them have per- haps aggravated, none of them have relieved the symptoms ; » It has been considered identical with croup by Dr. Bretonnean, who namsi it diphtherite. But the true croup begins in the larynx, and not jn the tonsils. f 631 nor do I know any plan which can be depended on, with the least confidence, after the croupy symptoms have decidedly appeared. If these have not taken place, or be only slightly threatened, the practice I have found most useful, consists in the administration of gentle purgatives, and the instant use of sulphate of quinine by the mouth, with such nourishment and cordials as the child can swallow or retain, or bark may be given in nutritive clysters ; as auxiliaries, we may endeavour to have the throat and mouth cleaned by washing with diluted solution of chloride of lime, attend to ventilation, and shifting the bed linen, and give ripe fruit. Rubbing the part over with nitrate of silver has in some instances seemed to do good, and to the best of my knowledge, was first prescribed a num- ber of years ago by Mr. James Watson, of this city, at the suggestion of Mr. Macarthur. Dr. Bretonnean afterwards advised muriatic acid or alum. I must, however, say, that no great dependance can be placed on either application, and most of the recoveries take place rather from the arrestment ofthe disease, in its progress down within the glottis, by some unknown circumstance, than by the power of medicine. In the variety described by Dr. Hamilton, he says, the superacetate of lead was useful in the dose of half a grain every three hours. In desperate cases, would tracheotomy be of any ayail ? It has been tried bene with success in a case apparently of this nature, and Dr. Bretonnean relates a successful instance. But I cannot urge it. SECTION TWENTY-NINTH. About the time of dentition, the tongue, gums, and inside ofthe lips, are sometimes spotted over with superficial exco- riations. They are seldom larger than a coriander seed, of an irregular shape, and covered with yellow or brownish mucus, adhering so firmly, and being so thin, as to resemble the solid base ofthe sore itself. They are tender, and gene- rally accompanied with salivation. They are cured by being touched with alumen ustum, or lightly with a pencil, dipped in weak solution of nitrate of silver. Borax also, or tincture of myrrh, seem to do good. But perhaps these would always heal easily, if left to follow their own course. SECTION THIRTIETH. Infants may be affected- with syphilis in different ways. They may be diseased in utero, in consequence of the state of one or both of the parents. They may be infected by 632 passing through the vagina, when the mother has chancres; or by sucking a woman who has the nipple affected. Of till these methods, the first is the most frequent ; and it is worthy of remark, that this mode of infection may take place, when neither of the parents has at the time any venereal swelling or ulceration, and perhaps many years after a cure has been apparently effected. I do not pretend to explain here the theory of syphilis, but content myself with relating well es- tablished facts. In such cases it is very common for the mother to miscarry, or have a premature labour, without any evident cause; and when this takes place, the child is found to have the epidermis wrinkled, or peeled off, as if it had been macerated, and some- times deeper ulcerations are discovered. The liquor amnii is turbid and foetid. We are not, however, to suppose, in every instance, where these appearances are met with, that the child is syphylitic ; for any cause, producing the death of the foetus, a considerable time antecedent to its expulsion, will produce nearly the same appearance. The diagnosis, then, must depend much upon the repetition of the premature labour, the circum- stances attending it, the history of the parents, and the distinct appearance of ulceration. In such cases, the parent originally affected ought to undergo a mecurial course ; and if the other parent have any suspicious symptoms, mercury should be administered to both. Sometimes the disease seems to wear itself out, without any remedies being employed; and the children born in future are healthy. But it often happens, that the child, though it have received the veneral disease in utero, and probably possessed it as a peculiarity of constitution from the time of conception, is born alive, and has even no apparent disease on the skin, or in the mouth. Frequently, indeed, it is born before the time, and perhaps it has been preceded by one or two dead children. It may be clean and healthy, and continue so for even a month or two, but oftener it is feeble, and rather emaciated; and sometimes it has at the time of birth, or soon afterwards acquires, a wrinkled coun- tenance, having the appearance of old age in miniature, so very remarkable, that no one who has ever seen such a child can possibly forget the look of the petit viellard. In such a case, the child has scarcely any hair upon the head, but may have pretty long hairs on the body; it cries in a low murmuring tone, and appears so weak, that it cannot suck for a minute at a time. But whether the child be apparently healthy or emaciated at the time of birth, other symptoms 633 presently appear ;* and of these the most frequent and earliest is generally an inflammation of the eyes, accompanied with ulceration of the tarsi, and purulent discharge. This appears a few days after birth. The eye presently, if neglected, becomes ulcerated, and the cornea opaque. Copper-coloured blotches, ending in ulceration, appear on the surface ; or numerous, livid, flat, suppurating pustules, cover the surface; or many clusters of livid papulae appear, which presently have the top depressed, and then end in ulceration. These papulae are sometimes attended by an eruption of pale shining pimples on the face, which enlarge, become red, and often run together. Children have sometimes an eruption of leprous or scaly spots, which I have formerly described, and which resemble syphilis. The syphilitic blotches are of a darker colour, are more apt to end in ulceration than in scurf, or to form crusts or scabs, and seldom disappear without the use of mercury ; or if they do, they soon return, and become worse by conti- nuance, and presently are combined with additional symptoms ofthe disease. The genitals and anust become ulcerated, and sometimes excrescences sprout out from these parts. Foul sores, having retorted edges, and a centre pale, and like lard, cover the inside of the mouth ; and chancrous ulceration takes place on the lips, especially about the angle of the mouth. These sores and chops are often surrounded pretty extensively with a whiteness of the skin, as if the part had been scalded, or recently rubbed with lunar caustic, and, perhaps, from this circumstance, these sores have been called, though improperly, * M. Mahon, from his observations in 1'Hospice de Vaugirard, says, that the symptoms appear as follows, the most frequent being put first. Ophthalmy ; purulent spots; ulcerations; tumours ; chancres on the mouth, and aphtha?; livid, ulcerating, and scabbing pustules; chancres on the genitals, and about the anus; excrescences; peeling off of the nails ofthe feet and hands. t Children aay have ulceration about the anus, genitals, and groins, succeed- ing intertrigo, owing to neglect of cleanliness, without any venereal affection. But the absence of other symptoms, particularly of sore throat, or ulcer of the mouth, and the amendment experienced by the use of lotions, and keeping the parts dry and clean, will enable the practitioner to form a diagnosis, and the aspect ofthe sores will assist him. This fretting of the parts, and even some degree of excrescence, may attend psoriasis, and the leprous spots of children formerly described; and in this case, especially if the child belong to a poor person, tho 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 tho progress of the disease. Many children are rashly put upon a course of mercury who do not require it; perhaps, because the practitioner thinks it a point of honour, to determine the nature ofthe disease at the first glance. 4 I 034 aphthae. They may, however, be combined with aphtha?. In some cases, the white and dusky patches cover the whole palate and inside ofthe cheek, whilst the gums are ulcerated, or even nearly gangrenous. The ulceration ofthe gums has always a very angry look. The nostrils become stuffed, and discharge purulent matter. On the face and hands we see obstinate sores covered with pus, others with crusts, whilst the interven- ing skin is sallow. The child early becomes hoarse, and the glands ofthe neck, with those below the jaw, are often swelled. Children, like adults, have in general the surface affected, and then the tonsils and mouth, but sometimes the one follows the other quickly. They seldom live long enough to have the bones diseased. They are always in great danger, and those who are much diseased never recover. Mahon, with great justice, ranks among incurable symptoms, the old decrepid visage, great destruction of the globe ofthe eye, chancres on the middle ofthe lip, spreading to the fraenum, and extensive ulceration of the mouth. It must be remembered, that syphilis not only may appear under its own peculiar characters, but may also exist under the form of some of the eruptions common to children ; such as crustalactea, lepra, psoriasis, foe. These are known to be venereal, by their being of a more livid colour than usual; they tend slowly to ulceration, and when the scab or crust with which they are furnished comes off, a foul honey-comb like ulceration is observed below. But the best diagnostic is, that they are soon attended with other symptoms, such as hoarseness, ulceration of the mouth and throat, foe. We must make up our judgment slowly, and with deliberation. I have seen a child entirely covered with psoriasis, have excoriation in the mouth, hoarseness, and pustules on different parts, and yet from the healthy condition both of the parents and hired nurse, it was doubtful if the disease were syphilitic. I admit, however, that gonorrhoea may produce these symptoms in the offspring. Diseases, infec- tious, are not always to be considered on that account syphilitic, as we see in molluscum contagiosum. Ecthyma cachecticum is also sometimes taken for syphilis. When a child is infected during delivery, the disease appears more promptly on the surface, in the form of ulcers ; and the usual train of symptoms follow, the mouth and genitals becoming presently affected. The disease generally appears within a fortnight after delivery, sometimes so early as on the fourth day. ...,,«.*. A- If the child receive the infection from the nurse, we discovei 635 ulcers on her nipples, and the disease appears on the child s mouth, before the surface of the body be affected. It has been proposed to cure this disease by giving mercury to the nurse alone, but this mode is now abandoned, mercury being given directly to the child ; and it ought to be remem- bered, that this medicine produces less violent effects on the bowels in children, than in adults, and scarcely ever excites a salivation. But if given too long or too liberally, it may kill the child by its irritation, or may excite convulsions. Calomel is very often employed, and with great benefit, a quarter or half a grain being given three times a day. Others advise frictions, which are equally useful. Fifteen grains of mer- curial ointment are rubbed on the thighs alternately once in two days, until the mouth be found hot, when it is intermitted or continued, according to the state of the system, and the effect on the disease; it must be used till the disease be re- moved. It has been remarked, that children apparently cured when on the breast, have had a relapse after being weaned. If the child be griped, a gentle purge, and then an opiate, will give relief. Some have used the ung. acid, nitros. in place of the mercurial ointment, but it is not to be depended on. It is, however, useful as an auxiliary, when applied to the affected part of the surface. It often happens, that after all appearances are removed, the disease returns some weeks or months afterwards. It is, therefore, necessary to continue the medicine for some time after an apparent cure. Sometimes, in consequence of the use of mercury, a pecu- liar eruption called the eczema mercuriale, takes place. This generally begins on the lower extremities, and spreads to the body. It consists of very small vesicles, which at first are like papulae. Each vesicle may, with a glass, be seen to be sur- rounded with redness; and if they be not disturbed, they.-* acquire the size of pins' heads, then their contents become opaque. They are attended with heat and itching, and a general tumefaction of the part affected. Presently, even if not scratched, the vesicles burst, discharging thin acrid fluid, which stiffens the linen, and sometimes excoriates the part. W hen the discharge ceases, the cuticle becomes of a pale brown colour, and then blacker ; and, separating in pretty large flakes, leaves the skin below of a bright red colour. After this, the skin comes off in scales or scurfs, perhaps two or three times. The disease ceases of itself, sometimes within ten days; often, however, it is protracted longer. Those parts which are first affected, are first cured. Relief may be 636 obtained, by applying saturnine lotions, or weak saturnine ointment.127 SECTION THIRTY-FIRST. The disease termed skin-bound is not distinctly mentioned till 1718, when a case was published by Uzembozius; since then many accounts have appeared. It may be divided into the acute and chronic, the last being chiefly met with in private practice. The acute species generally appears soon after birth, and proves fatal in the course of a few days. The best description of this disease is given by Dr. Underwood, and by M. Andry, as it appeared in the hospitals of London and Paris. In London, the children were seized at no regular period ; but it was observed, that, whenever the disease appeared, several children were attacked within a short time, and especially those in the last stage of bowel complaints, in which the stools were of a clayey consistence, and of which the induration of the skin appeared to be only a sequel. The skin was of a yellowish white colour, like wax, and it felt hard and resisting to the touch, but not oedematous. It wa3 so fixed to the subjacent flesh, that it would not slide, nor could it be pinched up. This state was found to extend over the body, but the skin was peculiarly rigid about the face and extremities. The child was always cold, did not cry, but made a moaning noise, and had constantly the appearance of dying immediately. In the French hospitals, the disease differed, in being more frequently attended with spasm, or tetanus, and always with erysipelas, especially about the pubis, which, though purple, was very cold. These erysipelatous parts rarely suppurated, but sometimes mortified. The legs were oedematous, and the children died on the third or fourth day, or at farthest, on the seventh day from birth. This disease differs, then, principally from that observed in this country, in being combined with erysipelas and tetanus, which are by no means essential symptoms; and perhaps the erysipelas of children has sometimes been mistaken for the disease called skin-bound. In private practice, the disease appears under a more chronic, though not less dangerous form. The children affected are generally delicate; and in such cases as I have seen, the skin, from birth, was not so pliable as it generally is, being most rigid about the mouth, which had more of the orbicular shape than usual. The skin gradually becomes tight, hard, and shining, and of a colour a little inclined to yellow- 637 In some cases, the whole skin is thus affected; in others, chiefly that about the jaws, neck, and joints. The scalp is often bald and shining, and the veins of the head peculiarly large and distinct. In some instances, parts of the skin are rough and slightly leprous. The appetite at first, is not greatly impaired, and the bowels are sometimes uniformly regular. Presently the child becomes dull and listless, and moans, and gradually sinks, or is carried off by fits. The complaint lasts for several weeks. In some cases, the disease is less severe, the appear- ance of the child being healthy, and the thickening and rigidity of the skin confined to the joints of the extremities,* or the disease may be confined nearly to one extremity. I have met with this circumscribed form, the Whole groin, leg, and thigh, for instance, being swelled and purplish, and the muscles hard ; the belly also discoloured, or red and mottled, as if numerous small veins were disposed over it, or as if there were a kind of ecchymosis, the child being, in other respects, pretty well. In such a case, the tepid bath and mild laxatives have been useful. It may be said this is merely a modification of erysipelas. No light is thrown on the nature of this com- plaint by dissection, which simply discovers a deficiency of oil in the cellular substance, with induration, or infiltration of thin albumenous fluid, tinged with bile. In the acute species, the liver has been found enlarged, and the gall-bladder distended. Camper says, there is always, or at least very frequently, a little hard tubercle found in the cheek, under the malar bone. Sometimes more children than one in the same family have been affected ; and in such cases, they have been always ofthe same sex. A variety of remedies have been made use of, such as mercury, laxatives, aromatic baths, and emollient frictions; but seldom with any advantage. Gardien advises vinegar, having gum ammoniac dissolved in it, to be poured on hot bricks, and the vapour applied to the indurated part. When there is stupor or determination to the head or lungs, a blister applied on the indurated part has been proposed, but I have no evidence of its utility ; others have, as a remedy for the induration, advised blisters to be * Adults are sometimes seized with this disease. A very remarkable case of this kind is recorded in the 48th vol. of the Phil. Trans—The subject of it was a girl, aged 17 years. She had excessive tension and hardness ofthe skin, all oyer the body, so that she could hardly move. The skin felt like a dry hide or piece of wood, but she had some sensation when pressed with a 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 her mouth. 638 applied to distant parts, with a view of producing counter- irritation. A gentle course of calomel has appeared to do good, when the affection is confined to the extremities. De- coction of sarsaparilla, with the frequent use ofthe warm bath. decoction of mezereon, and a variety of diaphoretics, maybe tried; and incases where more children than one, in the same family, have been affected with the chronic species of this disease, it might be worth while to try the effects of mercury, and some other medicines, on the parents. SECTION THIRTY-SECOND. The small-pox begins with a febrile attack, which com- mences generally about mid-day. It is marked by dullness, listlessness, pain in the back and loins, drowsiness, vomiting, pain in the region of the stomach, which is increased by pres- sure, starting, and coldness ofthe extremities. As the fever advances, the pulse becomes more frequent, the skin hotter, the face flushed, the eyes tender, and the thirst considerable. The child starts, grinds his teeth, or has one or more eclamptic fits, or sometimes complains of severe cramp in the legs, or lies in a kind of comatose state. On the evening ofthe third, or morning of the fourth day, an eruption appears on the face, and then on the neck, from which it spreads to the body. In mild cases, the eruption is completed by the evening of the fourth, but sometimes not till the fifth day, or even later, if the pustules be very numerous; and then the fever declines or goes off altogether. The eruption consists, at first, of small hard red pustules, of a fiery appearance. On the second day, the top is clear, and a very small vesicle is observed to be forming. On the face, we frequently find patches like measles, but containing many minute vesicles. Next day, if the eruption is to be copious, the number of pustules is farther increased, especially on the face, where we often find more patches. These patches, and the succeeding confluent vesicles, seldom appear in the inoculated small-pox, or in the natural small-pox, when very distinct. They are numerous, in proportion to the tendency to the confluent form of the disease. The pustules on the body arc more raised and rounder, though in some places they are flatter, and more extended. The base is surrounded with an inflamed rim ; and presently, if the eruption be copious, this inflammation spreads from one pustule to another, so that all the surface appears to be red. The cuticle ofthe vesicle, at this time, is iomewhat opaque, but its contents are limpid, like water. 639 On the fourth day, if there be any patches on the face, they are evidently covered with flat confluent vesicles; on the body and arms the vesicles are larger and rounder than the day before. The surrounding redness is a little paler, the skin of the vesicle is whiter, and more of the pearl appearance ; so that at the first glance, the eruption seems to consist of white elevations. The vesicles are full and smooth. On the fifth day, they are rather flatter. On the sixth day, the skin of the vesicles on the body and extremities is drier and harder, and the contents still limpid ; all those on the body are entire, but about the chin some have broken, and crusts are formed. If there have been patches on the face, these are now covered with flat vesications. On the seventh day, the vesicles on the body and extremities are of a dead white colour at the circumference, but more glossy, like candied sugar, at the centre. Their contents are a little turbid ; more crusts are formed on the face. On the eighth day, the fluid on the extremities is whitish. On the ninth day, the crusts on the face are more numerous, and they begin to be formed about the bend of the arm, foe. The pustules on the extremities are whiter, as if filled with pus, but the fluid is thin and milky ; the skin of the vesicles is thick. On the tenth day, the pustules on the face are covered with scabs, and many are formed on the extremities. On the breast, the vesicles are prominent, like two thirds of a sphere, but compressed, and have no redness round them. Many vesicles are empty, and covered with thin brown skin. Scabs are formed, by the skin becoming dry, hard, and brown, or sloughing. The contained fluid is partly absorbed, and partly effused bv exudation, so as to add a crust to the slough ofthe vesicle. When the scabs are'picked off, about the seventeenth day, the base of the mark is in general elevated above the rest of the skin, but the centre is depressed a little below the margin. The colour is light red. On the twentieth day, the Wanes on the body and extremities are smooth, flat, or slightly scurfy, so that they somewhat resemble leprous spots. The process is not always regular; for in very mild cases, the suppuration is indistinct, and the scab thin ; the pustule dries without forming much matter, so that inoculators can scarcely get their lancet wet. This is a favourable condition. Sometimes the matter, though considerable in quantity, does not exude to form a scab, but is absorbed, and the vesicle remains for a time entire, forming what has been called vario- la siliquosa. 040 About the seventh or eighth day of the disease, when the pustules are numerous, the face swells ; but about the tenth or eleventh, it subsides, and then the hands and feet swell. It is also common, about the sixth or seventh day, for the throat to become sore, with sneezing, and some degree of hoarseness or cough ; and in unfavourable cases, the secretion about the throat becomes tough and thick. When the pustules are numerous, a return of the fever may be expected about the eleventh day. This is called the secondary fever; but in mild cases it is very trifling, and does not last long. Such is a general history ofthe distinct small-pox ; but the disease may also appear under a different form, known under the name of the confluent small-pox. In this case, the erup- tive fever is more severe, attended with greater pain in the loins, and often with coma. It differs also from the former, which is of the inflammatory kind, in being of the typhoid type, so that sometimes petechiae appear. The eruption comes out earlier, generally on the morning ofthe third day, and is sometimes preceded by erythematic inflammation of the face or neck. The eruption is copious, and at first, more like measles than small-pox, so that some practitioners have, at this stage, mistaken the one disease for the other. The pustules, which are not so much elevated as the variola dis- creta, become confluent, especially on the face; and though they may be confluent only on the face, yet those on the body are not of a good kind. They form matter earlier, do not retain the circular form, and instead of having the interstices ofthe skin, where they do not coalesce, of a red colour, as in mild small-pox, these spaces are pale and flaccid. The coalescence is most remarkable on the face, which often seems as if covered with one extensive vesicle. The matter which these pustules form is not thick and yellow, like good pus, but either of a whitish brown, or black colour. Scabs generally form about the eleventh day of the disease, but these do not fall off for a length of time, and leave deep pits. The swelling of the face is greater and more permanent than in the former species, and the eruptive fever does not gooff when the erup- tion is completed; it only diminishes a little, till the sixth or seventh day, when it increases, and often proves fatal on the eleventh. The treatment of the distinct is different from that ot the confluent small-pox. During the eruptive fever, the antiphlo- gistic regimen must be carefully enjoined, the diet must be 641 light and sparing, the surface kept cool and clean, and the bowels loose. Emetics, at an early stage of the fever, are often serviceable, and it is generally proper to give laxatives. Eclamptic fits are relieved by opiates and cool air. When the eruption is coming out, the cool regimen should still be persisted in, and the bowels kept open. After the pustules have appeared, the fever generally abates ; and then, although heat should be avoided, the cooling and purging plan need not be carried so far as formerly. But if the fever still con- tinue, these means should be also continued. The diet must be sparing, and plenty of ripe fruit should be given. If ■econdary fever supervene, it is to be removed, chiefly by laxa- tives and cool air; or if there be oppression at the stomach, a gentle emetic may be given. In the confluent kind, during the eruptive fever, the cold plan should be diligently employed, and cathartics are of essential benefit. When the eruption appears, the cooling regimen should still be persisted in, and both vegetable and mineral acids ought to be given freely. Bark is also proper, provided that it be not productive of sickness or vomiting, When the fever is aggravated, at the height of the disease, emetics have been sometimes given with advantage ; but in general they are not necessary, and more benefit is derived from laxatives and clysters. Opiates are useful, for abating irritation ; and wine, with nourishing diet, should be prudently given, to support the strength, which is apt to be completely exhausted under the constant fever and irritation. On this accoiint, also, it is necessary to restrain diarrhoea, when it is frequent, and adds to the Weakness. Blisters have been advised as stimulants, but they are only useful when deep-seated inflammation exists. Sometimes the brain seems to be affected, the head being pained, the eyes impatient of light, and the patient delirious. In this case leeches may be applied to the temples, and a blister put on the head. When the lungs are affected, blisters on the sides or breast do good. When the stomach is very irritable, if saline draughts and opiates do not give relief, a small blister should be applied over the stomach. If the swelling of the face subside quickly, and be not followed by tumefaction of the feet and hands, blisters have been applied to the wrists, but sinapisms are better, though it is not decided that either are of great utility. When the throat is much affected, and filled with viscid phlegm, gargles are of use, and sometimes a very gentle emetic gives relief. If the eruption suddenly subside, cordials tend to brin" 4K 642 back a salutary inflammation ; or if it altogether recede, the tepid bath, with ammonia, and other internal stimulants, will be proper. The boils and inflamed pustules, succeeding variola, are very troublesome, and sometimes prove fatal. When large, suppuration should be hastened with a poultice ; when small, unguentum resinosum may be applied; or if they be indolent, gentle friction with camphorated liniment, and bathing with laudanum, is of benefit. The strength must be supported, and, as soon as possible, sea-bathing should be resorted to. The violence of the variolous disease is generally lessened by inoculation,* which was first introduced into ihis country in the year 1721. The operation itself is very simple, con- sisting merely in abrading the skin on the arm or leg with the point of a lancet, and then applying on the small scratch a little ofthe variolous matter, which should be taken early, as when it is delayed until the pustules are collapsing or scabbing, it sometimes produces a spurious inflammation. By the third day, we are sure of success, by observing a slight redness on the arm at the incision. On the third or fourth day, the part is hard to the touch. The redness gradually increases for the two succeeding days, and then a small vesicle may be perceived. By the eighth, or at farthest the tenth day, the pustule has completed the variolous character. It forms a circular elevation, surrounded with circumscribed redness, and the vesicle is a little flatted on the top. The constitution at this time becomes affected; and the earlier that the eruptive fever appears, the milder, in general, is the disease. The character of the succeeding disease may, it is supposed, be foreseen, even before the eruption take place, or be completed, by examining the arm ; but this is doubtful. The safety ofthe practice of inoculation is greatly increased, by having the system as free as possible from every diseased state ; and, therefore, children are not inoculated during den- tition, at least if they cut their teeth with any trouble. Very young children are not considered as favourable subjects, Dr. Fordyce observing that two thirds of those who died from inoculated small-pox were under nine months. If we have our choice, the best age is said to be from two to four years, but it is dangerous to wait so long, lest the child should take the casual small-pox ; and Dr. Adams informs us, that of three thousand children inoculated at the hospital in one year, two thousand five hundred were under two years of age, yet only * Inoculation, even after exposure to infection, is capable of producing a mild disease. 643 two out of that number died. Fuji plethoric children should be frequently purged, and fed sparingly, before the Operation. Some particular modes of preparation have been often em- ployed, such as giving calomel or antimony, but these have very little effect.123 The attention ought chiefly to be directed to bring the body into a state of good health, if previously delicate, or diseased : and, on the other hand, if requisite, diminishing plethora and inflammatory disposition by the obvious means. After the inoculation, the bowels must be kept open, and all stimulants avoided ; and when the eruptive fever commences, the antiphlogistic regimen is to be strictly practised, and often has so good an effect, that few or no pustules come out; or if they do, they do not maturate, and we have no secondary fever. In general, the arm heals kindly; but when it forms a sore, it should be exposed to the air, or dusted with chalk : if it threaten gangrene, it should be bathed with camphorated spirits, or tincture of myrrh. SECTION THIRTY-THIRD. As a preventive of the small-pox, the vaccine inoculation is now universally practised. This is productive, in general, of a very mild and safe disease, consisting of a single vesicle, forming on the place where the inoculation was performed. On the third day, the scratch is slightly red, and, if pressed with the finger, feels hard. Next day the red point is a little increased, and somewhat radiated. On the fifth day a small vesicle appears, but it is still more easily seen on the sixth. This gradually increases, until it acquire the size of a split pea. The colour of the vesicle is dull white, like a pearl. Its shape is circular, or slightly oval, when the inoculation has been made with a lengthened scratch, acquiring about the tenth day a diameter equal to about the third or fourth part of an inch. Till the end of the eighth day, the surface is uneven, being depressed in the centre ; but on the ninth day, it becomes flat, or sometimes rather higher at the middle than at the edges. The margins are turgid and rounded, project- ing a little over at the base of the vesicle. The vesicle is not simple, but cellular, and contains a clear limpid fluid, like the purest water. On the eighth or ninth day, the vesicle is surrounded with an areola of an intense red colour, which is hard and tumid. About this time, an erythematic efflo- rescence sometimes takes place near the areola, and spreads gradually to a considerable part of the body. It consists of patches, slightly elevated, and is attended with febrile symp- 644 tomsfi On the eleventh or twelfth day, as the areola decreases, the surface ofthe vesicle becomes brown at the centre, and is not so clear at the margin ; the cuticle gives way, and there is formed a glossy hard scab, of a reddish brown colour, which is not detached, in general, till the twentieth day. When it falls off, we find a cicatrix, about half an inch in diameter, and with as many pits as there were cells in the vesicle. During the progress ofthe vesicle, there is often some disorder of the Constitution ; and occasionally, a papulous eruption, like strophulus, appears near the vesicle. As security against the small-pox is not procured by spiw rious vaccine vesicles, it becomes necessary to study carefully the character of the genuine disease, which I have briefly described. A very frequent species of spurious cow-pox, is rather a pustule than a vesicle. It increases rapidly, instead of gradually* From the second to the fifth or sixth day, it is raised toward the centre, and is placed on a hard inflamed base, surrounded with diffused redness* It contains opaque fluid, and is usually broken by the end ofthe sixth day, when an if regular yellowish brown scab is formed. If the vesicle be regular in its progress, and have pretty much ofthe general aspect ofthe vaccine vesicle, but contains, on or before the ninth day, a turbid or purulent matter, it cannot be depended on; and the security will be still less, if the scab be soft* Besides these, Dr. Willan has characterized three spurious vesicles. First, a single pearl-coloured vesicle, less than the genuine kind ; the top is flattened, but the margins are not rounded nor prominent. It is set on a hard red base, slightly elevated, with an areola of a dark rose colour. The second is cellular, like the genuine vesicle, but somewhat smaller, and With a sharp angulated edge* The areola is sometimes of a pale red colour, and very extensive. It appears on the seventh or eighth day after inoculation, and continues more or less vivid for three days ; during which, the scab is completely formed. This is less regular than the genuine scab, and falls off sooner. The third is a vesicle without an areola* These forms ofthe disease do not give security against the small-pox ; and it would appear that a vesicle, which is even regular at first, or which runs through the whole course with regularity, may fail to secure the constitution; for there are well authen- ticated cases, where the small-pox has thus succeeded the cow-pox. Professed writers on this subject have enumerated three causes of failure. 1st, From matter having been taken from a spurious vesicle, or from a genuine vesicle at too late 645 a period. The best time for taking matter is about the eighth day; and after the twelfth,129 or when it becomes purulent, it cannot be depended on ; or the same effect will be produced by any cause which can disturb the progress of the vesicle. 2d, From the patient being seized, soon after vaccination, With some contagious fever, such as measles, scarlatina, influ- enza, or typhus. 3d, From his being affected, at the time of inoculation, with some chronic cutaneous disease, such as tinea, lepra, foe. The precise circumstances under which these causes produce their effect, or the degree to which they must be present in order to operate, have not yet been determined with certainty. It has also been supposed, that puncturing the vesicle in order to take matter from it, may, by disordering the process, sometimes prevent its efficacy. Even where none of these causes exist, and when the vesicle runs its course with distinctness, it does, though very seldom, happen that the constitution is hot rendered insusceptible of the variolous action. It were much to be wished, that some test could be discovered, by which the security could be determined. The constitution is often manifestly 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 are also assured, that even when no constitu- tional disorder has taken place, the child is secured. Other means, then, have been resorted to, in order to discover if the system be affected, so as to have a complete change induced by the inoculation. These are two in number : 1st, If a second inoculation be performed on the fifth or sixth day after the first, a vesicle will arise as usual, but it will be surrounded with an areola nearly as early as the first one. 2d, If a second inoculation be performed any time after the twelfth day after the first inoculation, some degree of 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 a small pustule, generally totally unattended with constitu- tional affection; but sometimes, even although the constitution have been changed by the vaccine inoculation, a slight febrile affection may be excited, either without any secondary pus- tules, or attended by an efflorescence on the skin, or an erup- tion 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 ; 646 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 the more requisite, as vaccination is often performed in a very careless manner, and by people ignorant ofthe character ofthe disease. It has been said, that if a child, properly vaccinated, should afterwards take the small-pox, the pustules are papulous, or tuberculated, and do not suppurate, but end in desquamation. 1 have, however, known very distinct cases of suppurating small-pox, in those who, some years before, had gone through the vaccine process in the most satisfactory manner. Few facts, I believe, are now better ascertained in our "ars conjec- turalis" than that small-pox may take place after vaccination; and I believe that the proportion will increase as we recede from the date of vaccination, and augment the activity ofthe infection. Many shall escape, who are merely exposed to the casual company of those who have small-pox, who should take the disease if inoculated with virus. This much, at least, I know, that a great majority of those whom I have inoculated, have taken a mild small-pox. The eruption has been more papular than if vaccination had not preceded, and has only vesicated and dried like chicken-pox. In other cases, the principal part of the eruption has been efflorescent, like measles. But all who were formerly conversant with small- pox know, that childien inoculated and properly treated, often had scarcely any eruption, and that not coming to suppuration. Those, again, who take small-pox from expo- sure to contagion, have the disease more severely; the fever may be high and attended with delirium, the body completely covered with pustules, which maturate, and leave for a time distinct blanes. The disease may even prove fatal. Variola bccuring after vaccination is contagious, and produces the same disease in those who are not vaccinated, as any other small- pox would have done. Some seem to think, that by changing the name they can change also the disease, and have called this, not variola, but a varioloid disease. It must either be small-pox, or it must be something else. If it be not, then, small-pox virus can produce a new disease. We are told it does so, and long ago it was maintained, that chicken-pox was merely a modification of variola ! The substitution of the term varioloid, is indeed a very good way of getting rid of the fact, that small-pox may occur after vaccination ; but it is not an original idea, for Falstaff fell on the same expe- dient with regard to stealing—" Call it conveying, Hal." I do 647 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 to mankind; and although the warmest friends of this discovery must admit, that it is not always successful, yet it has hitherto failed in so small a proportion of cases, that we must consider it as justi- fiable to rely upon it, and adopt it, in preference to the variolous inoculation.130 Experiments have been made to ascertain the effects of inoculation with a mixture of variolous and vaccine matter; and the result has been, that sometimes the cow-pox, sometimes the small-pox, has been thus pro- duced. When a person is inoculated with variolous and vaccine matter at the same time, the incisions being very near each other, the vesicles enlarging, join into one; and matter, taken from the one side, will produce cow-pox, from the other small-pox. When a person is inoculated with the two kinds of matter at the same time, or within a week of each other, both diseases will be communicated to the patient, whether the incisions be near or remote, and small-pox pustules will be produced on the body ; but they seldom maturate, and the disease is generally mild. When, however, the variolous inoculation is 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 alto- gether 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 vaccina- tion. 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 seldomer, than when the variolous inoculation was performed ; for then inflamed pustules and boils, with leprous and impetiginous eruptions, frequently succeeded the disease. Doubtless, chil- dren, after vaccination, may have crusla lactea, lepra, foe. but it does not thence follow, that these are the consequences of inoculation ; and it is not unworthy of remark, that no new 648 cutaneous disease has been produced by the introduction of the cow-pox.131 SECTION THIRTY-FOURTH. The chicken-pox is a disease sometimes mistaken for small- pox ; and at one time, and by some authors, described along with it. It is preceded by eruptive fever, which continues for three days, and is marked by languor, loss of appetite, thirst, furred tongue, pain in the head, back, and limbs, sometimes pain in the epigastric region, with nausea and vomiting. The pulse is quick, the face occasionally flushed, and cough and hoarseness may attend the disease. Convulsions also, in some cases, occur during the fever, or the child has tremours when asleep, accompanied with terrifying dreams, or he is slightly delirious. The eruptive fever does not always gooff when the eruption appears, but may continue even till the third day of the eruption. In general, however, the symp- toms are mild, and sometimes exceedingly trifling. The eruption commences on the back, or breast, and next appears on the face and head, which is not the order observed by the variolous eruption. Last of all it appears on the extremities, The pustules very soon contain lymph, and by the fifth day are covered with scabs or crusts, which is earlier than happens in the variolae. These drop off sooner than in small-pox, and very seldom leave any cicatrix. The eruption is attended with very considerable itching, in consequence of which the pustules are soon broken, The pustules are seldom or never confluent, and Dr. Heberden never could count more than twelve upon the face, but we sometimes meet with many more, In varicella, almost every vesicle, on the first day, has a hard inflamed margin. On the second or third, they are full of serum at the top ; and those which are fullest of the yellow liquor, resemble small-pox pustules of the fifth or sixth day, On the third or fourth day, the shrivelled and wrinkled state of the vesicles which remain entire, give a different appear- ance from the variola?; and on the fifth day, the presence of scab assists the diagnosis. It is proper, however, to add, that in some cases I have found the pustules longer than usual of running their course, and the disease altogether so like small- pox, that I would have been at a loss to decide on the nature ofthe disease, had not the rest ofthe children in the family had the chicken-pox at the same time in the usual form. Such is the general description of this disease ; but it con- 649 sisls of some varieties, which have very properly been sepa- rately described by Dr. Willan, whose distinctions I shall retain. 1st, The lenticular. The eruption consists, on the first day, of small red protuberances, not exactly circular, with a flat shining surface, in the middle of which a minute vesicle is soon formed. These, on the second day, resemble miliary vesicles, are about the tenth part of an inch in diameter, and are filled with whitish lymph. On the third day, the extent is the same, but the fluid is straw-coloured. Next day, many of the vesicles are broken; and those which are not, have shrunk, and are puckered at their margin. Few are entire on the fifth. On the sixth day, small thin brown scabs appear universally, in place of the vesicles. On the seventh and eighth days these turn yellow and dry, from the circumference toward the centre ; and on the ninth or tenth day drop off, leaving red marks without pitting. 2d, The conoidal. The vesicles rise suddenly, and have a hard inflamed border. On the first day, they are acuminated, and contain a bright transparent lymph. Next day they are more turgid, the lymph is straw-coloured, and they are surrounded with more extensive inflammation. On the third day, the vesi- cles have shrivelled, have inflammation round them; if entire, contain purulent matter; if they have burst, they are covered with slight gummy scabs. The scabs fall off in from four to five days, and often leave durable pits. A fresh crop of pus- tules comes out on the second or third day, and runs the same course with the first; so that the eruptive stage in this species is six days, and the last formed scabs are not separated till the eleventh or twelfth day. 3d, The swine or bleb-pox. The vesicles are large and globated,but the base is not exactly circular. They are surrounded with inflammation, and con- tain transparent lymph, which on the second day resembles whey. On the third day, they subside and shrivel, and appear yellowish, the fluid being mixed with a little pus. Before the end of the fourth day, they are covered with thin blackish scabs, which fall off in four or five days. The chicken-pox is a very mild disease, and requires no other management than keeping the bowels open, and the sur- face moderately cool. The skin may be spunged with cold water, which diminishes the heat, and lessens the number of pustules, if done during the eruptive fever; at a later period, it abates the itching. I have, especially in scrofulous children, observed, that if the bowels were neglected by the parents, and the diet were full and heavy, the pustules became much 4L 650 inflamed, and ended in sloughs, which left large and perma- nent cicatrices; and in some cases, boils and ubscesses have occurred from the same cause. SECTION THIRTY-FIFTH. Urticaria, or nettle rash may appear either as an acute or chronic disease.* The first is most frequent with infants and children. It is preceded by languor, sickness, and fever, on the third day of which, but sometimes earlier, an itchy erup- tion appears, bearing a very exact resemblance to that pro- duced by the stinging of nettles. It consists of irregular patches, slightly elevated above the surface. These are of a dull white colour at the centre, and red towards the margins, which are sometimes hard and well defined. The size and shape of the patches are very various. Generally they are about the size of a penny-piece, but sometimes form pretty long stripes. This eruption is, in some cases, attended by a slight turgescence of the skin, but especially ofthe face and eyelids. The patches do not remain constantly out, but appear and disappear irregularly during the disease, which lasts for seven or eight days, including the period of the eruptive fever. When the eruption declines, the languor, stomachic symptoms, and feverishness, go off. The disease terminates by slight exfoliation ofthe skin. In infancy and childhood, it is often dependant on detition, or affections ofthe bowels; and from the itching which attends it, great distress is produced. The febrile ulticaria is not infectious, but in certain seasons it is very prevalent; and the same holds true with regard to the chronic species. Chronic urticaria is more rare in infancy. It differs from the former, chiefly in being destitute of fever, and vexing the patient at intervals for a length of time ; some- times even for years. The patches seldom continue out, however, for above a few hours at a time. They are, like the former, reproduced readily by exposure to cold, and are also particularly troublesome after undressing to go to bed. A temporary eruption of this kind, without fever, is often con- sequent to eating particular kinds offish, or substances which disagree with the stomach. An eruption somewhat resem- bling urticaria, is described by Dr. Willan, under the name of roseola annulata ; it differs in size, and some other circum- stances, whilst it agrees in others. It consists of circular patches, about half an inch in diameter, the margins rose- * Dr. Willan notices five different species of this disease ; but for the present purposs, this simple division is sufficient. 651 coloured, the centre of the usual colour of the skin ; but I have seen the patches of a purple colour, and with very little central white. These cover the body, and produce, especially at night, a sensation of heat and itching. When unattended with fever, the eruption fades in the morning, and becomes round and elevated at night. The use of mineral acids and sea-bathing will be of service. A gentle emetic, followed by one or two purges, gives relief in acute urticaria. The child should, if possible, be kept from scratching, so as to tear the skin; and this will be the easier done, if he be preserved in an uniform temperature. The tepid bath sometimes gives relief. The chronic species is more obstinate, and in consequence of the abrasion ofthe skin, from frequent scratching, it has sometimes been treated as itch, but, of course, without advantage. The bowels are to be kept open by small doses of calomel, or rhubarb and magnesia, and some tonic medicine should be administered. The tepid bath daily will also be proper, but sometimes, sea- bathing continued for some months, succeeds better. Mercu- rials have been tried with very little good effect, except in so far as they acted on the bowels. Soda is useful. SECTION THIRTY-SIXTH. Scarlatina may appear under two different forms. In the firit, it is accompanied with inflammatory fever,, and is gene- rally mild ; in the second, it is connected with a typhoid fever, and is very malignant. The first species admits of a farther subdivision, according to the degree of mildness ; one variety being attended with slough or ulceration of the throat; another, still milder, with little or no affection of the fauces. This has by some been called scarlatina simplex, to distinguish it from the first, or scarlatina anginosa. The scarlatinasimplex begins with a febrile attack, attended with considerable debility, dullness, nausea, and pain in the belly and about the loins and extremities. It generally attacks very suddenly in the afternoon or evening, the patient having been, not an hour before, lively, and apparently in good health. The pulse is extremely rapid, being often 140 in the minute ; the trunk is very warm, and the feet cold: the respiration frequent, irregular, and sometimes sonorous ; the eye dull, and the eyelids turgid and red on the inside. Sometimes, but not often, convulsions occur early, and are to be considered as unfavourable. On the next day, if not earlier, an eruption appears, first on the face and neck, and 652 very Soon, always within twenty-four hours, it is diffused over the whole body. It consists of numerous minute specks, so closely set together, that the skin appears altogether of a red colour, like a boiled lobster, and it feels rough. Broad patches njso appear on those parts which are most exposed to heat or pressure. The inside of the eyelids, nostrils, cheeks, and fauces, are of a deep red colour, and the tongue participates in the appearance. The eruption is most vivid at night, and especially on the evening ofthe third or fourth day. On the fifth day it declines, and is wholly gone by the seventh, when desquamation takes place. During the eruptive stage, the patient is generally either restless, or very drowsy, often slightly delirious, and both during this stage, and the process of desquamation, complains much of itchiness. AVhilst the fever lasts, the skin is extremely hot. The contagion, in general, operates on the third or fourth day after the person has been exposed to it. The scarlatina anginosa is attended with more severe symp- toms. It commences with the usual symptoms of fever ; and in general, whenever these appear, or even before the fever commence, the throat will be found, on inspection, to be affected ; but sometimes the cynanche does not take place till the eruption come out, which is nearly about the same period as in the former species. Dr. Sims says, that the first marks of disease are paleness and dejection of countenance, and that at this time the fauces will be found to be red. I am very much inclined to adopt the same opinion. From the first, there is a sensation of stiffness about the muscles of the jaw and neck; and very soon, generally on the second day, the throat feels as if straitened, the voice becoming hoarse, and sometimes a croupy cough takes place. In this case, the breathing often becomes sonorous, or even so obstructed that the child is suffocated, as in cynanche trachealis. In very many cases, deglutition is performed with difficulty, and some- times the drink returns by the nose. On examining the mouth we find, at the first, that the tongue has a very red colour, and its papillae are evidently elongated. In the pro- gress of the disease, it is often covered with a fur. The tonsils are early observed to be of a deep red colour, and very soon whitish streaks may be discovered. Superficial ulcera- tion is frequent on the second or third day, and the parts become covered with a white or ash-coloured substance or slough, whilst the rest of the tonsil becomes of a dark red colour. These sloughs are sometimes not removed for a week 653 or more, but often are detached on the fifth or sixth day, when the cuticular eruption declines. The inside of the nostrils is inflamed, and sometimes ulcerated. The lips, likewise, become tender and itchy, and, owing to the child picking at them, they, as well as the gums, are apt to be covered with black patches, chiefly from effusion of blood. The eruption, in this variety, is the same in appearance and duration as in the former. When it is slight, or disappears suddenly, it has been said that the event is hazardous, but this is not always the case. The fever is attended often with great nausea, bilious vomiting, restlessness, headach, and delirium. The heat is excessive, the pulse feeble, and sometimes fluttering, always very rapid. The languor and inquietude are great, especially when the sloughs are forming. About a week or ten days after the eruption fades, anasarcous swelling ofthe legs may take place, and continue even for two or three weeks. Sometimes other parts ofthe body swell, or the patient has ascites. Scarlatina is sometimes succeeded by pain in the ear, followed by temporary deafness, and the discharge of foetid serous fluid. This often abates, upon syringing the ear with decoction of camomile for a few days ; but it may be more obstinate, and the child remain permanently deaf. The ton- sils occasionally suppurate, after the external disease abates. Swelling of the parotid gland is not uncommon; and it is said by various authors, when it is late of appearing, to pro- tract or renew the symptoms, even the eruption itself; but this I do not believe. Sometimes the glands of the neck swell and suppurate, or the bones of the nose, after obstinate ulceration, become carious. I have seen some unfortunate cases, where the lips have sloughed completely away, and these ended fatally. Even after the patient has, to all appearance, recovered from scarlatina, there sometimes unex- pectedly supervene languor, debility, and pain ofthe bowels, frequent pulse, and loss of appetite, which symptoms termi- nate in dropsy. Bronchitis or pneumonic affections may also be produced. In soma cases the patient becomes languid without fever or dropsy, but these generally do well. In the second species, or scarlatina maligna, the pulse is very small and feeble, sometimes indistinct. The debility is very great, the patient fainting on making the smallest exertion, and very generally he is unable to sit up in bed. In the scarlatina benigna, the tongue is red, the eyes and eyelids red, the throat at first red, and the skin like a boiled lobster; 654 but in this species, the tongue is livid, tender, and booh covered, together with the teeth and lips, with a brown or black crust, the eyes are dull, and the inside of the eyelids dark-coloured, the cheeks are livid, the throat of a dark red colour, with brown or blackish sloughs; there is very foetid breath, with much acrid discharge from the nostrils. The inside ofthe labia pudendi of girls, and ofthe prepuce of boys, has in scarlatina the same colour with the inside of the cheeks and lips; in the scarlatina maligna, the vulva and lips are of a dark colour, and sometimes mortify. The eruption is some- times faint, in other cases very dark and purple-coloured, and often appears and disappears irregularly. In the progress of this disease, delirium, great fretfulness, or coma, may come on. The breathing is rattling, the neck seems to be full, and of a livid colour, and the head is bent back. This disease sometimes proves fatal in a few hours. It is not, however, always alike mortal, for there are several smaller degrees of malignity, forming a gradation betwixt this and the scarlatina anginosa. The first species, when properly managed, is not very dangerous, but the last is attended with great hazard. The prognosis must be made, by attending to the symptoms of debility, the progress of the affection of the throat, the tendency to inflammation of the trachea, and the general character ofthe epidemic. Drs. Withering, Adams, and Willan, believe, that the scarlatina does not attack the same person twice, though the throat may be to a certain degree repeatedly affected. Although I have had many opportunities of attending to this disease, I cannot form a decided opinion on this important pooint ; but I am inclined to adopt the same conclusion. Aphthous affections of the throat, and exudation of lymph from inflammation, are often considered as belonging to scarlet fever, though the eruption be absent, but the conclusion is incorrect. Those who are exposed to the contagion of scarlatina, may have sloughs in the throat, attended with considerable debility, but a regular repetition of the scarlet fever is certainly not a frequent occurrence. Sometimes other eruptive diseases, such as roseola infantilis, have been taken for it. The scarlatina simplex and anginosa, are often so rnild diseases, as to require little medicine, but still great attention is necessary. When there is a considerable appearance of inflammation, venesection has been recommended ; but this is 655 very seldom necessary, often hurtful, and may almost uniformly be superseded by other means. In adults or children, how- ever, who have a determination to the head, marked by severe headach, or feeling of weight, accompanied with much fever, the instant use ofthe lancet has been attended with immediate and permanent relief, or at a later period, I have found leeches of much advantage. If there be delirium, preceded by much earach, a blister to the head may afterwards be applied with good effect. By neglecting these means at the proper time, the patient is apt to be carried off in a fit, or in a comatose state. Emetics, given early, are said to be attended with advantage, and supposed to render the subsequent disease milder. But of the truth of this opinion, I have not been able to convince myself. Laxatives are still more useful, and in rnild cases are the only medicines which are required. In some epidemics, the bowels are moved with greater difficulty than in others, and in those cases the laxative must be stronger. Even when there is a tendency to diarrhoea, if the stools be foetid and unnatural in their appearance, purgatives are equally necessary as in the opposite state. The best medicine, to be given at first, is calomel either alone in a brisk dose, or combined with some other laxative to insure its operation ; this often, even at the commencement of the disease, brings away foetid stools. This medicine cannot be used too early ; and if an emetic have been given, calomel ought rapidly to succeed it. After the operation of the first dose of calomel, the bowels must be kept open, or even rather loose, by the daily use of infusion of senna with an aromatic. This is better than repeated small doses of calomel, which often affect the mouth considerably. But if the stools be very foetid, the patient oppressed, and the belly full, a brisk purgative may be given oftener than once, in the course of the disease. Another remedy of utility, is affusion with cold water. From careful observation, and repeated trials, I can, with confidence, when the heat is great, and the skin dry, and the pulse very frequent, recommend this remedy, which by no means prevents the exhibition of purgatives at the same time. It is of consequence to use this early, if it be to be done at all, and whenever the patient feels steadily hot, the shivering having gone off, and the skin feels very warm to the hand of another person, it is time to put him into an empty tub, and pour over him a large ewer-full of cold water. By this I have known the disease arrested at once, the eruption never becoming vivid, and the strength and appetite in a few hours returning. Even where (>56 it is not arrested, it is pleasant to observe the change pro- duced. The patient, from being dull, languid, and listless, feels brisk, and disposed to talk or laugh ; the skin becomes for a time colder, and refreshing sleep is frequently procured. The repetition must depend on the degree of heat; one appli- cation is sometimes sufficient, but it often is necessary the first day to use it twice, and once the next day. It is seldom requisite afterwards ; for although the disease may continue, it is mild, and laxatives complete the cure. If the fever be mild and the heat not pungent and great, we may, in place of using the affusion, have the surface cooled frequently with a sponge dipped in cold water. Even an advanced state ofthe disease, if the bath have not been previously employed, and the skin be hot, does not preclude the use ofthe sponge. On the contrary, this revives the patient. The use of cold is generally beneficial when it is not succeeded by dullness or languor; in such cases it must on no account be rejected. These two remedies do not only mitigate the disease, but lessen the risk of dropsical swelling taking place afterwards.* Gargles are often useful, when they can be employed. Water, acidulated pretty sharply with muriatic acid, or mixed with capsicum vinegars, forms a very good gargle. Acid fruits are proper. The diet should be light and nourishing. In mild cases, it is not necessary to give wine ; but if the debility be considerable, small doses of wine may, toward the end of the disease, be administered. Should anasarca take place, laxa- tives and diuretics, such as digitalis, are proper. When the glands about the throat or neck swell, the best application is cloths wet with cold water ; or if the glands be painful and tender to the touch, one or more leeches, according to the age and other circumstances, may be previously applied. If suppuration take place, it is to be hastened by a warm poultice. The scarlatina maligna is much more dangerous, and requires the most vigorous practice. Early sponging with cold water is proper, provided it give comfort and be not followed by dullness, and often gives a favourable turn to the future disease. Laxatives are likewise necessary, and so far from weakening the patient, if prudently administered, seem to increase his strength. Wine should be given, in such doses as do not flush the patient, or make him hotter. Ammonia * Dr. Hieglitz recommends in scarlatina, first, an emetic of ipecacuanha, and then so much Epsom salts as shall procure four stools. In bad cases he gives four grains of calomel daily, or rubs in ung. hyd. Whenever the salivary glands become affected, the disease, he says, takes a turn. I doubt it much. 657 us sometimes of benefit. Two drachms should be dissolved in six ounces of water, and the solution sweetened with sugar. To infants, two tea-spoonsfull, and to elder children, from a dessert to a table spoonfull of this solution may be given every two hours, or oftener if possible. An infusion of capsicum in vinegar is also employed with advantage; so much of it is to be added to a given quantity of water, as renders it pungent. This mixture may be given in the same doses as the solution of ammonia, and it both acts as a general stimulant and as a local application to the throat. Bark has certainly, in many cases, been of service; but in general, children do not take it in such doses as to do much good ; or they loathe it, or reject it by vomiting. Even when taken freely, it is not a medicine that can be depended on, in the cynanche maligna of children, but at present I know of nothing better to propose. When it is prescribed, it may be combined with ammonia or capsi- cum. But in general, it is better to give it in clysters made of beef tea without salt, or to use the sulphate of quinine. Myrrh has also been given, combined with vinegar; but of the effect of this I cannot speak from my own observation. Oxygenated muriatic acid, in doses of twelve drops to children. has been employed; but I question if it produce better effects than water acidulated with sulphuric acid, which, if the ammonia be not employed, makes a very proper drink. If the patient, at an advanced period, be restless, and the skin dry and rough, ablution with tepid water will be useful. As gargles, capsicum vinegar with water, or muriatic or nitrous acid with honey and water, may be employed; but as children often cannot, or will not use gargles, their utility must be limited. They might be thrown on the tonsils with a syringe, but are apt to go into the windpipe if they get so far back as the fauces. It is also proper to touch the sloughs and tonsils frequently, with a pencil dipped in solution of chloride of lime, or a weak solution of this may be used as a gargle. Fumiga- tions, made by pouring sulphuric acid on nitre, placed in a vessel in the bed-room, have sometimes a good effect on the throat. When the sloughs are large, or the child breathes with difficulty, or has a croupy cough, gentle emetics have been proposed. On this subject, I must refer to what I have said already, (sect. 28,) respecting laryngeal disease, occurring in putrid sore throat. Blisters have also been applied to the throat, but they never do good, and decidedly add greatly to the irritation of the child. In bad cases, there is risk of their being followed by mortification of the part. Sometimes, in 4 M 65S the course of this disease, apoplexy succeeded by hemiphlegia, and inability to articulate distinctly, takes place. Blisters should be applied to the head, and if the patient survive, the paralytic symptoms go off in a few weeks. During the course of the disease, the strength must be supported by nourishment, or if that cannot be swallowed, by nutritive clysters. When a disease of this kind appears in a family, the chil- dren who are unaffected ought, if possible, to be sent away, and should not return for a month. In the meantime, the clothes should be washed, and the apartment well ventilated, and fumigated with the vapour of oxygenated muriatic acid. This fumigation may be employed, even during this disease, for the destruction of the contagion, and of the smelling matter in the room. SECTION THIRTY-SEVENTH. Measles commence with a distinct eruptive fever ; on the first and second days of which, the patient complains of irregular shiverings, alternating with heat, general debility, languor, loss of appetite; has white tongue, thirst, pain in the back and limbs, slight sore throat, hoarseness, with dry cough and sneezing, weight and pain across the forehead, giddiness, drowsiness, sometimes convulsions, frequent and irregular pulse, costiveness, and high-coloured urine. On the third or fourth day, the symptoms become more severe; the eyes are tender, water, and appear as if inflamed, the eyelids are often swelled, the nostrils discharge thin serum, and the patient sneezes more frequently. There is now often some degree of dyspnoea, and sometimes pain and tightness in the chest. These febrile symptoms usually come on distinctly,about twelve or fourteen days after exposure to infection ;* but I have known children seized more gradually, being teased with hard cough, and rendered more irritable and fretful for many days before the eruptive fever commenced. The eruption appears betwixt the third and sixth day of the fever, but most frequently on the fourth, and it remains for about three days. It is first visible on the forehead, then on the throat, then on the face. Next day it appears on the breast, and by the evening it covers the trunk and extremities. The eruption consists at first of * It would appear, that during this period the constitution is susceptible to other diseases; thus, I have seen a child seized with chicken-pox, and before this had well gone off, measles appeared, and immediately after that hooping-cough. I have also seen scarlatina precede measles, only by three or four days. 659 small red spots, • apparently a little raised, like papulae, but without vesicular tops. Then the spots extend so far as to form an oval or irregular figure, slightly elevated, but flat, resembling a flea-bite. Very soon large patches appear inter- mixed with the distinct spots. These are irregular in shape, but tend to the semilunar figure ; they are made up of clusters of distinct spots. In some cases, the eruption, though vivid, is not considerable ; and in this case, it consists almost equally of patches and circular and irregular spots, and the interven- ing skin is of the natural appearance. When the eruption is more copious, the patches are most numerous and extensive. In children under a year old, the eruption is not so thick and confluent as in older subjects, and in many places has a papu- lous appearance, especially on the face and hands. In some cases, the eruption, though ofthe usual configuration, is pale and indistinct; but in general, whether vivid or not, when the finger is passed over the surface, the skin feels unequal, from the elevation of the spots and patches. The colour is most vivid after the eruption has been out for a day. Sometimes the eruption suddenly and prematurely recedes, or never comes fully out. Both of these cases are unfavourable, the fever is high and the oppression great. In the regular course of things, the eruption on the face fades a little on the sixth day, and next day, that on the body becomes also paler.* From this to the ninth day, the eruption is going off, and then the former situation of the rash is only marked by a slight discoloration. 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 next day have a scattered or streaked appearance. The inflammation ofthe eyes, sneezing, and hoarseness, generally decline 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 eruption comes out, and about the sixth day the heat and restlessness go off. A spontaneous diarrhoea 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 erup- * Sometimes, instead of this, the eruption becomes very dark coloured, or pur- ple, with increase of the languor and fever. Mineral acids in this state are useful, and most children recover. The danger is greater when petechia? appear among Hip patches, for this marks great debility. 660 tion of inflamed pustules* over the body, which may ulcerate. and prove troublesome, but more frequently they fade, or by a vesicular herpetic-looking eruption about the mouth, or sometimes by gangrenous affections of the lips or vulva,t or by enlargement of the glands of the neck, or dropsy, or a cough, somewhat resembling that in hooping-cough, or by hectic fever, continuing for many weeks. Sometimes the sickness and oppression are great and per- manent. The child never looks up, but breathes heavily, and, owing to stuffing of the nostrils, loudly. He coughs often, has frequent pulse and hot skin. He can scarcely be roused up, even to take a drink. This state arises more from the brain than the lungs. In measles, the membranes are very apt to be affected. Generally, the membranes of the wind-pipe, bronchia?, fauces, nostrils, and eyelids, are chiefly affected, but sometimes that of the stomach or bowels principally suffers, producing sick- ness, vomiting, or purging. At other times that of the brain is affected, producing coma. Rubeola, in general, is not a fatal disease, when stimulants are avoided. When it proves fatal, it is most frequently in consequence ofthe pulmonic affection, sometimes of coma, or fever and oppression, with symptoms of effusion in the brain connected with recession, or imperfect appearance of the eruption* The treatment is extremely simple, and may be briefly explained. During the eruptive fever, the use of mild diaphoretics, and the tepid bath, will be of advantage. The bowels should be kept open, but the child should not be much purged after the first day. If there be a considerable diarrhoea from extraneous causes, as dentition, or directly connected with the fever, it is often found that the eruption is late of appearing, and a late eruption is generally attended with some troublesome symptoms, as it indicates a tendency to affection of some internal membrane. A little rhubarb, given early, often moderates this. * These are sometimes taken for a kind of small-pox. They are occasionally succeeded by a scabby disease of the skin. The skin is inflamed and covered with rough loose yellow scabs. t The measles, about twenty-five 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. \ had occasion, during that epidemic, to see different instances ofthe gangrenous affection I have mentioned. The children all belonged to the poor, and lived in confined houses 661 If the eruption do not come freely out, or recede prema- turely, and the child be sick, oppressed, and breathe high, we must attend first of all to the bowels. If diarrhoea exist, and the child be not plethoric, a little rhubarb should be given, and then spiritus ammonia? aromaticus with laudanum, and the child should be put into a warm bath, having a little mustard diffused in it; afterwards a sinapism, followed by a warm plaster, should be applied over the stomach, and we determine to the surface by giving a saline julap. If in this state the child be costive, a gentle purgative should De given, for the bowels may be either too torpid or too irritable. I have not advised the liberal use of purgative medicines, though these are found beneficial in scarlatina, because we often find that diarrhoea interferes with the eruption. But the bowels are upon a general principle to be kept regular, or rather open: and if the stools be fectid or ill-coloured, then, even although diarrhoea exist, small doses of calomel should be given, and afterwards, if necessary, the purging is to be moderated by anodyne clysters. So far as I have observed, the continuance of the diarrhoea, in this case, does not mitigate the symptoms ; and if the child recover, it is either by the use of medicines bringing the bowels into a better action, or it is independent of the mere evacuation produced by the diarrhoea. If the pneumonic symptoms be considerable, marked by cough, oppressed breathing, flushed cheeks, and pain in the 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 symptoms be urgent, either the lancet must be early used, or leeches may be applied to the top of the sternum, according to the age and constitution ofthe child, and moderate doses of calomel given to keep the bowels open. If the cough be frequent, without inflammatory symptoms, opiates give great relief. If the symptoms of inflammation be such as to require bleeding, or to render the propriety of using laudanum doubtful, then small doses of solution of tartarite of antimony may be given every two hours, but not to such extent as to produce sickness or vomiting. Diarrhoea should not be checked, unless severe, and it increase debility, or produce hurtful effects. Anodyne clysters are then the best remedies. Coma or drowsiness very frequently attends the measles, and the child may perhaps scarcely look up for some days. When the nostrils are stuffed with mucus, the breathing, in 662 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 secu- rity 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 relieved by opiates. Hectic fever is often removed, by keeping the bowels open, giving an anodyne at bedtime, 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 erup- tion 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 nature of measles, is not easily determined, but certainly the external resemblance is very great, in so much that this eruption has been called rubeola sine catarrho. It requires no particular treatment, and is only noticed because it is sometimes mistaken for measles, but does not prevent the patient from a second attack.132 SECTION THIRTY-EIGHTH. Sometimes an eruption, termed by Dr. Willan roseola,f is mistaken for measles.^ The first species, roseola aestiva, has no small resemblance to rubeola. It is often preceded by dullness, alternating with flushes of heat, languor, faintness, restlessness, occasionally with severe headach, delirium, or convulsions. At some period, betwixt the third and seventh day from the commencement of these symptoms, the rash appears, generally first on the face and neck, and afterwards * During the epidemic, some years ago, ophthalmia was extremely prevalent amongst young and old. T This he defines to be rose-coloured rash, without scales or papulae, variously figured, and not contagious. By some former writers, this term is applied to a disease resembling nettle-rash. Vide Lory, 398.—The appearance of roseola restiva is extremely well expressed by Dr. Willan in his plate. X Lichen simplex is also apt to be at first mistaken for measles. From its itchiness, and the effects produced by rubbing or scratching the extremities, it has also been mistaken for itch. 663 in a day or two over all the body. The patches are larger and more irregular than those of the measles,* in which the eruption consists of spots like flea-bites, and patches made up of these spots arranged sometimes in a crescentic form, and of a 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 Dr. Willan gives its name. The fauces are tinged with the same colour, and the patient feels a slight roughness in the throat. The eruption appears first at night, and continues vivid next day, with considerable itching. On the third or fourth day, only slight specks of a dark red colour are observable, which next day disappear, and, together with these, the internal disorder. In some instances the skinon many parts becomes of a dusky colour, with an appearance of slight vesication or desquamation. The drowsiness, sneezing, watery eyes, and running at the nose, so common in measles, are wanting in roseola, and there is no pulmonic complaint, whilst at the same time, the patches are larger, and occasionally intermixed on the body with an appearance of nettle rash. Sometimes the rash is only partial, appearing in patches slightly raised above the surface, with a dark red flush of the cheek. This form lasts about a week, the rash appearing and disappearing 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 sometimes on the breast or trunk, the eruption has a resemblance to urticaria, whilst on the arms the appearance is like roseola. This disease decidedly is infectious. For, in particular seasons, I have observed it to be unusually frequent", and to affect all the children, and many of the adults in a family. In such cases the eruption has lasted from two to four days, but has been attended with very little fever. The only treatment which is necessary consists in 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 determina- tion to the head, brisk purgatives are proper. Another species, called roseola autumnalis, affects children generally in the harvest, and consists of distinct patches, of an oval or circular shape, which increase to nearly about the * 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. 664 size of a shilling ; they are not elevated, but are of a ver\ dark colour, appearing at a distance, as if a black cherry or brambleberry had been pressed on the skin, so as to leave the impression. The patches are not attended with fever, are usually diffused over the arms, and disappear in about a week. Acids may be taken internally. The roseola infantilis appears during dentition, or in a dis- ordered state of the bowels. It consists of a red efflorescence, usually very closely set, so that the surface is almost entirely of a red colour, as in scarlatina; but there is more appearance of patches than in that disease, and the other symptoms are wanting. The eruption generally goes off in a day, but it sometimes appears and disappears for several days, with symptoms of great irritation. No particular treatment is necessary, except what is required on account of concomitant circumstances. It is sometimes preceded or attended by vomiting or convulsions, with pale face and languor. In such cases, a gentle emetic, the warm bath, and cordials are proper. CHAP. V. Of Cerebral and Spinal Irritation. The action of the brain and spinal marrow may be affected in different ways. Certain parts of the animal system sympathize with each other in a manner which cannot always be accounted for on the principle of communication of nerves. This sympathy manifest itself variously; but three of the most important modes are, First, where one part becomes associated with another in action, the former having its action increased or altered by the latter. This sympathy of associ- ation may exist between remote parts which come to act similarly, but not always exactly in the same degree or pro- portion. Second, where action spreads without interruption, from a part to the neighbourhood, or perhaps, to a great extent. This I would call communication of action ; and it may be salutary, or the contrary, according to circumstances. Third, when one part has its action diminished in conse- quence of another having an increase, and vice versa. This I have called the sympathy of equilibrium. In all of these ways the brain and its appendages may be influenced; but 665 these are not the only modes, and some others seem also to assist those. For instance, the brain, considered as the senso- rium commune, or origin of the nervous system, may undergo certain changes peculiar to it in that view. A sudden failure in its power or action, by whatever cause or in what- ever way it may be produced, must occasion instant debility, or even death itself. A slighter degree, gradually produced, is followed by less striking, but not always less serious changes. A similar degree, suddenly produced, occasions not only debility at the instant, but important secondary effects afterwards. These, which have been attributed to re-action, as it has been called, proceed from the communica- tion of action, already mentioned, whereby the part which is weakened, is not allowed to act in that degree which is pro- portioned to its vigour ; but has more excited in it than it can properly perform ; and the same consequence is produced as if a positive and direct stimulus had been applied to it. This is illustrated by bruises and the effects of cold, inflammation attacking frostbitten parts, not only from the improper appli- cation of heat, but also from the communication of action from their vicinity. Hence one object, in such cases, is to prevent communication of action, by endeavouring to mode- rate that of the neighbourhood, or even of the system, at the same time that we avoid the operation of stimuli on the part itself. It is also illustrated by concussion ofthe brain, where, in the stage of re-action, as it has been called, venesection is required to cure the disease which is excited. A similar state is produced in those who, having been long exposed to hunger and cold, have heat suddenly applied to the body, and warm soup speedily given, or cordials administered. Such excitement ofthe brain thereby is produced as requires depletion and great care. Another mode of affecting the action of the brain is by the direct operation of stimuli, both mental and corporeal, on it. In the latter case, it is similar to any other viscus. The heat ofthe sun, especially if the person be stooping, a current of cold air blowing on the head, in Tra»s. of Coll. of Phys. at Philadelphia, vol. I. p. 227. and by Dr. Colles, Dub. Hosp. Rep. vol. I. p. 235. 707 When there is much determination to the head, especially in the first attack, either the lancet or leeches ought to be used. If these means be not successful, an issue ought to be estab- lished in the neck. But in obstinate and protracted cases, organic alterations have generally taken place, and the patient becomes fatuitous, a state sometimes preceded by morbid perversity of disposition. This condition ofthe brain is more apt to take place, if suitable evacuations have not been made early. Bleeding and purging, timously employed, may be of the most signal service, in preventing organic changes. Eclampsia occurring at the menstrual period, although partak- ing much of the nature of hysteria, requires the same treat- ment. 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. I do not mean to enter on the consideration of epilepsy here. CHAP. VIII. Of Chorea and Paralysis. The convulsions called chorea sancti Viti, attack children most frequently from the age of eight years to that of puberty. This disease makes its approach with languor, and dislike to the entertainments of the age; a variable and sometimes very keen appetite; in general, continued costiveness, attended usually with a hardness and swelling of the abdomen, espe- cially at the lower part, though occasionally the belly is flabby, and rather small, instead of tumid. Sometimes the bowels are open, but the stools are not of a natural appear- ance. Presently convulsive twitches and motions of the muscles of the face, take place, and are succeeded by more marked convulsive affections of the muscles of the extremities and trunk, so that the patient cannot sit still, nor carry a cup of tea safely to the mouth ; and this motion in different cases and different periods, varies greatly in extent and degree, from a mere fidget, to a universal agitation. In some cases the twitches and contractions evidently proceed from spasm ofthe fibres, but in others, and these not the least frequent, they depend on temporary paralysis ofthe antagonist fibres. 708 These are often almost constant; even when the patient is aleep the limbs are in motion, and the sleep is greatly disturbed. He does not walk steadily, and sometimes seems to be palsied, or the motion may be very rapid, the head shaking like a rattle. The patient is sensible during the convulsive motion. At a more advanced period, the countenance becomes vacant, the eyes dull, the speech is affected, and in some cases the patient cannot even swallow without difficulty. Emaciation takes place, and a febrile state may be induced. This disease generally originates from the state of the ali- mentary canal, which is irritated by bad or indigested faeces, and thus the extremities of the nerves are acted on. Other irritants have the same effect, and hence chorea has followed the exhibition of strong saline or poisonous substances. But independent of all irritation by fseces, the condition of the bowels themselves, considered as organs capable, by their sym- pathetic influence, of acting on the nervous system, particu- larly on the origin ofthe spinal nerves, may produce this state. 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 the disease be 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 of the former, till the movement and expulsion ofthe accumulated matter are effected, when symptoms of returning health appear." Calomel and jalap are useful purgatives in this disease, and Dr. Hamilton is in the habit of using aloetic pills on the days when these are not employed, which is a useful practice when the patient can swallow pills. My own expe- * " Having described the nerves, I now come to the symptoms, which are easily explained by their connexion. I will begin with tremor ofthe feet, which is common in hysterical cases. But I ought in the first place to mention, that the dreadful hysterical symptoms, which we daily see either in individual parts, or in the whole body, are altogether dependant upon the accumulation of acrid matter in the primee viae ; for the intolerable foetor, the scantiness and unnatural appearance ofthe faeces, always warn us of an approaching paroxysm of rigors and convulsions." " Ought not purgative medicines, and even the most drastic ones, to be exhi- bited ? They probably might cure spurious epilepsy, chorea sancti Viti, and other spasmodic diseases, hitherto generally deemed hopeless by medical men." Camper on the Pelvis, chapter iii. section 7. 709 rience leads me decidedly to agree with Dr. Hamilton in the employment ofthe aloetic pills, which must be given in suffi- cient number daily, to produce a full effect. Infusion of senna alone, or with the addition of sulphate of magnesia, may be occasionally substituted. Dr. Underwood recommends aloetic and mercurial purges. By these means, chorea is perhaps cured in a fortnight, or in obstinate cases, within two months. Boys are said to be more readily cured than girls. If no great amendment take place soon, we must not on that account desist, but continue the purging plan for several weeks ; but it is a great mistake to suppose that purgatives can infallibly cure the disease. Removing irritating faeces, and more particularly exciting the action of the alimentary canal, are essential to the cure, but cannot always alone effect it. In obstinate cases, we must take the assistance of tonics, arsenic, nitrate of silver, carbonate of iron, and the other reme- dies which formerly were chiefly trusted to for the cure of con- vulsions. But of all these, none, I think, equals the copper pill, or a prescription may be given for a smaller dose of the cuprum ammon.; if the patient be very young, a pill should be given twice a day, if the bowels bear it. The food should be light and nourishing, and due exercise taken in the open air. If other means fail, the scalp and spine should be rubbed with tartar emetic ointment, which has been found useful.138 There is a variety of chorea, in which the patient, generally a female, has paroxysms of starting, and convulsive contrac- tion of the muscles, particularly after eating, sometimes accompanied with pain in the region of the stomach. When this state has continued for some time, she is seized more acutely with an attack of severe general spasms, in which the whole body feels as if it were cramped. The face is flushed, the pulse frequent, and much weight is felt in the head, but the patient does not become insensible. It participates in its nature with an obstinate spasmodic disease, considered in Chap. 6th, and may attack those who have recovered for some time from that. The acute paroxysm, which may be mistaken for a common hysterical fit, demands the instant use of the lancet, and the application of a blister to the neck ; afterwards the usual treatment of chorea is to be strictly adopted. A gentle mercurial course is sometimes of service, and the assistance of varied tonics is not to be neglected. Fcetids are also occasionally serviceable. When chorea occurs in a child of a family prone to hydro- cephalus, we ought, if it do not speedily yield to the usual 710 remedies, to establish a small issue on the scalp or neck, and redouble our attention to the bowels. Some children are apt to awake during the night, scream- ing violently, or in great agitation, as if in dreadful terror. This proceeds from a dream, but the imaginary scene con- tinues after awaking ; the child, for example, insisting that snakes are crawling along the curtains. This is cured by a smart purgative, given every two days, for some time, and avoiding much supper. A weak, or even completely paralytic state of one of the superior or inferior extremities may take place, in consequence of a bad state of the bowels, in which case the stools are offen- sive, and the belly tumid. This is cured by purgatives and friction. But it may also proceed from some slight disease of the brain, or medulla spinalis, though no mark of this can be discovered locally, unless it be that often the head is rather larger than usual. Sometimes one arm appears to be either powerless or weak for many days, and yet, otherwise, the child is in health. This yields to a purge and friction with oil of amber. In other cases, one leg is long weak, and the child drags it slightly. Whimsical practitioners have mistaken this for diseased hip-joint, though the bone were precisely the same with that on the other side. It goes off in course of time, and only requires the cold bath and laxatives. When paralysis occurs, as a prominent symptom in chorea, or in the sequel of that disease, brisk purgatives are to be employed, along with the hot bath, friction, small blisters to the spine, mix vomica, electricity, foe. The violent and involuntary jumping, tossing, or dancing, described by some authors, are to be referred to the same cause as chorea. It is not easy to point out a cure, but the disease sometimes ceases suddenly, without any very evident reason.* * A case which occurred in this city is described by Dr. Watt, Med. Chir. Trans, vol. IL, and another by Mr. Wood. Ibid. VII. 337. 711 CHAP. IX. Of Croup. The croup is divided by some writers into two species, the inflammatory and spasmodic; but there is perhaps no case of croup in which muscular action is not concerned, only in some cases the inflammatory symptoms are more prominent than in others. The croup begins with shivering and other symptoms of fever, which, when the child is old enough, can be very well described by him ; but in infancy, we discover them by thirst, restlessness, starting, hot skin, and a tendency to vomit. Along with these symptoms, but sometimes even for a day or two preceding them, the child has a dry hoarse cough. Often, however, the attack is very sudden, the pre- vious indisposition being short and scarcely observable. The local disease manifests itself by a difficulty of breathing, 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. This barking hoarse cough, however, is of much less importance than the symptom of dif- ficulty in breathing. 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 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 instantly to the nearest object, and stares most piteously. If the disease be more mild, the face, in this remission, is sometimes pale, otherwise it is 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 suddenly fatal, the face and lips become tumid in the course of the disease. Convulsions sometimes succeed the cough, and, in most cases, more or less, coma takes place. The duration of the complaint is various ; in some cases it 712 proves fatal in a few hours, in others not for a week, but most frequently within two days. Much depends, in this respect, on the degree of inflammation, the violence of the spasm, and the strength and constitution ofthe child. Sometimes there isjmuch 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 suffocation are not milder. Much also depends on the degree of cerebral affec- tion. Those cases end best, where the 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, and where there is no.*mark of cerebral disease, which is more intimately con- nected with the spasmodic respiration than many imagine. Dissection has always discovered on the inside of the larynx, a lymphatic incrustation, or layer of membranous- looking substance, which is sometimes coughed up in consider- able portions. This, though it add greatly to the danger and distress of the patient, is not to be considered as the cause of the disease : for it is merely an effect of inflammation, which, together with spasm, could produce all the symptoms without its aid. This is evident from observing that the exudation is often only partial, whilst we always find the membrane red and inflamed, or altered in its structure. If the disease do not prove very rapidly fatal, the lungs are found to be inflamed, although there were no pain felt in the chest.* The stethe- scope has been proposed, to ascertain the existence of this state ofthe lungs. 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.137 They are peculiarly liable to it soon after being weaned. From the nature of the disease, blood-letting evidently is the appropriate remedy, and the most ample experience has now convinced me, that it is the only one on which, in such cases, dependance can be placed. There are two facts, how- ever, which I wish earnestly to impress on the reader. The one is, that this remedy is only useful in the very commence- ment of the disease ; for if it be neglected until the symptoms become severe, and more especially till they have lasted for * A pretty good epitome of the symptoms, causes, and treatment of thisdisease, up till the year 1808, will be found in the tract of Schwilgue\ See also obser vations by Lobstein, in Mem. de la Soc. Med. d'Emul. Tom. VIII. p. 500. 713 many hours, it only increases the suffocation, and hastens death. The other is, that the blood ought to be taken at once from the arm, by a lancet, and not by leeches. I am not prepared to affirm that leeches applied to the throat itself are of no avail; and, therefore, when a vein cannot be opened, this is the practice to be adopted. But I am quite at liberty to pronounce, that leeches applied to a distant part, as, for instance, to the foot, are worse than useless ; and the practi- tioner who advises or acquiesces in this application is guilty of a great crime. In a disease so formidable as croup, it is not to be expected that any remedy shall be uniformly suc- cessful; and, therefore, I am not surprised, that venesection may have fallen into discredit; but I would wish to learn from the practical physician, what remewy has proved more beneficial, or better deserving of confidence.138 Emetics have been greatly recommended by some, whilst others have little faith in their utility. I have sometimes observed 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 sometimes do ser- vice, appearing mechanically to remove the lymphatic mem- brane ; but their principal utility, perhaps, is by their action on the eighth pair of nerves ; and, therefore, they are chiefly beneficial in the early stage of what is called spasmodic croup. Decoction of seneka, and preparations of squills, have been used to assist the expectoration ofthe 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 sometimes useful, and should not be absolutely neglected. But, on the other hand, we must remember that they add prodigiously to the irrita- tion, and if they fail to do good, they do positive harm, by exhausting the child. If the other means, particularly bleeding, do not give immediate relief, a blister should either be instantly applied, or not at all, and it never should be allowed to remain on above four or five hours. It can do nothing but harm in the end of the disease. The warm bath is of service in slight cases. The affusion of cold water on the body has been advised by a Russian practitioner. I tried it without doing evident harm, neither did it do good. Calomel would appear in some instances to be a powerful 4T 714 remedy in thisdisease. I do not, however, recommend it to the exclusion of other remedies, with which it is by no means incompatible, and to which in general it is only subsidiary. The early detraction of blood, followed by an emetic, and the subsequent use of calomel, will afford the greatest hope of removing the disease. But I think it my duty to state, that in some cases no alleviation was obtained by any remedy but the calomel; and in others it was trusted to alone, and with success. To an infant of six months, a grain and a half of calomel may be given every hour, until it purge freely ; to a child a year old, two grains ; and to one of two years, sometimes even four grains are given every hour, until the bowels are acted^on, and the child purges freely or vomits repeatedly. The Sools are 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 some time, then still seldomer, and finally abandoned. Should the child be greatly weakened, either by the disease or the medicine, the strength must be afterwards carefully supported by nourishment and cordials. It is astonishing how great a quantity of calomel is sometimes taken in a short time, without affecting the bowels, or purging violently afterwards. Occasionally above 100, and often 50 or 60 grains, are given'in this disease. Salivation is not produced in children.139 That experienced practitioner, Dr. James Hamilton, jun., to whom we are chiefly indebted for the introduction of the use of calomel in croup into this country, from the practice of Dr. Rush, is extremely unwilling to bleed children freely in their diseases, from its subsequent debilitating effects ; and in croup, begins at once with the calomel, after having used the warm bath.140 He observes, that "in every case where it was employed previous to the occurrence of lividness of the lips and other mortal symptoms, (amounting now to above forty,) it has completely succeeded, both in 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 stop the calomel, whenever the symptoms begin to yield. The alleviation, in true croup, follows the discharge of dark green stools, like boiled spinage ; in spasmodic croup, it takes place whenever vomiting has occurred. When much debility is produced, 715 he, besides using cordials, applies a blister to the breast. I have a good opinion of the efficacy of calomel, but I cannot speak by any means so strongly as Dr. Hamilton; for even when it was early, pointedly, and exclusively employed, and brought away green stools, it frequently failed, and I deem it my duty most earnestly to caution the reader against trusting to it exclusively ; at the same time 1 must add, that in one or two cases I have known it procure recovery under very desperate circumstances, even without evacuation by stool; and when, after a great quantity of calomel was given, and relief obtained, it was necessary to open the bowels by clysters. In those who are old enough to express their feelings, we generally find that relief is not obtained, till the medicine gripe, as well as purge. Whether it act by positively dimin- ishing inflammation, or principally, if not entirely, by relieving that part of the disease which is muscular or spasmodic, is not determined ; but I am inclined to the latter opinion, as it is not of much efficacy in the laryngitis of adults. Calomel has been combined with ipecacuanha to produce vomiting, but I cannot satisfy myself that I have ever seen this com- bination do more good than ipecacuanha would have done singly. In cases otherwise hopeless, it has been proposed to perform the operation of bronchotomy, and it is in certain circum- stances justifiable on every principle both of science and prudence. Assuredly we would not wish rashly, or too early, to have recourse to this operation; but if relief be not early obtained by the vigorous means I have advised, and more especially, if these have not h0n employed, and the disease have run on with little effectual check, we are too well warranted in saying, that death must be the result. If this state of danger arise from the mere existence of inflammation of a sensible or vital part, acting by sympathy on the system, as that ofthe lungs or stomach would do, then an operation, as it cannot remove that, would do no good, and it would be worse than folly to propose it. But if it proceed not so much from this source, as from the effect produced on respi- ration, and the organs concerned in that function, some hope may be entertained, that if we can obviate this immediate and urgent effect of the disease, time may be allowed for the subsidence of the complaint. I acknowledge the great diffi- culty of deciding as to the precise degree of danger to be ascribed in any one case, to either of these sources. But if the disease be very early severe, and the symptoms rapidly 716 and steadily increasing in spite of the remedies used, and, at the same time, the child be not already so ill as to extinguish hope, and be free from appearance of cephalic disease, the operation as a last resource may be performed. It should not when it is to be resorted to be delayed too long, for the risk is increased by the tendency which exists to the induction of inflammation ofthe lungs; and, independently of this, by the debility produced by the continuance of the disease. Parents naturally recoil from an operation, and practitioners too often shrink from responsibility. Let such timid people bring forward the opinion of Dr. Baillie, and the conduct of eminent men in our profession, as a shelter from reproof, if they fail; and, above all, let them solace themselves with the gratifying reflection, that if they have not succeeded, where there was enough of hope to warrant a trial, they at least have done all that skill could suggest or art accomplish. One of the earliest successful cases of trachotomy, in this disease, is that of the boy, five years of age, operated on by Mr. Andree.* Another boy, two years older, was operated on by Mr. Chevalier, on the afternoon of the third day, when venesection and other means had been tried in vain. His breathing was difficult, his pulse 160, countenance livid, he was covered with cold sweat, and although still sensible, was evidently sinking. On dividing two rings of the trachea, one ounce and a half of frothy coloured mucus was discharged. Next day his pulse fell to 144, and in the same evening the breathing became easy. The third day he coughed up some tough mucus, and soon recovered.t In this case surely the operation was too long delajfcd, if it were at all in contem- plation. Far, indeed, be it from me to make this remark with a view to blame the operator, who so fortunately perform- ed it with little encouragement before him. But I make it with the hope of others profiting by the case, and being ex- cited to a still earlier operation, where circumstances indicate that there is no other probable alternative but that of death. I frankly say, I could not have expected any good to result from an operation so long delayed, and under so desperate symptoms. There is no occasion for employing a tube after this operation. Spasmodic croup, or acute asthma, is often, but not neces- sarily connected with inflammatory croup. There is, perhaps, no case of the latter disease unattended with affection of the * Med. Chir. Trans, voh III. p. 335. t Ibid. vol. VI. p. 151 717 muscles of the larynx, but there are many cases of thi* affection without inflammation ; yet if it continue long, there is a great risk of inflammation taking place, and of a mem- brane 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 succession, especially if the child be agitated, or the mind of the young woman anxious respecting it. The patient breathes with difficulty, and with a wheezing sound, has a hard barking cough, with paroxysms of suffocation, as in inflammatory croup. The extremities become cold, the pulse, during the struggle, is frequent, but in the remission it is slower ; and if the remis- sion be great, it becomes natural, unless kept up by agitation. There is little or no viscid phlegm in the mouth, some drow- siness, but more terror, and the eye stares wildly during the paroxysm. The disease is often suddenly relieved by sneezing, vomiting, or eructation. It differs, then, from the inflamma- tory croup, in the suddenness of its attack, in there being little fever, but only quickness of pulse, greatly abating when the child does not struggle for breath ; less drowsiness, and little phlegm about the mouth. The cough is less shrill, and the fit often goes off suddenly and completely, either spon- taneously, or by the use of the remedies acting quickly. Sometimes, however, even in adults, 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 ; but oftener the spasm comes on without any precursory symptoms, and seems to arise sometimes perhaps from direct affections ofthe brain at the origin ofthe eighth pair of nerves, but much more frequently, indirectly, from irritation or injury dependant on abdominal disorder. The recurrent of the eighth pair seems to be often chiefly affected; and when we call the disease spasmodic,* we probably are * I retain the name of spasmodic croup, both because it is generally received, and as it is probable that spasm may in certain cases be the cause. There, however, is often a mistake made, by cousidering the contraction of one set of muscles, produced by torpor or paralysis of the antagonists, for spasm: and it is this kind of contraction which often takes place in croup, and produces doubtless the same feeling and effects as spasm. Inaction of both sets of muscles about the glottis would have the same effect. Where the recurrent is cut, the rima closes, and the animal dies. 718 often wrong; its nature being, in many instances, rather a temporary paralytic state of that nerve, or, at least, a condi- tion unfitting it for its function, and the modus operandi of emetics may be to excite the nerve. Bleeding, on the other hand, relieves the cerebral affection, or state ofthe origin of the nerves. I have, in a former chapter, noticed this symp- tom, in a particular and very obstinate affection dependant on abdominal disorder ; and am inclined to think, that a great majority of cases of croup, in infants, are of this description at first, and that inflammation is only an effect. The drowsiness which often attends this complaint, is owing to the affection of the base of the brain, which is thereby produced, and which might prove fatal independently either of laryngeal spasm or of the inflammation, often by the secretion of serum.* Sometimes this disease is excited by dentition, or, if the patient be older, by passions ofthe mind. Not unfrequently a renewal of the disease is excited, in those who are subject to it, by eating a full meal in the evening. With regard to the treatment, I shall briefly state the 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, and indeed is nearly useless. But if the paroxysm should be repeated for many nights, venesection cannot be employed on^every attack, as it debilitates and predisposes to the disease. Emetics, such as sulphate of zinc, or ipecacuanha, have the effect of abating, and occasionally of removing the paroxysm, but not of stopping it so soon, and so suddenly and entirely as blood-letting. They debilitate less, however, and may be oftener repeated. In this species, and in the commencement of inflammatory croup, they act probably through the eighth pair of nerves, or the recurrent, which is much affected ; but sometimes the fit, though impeded during their operation, returns, and in such cases has yielded to venesection. When the emetic has been very long of ope- * I have great pleasure in referring to a valuable dissection, published by Dr. Monro, in his recent work on the Morbid Anatomy of the Brain, vol. I. p. 76. All the nerves at their origins were sound, except the fifth and eighth, which were of a deep scarlet colour, and there was water in the spinal canal. The whole cord was affected. The cervical portion was of a vermilion colour, the lumbar dark red. The eighth pair of nerves was of a deep led colour, as far as its branches to the lungs. 719 rating, the stomach not being easily acted on, 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, occa- sionally checked it, but have not always that effect, and, if not given soon, are longer of procuring relief. A full dose of prussic acid, determined by the age of the patient, has sometimes had the effect of checking the fit, by inducing a species of carus, without which it does no good. If there be much spinal excitement, I have already noticed that it may induce tetanic spasm. Calomel, in croup affecting girls and women, is out ofthe question ; for the paroxysm is so severe, that we cannot and must not trust alone to its operation. A relapse is to be prevented by giving purgatives, and avoiding exposure to cold damp air, and in infancy, great attention must be paid to the state of the head. When there is any suspicious symptom, a small blister should be applied to the back of the head, and a part of it kept open for some time. When the paroxysms return every night, in older children, there is strong ground to suspect that the bowels are in fault. Aloes, combined with a little calomel, or with the mass of the blue pill, ought to be given so as to operate freely and effectually, and we are not to relinquish this plan, because it does not immediately cure the disease. In young girls, a course of tonic medicines alone, or combined with assafoetida or valerian, will be useful; and when the attacks have been kept off for some time, sea-bathing will be proper. With infants we generally succeed, by giving instantly an emetic, and afterwards calomel in considerable doses, so as to produce sickness and vomiting, or free purging. But if the emetic do not decidedly and immediately mitigate the disease, then, in place of trusting solely to the calomel, we premise venesection. Assafoetida* has been strongly recommended in this disease, and has sometimes a very good effect. The warm bath is also useful. If the child be about the period of dentition, the gum should be examined, and cut if tumid. If the disease do not soon yield to these remedies, there is • Dr. Millar has given an ounce of this gum to a child of eighteen months old in forty-eight hours, and almost as much at the same time in form of clyster. His formula is as follows : R. G. assafoetida, 3ij. ; Spt. Mindereri, g j.; Ap. puleg. 3hj. M. s. a. A table-spoonfull of this is to be given every half hour. Vide Observations on Asthma, p. 43. This medicine is also pre- pared as a nostrum, under the name of Dalby's Carminative, which has been used for children. 720 ground to suppose that it will be converted into the other species of croup; but this affects the prognosis rather than the treatment.141 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 windpipe, producing a temporary feeling of suffocation with a crowing sound, but there is no hoarse cough. It is apt to take place suddenly at night, or when crying. It is relieved by giving a combination of tincture of assafoetida, and of hyoscyamus, and using laxatives. The tepid bath is also useful. The gum should be cut, and if there be any tendency to return, particularly if the child be hot and the pulse quick, the eye heavy, and the face unusually pale or flushed, leeches should be applied, and then a blister to the back ofthe head. I have, in the seventh chapter, noticed the spasmodic breathing, which is complicated with convulsions. This sudden, and perhaps transient, attack of spasmodic croup, requires constant attention, as it is often the prelude to incur- able disease in the head or spinal sheath, and is more imme- diately alarming, if complicated with, or succeeded by general convulsions. It is too often connected with an inflammatory, or highly disordered, state of the origin ofthe nerves coming off at the base ofthe skull, and this points out the imperative demand for prompt treatment. Immediate detraction of blood by the lancet or leeches is essential; then a purgative; and next an issue should be kept open for some time on the under and back part of the head. The diet and bowels must be regulated. Some children, very nearly from the time of their birth, have a constant wheezing or sonorous breathing, subject to exacerbation. This does not indicate the existence of an organic affection, for I have known it removed by change of air. Besides these affections, ending acutely, there are others which produce more slow effects. The parts about the larynx inflame, and this may doubtless cause speedy death, by suffo- cation ; but in other instances, necrosis ofthe cartilages, or abscess, or ulceration, takes place, and the patient is thrown into the disease called laryngeal phthisis. This is to be pre- 721 vented in the outset, by vigorous antiphlogistic treatment? but when it takes place, if issues do not give relief, we have only to consider the probable effects of laryngotomy. The oedeme de la glotte, described by the late M. Bayle,* is merely laryngitis, attended with serous effusion. CHAP. I. 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. I believe that this fever may sometimes be strictly and essen- tially connected with the specific disease of hooping-cough, but the most alarming degrees of it are, I suspect, connected with, and greatly dependant on, an inflammatory state ofthe lungs. The cough generally comes on very abruptly, and is sometimes early attended with that sonorous spasmodic inspi- ration, denominated hooping; in other cases, not for a con- siderable time ; and this is considered as a favourable circum- stance, but it is not always so, for in young children, death may take place, although the disease never fully form. The fits are generally most frequent, and most severe, during the night. When the cough becomes formed, the paroxysm con- sists of a number of short expirations, closely following each other, so as to produce a feeling of suffocation, relieved at last for an instant, by a violent, full, and crowing inspiration ; then, in general, the cough or spasmodic expirations recom- mence, and the paroxysm, consisting of these two parts, con- tinues until a quantity of phlegm be coughed up or vomited, alone, or with the contents ofthe stomach, and this ends the attack. The expirations sound like a common cough, but are more rapid, and frequently 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 frequency and duration. Sometimes they are slight; * Journ. General, Avril, 1819. 4 U 72-2 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, and blood gushing from the nose or other parts. The extremities become cold during the fit, and the whole frame is much agitated. But even severe as the paroxysms are, if the disease be not attended with fever, the patient seems quite well after the fit, and begins to eat with a renewed appetite. A fit of crying will, at times, even after the disease have 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 peripncumony is produced, or the lungs become oedematous. Convulsions may also occur, and carry off the child. These may either precede the fit of coughing, and go on along with it for a short time, and then leave the cough in full possession of the child, or the cough first begins, and almost immediately the convulsions take place, and suspend the cough, or the respiration is arrested, and death takes place. When the face and extremities are swelled, the danger is greatest, and scrofulous children suffer most. The danger arises from various sources. The fever may exhaust the child without much cough; the inflammation of the lungs, or secretion of phlegm, owing to a bronuhitic state, may destroy him, or pus may form, and hectic fever be pro- duced, or cephalic disease and convulsions may take place, or the child may be suffocated. Many remedies have been employed in this disease, which it will be proper to divide into those intended to abate the fever, and those given to relieve the cough. Venesection has, for the first of these purposes, been recommended ; but it is very rarely requisite, and only when the patient is plethoric, and we apprehend that some vessel may burst in the lungs from the violence of the cough, or when there are symptoms of inflammation. Leeches may in these circumstances be applied to the chest, but this practice falls rather to be con- sidered as a mean of removing a partial complication. The most generally useful remedies are laxatives and the saline julap, which often in a few days moderate the fever greatly. 723 The tepid bath is useful, and, if there be much irritation and restlessness, hyoscyamus sometimes does good. The diet ought to be mild. For the relief of the cough, nothing is so beneficial as emetics. These have been given in nauseating doses, so as to make vomiting be readily excited by the cough; but, in general, a full dose of ipecacuanha will be as effectual, and is less dis- tressing. 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 combination of soap, cam- phor, and oil of turpentine; or juice of garlic, or oil of amber, or of thyme, foe., rubbed over the spine, particularly the cervical portion, so as to produce tenderness of the skin, have a good effect. Opiated frictions over the thorax are also proper ; and stimulating applications to the soles ofthe feet have certainly in some cases done much good. Antispas- modics, such as assafoetida, ol. succini, musk, foe., have been recommended, and in some cases are successful. Opiates are also of service. Dr. Willan says, that he found the watery infusion of opium more useful than any other narcotic. When the disease is protracted, cicuta has been recommended, but it does not seem to have any advantage over opium or hyoscyamus. It has also been applied externally. Prussic acid given three times a day in small doses, that is to say, in such doses as do not produce strong or sensible effects, has been praised, but it cannot be relied on. Lactuca virosa has also been employed. The most effectual remedy, however, is change of air, which often has a marked effect on the disease, in a few hours. When the patient becomes restless, and coughs more, it should again be changed. The diet ought to be light. If there be fixed pain in the chest, difficulty of breathing, and fever indicating inflammation, either venesec- tion or leeches, according to the age and circumstances of the child, will be absolutely necessary ; but our evacuation must be prudently conducted. Blisters in such cases are useful, but once for all, I would observe, that they are never to be used rashly in infantile diseases, nor repeated if they do not at first do good, for with the exception of those applied to the scalp, they generally produce much irritation and sub- sequent debility. They ought not to be allowed to remain 724 nearly so long on a child as on an adult, and may even be prepared with a smaller proportion of cantharides. Pain produced merely by the violence 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 breathing oppressed, the cheeks livid, and the pulse very weak, some children have been saved by the application of leeches to the chest, blisters and small doses of the com-* pound powder of ipecacuanha. When the patient is threatened with hectic, or becomes emaciated and weak, nothing is of so much benefit as country air and milk diet, at the same time that we keep the bowels open. Small blisters should be applied to the breast, if there be fixed pain or dyspnoea. If there be anasarcous swelling, digitalis, conjoined with squills and cordials, will be useful, but digitalis never ought to be given to the extent of producing weakness, nor persisted in if it do not act on the kidneys. Convulsions accompanying the fits are very alarming, and may suddenly carry off the infant, especially if he be very young. The child should instantly be put into a warm bath, which is to be repeated as often as the convulsions come on. If the child be plethoric, one or more leeches ought to be applied to the temples. The bowels should be opened, and the head shaved, and even a small blister applied to it, if the fits be repeated. The air ought also to be, if possible, imme- diately changed. In some cases, tincture of hyoscyamus 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 had gone off for a time, a gentle emetic is the best remedy.142 A sudden change of weather from warm to cold, is very apt to renew the cough. If the face or lips remain swelled, gentle laxatives are proper. Inflammation ofthe lungs may occur by very slight causes after hooping-cough, in consequence ofthe predisposition by it. During the continuance of the disease, the diet must be light, but nourishing, if the patient be weak: but more sparing at first, if he be, on the other hand, plethoric, and inclined to inflammation. Toward the conclusion of the disease, bark and tonics are useful to re-establish the health. There is a cough very like hooping-cough, and which gives rise sometimes to the groundless fear that the child is going to take that disease : or, on the other hand, if somewhat pro- 725 longed, it may pass for hooping-cough ; and afterwards the child, being exposed to infection, takes the disease, and is said to have had it twice. This kind of cough has less of the suffocating appearance than the hooping-cough ; the expira- tions are fewer, and do not follow each other so quickly, and the inspiration is not performed so rapidly, and with the dis- tinct hooping sound. It sometimes succeeds measles, or appears as a kind of influenza. It is cured by an emetic and anodynes. CHAP. XI. Of Catarrh, Bronchitis, Inflammation of the Pleura, and of the Stomach and Intestines. Infants are subject, as in after life, to catarrh, either com- mon or epidemic. It is attended with fever and inquietude, redness of the cheeks, watery discharge from the eyes and nostrils, disposition to sleep, frequent and sometimes irregular pulse, panting and shortness of breathing, with frequent cough, which, however, is not severe. It generally goes off within a week, by the use of gentle purges, antimonials, and, if the fever be considerable, leeches applied to the breast; if more obstinate, a very small blister should be applied to the sternum. A hoarse barking cough is cured by an emetic, and wearing flannel round the throat.143 Bronchitis it far from being an uncommon disease of infants, but it is seldom met with in a severe degree alone, for the lungs soon become affected. It sometimes takes place very early after birth ; in other instances not for several weeks. It begins with fever, cough, and pretty copious secretion of mucus or phlegm, which, however, the child will not allow to come out of the mouth, but swallows. The cough is frequent, but not uniformly so, coming on in paroxysms. It has a stifled sound, and is somewhat hoarse, or occasionally even shrill, from slight inflammation at the top of the windpipe, and at first is dry. The breathing is oppressed, hurried, or rattling, but not permanently so. Vomiting is also not an uncommon attendant, the epigastrium is distended, the stools are generally bad, the face is pale, and the child sick and oppressed. He takes the breast, but dislikes all meat. Presently, if death be not produced by the accumulation of 726 phlegm, the secretion becomes more of a purulent appearance. The respiration is more oppressed, and the noisy breathing is more frequent. There is a degree of stupor. The hands, but especially the feet, swell a little, whilst the body becomes emaciated. The cheeks are occasionally flushed in the evening, and the pulse, which was always frequent, becomes still more so, and 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 the trachea filled with purulent-looking matter, and in some parts there is an approach toward the formation of tubercles. The lungs are sometimes paler than usual, but generally darker and more solid. This is a very obstinate disease, but it does not prove very rapidly fatal; seldom sooner than in a week or ten days, sometimes not for several weeks. Milder cases terminate favourably within a week. In the commencement, it resembles common catarrh, and requires the same treatment, purgatives, venesection, or leeches, and a blister, which ought to be promptly employed. In the advanced stage, and under various circumstances, I have tried emetics, blisters, calomel, and expectorants, but without decided benefit. A small blister, with the use of calomel, combined with ipecacuanha, to act both on the bowels, and also as an expectorant, together with a removal to the country, appear to constitute the best practice. I think it right to mention, that though the pectoral disease may be slight, yet by the sickening effect of a purgative, especially castor oil, great panting, paleness, and other appear- ances of danger, have been produced, which have all gone off after having the bowels opened freely by a clyster, which brought off the purgative. Inflammation of the pleura is more frequent with children than many suppose, and like the former disease, soon affects the substance of the lungs. 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 on bed. He is likewise more disposed to cough, and is more uneasy on the one side than on the other. If not relieved soon, the breathing becomes laborious, the extremities cold, the cough stifling, with rattling in the throat and stupor : or the pulse becomes irregular and inter- mittent, the extremities swell, the countenance is sallow or dark-coloured, the breathing difficult, with short cough, and p~othy expectoration, which oozes from the mouth. On 727 inspecting the chest, the inflammation is sometimes found to have terminated in hydrothorax, oftener in adhesions, not unfrequently in hepatization. This disease requires venesec- tion, or the early application of leeches to the sternum, according to the age and constitution of the child ; the subse- quent use of a blister, calomel purges, and the tepid bath. Antimonials, given in a pleasant saline julap, are also some- times of service, but never ought to be given to such an extent as to produce decided sickness. 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.144 This disease sometimes terminates in abscess and purulent spitting, with hectic; but 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.145 The expectoration is generally swallowed, but sometimes it is rejected, or it is vomited up, and is found to be purulent. There is seldom any cure for this state; all that can be done is to send the child to the country, apply small blisters to the breast, keep the bowels in a proper state, give a mixture containing opium and diuretics, 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 be consumptive, the danger is much greater. This state, however, does not in general succeed pleurisy. It is generally induced more slowly, by tubercles, accompanied with enlargement of the bronchial glands.* Inflammation of the stomach is not a common disease of infancy, nor is it discovered without considerable attention. There is great fever, frequent vomiting, the mildest fluid being rejected soon after it is swallowed, the throat is first inflamed, and then covered with aphthae, which spread to the mouth. The child cries much. The region of the stomach is full and very tender to the touch. The bowels are gener- ally loose. If the child be old enough to describe the sensa- * Although it is not exactly connected with my present subject, I may men- tion, that sometimes the bronchial cells are much enlarged, the child has cough and difficult breathing. The air escapes, and passes from the root of the lungs to the mediastinum, insinuating itself betwixt its layers, and thence to the neck, where it produces emphysema. Punctures ought immediately to be made. 728- tions, he complains of heat or burning about the stomach and throat; if younger, it is known by the incessant crying, fever, thirst, with constant vomiting, and increase of crying on pressing the abdomen. It is not necessary to be too minute in drawingthe distinction between inflammation ofthe stomach and enteritis, as they both require the same treatment, and I have seen both prove fatal in a few hours. There is some- times, from the first, a cough and short breathing, but the constant vomiting shows the disease to be in the stomach. It is not easy to say what causes this, for it cannot always be traced to acrid or stimulating substances swallowed. It is proper immediately to bleed, or apply leeches to the pit of the stomach, according to the age and strength of the child ; then a blister is to be applied, and stools are to be procured by clysters and afterwards by mild laxatives. 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 opiates.146 There is another state of the stomach, which, from the softness of the 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 stomach,* 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 easily discovered before death, for its most prominent symp- toms, namely, purging, with griping pains, occur in other diseases of the 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 oftener than the stomach. This state ofthe stomach cannot always be attributed to the effect of the gastric juice. When the stomach is acted on by this solvent after death, we find that it is very soft, some of it in a state of semi-solution, the inner surface being dissolved, and some of it actually removed, so as to make a hole. When the preparation is put into spirits, and held between the eye and the light, the flocculent appear- ance of the inner surface is distinct, and numerous globules * Dr. Armstrong mentions a case of this kind, where the upper part, of the stomach was thus diseased, but the pylorus sound. The stomach was distended with food, but the intestines were very empty, which might be owing tp dimin" ished power of contraction in the stomach. 729 are seen within the peritoneal coat, which are probably the glands undestroyed. Peritoneal inflammation, or enteritis, is not an uncommon complaint with children. It begins with violent pain in the belly like colic, but is more constant and continued, and is accompanied with a considerable degree of fever, 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 exa- cerbation in the evening. There is increasing emaciation, and at first 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, afterwards there is frequently a diarrhoea. On examining the belly externally, induration may sometimes be discovered. The appetite is lost, the thirst is considerable, the pulse becomes more fre- quent and feeble, the debility increases, and the extremities become cold, and in this exhausted state, the child sometimes lies for many hours before dissolution. On inspecting the abdomen, the bowels are found adhering, or forming knots, and sometimes the liver partakes ofthe disease. A less severe degree of inflammation is productive of general secretion of purulent fluid, swelling the belly like ascites, and attended with hectic fever. In younger infants, the consequence of peritoneal inflam- mation, when it does not prove rapidly fatal, or excite con- vulsions, are abdominal pain or tenderness, obstinate 6limy purging, vomiting, and increasing emaciation. In young infants we cannot carry evacuation far. But whenever there is a prolonged attack of colic, we may appre- hend a severe disease, and must use the warm bath, clysters to open the bowels immediately, and then an opiate clyster to allay morbid sensibility ; a rubefacient should be applied to the belly, and if the symptoms be very urgent, this should be preceded by the application of one or more leeches to the abdomen. In elder children, the attack is often brought on by cold, or by eating indigestible substances, as for instance, nuts. No time is to be lost in opening the bowels by clysters and laxatives, and in detracting blood from a vein. Fomen- tations and blisters are useful ; but the latter are not to be repeated. If these means be neglected, or do not succeed, there is little hope afterwards of saving the patient, unless 4 X 730 the bowels adhere to the abdominal muscles and an abscess take place, which is indeed very rare. When abscess has taken place near the pelvis, or about the rectum, the child cries much on going to stool, seems afraid to pass the faeces, and may at the time be seized with spasm or convulsions. The faeces are very offensive, and occasionally purulent matter is discharged, and sometimes comes continually away, or consti- tutes the whole or the greatest part of the stool. In such cases, occuring in infancy, I have found magnesia useful as a laxative, and hyoscyamus with oil of anise of great benefit as an anodyne. Older children may have castor oil, senna, or any other laxative they prefer. If the appetite be not lost, there is hope of a cure, and I have known desperate cases recover. Mild tonics with suitable nourishment promote this. Some- times this produces a contraction of the rectum ; or a stricture may exist there naturally, and produce great pain on going to stool. In either case a cure is effected by cutting the stricture, which is generally membraneous and easily divided. The accumulation of purulent matter in the abdominal cavity, preceded by mild symptoms of inflammation, is gene- rally cured by paracentesis, at least every case I have seen of this kind has recovered. Cystitis, also, may occur in infants, and is known by the frequent and painful micturation, pain on pressing the pubis, and fever. It requires leeches to the pubis, or venesection, and the tepid bath, with laxatives. CHAP. XII. Of Vomiting. Vomiting is very seldom an idiopathic disease of children. Many puke their milk after sucking freely, especially if shaken or dandled. This is not to be counted a disease, for all children vomit more or less under these circumstances. A fit of frequent and repeated vomiting, soon after sucking or drinking, if unattended with other symptoms, and the egestabe of natural appearance, may be supposed to depend on irritability ofthe 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, however, 731 the egesta be sour or ill smelled, and the milk very firmly curdled like cheese, and the child be sick, it is probable that more of that caseous substance remains, and a gentle puke of ipecacuanha will give relief. On the other hand, should the egesta be green and bilious, gentle doses of calomel 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, desira- ble to restrain it, which is done by giving small doses of saline julap, and removing the primary disease. When it is imme- diately succeeded by a stool, there is reason to suppose it to be dependant on the state of the bowels, but if accompanied merely by fever we must look to the state of the head. Some- times the oesophagus is found ruptured in children, and the contents of the stomach poured into the thorax. This pro- bably happens from spasm taking place at the upper part of the oesophagus, whilst the stomach is rejecting its contents, CHAP. XIII. Of Diarrhaa. When we consider the great extent of intestinal surface, its delicacy, and the intimate connexion which exists betwixt the bowels and other organs, we shall not be surprised at the powerful and important effects produced on the system at large, by disorder of the alimentary canal. In attending to diarrhoea, we must examine the structure of the intestine, and the purposes it is destined to perform. The bowel itself consists of muscular fibres, of glandular apparatus, of nerves and blood vessels, and of a system of lacteal vessels, which probably do more than absorb, assisting also, by glandular action, in the formation of chyle, which does not likely exist in a perfect state in the contents of the bowels. Now although these different parts tend to consti- tute one organ, yet they are not so blended in action, that all must be alike affected when the organ is deranged. AH 732 may be disordered, but one sooner, and to a greater degree, than the rest. The fibres may be excited to inordinate action, producing rapid contraction, and speedy expulsion of the contents; and this may, or may not, be accompanied with spasms and great pain. The exhalents may be greatly affected, 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 be not duly absorb- ed. 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, foe. This leads us to consider the contents ofthe bowels. If the food be good, and the stomach digest properly, the chyme is good and natural. But if the food be bad, or in exuberant quantity, or the power of the stomach be impaired, the chyme is not properly formed, and the food is found in the intestines not thoroughly changed or digested ; perhaps little altered in its appearance. If the bowels have the same torpor with the stomach, it is retained, and forms accumulations, ending in great mischief. If the bowels be irritable, as in diarrhoea, it is generally passed speedily. The egesta from the stomach are naturally mixed with the bile, pancreatic juice, and intestinal secretion ; and the colour of the compound is yellow, or yellow with a brown tinge ; and during its passage downwards, a certain quantity of gas, possessing a peculiar smell, is extricated.* In young infants, however, when they are properly suckled, the stools are somewhat different from their state at a more advanced period. They are of a yellow colour, are something like cus- tard, or are curdy, and have by no means the offensive smell they afterwards possess. If the stools have a very curdy appearance, or are too liquid, or green or dark coloured, or ill-smelled, they are unnatural. The changes effected in the passage of the chyme are not merely chemical, but dependant on animal action ; for the contents ofthe stomach, 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 putrefactive fermentation. If the powers of the stomach and intestines be impaired, then this fermentation goes on to a great degree in * Both the smell and the colour of the freces are found to depend grnatly on the bile. When the bile is obstructed, the stools arc clay-coloured or pale, and have not the feculent smell. 733 the stomach and bowels, much gas is extricated,* inflation is produced, and the aliment becomes sour or putrid. If too much bile be added, the faeces are green, sometimes dark coloured. This redundancy of bile may be produced by causes acting immediately on the liver, at least not through the inter- position ofthe intestines, and the bile comes even to be a source of irritation to the bowels, and excites diarrhoea; or the affection ofthe bowels may influence the liver, and excite it to a greater secretion. Some children are more bilious than others, and are subject to fits of paleness, sickness, and bilious vomiting. The pancreatic juice and intestinal secretion, when not changed in quality but only 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,t which sooner or later pro- duces very bad effects. In other instances these form a more watery substance, which is passed off with griping and purg- ing of stools like moss water. The colour of stools in diarrhoea varies according to the violence ofthe disease. In slight cases, where the action of the bowels is only increased in degree, but not altered in kind, and the stomach is not injured, the feeces are of a yellow colour, but thin, owing to the increased discharge, and have not run into fermentation. When in children the digestive faculty is somewhat impaired, and the aliment is improper, fermentation goes on more strongly, and the faeces contain more acid than usual, which, although the bile be not increased in quantity, may give them a green colour,\ and the intestines are distended with air. Very green stools, however, imply a redundancy of bile, and the darker the shade of green the * Vauquelin has ascertained, that the stools are always more or less acid. When exposed to the air, they become more acid, and soon afterwards exhale ammonia, which they do till destroyed. The greatest part ofthe gas extricated in the bowels consists of carbonic acid, with carbonated and sulphuretted hydro- gen, more or less foetid. In indigestion, the greatest part of the gas is inflam- mable. Fourcroy's System, &c. tom. X. p. 75. t The decomposition of bile by acids, which combine with its soda, furnished a precipitate, which is thick, viscid, very bitter, and inflammable. This is pro- bably the origin of pitchy looking stools in some cases, though in others they may proceed from effused blood. X 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. 734 greater is the quantity of bile. When the irritation is great and universal, the stools are very watery, and of a dark green colour; or if the irritation be still greater, they are brown ; and in either case, if the child be on the breast, portions of coagulated milk are found swimming in the fluid ; if not, we have either bits of any solid food taken by the child, or small masses of dark-coloured faeces which had been accumulated in the bowels. When the digestive faculty is almost gone, the stools consist ofthe aliment mixed with bile. Thus, if the child be drinking milk and water, or be not weaned, the stools consist of green watery fluid, with clots of milk, streaked with bile. When the irritation is greatest at some particular part ofthe intestines, it is not unusual for these appearances to alternate with discharge of slime and blood, as we see in intus-susceptio. 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 increased peristaltic motion of so great a tract of sensible muscular substance, must, like other great muscular exertion, weaken the bowels, and thus the whole body which sympathizes with it. Great debility is often rapidly excited by affections ofthe intestinal fibres, though there have been little evacuation. Diarrhoea likewise injures the system by the irritation and great secretion which often accompanies it; add to this the diminution ofthe powers of digestion, and the obstacle afforded to the absorption of the due quantity of chyle, together with the derangement which other parts ofthe system may suffer, and the diseases thus excited, such as convulsions, anasarca, foe. On inspecting the bowels after death, they are sometimes found in a state of inflammation, but oftener greatly inflated and relaxed, or with more or fewer intus-suscepted portions. In one case, no fewer than 47 intro-susceptions were found in the same body. On examining these portions, the valvulae conniventes are found to be rather more prominent than usual, but the parts are not inflamed. Invagination of the intestine is a very frequent cause of fatal diarrhoea, not less than 50 cases having occurred to my brother in the course of his dissections. Intus-susceptio may be produced suddenly, in consequence of spasm, and may occasion great pain, with purging; oi it may be caused by acrid purgatives, or those 735 which produce much griping, as senna tea, made by boiling the leaves ; or it may take place in diarrhoea, when attended with considerable irritation, and it adds to the violence of the disease. It is sometimes accompanied with a diseased state of the glands. In this case there may be a swelling of the external glands, and there is often a tendency to cough. There may be a double intus-susceptio, and the tumour so formed may lodge in the pelvis and fill it. Inflammation is very far from being a necessary attendant on this state; it is even uncommon. The diagnostic of intus-susceptio is very obscure, and what- ever may be said to the contrary, 1 believe we have no certain mark by which to judge. It has been discovered, when no previous circumstances led to a supposition of its existence. But in general there is considerable pain, and marks of local irritation ; such as slimy stools, with or without blood ; some-* times a little frothy slime is passed, sometimes a substance like rotten eggs, and at times the contents ofthe intestines are vomited. It is attended with stretchings and cryings, as in colic, with occasional attacks of great paleness, like syncope; the belly is tender to the touch, and sometimes in infants the pulse is slower than ordinary. When the disease continues long, the emaciation is very great, the face resembling the bones, with merely a skin covering them, whilst the eyes are sunk. On the extremities, the skin is lax, and seems much too wide for the bone and muscles. Sometimes the intus- suscepted portion is thrown off, and passes by the rectum. Dissection likewise shows, that a diseased state of the liver not unfrequently accompanies diarrhoea, and this may be a cause of purging oftener than is supposed. It is to be sus- pected, when the biliary secretion is most affected, and the region ofthe liver is fuller than usual, when there are cough, frequent fits of sickness, and vomiting or purging of bile. It is most effectually remedied by small doses of calomel. Obstinate diarrhoea also depends on inflammation of the mucous coat of the bowels, marked by fever, pain on pressing the belly, bloody and slimy stools, tenesmus, and tormina. If not attacked early by bleeding and mild laxatives, followed by opiates, it is apt to become chronic and often incurable. 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 736 with regard to the nature of the stools, but their frequency, the pain which attends thern, the duration of the complaint, and the effect on other parts. In some cases the stools are extremely frequent and uniformly so. In others, the dejec- tions come on injparoxysms, being worse, either through the night or through the day. Some children are greatly griped ; others are sick, oppressed, and do not cry, but moan. In severe cases, the stomach is very irrituble, 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 appetite is more or less impaired, and in bad cases the aliment quickly passes off, and every time the child drinks it is excited to purge. The mouth, in obstinate bowel complaints, generally becomes aphthous, and the anus excoriated or tender, and it is not uncommon for the feet to swell. Sometimes 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 the disease is always unfavourable. The stools may come away with much noise from wind, or maybe passed as in health. When there is great irritation, they are either squirted out forcibly, or come in small quantity, with much pressing. Diarrhoea sometimes proves fatal in 48 hours, but it may be protracted for several weeks, as is often the case when intus-susceptio has taken place. In such pro- tracted cases, the emaciation is prodigious, the face is lank, the eyes sunk, and the expression anxious; the strength gradually sinks, the eyes become covered with a glossy pellicle, the extremities cold, the respiration heaving, and the child dies completely exhausted. Diarrhoea may be excited by a variety of causes ; such as too much food, or sudden change of the kind of aliment, and hence it is often caused by weaning a delicate child. Attempts to bring up children altogether on spoon meat, some injurious quality of the nurse's milk, improper diet after weaning, the irritation of ill-digested food, redundancy of bile, previous costiveness, dentition, the application of cold to the surface, of a morbid state of the bowels connected with general debility, produced either" by bad air or natural delicacy of constitution, are causes of diarrhoea. Irritation of the origin ofthe nerves is another cause, hence diarrhoea often precedes more'marked disease in the head. The first might be cured, and the second prevented from running its fatal course, by 737 an issue on the back of the head, preceeded by leeching, it there were fever. Those children suffer most who are feeble, puny, or delicate. As diarrhoea is a frequent cause of death, we cannot be too attentive to its treatment, nor too early in the use of remedies, especially as we find, that if it be neglected in its commence- ment, it is apt to end in a very obstinate or incurable 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 continu- ance 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 in producing the oppo- site 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 con- sidered, how far it is proper to check the inordinate action of the fibres of the intestines. This is readily done by an anodyne clyster. But if the diarrhoea have been excited by improper food, or redundancy of food, or if it 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 calomel. The tepid bath is also beneficial. If there be oppression, with fever or sickness, a gentle emetic will be a proper prelude to the laxatives. Afterwards, if the disease continue, and there be marks of much irritation ofthe fibres, anodyne clysters will be of signal service. If the diarrhoea come on quickly, and the stools be from the first green or morbid, and the stomach be irritable, or its functions impaired, we should examine the gums, and cut them if the child be getting teeth. This removes or lessens a source of irritation. But whether the disease be produced by teething, by change of food consequent to weaning, or other causes, great attention is necessary. If the child be sick and oppressed, a few grains of ipecacuanha will be proper ; and afterwards small doses of calomel,* or some other laxative,t * 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 infants 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. t Cold drawn castor oil may be given in the following form : R. 01. Ricini, 1 Y 738 should be given morning and evening. These carry off the morbid feculent matter, and excite a better action of the bowels. The calomel is usually a most effectual remedy, and it may be given even to infants a few days old. To them a quarter or half a grain, rubbed up with sugar, is a proper dose, and may be given morning and evening. To older chil- dren we give a grain. If laxatives do not increase the debi- lity and pain, and if they render the stools more natural in appearance, they do good, and may be continued in decreasing quantity till they be abandoned altogether. But if they merely increase the frequency of the dejections, without greatly alter- ing their quality, the stools continuing watery, ill-coloured, and offensive, and the strength and appetite sinking, we can expect no good by continuing them, and must restrain the purging by repeated anodyne clysters, taking care that we do not delay their use too long. When the secretion is copious, and the stools frequent, and perhaps squirted out with great irritation, the strength will sink very rapidly, and a few hours may decide the fate of the child. In these cases there is more or less inflammatory action, and therefore, in the commence- ment, we should, if there be tenderness on pressure, apply leeches to the belly, and use fomentations. It is also imme- diately necessary, even although the contents of the bowels be morbid, to moderate the fibrous and secretory action, by ano- dyne clysters. Afterwards the morbid matter is expelled, or can be removed by gentle laxatives. Opiates given by the mouth have often a bad effect on the child, and never are equal in benefit to clysters. Cretaceous substances, joined with aromatics, are useful when there appears to be a redun- dancy of acid ; but astringent medicines, such as kino or catechu, though they sometimes seem in slight cases to be of service, yet in more obstinate diseases fail, unless they be combined with opium, and then the benefit is perhaps more to be ascribed to that drug than to their effect; or if given in great quantity, they may perhaps excite to invagination of the intestines. In obstinate cases, small doses of the mercu- rial-pill-mass, given morning and evening, with the use of ano- dyne clysters at the same time, to keep the purging within due bounds, are of more service than any other remedies; I can speak of this practice with confidence. Dr. Armstrong, how- ever, when the stools are liquid or watery, sometimes colour- less or brownish, or streaked with blood, and of very offensive 3iij.; Mannae, 3SS- ! Spt. amnion. Arom. 3j. , Aq. Cassiae, %ss. ; Aq. Font 3 jes. Fiat emulsio. Of this a teaspoonful mnv be given as often as necessary 739 smell, advises antimonial vomits, repeated every six or eight hours, till the stools change their appearance. But this remedy operates severely, and may induce no small degree of debility. If the plan be rejected, he advises a solution of Epsom salts, with a small quantity of laudanum. I object to both plans. Dr. Underwood in this disease, prescribes emetics, then warm purges, and afterwards small doses of ipecacuanha, with ab- sorbents 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 ofthe tepid bath morn- ing and evening, and small doses of saline julap, or compound powder of ipecacuanha, and clothing the child in flannel, will be of great benefit. When along with fever there is much pain, and the stools are slimy, bloody, or squirted out forcibly, there is reason to fear inflammation of the mucous coat, and leeches should precede the bath. 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 better. Small blisters applied to the belly are highly useful, if they do not give much irritation. It is also proper to bandage the belly pretty firmly, but by no means tightly, with flannel. During the whole course of the disease, it is proper to support the strength with light nourishment, such as beef tea, arrow-root jelly, toasted flour boiled with milk, &c. ; or if the child be not weaned, it is sometimes of service, in continued 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 frequently the case, will not take nourishment, then clysters of beef tea, or arrow-root, are to be employed, mixed with a few drops of laudanum. These are of signal service, and ought to be early and carefully employed till the child can take food into the stomach. * Such as the following: R. Saponis, 3j.; Empl. Lytharg. 3yj.; Ext. Ci- cuta?, 3ij.; 01. Menth. pip. 3ss. Fiat. empl. Or, R. Empl. resinos. 3vj.; Pulv. Opii, 3j.; Camph. 3ij.; Ol. Junip. 3ss. Fiat. empl. Or if there be much spasm, we may use the empl. assafcotidae Pharm. Edin. with the addition of opium. 740 When the mouth becomes aphthous, it may be washed with a little sirup, sharpened with muriatic acid ; or borax may be employed, along with the proper internal remedies ; and when these restore the bowels to a healthy state, the mouth becomes cleaner. The appearance and disappearance of the aphthae generally mark the fluctuation of the bowel complaint. The excoriations which appear about the anus 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 may be derived from shaving the head, and applying a small blister to the scalp. Affections of other organs, 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, lessening cerebral excitement when it exists, and re- gulating the diet when the quality of the food may be sup- posed to have disordered the bowels. Second. To lessen sickness and oppression of the stomach by a gentle emetic ; but particularly to remove irritating faeces, and excite a better action ofthe intestinal surface, by small doses of calomel in prolonged cases, or by a dose of rhubarb and magnesia in recent cases of purging. The circumstances 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, or hydrargyrus cum creta. Fourth. To remove or allay coincident or consecutive symptoms, by appropriate remedies. Fifth. To support the strength from the first by suitable nourishment and cordials; and whenever the stomach cannot receive or retain food, to give nutritive clysters. 741 CHAP. XIV Of Costiveness. Costiveness is natural to some children,—acquired by others. In the former case, it often happens, that the mother is of the same habit, and in these circumstances, we find that less detriment accrues than in the other; yet even here it is necessary to prevent the costiveness from increasing, as it may excite not only colic, but more serious diseases, such as convulsions, or diseases in the bowels. Some children, of a very irritable habit, have the rectum spasmodically affected at times, on passing the faeces, which may be followed by a convulsion. This being frequently repeated, the child becomes afraid to go to stool, and retains the faeces as long as possible, which induces a costive state. Sometimes the terror is so great, that the child can only be made to pass the faeces when half asleep. In hereditary costiveness, it is difficult, if not impossible, to induce a regular state of the bowels ; and perhaps in some cases, this, if it could be done, would, seeing that it is not natural to the constitution, be injurious to the child. But we must beware, lest, by indulgence, this habit increase. Whenever the child is pale and puny, or dull, and does not thrive, there is risk of convulsions or some severe disease being 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 laxa- tives. 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; employing 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. An injection of tepid water, given morning and evening, if not sufficient of itself, will, at least, make less medicine operate ; as, for instance, two grains ofthe mass of pil. hyd. It is also proper to change the nurse, or alter the diet ofthe child, giving barlcy-mcal porridge, veal soup, ale- 74:2 berry.147 I wish explicitly to say, that the milk, whether that of the mother or of a nurse, may be costive ; and in such cases, if another nurse be not procured whose milk is more laxative, the most serious effects may follow. In the early weeks of infancy, fits are apt to occur, often attended or preceded by fever. In later periods, hydrocephalus is induced, possibly even also in the earlier stage. CHAP. XV. Of Colic. Colic is a frequent complaint with children, especially when they are costive. It is often produced by too much food, exposure to cold, irregularities in the diet of the nurse, or some bad quality of her milk. It makes its attack suddenly, and is known by violent screaming, induced without any warning, and accompanied with hardness of the abdominal muscles, kicking, and drawing up of the legs, and often sup- pression of urine. These symptoms are soon removed by a clyster or suppository, which brings away both faeces and wind. The warm bath, fomentations, and friction on the belly with anodyne balsam or laudanum, will be serviceable ; and if the pain continue, two or three drops of tincture of opium, or a rather larger dose of tincture of hyoscyamus, with oil of anise, may be given.148 When the child is costive, a laxative is to be exhibited after the anodyne. If a child be subject to repeated attacks of colic, a few drops of tincture of assafoetida are useful, and we must always take care to prevent the long continuance of pain, as it may end either in visceral inffammation or convulsions. CHAP. XVI. Of Marasmus. CONNECTED with, and generally dependant on, a morbid state of the bowels, is the marasmus, or wasting of children. This disease is preceded and accompanied by costiveness, sometimes alternated with a diarrhoea, in which the stools a 743 are foetid or unnatural in appearance. It begins with lassi- tude and debility, loss of appetite or depraved appetite, foetid breath and foetid stools, tumid belly, pale leucophlegmatic countenance, with swelling of the upper lip. Presently, fever supervenes, the countenance becomes at times flushed, and the skin hot and dry, with frequent pulse, thirst, restlessness, picking of the nose, and disturbed sleep, in which the patient grinds his teeth and starts. The debility gradually increases, and if relief be not procured, death, preceded by great emaciation, takes place. This disease is most frequent with those who are fed on improper food, or eat many raw roots or much unripe fruit; or those who have the digestive faculty impaired by confinement, bad air, or neglect of the bowels. It very often is considered as produced by worms ; but these, although they may often exist in the bowels, are by no means essential to the disease. It is still more frequently, and more certainly, caused by some disorder of the branches of the sympathetic nerve, occuring in a modification of the affection considered in the chapter treating of cerebral and spinal disorders. In such a case it is often the only very marked symptom, and exists to a great degree. In this state there is a very languid pulse, it is small and nearly impercep- tible, the skin is often cold, and there is either little or voracious appetite. This may also affect adults, and is attended with almost paralytic weakness of the legs. It is relieved by rubefacients applied to the spine, or issues, if any one spot can be discovered to be tender on pressure. Laxa- tives are useful, and the copper pill I have known of great benefit. This disease may, in the commencement, and before the appearance of fever, be arrested by a course of active purges, given at proper intervals ; at the same time we may give light nourishing diet, and inculcate the necessity of exercise in the open air. In the febrile stage, the cure is more difficult, but is to be accomplished on a similar principle, by attending to the state of the bowels. For this purpose purgatives must be frequently repeated, especially calomel; and here it is necessary to remark, that the stools are not always hard ; they are often fluid, but generally foetid, and dark in the colour, or appear to contain indigested food. A course of purga- tives, however, by degrees, procures discharge of faeces of natural appearance. Whilst this course is conducting, the strength is to be supported by proper diet, and the prudent use of wine. The power of the stomach may be increased 744 by chalybeates or other tonics, provided these be not nause- ated by the patient. After recovery have taken place, wc mast, 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 have already noticed. An emaciated or general unhealthy state may be produced by the milk not agreeing with the child, or being deficient in quantity. The nurse ought to be changed immediately. CHAP. XVII. Of Tabes Mesenterica. *' Tabes mesenterica, or hectic from disease of the mesen- teric glands, is a very frequent disease. It is not often met with before the time of weaning, nor after puberty, seldom after the age of eight or ten years. The disease consists in enlargement ofthe mesenteric glands,t which are sometimes universally affected, but are especially enlarged into a hard mass about the root ofthe mesentery. These tend slowly to the formation of a cheesy substance, but death may take place before that process be accomplished. The commencement ofthe disease is slow and obscure; the patient complains of little or no pain, but is subject to an irregular state of the bowels ; is either costive, or passes dark loose faeces ; is unhealthy 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 * Those who wish to know what other remedies are employed, though with- out much benefit, may consult Baumes de l'amaigrissement des enfans. t This state is sometimes accompanied with swelling of the thymus gland, and the lymphatic glands of the neck. Swelling of the thymus gland, by pressing on the trachea and oesophagus, produces difficulty of breathing and of swallowing, and sometimes suffocation. By pressing on the subclavian vein, it obstructs the passage ofthe chyle, and may thus excite disease in the mesenteric glands. Blisters applied to the top ofthe sternum sometimes do good. 745 very much that of marasmus proceeding from affection ofthe bowels independent of diseased glands. As the disease advances, 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, of short duration, however, 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 intermit- ting, becomes more acute and distinct, with exacerbation in the evening, attended with restlessness and acceleration ofthe 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 supervenes. As the disease proceeds, the ema- ciation of the body increases, the eyes are sunk and glossy, the nose sharp, and apparently elongated, the face sallow, but the lips are sometimes florid, and the cheeks flushed at night. The abdomen is hard, and sounds like a drum when struck upon, or if not very tense, kn&ts may sometimes be felt within it.* The urine is lessened in quantity, and it often deposits a white or lateritious sediment, the feet swell, and during sleep, the forehead, scalp, and sometimes "the breast, are 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 repeated use of mild purges with calomel, conjoined with some light bitter infusion, decoction of bark, tonic medicines, and gentle friction over the belly continued for a considerable length of time, morning and evening, would appear to be of more service than any other plan of treatment. It has been proposed to give calomel in small doses, as a mercurial; but it does not appear to have great efficacy, and is chiefly of use; in so far as it acts as a gentle purgative. Copious evacuations in this disease are not required. It is sufficient that the * Sometimes a hard tumour may be felt within the belly, pretty early in the disease. It is often felt in the right side, near the origin ofthe colon, 4 Z 746 bowels be brought into, and kept in a regular suite, 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 tumour of the belly, making the stools more natural, and do not impair the strength. The lax stools which take place in this disease spontaneously, never abate the tumefaction ; but a gentle course of laxatives often does, and this is a most favourable effect. Farther, if the par- oxysms of fever be severe, and early in their appearance, we find it necessary to use purgatives more freely than in opposite circumstances; evacuation by stool being in such cases advantageous. In the confirmed and advanced stage, it is sufficient that such a dose of calomel be given every night, or every second or third night, as shall keep the bowels open, if disposed to be costive, or, if loose, make the stools more natural in their appearance than they would be without the administration of medicine. We must, however, take care that the mercury do not excite much effect on the constitution, lest debility be increased ; it is'therefore prudent, sometimes, to combine the calomel with rhubarb, or to employ a little castor oil emulsion. Along with this plan, we may, in every stage ofthe disease, derive advantage from the use of tonic medicines, such as bitters and chalybeates, especially in the form of mineral waters. But the last are to be used cautiously, if there be marks of inflammation existing in the glands; and in such cases, some light bitter infusion is preferable to chaly- beates. In such circumstances, the laxatives are to be used more freely, the tepid bath is to be employed, and the belly rubbed freely with anodyne balsam. Gentle exercise in the open air is of great service, and it is useful in the early part of the disease to reside near the sea ; but if the glands seem to be in a state of inflammation, discovered by shooting pain with fever, the patient must not bathe ; and indeed at all times the utility and safety of the cold bath seem to be doubtful, except when the disease is so far removed, that we have chiefly to contend with debility. The warm bath is more generally useful. The diet should be light and nutri- tious, but all stimulating and indigestible substances must be avoided. If an inflammatory state exist, milk in different 747 forms, soft boiled eggs, and vegetables, are proper. If no inflammation be present, some animal food will be of service; nay, as in other scrofulous affections, a very considerable proportion of animal diet is sometimes beneficial, in preventing the tumour from inflaming and forming a cheesy substance, or in giving a favourable turn to the action, when the acute state of inflammation has abated, in those cases where it is met with, for it is by no means a universal occurrence. In the latter end of the disease, little can be done except palliating the symptoms, and supporting the strength by soups and a little wine. Diarrhoea should be restrained by anodyne clysters. Cicuta, burnt sponge, iodine, and some other medicines, have been advised in this disease, but 1 cannot say that they have been employed with advantage. Electricity is sometimes of service. CHAP. XVIII. Of Worms. Worms exist in the bowels, perhaps of every child,* but especially in those whose bowels are debilitated by bad management, or by acute disease ; and hence, in the end of disease, or after recovering from such illness, worms are often expelled, both by children and adults. Worms are of different kinds, but infants are chiefly infested with lumbrici and ascarides, the teniae being rarely met with until children are four or five years old. We also sometimes meet with some uncommon species of worm, whieh are ejected by vomiting, and some lususes 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 into a common trunk, ending in a tapering tail. Insects of different kinds may also be introduced accidentally into the stomach and bowels, and live there for some time. Ascarides generally occupy the rectum, producing much itching in that part, so that sleep is often prevented. The irritation causes indigestion and pain in the belly, with picking ofthe nose and white face, a variable appetite, and sometimes • Worms rarely appear in the bowels, till after the child is weaned. 74* a desire for indigestible substances. The worms arc discover- ed in the stools like small white threads, and occasionally they creep out from the rectum. The stools are often slimy or mucous. This kind of worm is removed by injections of aloes mixed with water, or decoction of semen santonicum, or any strong bitter infusion containing salt in solution, or the common turpentine injection ; lime water and olive oil also sometimes destroy them, but cannot be depended on. Calomel purges are proper likewise ; and any disordered state ofthe alimentary canal which exists, is to be treated on general principles.149 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 distinctions, 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 eel, and does not shorten the body like a worm. Dr. Hooper, in the fifth vol. ofthe Mem. of Med. Soc. has a valuable paper on intestinal worms. Lumbrici may exist in every part ofthe alimentary canal, and frequently are ejected by vomiting, as well as by stool. The symptoms are those of intestinal irritation,* 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 great terror, and being liable to starting and grinding of the teeth. When awake, he picks his nose, is plagued with temporary headach, some- times has a dry cough, with slow fever, or convulsive affections, or eclampsia. I have already pointed out several diseases proceeding from disorder of the bowels, and these may arise from worms, inasmuch as they are capable of irritating the bowels, or injuringtheir action, or increasing such a debilitated state, as may have predisposed to their accumulation. A variety of anthelmintics have been advised, for an account of which, I refer to the writers on the Materia Mcdica. Sulphur, tansy, aloes, spigelia marylandica, dolichus pruriens, the * Hence it is not easy to say that worms are the cause of a child's complaint, for other morbid affections ofthe bowels produce the same symptoms. A course of purging removes these symptoms, without bringing away any worms; although the slimy appearance of the stools is attributed to the worms being dissolved. 749 geoffraea, worm seed, tin powder, filings of steel, foe. have all at times a good effect; but in general, calomel purges given repeatedly and liberally, provided the constitution of the pa- tient will bear them, will be found very effectual; or these may be alternated with saline purgatives, oil of turpentine, or suitable doses of aloes or jalap. In obstinate cases, much benefit will be derived by giving a regular course of purgatives, so as to keep up a constant but gentle effect on the bowels. After the worms are expelled, a bitter infusion, or chalybeate water, will be useful to strengthen the bowels, or these may even be employed whilst we are using the purgatives. The trichurus, 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 taenia consists of many flat jointed portions, and : divided into the T. Solium, where the orifices are placed c the margins of the joints, and the T. Lata, where they a; found on the surface. The usual symptoms are produce The best remedies are smart purges of calomel, alternating with doses of oil of turpentine proportioned to the age; a dessert spoonful may be given to a child of four years of age.150 But to insure its quick operation by stool, and to prevent strangury, another laxative should be combined with it. Colchium may also be prescribed at a more advanced age. The taenia is more difficult to be removed than other worms. CHAP. XIX. Of Jaundice. The jaundice of infants is a disease attended with greet danger, especially if it appear very soon after birth, and the stools evince a deficiency of bile ; for we have then reason to apprehend some incurable state of the biliary apparatus. I conceive that there are two species of this disease, which are very opposite in their nature. In the first there is an obstacle to the passage ofthe bile into the intestine, the child is costive, and the meconiun is paler than usual, and after it is removed, the stools become light-coloured ; the skin, very early after 75U birth, becomes of a deep yellow colour, which extends to the eyes. The child sucks very little, has occasionally 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, colic, and fever, occasionally supervene. In some cases the li ver 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 degrees of violence for a considerable time, and at last to disappear, though such children continue long delicate. With regard to the cause of this disease, we find, that sometimes it consists in obstruc- tion of the hepatic duct, or ductus communis, either by thickening of the coats, or pressure, in consequence of enlarge- ment of some part in the vicinity of the duct; or it may consist in imperforation of the duct. Sometimes it proceeds from temporary obstruction in the duct, owing to viscidity of the bile. Now, some of these cases are irremovable, others are not; but as we cannot, a priori, say what the cause may be, in any particular instance, we must use the means of cure in every case. The most likely remedies for removing this disease, are gentle emetics, given very early, and followed by the exhibition of half a grain of calomel, morning and evening, till the bowels are acted on; or we may give this medicine even three times a day, in some cases; but we must be cautious not to induce much purging, or push the mercury far, lest we bring on fits. The second species differs from the first, in the stools being dark-coloured or green, showing that there is no obstruction, or at least no permanent obstruction to the passage of the bile.* Like the first species, it appears soon after birth, and is accompanied with great oppression, moaning, colic, and convulsive affections. It is attended with much danger, and frequently carries off the infant in a few days. The early use of calomel would appear to be the most proper practice, and the strength must be supported in all those cases by the breast milk, given with the spoon, if the child will not 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. * It is in this species alone that the opinion can be admitted, that infantile iaundice depends on absorption of bile from the intestines. 751 CHAP. XX. Of Diseased Liver. Enlargement and inflammation of the liver are not uncommon in infancy and childhood, but the first is most common in infancy. It is productive of vomiting, oppressed breathing, cough, fever, and sometimes purging. The liver can be felt enlarged, and extending lower down, or more to the left side than it ought to do, which will distinguish this complaint from inflammation of the lungs, which is also not so frequently attended with vomiting.* I cannot say much that will be satisfactory respecting the treatment. Mercurial friction and blisters are chiefly to be relied on.151 Hepatitis in infancy is frequently attended by the symptoms of enlargement of the liver; but there is more fever, and some- times pain, when the liver is pressed on. The disease often begins with symptoms of disordered stomach, and colic pain. Fever comes on, accompanied with cough, which is sometimes soon succeeded by jaundice. The stools are often like yolk of egg, or, if there be obstruction to the passage ofthe bile, they are clay-coloured, and the urine red, with much sediment. On inspecting the body of; nfants who have died of this disease, the surface ofthe liver, sometimes only its convex surface, is often found of a deep red colour, with an exudation of white lymph, exactly resembling the cuticle of a blistered part. Betwixt the liver and diaphragm, we find white flaky fluid, something like pus, and similar matter is often found among the bowels, mixed with pieces of fatty-looking lymph. The liver is not necessarily enlarged, nor its substance affected. The stomach and bowels are not inflamed, but sometimes have a white blanched appearance, and contain a fluid like thin custard. The bile is not changed in its colour. In some instances of chronic inflammation, the liver is somewhat enlarged, of a dark colour, and the veins turgid. Leeches, blisters, and a gentle laxative course of mercury, are the means of cure. In older children we find hepatitis to commence either acutely or slowly. When it begins acutely, the child, probably after a surfeit, or some irregularity of diet, * On examining the liver, it is sometimes found soft, and not much altered in structure, sometimes hard, and almost cartilaginous, with the pori biliarii 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. 752 or exposure to cold, complains of severe pain in the uppei part of the belly, like colic, accompanied with sickness and vomiting ; and either attended, or soon succeeded by fever, short cough, and pain, sometimes dull, sometimes sharp in the right side, and occasionally affecting the shoulder. Jaun- dice also,not unfrequently, is produced, and lasts for a few days. There is thirst, no appetite, but the child feels continu- ally as if he had ate too much, is subject to fits of squeamish- ness, and complains when the liver is pressed. If the remedies do not check the disease, the liver enlarges, and its region is full ; abscess is formed, attended with irregular chilness, 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 coughed up, which is followed by copious expectoration; or he ejects pus as if he vomited it from the stomach. The cough and spitting, with hectic symptoms, continue long, but at last, decline and go off. In the early stage, blood-letting, if instantly resorted to, may be of service, but not if delayed. Blisters are always proper. The bowels should be freely opened, and afterwards a gentle course of mercury employed. In the suppurating stage, mercury should not be used, but the strength is to be supported by proper diet. In the expectorating stage, the same plan is necessary, with the use of tonics, such as chaly- beates joined with myrrh, and occasionally opiates. A speedy removal to the country, if the weather be mild, is advantageous. 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 tumour like ascites, bursting at last by the navel, which inflamed ; or it has been drawn off with a trocar, and recovery has been accomplished. This I have in the eleventh chapter of this book noticed, as also following a certain degree of peritonaeal inflammation. The more slow or chronic species may be excited by a torpid state of the whole chylopoetic viscera, consequent to neglected bowels, or other causes ; or it may occur after some other disease, such as peripneumony, scarlatina, &c. The child has fits of sickness, vomits bile in the morning, and loses his appetite ; or if he have a strong desire for particular kinds of food, or feel very hungry at times, he cither cannot eat 'vhen he receives food, or is instantly filled. The strength 753 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 swelled at night, but there is little or no pain in the region of the liver ; if any be felt, it is rather referred to the bowels. By and by considerable pain, like colic, is felt near the stomach, especially at night, and that part ofthe 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, irritation 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 tubercles. I do not know any other diagnostic symptom, than the belly being tumid and hard in the region ofthe spleen ; frequently a cough attends this state. Mercurial laxatives and blisters are the best remedies, but most cases I have met with have proved fatal.132 CHAP. XXI. Of Fever. Fever is a frequent disease in infancy and childhood, but it is generally symptomatic, or produced by some local irritation, and has been considered in some of the former chapters; particularly in the chapter on spinal and cerebral irritation. 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.153 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 oppression, succeeded by stupor, precedes death. In the 5 A 754 course of the disease, the bowels are generally bound, the stools foetid and the urine thick. It requires the early use of emetics in the cold stage, succeeded by saline julap. If the hot stage, however, be fully established, and the heat con- siderable, cold sponging 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 be proper ; or if the pulse be full, a little blood may be taken from the arm. If pain continue, or stupor, or constant drowsiness supervene, blisters will be proper. The strength, in the latter end of the disease, is to be supported by the prudent use of wine. Cough in general requires blisters to the breast, with squill vinegar. NOTES. ], Page 21, line 16. More commonly called the projection of the sacrum, 2, Page 25, last line of Note at bottom. There is an animal, however, in which this separation of the bones of the pelvis during pregnancy and parturition does really take place, and in whom it appears to be an operation of nature to facilitate the latter process.—This animal is the Guinea Pig. Le Gallois says, that upon comparing the pelvis ofthe female ofthe Guinea Pig with the head of a full grown Foetus, il appears utterly impossible, that the latter should pass through the former, if the pelvis constantly preserved the state and dimensions at any other time than that of {Testation. When the female Guinea Pig is ajive, the diameter ofthe pelvis is asserted to be but about one half of the head ofthe Foetus ; and nevertheless, Guinea Pigs are delivered with much ease. The duration of gestation in these animals being about R5 days—about three weeks before delivery, the symphysis pubis is observed to acquire more thickness, and a slight mobility ; these are continually increasing. Eight or ten days bo- fore delivery, the two ossa pubis begin to separate from each other. This sepa- ration increases slowly at first, and only begins to go on rapidly for the three or four days which precede delivery,—At the moment of parturition, according to Le Gallois, it is such as readily to admit the middle finger, and sometimes both Uie middle and fore finger together. The delivery being accomplished, the bones ofthe pubis soon close. Twelve hours after, the distance of the separation has lessened more than one half; and 24 hours after, ihey are in contact at their anterior extremity ; and in less than three days they are perfectly so through the whole extent of their symphysis, which then only presents a slight thickness and mobility. A few days after, nothing is to be seen. But when ihe females are old or sick, the union takes place more slowly. Vide Le Gallois' experiments. 3, Page 29, end of Chap. If. DIFFERENCE OF TUG FEMALE FROM THE MALE PELVIS. A slight inspection is sufficient to show the difference in form and proportions, between the female and the male pelvis. The crisUe, as well as the anterior and superior spinous processes of the ossa ilia, are farther separated in the female pelvis, hence affording a greater conca- vity to the iliac fossae, and greater capacity to the large or superior pelvis. The two straits which terminate the cavity of the pelvis, differ also considerably in the two sexes. The circumference, or brim ofthe superior strait is larger and more rounded in the female, the sacro-vertebral projection is less prominent; the two tuberosities of the iscJiia are also less roueh, less projecting, and farther separated, than in the male ; and finally, the extremity of the os coccygis does not approach so near to the arch ofthe pubis, which affords to the inferior strait greater extent from its anterior to its posterior termination. 5 B 756 With regard to the excavation of the pelvis, it is more concave in the poste- rior part of the female, because the sacrum has greater height and curvature ; the arch of the pubis is broader, and its branches are also turned more outward and forward. Soemmering observes, that the angle between the diverging branches ofthe pubis, is in the male an acute one ; but in the female forms an angle of from 80 to 90 degrees, and hence approaches nearer to the figure of an arch, from which it receives its name. The region ofthe pubis is less convex, and the cartilage, which forms the symphysis, is thicker and shorter, offering towards the interior of the pelvis a prominence more remarkable than in the male. But in this very conformation, which nature appears to have intended to ren- der labour more easy, there are certain circumstances exposing the female to peculiar inconveniences, which in men are more rarely observed ; thus the supe- rior spinous processes which anteriorly terminate the cristrje.or spine of the ilium, could not be separated to a greater distance, without increasing the length of Poupart's ligament, forming the crural arch ; from thence it follows, that the intestine and epiploon, finding in this part less resistance and a larger aperture, must more frequently pass down and produce femoral hernia. Again, women having their hips farther separated, must necessarily step with less firmness than men : for in piogressing, when one leg is elevated, the centre of gravity of the body is less readily thrown upon the other, which rests on the ground ; from hence results a species of claudication or vacillating gait, in which the trunk and the inferior extremities, instead of advancing directly, or in a straight line, describe greater or smaller arches of circles. Vide Capuron. cours theorique et practique, &c. Soemmering, Tabula Sceleti feminini juncta descrip- tione. 4. Page 37, line 19. There may be some variation in dimensions, as stated by different writers; but it is probable, these were given by our author, from actual measurement, of what he considered a standard pelvis. A similar observation may be applied to the dimensions ofthe child's head, as stated in the succeeding chapter. 5. Page 37, line 32. The very ingenious and indefatigable Bichat has observed, that stature has no influence, or at least very little, on the dimensions ofthe pelvis; and that the individual differences which may occur, are totally independent of stature. It is acknowledged, continues he, that delivery is as easy in small as in large women, although the first may bring forth veiy bulky children, and who, indeed, maybe disproportioned to the bulk of their mother's bodies, if a comparison of size should b« instituted between the two.—Anatomie Descriptive, vol. I. p. 181-2. 6. Page 38, line 23. This remarkable difference in the comparative dimensions ofthe female pelvis before and after puberty, has been pointed out by analogy, and observed among the females of quadrupeds whose pelvis does not complete its developement, nor acquire the form and proportions necessary for the expulsion of the fcetus, until the period of puberty.— Vtd. Capuron. 7. Page 40, sec. 2d. The diameter from the vertex to the chin, is termed the oblique diameter- from the root ofthe nose to the vertex, the long diameter; between the parietal protuberances, the transverse diameter; from the nape ofthe neck to the ciown ofthe head, the perpendicular diameter. When the vertex is stretched out in laborious births, the oblique diameter is sometimes extended to six or seven inches. 8. Page 47, line 30. Deformity ofthe pelvis, from the above causes, may be considered as compa ratively a rare disease in the United States. In the course of my obstetrical 757 practice, I can at present recollect very few cases, where embryulcia and the employment of the crotchet became indispensably necessary ; and what may be worthy of remark, these were in individuals natives of Europe, chiefly of Ireland. A deformed pelvis is scarcely known among the aborigines of our country. This subject shall again be taken up when embryulcia is treated of; an operation which, we fear, is frequently resorted to very unnecessarily at least, to make use of the mildest term. 9. Page 58, line 2. Haller, in his Elementa Physiologiae, asserts that the hymen is peculiar te the female of ihe human species ; but Duverney, in a Memoir read before the Insti- tute and the School of Medicine, at Paris, asserts, that it is common to others of the mammalia. 10. Page 61, line 18. The reader is referred to a very interesting paper " on the muscularity of the uterus, by Charles Bell, Esq. F. R. S. Ed. &c." published in the 5th vol. of the Eclectic Repertory, p. 37, and sec. 9. 11. Page 73, line 28. An immense tumour was successfully extirpated from the labia of a negro wo- man by Dr. Hartshorne, at the Pennsylvania Hospital, in December, 1815, said to be produced by the kick of a horse, and of upwards often years standing. In this case, the labia were much enlarged, and almost as hard as cartilage. The hardness and enlargement of the integuments extended anteriorly three inches aoove the pubis, and posteriorly to within two inches ofthe anus. The patient walked with great difficulty, as the circumference ofthe middle of the tumour was at least twenty inches, and its lower part almost reached the knees. The weight of the tumour removed was upwards of eleven pounds. On the evening -of the third day after the operation, unequivocal symptoms of Tetanus appearing, and the violence of the spasms increasing, caustic potash was freely applied to the neck, over ihe cervical vertebras. The effect of this applica- tion in [essenmg the convulsive action of the muscles was very evident. The woman was discharged well, on the 6lh of April ensuing. In Larrey's Memoirs, vol. I. p. 299, will be found a description of a similar tumour ; and in plate X. an engraving. 12. Page 74, line 3. Would it not be more eligible, when practicable, to extirpate the cyst com- pletely by the knife, to prevent the risk of its sloughing away? 13. Page 81, linn 25. Sutures should be rarely had recourse to, as they occasion considerable irrita- tion, and are liable to be torn, or to slough out. 14. Page 94, line 36. Mr. Roberton, a surgeon of Edinburgh, in a paper published in the London Medical and Physical Journal, vol, XV., and also in a distinct work on the Ef- fects of Cantharides, when taken internally, strongly recommends this powerful article of the materia medica, in obstinate cases of Leucorrhcea ; and recites a number of instances, in which it appears to have produced the best effects. In his exhibition of this medicine, he generally' begun with about 3'j or 3'jsa °^ the tincture, in 3 vj of water ; a table spoonful of which was given thrice a day. He continued gradually increasing the dose, until bis patient had taken 3IV *» the tincture in 24 hours, 3j of the tincture being added lo 3 vj of water. It was generally given, until considerable pain, and a puriform discharge from the va- gina, was produced. I cannot say, that in the few trials 1 have made of it in this complaint, the beneficial effects have been so conspicuous. 758 15. Page 96, line 9. Our author has omitted to mention the efficacy of magnesia in calculous com* plaints, as recommended by Mess.s. Brande and Hatchet. The result of the1 inquiries of these ingenious gentlemen on this very interesting subject, has been communicated to the scieniific world in a paper printed in the Philosophical Transactions for the year 1810, entitled, *4 Observations on the effects of Mag- nesia, in preventing an increased 'ormation of the Uric Acid, by William T. Brande." This gentleman (in a communication to Sir Jihn Sinclair) says, that the best method of giving the magnesia, is in plain water, or milk, to be taken in the morning early, and at mid-day. !f the stomach be weak, and this pro- duce flatulency or uneasy sensations, some common bitters, such as gentian, may be taken with it ; if it purges, a little opium may be added. He supposes its beneficial operation depends on preventing the formation of acid in the stomach. The dose of magnesia, he observes, must always depend upon the circumstan- ces ofthe case ;—generally, five grains twice or ihrioe a day to children ten years of age ; fifteen or twenty grains to adults. Mr. Brande has always given the common magnesia, although he remarks that the calcined may be occasionally used with advantage. For fuller informa- tion on this subject, the reader is referred to Brando's paper, above quoted, in the Phil. Trans., and to a letter from Sir John Sinclair. Vide Eclectic Repertory, Vol. III. p. 120. Dr. Gilbert Blane, so well known in the medical woild, has also written an interesting paper on the effects of large doses of mild vegetable alkali, or potassa carbonata, in gravel, and the beneficial effects of opium combined with it. 16. Page \\l,line 16. Professor Francis gives the history of an enormous fleshy tubercle, proceeding by a small pedicle from the fundus ofthe uterus, which, together with the ex- crescences connected with it, weighed rather more than 100 pounds. 17. Page 120, after sec. 29. CAULIFLOWER EXCRESCENCE FROM THE OS UTERI. Dr. John Clarke, of London, considers himself as the first writer who has taken Hot ice of this disease. The cauliflower excrescence* according to him, arises always from some part of the os uteri. As several ofthe early symptoms are not very distressing to the patient, the tumour^ in the beginning, is rarely the subject of medical attention. The first changes of structure have therefore not been observed. In general, the tumoiir is hot less than the size of a blackbird's egg. At this period it makes an irregular projection, and has a base as broad as any other part of it, attached to some part of the os uteri. The surface has a granulated feel) considerable pres- sure on handling it doe3 not occasion any sense of pain. The remainder of the Os; uteri will at this period be found to have no sensible alteration of structure. By degrees, more and more ofthe circle of the os uteri, and the external part of the cervix uteri, become affected with the same morbid alteration of structure, till at length the whole is involved in the disease. The growth is in some cases slow, but in others rapid, so that in the course of nine months it will sometimes entirely fill up the cavity ofthe pelvis, and block Up the entrance ofthe vagina. As the bulk of the tumour increases, the granulated structure becomes more evident, and is found to resemble Very much ihe structure of the cauliflower when it begins to run lo seed. In most cases it is of a brittle consistence, so that small parts of il will come away, if it be touched too rudely ; and such pieces appear lo be very while Sometimes, though no violence has been used, small portions of a white substance come away with the urine of the patient, and in the discharge from the vagina. When the tumour has arrived at a size greater than that of the os uteri, it spreads very much, and as the base is the smallest part of the tumour, persons not conversant with the disease have often mistaken it for polypus. A little 759 attention, however, to the feel ofthe tumour, and tho breadth of its base, will be sufficient to distinguish them. . In the very early state of the cauliflower excrescence, a discharge from the va- gina lakes place like flm-r albus ; it^ery soon becomes thin and watery, and is sometimes tinged with blood. In most cases, upon coming away, it is apparently as thin and transparent os pure water; but the linen on which it is received, wjien dry, becomes stiff, as if it had been starched. The quantity of the discharge, When the excrescence is large, will sometimes be sufficient to wet thoroughly ten or twelve napkins in a day. Now and then a discharge of pure blood appears. When this ceases, the discharge of thin transparent fluid re-appears. An offen- sive odour generally accompanies the discharge, which is greatest when there has lately been an evacuation of pure blood, or ofthe catarhema. Mucus has sometimes been found in the fluid discharged, but pus never. Patients labouring under this disorder, are variously affected with regard to pain. In ihe commencement none is felt; but during its progress pain is in some cases experienced. Generally in the advanced stage, the patient feels pain in »he back, and in the direction ofthe round ligaments of ihe uterus. The pain is not described to be lancinating, as in cancer, and is without any sensible aggra- vation by paroxysms; but, on the whole, it is most felt after the patient has been in a perpendicular attitude. The disease attacks indiscriminately women of all ages. The patient is de- stroyed by the debility occasioned by the profuse discharge ; and in the course of the disease, she always becomes extremely emaciated from the above cause. It always terminates fatally. Respecting the treatment of this disease, nothing satisfactory can be offered. All stimulating substances, eilher in diet or medi- cine, seem to aggravate it, by increasing ihe discharge ; and no astringents inter- nally given appear to lessen it. The only means from which any benefit has been derived, is the injecting into the vagina, three times a day, a strong decoc- tion of cortex granat'uor of cortex quercus, in which alum is dissolved in the pro- portion of eight or ten grains to every ounce of it. This has the double effect of lessening the quantity ofthe discharge, and rendering it less offensive. The use of anodynes must be resorted to for the mitigation of pain, and the occasional symptoms of suppiession of urine, and costiveness, are lo be relieved by the use of a catheter and mild laxatives. Vide a paper on the Cauliflower excrescence from the os uteri, &c. by John Clarke, M. D. Transact, of a society for the im- provement of Medical and Chirurgical knowledge, 1812. And New Medical and Physical Journal, July, 1812. 18. Page 126, line 16. The reader is referred to the following interesting paper on the subject of the preceding article, viz.: Memoir sur l'organi/.ation des polypes uterus, &o. par P. J. Roux, Tom. 111. des ceuvres chirurgicales de P. J. Desault, par Xav. Bichat, p. 370. 19. Page 130, line 29. Ruy«=ch in the first volume of his valuable works, has given two very curious and accurate plates of these hydatids ofthe placenta or uterus. There is also n representation of these vesicles in BaiUie's plates of Morbid Anatomy, execu- ted with great truth and elegance. It is now generally considered by natural- ists, that the hydatids found in the human body, are a sort of imperfect animals; and as Dr. Baillie has observed, although there may be some difference between them in simplicity of organization, this need be no considerable objection to the opinion, as life may be conceived to be attached to ihe most simple form of or- gaForafu°r"iier information on the subject of hydatids, particularly those of the uterus, the student is referred to a paper by the editor, inserted in the'Eclectic Repertory, vol. I. p. 499, and seq. Also to Munro's Morbid Anatomy of Uie human gullet, stomach, and intestines. Edin. 1811, p. 255. 20. Page 137, line 15. The oval form is nevertheless preferred by many, and apparently not without reason. 760 21. Page 138, line 29. In my own practice, I have generally preferred the oval pessary of elastic gum, by being applied transversely ; as regards the vagina, there is less danger of impeding the evacuation of the feces and urine, by pressure on the rectum and heck ofthe bladder, or urethra. Where this cannot be procured, pessaries n»ay be made of silver, of the oval form and hollow, and wilh care may be found to answer. But it is probable, that the sponge pessary, under proper manage- ment, will be found to answer every intention. This kind of pessary appears first to have been publicly recommended by Dr. Haighton, of London, and has since been approved and adopted by several practitioners of respectability. See a paper on this subject, by Mr. Dawson, in the 13th vol. of Lond. Med. Phys. Journal. 22. Page 146, line 26. Where the tumour in the vagina occupies a largo space, Dr. Merriman thinks it a warrantable practice to remove it by excision, if it consisted of a solid sub- stance, and certainly to puncture it if it contained a fluid. Vide Medico-Chirur- gical Transactions, vol. 111. p. 47. 23. Page 152, line 15. See a case of deficiency ofthe ovaria, by Charles Pears, F. L. S., in the Phil. Trans, for 1805. This woman died at the age of twenty-nine. She had never Menstruated. She ceased to grow at the age of ten years. 24. Page 154, line 27. The periods of the commencement and cessation of the menstrual discharge, mentioned by our author, as occurring in Great Britain, agree pretty nearly with what is observed to take place in the United States. 25. Page 154, line 32. This is a point still debated. The weight of authority is, however, decidedly against menstruation continuing during pregnancy. By Bnudelocque, Denman, and almost all the modern writers, it is denied. Those who maintain the con- trary opinion,have very probably mistaken a hemorrhage from the vagina, which sometimes recurs with considerable periodical regularity, for the menstrual flux. Several cases of this kind have come under my own observation, wheie 1 had an opportunity of examining the discharge accurately. In every instance, 1 found it pure coagulable blood. By adverting to the slate of the pregnant uterus, this is exactly what we should be led to expect. Contemporary with conception, we know that the uterine eavity is lined with the membrana decidua, and ihat soon afterwards the os tineas is completely sealed with impacted mucus. Were an eflusion, therefore, to take place, especially in ihe early months of gestation^ it would destroy the attachment of the membrane, and produce all the consequences of uterine he- morrhage. It would seem, moreover, that the action which the vessels of the uterus take on to fabricate and support this membrane, is totally incompatible with the men- strual secretion. The two actions cannot co-exist. This is proved not only by the alleged cessation of ihe menses during pregnancy, but still more clearly by the fact, which has not been sufficiently attended to, that in a large proportion of cases of obstinate ameriorrhoea, ihe membrana decidua exists, and that the first symptom of ihe return of the discharge is the coming away of the membrane. Ofthe identity ofthe two membranes there can be no doubt. It has been ascer- tained by Dr. Baillie and many other competent judges. C. 26. Page 154, line 38. The celebrated John Hunter was, perhaps, the first physiologist who took notice publicly of this fact, at least in Great Britain. In his Lectures on the Theory and Practice of Surgery, (as quoted by Dr. R. W. Johnson, System of Midwifery, 2d edition, 4to. p. 34 and 35,) he observes, that " the blood discharged 761 in menstruation, is neither similar to blood taken from a vein ofthe same person, nor to that extravasated by an accident in any other part ofthe body; but is a species of blood changed, separated, or thrown off from the common mass, by an ection ofthe vessels of the uterus, in a process similar to secretion ; by which ac- tion the blood having lost its living principle, it does not afterwards coagulate." In his Treatise on Ihe Blood, vol I. p. 24, Philadelphia editioi:, he says, "in healthy menstruation, the blood which is dis-cbarged does not coagulate ; in the irregular, or unhealthy, it does. The healthy menses, therefore, (he continues,) show a peculiar action ofthe constitution ; and it is most probably in this action that its salubrious purposes consist." 27. Page 155, line 3. I am, loo, very much inclined to believe, that menstruation results from a se- cretory action of the uterus. Every other theory on the subject is indeed totally irreconcilable with facts. I will briefly enumerate the leading arguments by which the doctrine may be defended. 1. That the uterus, in its villous and vascular structure, resembles, in some degree, a gland ; and also, in its diseases, being equally liable to scirrhus, can- cer, Sic. Sic. 2. That, like other secretory organs, blood is very copiously diffused through it. 3. That by the arrangement of its vessels, it is evidently designed that the cir- culation should be retarded for the purpose of secretion. The arteries are not only exceedingly convoluted, but they are larger, and with thinner coats, than their corresponding veins. Thus, Haller says, "the blood is brought to the womb in greater quantity, and more quickly, through its lax and ample arteries, and on account of the rigidity and narrowness of the veins, it refurns with diffi- culty." 4. That, in common with other secretions, menstruation is often, at first, im- perfectly done, and is subject afterwards to vitiation and derangement. At its commencement, the discharge is commo/ily thin,-colourless, and deficient, and recurs at protracted and irregular intervals, wilh'pain and difficulty. 5. That, in many of the inferior animals, during the season of venereal incales-* cence, there is an uterine discharge which is undoubtedly a secretion. This an-> swers seemingly the same end as menstruation, namely, giving to the uterus an. aptitude lo conception. Though this fluid generally differs from the menses in com- plexion, yet in some instances they are precisely similar. Whenever the vehe-i real desire suffers a violent exacerbation from restraint, or other causes, the dis- charge in these animals becomes red. This has been more especially remarked in bitches kept from the male. 6. That the menses are a fluid sui generis, ur at least varying very essentially from the blood, having neither its colour, nor odour, nor coagulability, and on che- mical analysis presents different results. These last circumstances are enough alone to establish the theory. 7. To the objection that the uterus is not sufficiently glanular for the function of secretion, it has been, 1 think, very satisfactorily replied, that there is hardly a viscus or surface ofthe body which is not competent to the secretion of a fluid. It would really seem that no operation of the animal economy requires a less complex apparatus. Of what indeed does a gland consist, except a congeries of vessels ? Even the most perfect of the secretions are effected by this simple contrivance If a few vessels, "creeping over the coats of the stomach," can secrete the gastric liquor, why may not the infinitely more glandular organization ofthe uterus elaborate ihe menstrual fluid ? C. Saundeis has been presumed by some to have been ihe first who considered the catamenia as a secretion ; but Bordeu, a French physiologist of great merit, and of earlier date, treats of the uterus as a giand ; and of course, il is to be pre- sumed, must have viewed the menses as a secreted fluid. Haller also, in his Notes on the Prelectiones Academicae of Boeihaave, [Amstelodami, A. D. 1744,] speaks of the menses as a secretion. His words are '• Sed facile ipsa fabnea partium demonstrat uterum naturale organum esse hvjus secretionis." Vol. VI. 763 p. 72. Dr. Chapman says, that Dr. Craven supported this opinion, in a Thesis published at Edinburgh in the year 1778. 28. Page 161, line 40. There is much reason to believe, that an influence somehow derived from the ovaries, excites the uterus to the menstrual effort.—Certain it is, that in several instances, a permanent suppression ofthe menses has followed the loss of these organs. May not amenorrhcea, oftener than we suspect, be occasioned by a diseased state of the ovaries ? This, at least, was the opinion of the celebrated Cullen. Cases have also occurred, where, from original deficiency of the ova* lies, menstruation never took place. C. 29. Page 168, line 15. tn suppression of the menses, evidently connected with atony of the uterus, I have had some success with the tinct. cantharid. I give it in the dose of ten drops, morning, noon, and night, gradually increasing the quantity till it amounts to two or three drachms in the day. The most obvious effects of this medicine, which I have observed, are an increase in the force ofthe pulse, and a very co- pious flow of urine. From the sp. teiebinth. I have also, under similar circumstances, derived some advantage. In one case of this complaint, in which there was general torpor of the system, accompanied with a low degree of temperature, I administered phosphoius, but its use was interrupted too soon, by the prejudices ofthe patient, to judge of its efficacy. The phosphorus is a most powerful medicine, and requires great care in its administration. I gave of it, a tenth of a grain intimately blended with olive oil. Even in this small dose, it produced a universal glow and excitement. When properly regulated, phosphorus is both a safe, and, I believe, an eminently useful remedy. In ihe armies of France, it has recently been employed, 1 am told, with extraordinary success in typhus fever, gangrene, &c. Does it not also promise to do good in many other diseases, such as paralysis, epilepsy, chronic mania. Sic. Sic. ? C. To the abov"e list of emmenagogue medicines, may be added the polygala, senega, first used in this complaint, as far as 1 know, by Dr. Harlshorne, of this city, and introduced to the notice of practitioners generally, by Dr. Chapman, in a paper on ihis subject inserted in the Eclectic Repertory for October, 1811 ; in which some inleroting cases and remarks, in illustration ofthe use of this article ofthe materia medica ate given. The mode in which it is prepared and used, is as follows. In making the de-. coction, a pint of boiling water is added lo an ounce of the senega, bruised in a elose vessel ; and it is suffered to simmer over the fire, till the quantity is re* duced one third ; to prevent nausea, it is best to make the addition of an aro* matic, such as the orange peel or cassia. Four ounces of this decoction at a me* dium, is to be given during the day. But at the time when the menstrual effort is expected to be made, and till the discharge is actually induced, the dose is to be pushed as far as the stomach will allow. In the intervals cf the men* strual periods, the medicine is directed to be laid aside for a week or two ; as without these intermissions it becomes nauseous and disgusting to the patient. While under a course of the senega, it is lecommended to keep the general system properly regulated ; and it is observed, that excessive excitement or de- bility in to be equally obviated by the use of the appropriate remedies. For fuller information on this subject lhan can be compressed into the limits of a note, tho reader is referred to the interesting paper by Dr. Chapman, above alluded to, 30. Page 168, last line. In chlorosis, and, indeed, in all the forms of amenorrhcea, I have found purges very beneficial. Calomel and aloes combined, 1 have preferred in these cases. To be useful, it is necessary to continue this plan of treatment for weeks. Professor Hamilton, of Edinburgh, who is a most skilful practitioner in female 763 complaints, advises, very strenuously, a mixture of digitalis and the sp. ether. nitros. in chlorosis. The former, he directs in large doses, as much as ten drops ofthe tincture every hour. It would seem that digitalis is onlv applicable tq tho• - - - 1-8 cases. The shoulders ------ r . . 38 The head and umbilical cord ------ 15 The thighs ---------- 22 The feet _--------, H Oilier parts not specified - * - - - - - 24 Convulsions and floodings ------- 4 As 1 to 96 1-5. 132 The forceps were applied in 37 cases, which is as 1 to 344f. The cranium was perforated, or the crotchet applied, in 9 cases only. Gastrotomy was performed in one case only, and that to extract an extra-ute- rine fcetus. It also appears from a late periodical publication, that there were admitted into the lying-in hospital at Paris, called Maison d'Accouchemens, between the 9th of December, 1799, and the 31st of May, 1809, 17,308 women, who gave birth to 17,499 children ; of which number 16,286 were preseulalions of the vertex to the os uteri. 215 were presentations ofthe feet, being in proportion as 296 the breech - ..... 59 the face -------- 52 one of the shoulders ------ 4 the side ofthe thorax ------ 4 the hip -------- 4 the left side of the head - - • 4 the knees -------- 4 the head, an arm, and the cord ... - 5 D to 81 § 59J _ 296* _ 336J -, 4374| — 4374J _ 4374| — 4374i — 4374J 772 3 were presentations of the beUy, being in proportion as 1 to 5833 3 the back - . - - 1— 5833 3 the loins . . . 1— • 5833 1 the occipital region . . - 1— 17499 1 the side, with the right hand * - - 1— 17499 1 the right hand and left foot . - - 1— 17499 1 the head and the feet . . - 1— 17499 2 the head, the hand, and fore-arm . - . 1— 8749* 37 the head and umbilical cord - •" - - - 1— 473 Of this great number of women, 230 were delivered by art, the rest were natu- ral births, being in the proportion of 1 to 76* ; 161 were delivered by the hand alone, the children being brought by the feet ; 49 were delivered by the forceps, either on account of the small dimensions of the pelvis, the falling down of the umbilical cord, or the wrong position ofthe head, when the woman was exhaust- ed, or her life was in danger by convulsions, &c ; 13 were extracted by the crotchet after perforation of ihe head, on account of mal-conformation ofthe pel- vis ; in these instances the death of the child was first ascertained. The csesarian operation was performed in two cases, the diameter ofthe pelvis being only one inch six lines from sacrum to pubis. In one, the section ofthe symphysis pubis was performed, the diameter of the pelvis from sacrum to pubis being only two inches and a quarter. Gastrotomy was performed once, the fcetus being extra-uterine; the child weighed 81b. 2oz. 59. Page 367, line 22. The ligature should not be applied, until the pulsation ofthe funis has ceased, or at least until the child has cried, that the new circulation now to commence may bo thus properly established. Until this has taken place, the life of the child, according to Mr. White, is to be considered as merely foetal, or as if it were yet in utero. Whilst there remains a pulsation ofthe arteries of the funis, it proves the existence of the festal life, and the existence of the festal life proves the imper- fection ofthe animal life. Whilst the animal life, therefore, is imperfect, Mr. White lays it down as a rule, that the foetal life ought not lo be destroyed. The funis umbilicalis, therefore, should never be divided or tied, whilst there is any pulsation in its arteries. " By this rash inconsiderate method of tying the navel string, before the circulation in it is stopped, I doubt not (continues Mr. White) but many children have been lost, many of their principal organs have been in- jured, and foundaiions laid for various disorders.'' White on the Management of Pregnant and Lying-in Women, page 87. Wliilslon tho subject of tying ihe funis, we may mention an observation of Sa- batier, which is worthy of notice. He says that he has often known, in cases of congenital umbilical hernia, that the displaced intestines have protruded along the umbilical cord wiihout much increasing its size, and have been tied by the ligature made on it, occasioning the death of the infant. Medicine Operatoire, Tom. I. p. 152. 60. Page 367, line 24. If a second child remain, we very distinctly feel the enlarged uterus between the pubis and umbilicus, and even above the latter, and not so much diminished in size as we should have previously supposed; but if there is no second child, we feel the uterus contracted into a small round ball, extending not far above the symphysis pubis. 61. Page 369, line 5. The celebrated Ruysch, we are told, was the first to abandon the absurd prac- tice of hasty extraction of the placenta, enlightened, no doubt, by his superior anatomical knowledge. Dr. Hunter, in Great Britain, fully pointed out its im- propriety. He, however, erred on the other extreme : " Incidit in Scyllamcupiens vitare Charybdim." 773 Teaching that nature unassisted was adequate to the expulsion of the placenta in every case, he never interfered ; but experience, says Dr. Hamilton, soon taught him the error of this practice; for by suffering the placenta to remain too long, he. lost five patients of rank in one year. 62. Page 375, line 35. Baudelocque bas divided the presentations of the breech into four positions. In the 1st. The child's back is towards ihe mother's left side, and a little forward. But in proportion as it descends, its greatest breadth becomes parallel lo the antero-poslerior diameter of the inferior strait; the left hip placing itself under the pubes, and Ihe right below the sacrum. 2d. The child's back is towards the right side of the uterus, and a little for- ward ; the right hip placing itself under the arch of the pubes, the left being turned towards the sacrum. 3d. The spine of the child's back is turned directly towards the umbilicus of the mother ; although it is allowed seldom to descend in this position. 4lh. The spine of the child is towards the sacrum of the mother, and its abdo- men towards the anterior and middle part of the uterus of the mother. As it de- scends, the breadth from one hip to the other becomes parallel to one ofthe ob- lique diamelers ofthe pelvis. 63. Page 379, line 2. Baudelocque distinguishes four principal positions ofthe knees also. In the first position, the child's legs, which are always bent when the knees present, are towards the mother's left side, and the thighs towards the right side. In the 2d, the thighs#answer to the left side of the pelvis, and the legs to the right. In the 3d, the anterior part of the thighs is turned towards the sacrum of the mother, and tho legs are under the pubes. In the 4th, it is the reverse, the child's thighs being behind the pubes of the mother, and the legs placed against ihe sacrum. The presentations ofthe shoulder aro divided into four species by Baudelocque. In the 1st, the side of the neck rests on the edge ofthe os pubis, and the side of the breast over the sacrum, so that the fore part of the breast is towards the left iliac fossa, when the right shoulder presents, and towards the right Miac fossa when it is the left shoulder. In the second position, the side of the neck is over tho superior edge of the sacrum, and the side, properly so called, is over ihepubes; the breast answers to the right iliac fossa, when the right shoulder presents, and vice versa. In the third, ihe neck and the head rest on the left iliac fossa, while the side and the hip are over the right; so that the back is placed transversely under the ante- rior part of the uterus when it is the right shoulder, and on the posterior part of that viscus, when it is the left. The child is also placed transversely in the fourth position of the shoulder, but the head lies in ihe right iliac fossa, and the lower part of the trunk over the left; the breast is under the anterior part of the uterus when it is the right shoulder, and over the sacrum when it is the left. 64. Page 379, line 30. Baudelocque distinguishes four principal positions of the feet, to which he con- siders all the resl may be referred. Of these four positions he constitutes as many species of labour. In the 1st position, the heels answer to the left side of ihe pelvis, and a little forward ; the toes to the right side, and backward, nearly opposite the sacro-iliac symphysis. Above that symphysis are placed the breast and face; while the back is situated under Ihe anterior and left lateral part of the uterus. In the 2d position, the heels are towards the right side ofthe pelvis, and the toes to the left and a little backward. The trunk and head are so situated, that 774 the breast and face answer to that part ofthe uterus which is over the left sacro- iliac symphysis, and the back to the anterior and right lateral part of that viscus. In the 3d position, the heels are turned towards the pubes, and the toes to the sacrum. The child's back is under the anterior part ofthe uterus, and its breast answers to the lumbar vertebra- <>f the mother. The 4th position is exactly the reverse ofthe 3d ; the child's back and heels are towards the posterior part ofthe uterus, while the toes, the face, and breast, afe under its anterior part. 65. Page 382, line 6. It is not absolutely necessary Ihat both feet should be found and grasped, in the first instance ; it will be sufficient to find and bring down one, if both cannot be easily reached ; the second foot, with proper management, (to be hereafter directed,) will soon follow. 66. Page 384, line 3. By means of a noose applied round the ancle. 67. Page 384, line 31. We would strenuously dissuade from unnecessarily mutilating the foetus, even under the supposition of its death. We have known the child born with symp- toms of life, even after the head has been opened, and the greatest portion ofths brain evacuated ; and born alive, after its death had been considered as.certainly ascertained. It can seldom, if ever, be necessary to take off the arm to facilitate the operation of turning! 68. Page 387, line 39. Delivery by spontaneous evolution is a very rare occurrence. But that it orcaj sionally happens, is proved beyond suspicion by the case's recorded by Dr. Den* man and other respectable practitioners. Considering the difficulty and evert danger often incident to turning, it is certainly important to know how to distin-" guish those particular cases in which this curious resource of nature will probably Be successfully exerted. To warrant such an expectation, it must clearly ap- pear Ihat the uterine action, instead of operating on the presenting part, fixing it more closely in the pelvis, has ihe contrary effect of displacing it, and gradually bringing il out of the pelvis. But if we are convinced, after a careful examina- tion, that there is no tendency to spontaneous evolution, we should proceed to turn the child, as in proportion lo the delay ofthe operation is commonly the hazard attending it. C. 69. Page 388, line 25. Of each of these, Baudelocque has constituted four varieties of presentations { Tor a synopsis of which we must refer to the table, which the reader will find at the end of the Notes. 70. Page 388, line 30. Of each of these presentations, there are also, according to Baudelocque, four" varieties ; for an enumeration of which, the reader is referred to the table at the end ofthe Notes. 71. Page 389, tint 18. This includes the fourth and fifth presentations ofthe vertex, according to the division of Baudelocque, and have already been explained in note 57. ° 72. Page 390, line 2. The editor can also unite, from his own experience, in recommending the attempt at altering and correcting ibis malposition of ihe head, as above recom- mended ; it has olten proved successful in his own practice. It will he found that this mode of proceeding was first inculcated by Baudelocque, from ob- serving ihat nature herself sometimes obviated difficulties, and accelerated the termination of the labour, by converting the fourth position into the second, 775 fcnd the fifth into the first; or, ih bringing the posterior fontanelle from thd right or left sacro-iliac symphysis, to the right or left acetabulum. Vide Art des Accouchemens. 73. Page 390, line 34. These constitute the third and the sixth positions ofthe vertex, according to Baudelocque. The comparative unftequency of their occurrence is illustrated in the table in note 53. 74. Page 390, line 43. This by the French writers is termed enclavement, and by the English impac- tion, or the locked head. 75. Page 393, line l£. Mauriceau, in these cases, recommends turning the funis, and pushing a piece of soft linen after it, the end of which may remain hanging without. Dr. Mac-1 kenzie, a celebrated accoucheur of London, in a case where the funis presented, pulled down as much as he could, which he enclosed in a leathern purse ; and thus returned it, pushing them up together into the uterus; in this case the child was born ali/e. He afterwards pursued the Same practice, and sometimes suc- ceeded ; and others have since followed his example. 76. Page 399, line 34. In cases where the contractions ofthe uterus are inefficient from want of ener- gy, or irregular action of the uterine fibre, provided the cervix and os uteri, as Well as the external parts, are sufficiently dilated, or disposed to dilate, recourse may be advantageously had to the ergot. Under these circumstances, the editor has frequently derived the most decided advantage from its use, given in fine powder, in the dose of about one scruple in sirup, and has seldom had occasion to repeat it. In about twenty minutes after the exhibition of the article, the Contractions of the uterus are invigorated, and the process accelerated, in some instances-, probably several hours. In judicious and discriminating exhibition, this article of the materia medica may be considered as a valuable acquisition in the practice of mid wifery ; although, like all other powerful medicines, in rash and inexperienced hands il may possibly do harm. For fuller information on this subject, the reader is referred to the papers of Drs. Stearns, Prescolt, and Bigelow. The credit of introducing this medicine into obstetrical practice generally, is exclusively due lo the practitioners of the United States. 77. Page 413, line 12. Which may frequently bo safely done by the judicious use of the ergot, or spurred rye. 78. Page 413, last line. It is observed, generally, that women in labour bear well the loss of blood. Bleeding, undoubtedly, when used judiciously, facilitates the expulsion of the child, and secures a more speedy recovery, or " getting up." It moreover ob- viates the train of unpleasant consequences lo 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, bleeding is never to be neglected, provided the woman is not exhausted. But when it does not produce that effect, which will often happen, then opium in a large dose may be icsortcd to with ad- Vantage. It is correct practice, however, in most cases, to let bleeding precede the anodyne. C. 79. Page 416, line 19. These remedies are mostly inefficient or injurious. The warm bath is produc- tive of no advantage, and is apt to detach the placenta, occasioning thereby dan- gerous hemorrhages. But I confess my objections to it arise rather from what 776 I have learnt of others in whom I can confide, than from my own experience, having rarely seen the bath employed. Nauseating medicines, 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 Ihe remedy in these cases. It may often be pushed to a considerable extent. 1 have drawn as much as fifty ounces of blood in the course of a day, or nijiht, where the os tincte obstinately refused lo yield. In rigidity of the vagina, owing either to natural or acquired causes, and in tumefaclion ofthe external parts, attended with soreness to the touch, it is equally useful. C. 80. Page 417, line 11. A case of this kind occurred not long since to tho Editor, where, in conse- quence ofthe great tumefaction ofthe labia and parts in the vicinity, it became necessary to have recourse to punctures, to prevent the bursting or laceration of the immensely distended integuments. The tumefaction was so great, that the patient could only lay on her back, with her knees drawn up, and her thighs supported by pillows—the canal ofthe vagina was so lessened by pressure from the effusion in the surrounding parts, that the examination lo discover the state ofthe labour, was made with considerable difficulty. After the punctures in the labia (which jointly appeared to be as large as a child's head) weie made, the fluid continued oozing out for several hours, and it was supposed by a judicious assistant that nearly three pints of water had been evacuated. The labia ulti- mately were completely reduced, and indeed became flaccid, and the labour then progressed, and was accomplished without any great difficulty, but the child was dead. 81. Page 418, line 5. Two very interesting papers on tumours within the pelvis, obstructing partu- rition, have been published of latter years : the first by H. Parke, Esq. of Liver- pool, in the 2d vol. of the Medico-clururgical Transactions, and also in the Eclec- tic Repertory, vol. IV. The next and the most important memoir is by Dr. Mer- riman, in the Medico-chirurgical Transactions, vol. X. It would appear from the eases related or referred to in these papers, the,Em- bryulcia and ihe Crotchet can be rarely necessary in such instances. ^ From ihe evidence we at present possess, as has been observed by Mr. Parke and Dr. Merriman, the most eligible practice would generally appear lo be to puncture ihe tumour, or to make an incision into it, which gives both the mother and child the best chance of-existence. In the case related by Professor Francis, in a note to his valuable edition of Denman's Introduction,it nevertheless appear- ed to be necessary, after puncturing and breaking down the tumour, to deliver by the crotchet. The woman recovered, and again became pregnant. 82. Page 419, line 1. This retraction ofthe head during the recession of a pain, is more frequently owing to the rigidity of re-action of the external parts; and may often be obvia- ted, if necessary, by venesection. We believe it is rarely owing to the cause hero assigned for it by our author. 83. Page 419, line 14. In some cases where it has been found impracticable, without great danger of rupturing the cord, to bring it over the head of'lhe 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. 84. Page 436, line 2. I am pleased to find that the author has corrected some opinions too favoura- ble to the use of the lever, advanced in the former editions of this work and which the Editor then controverted; and now repeats his decided recommenda- 777 lion to young practitioners, rarely to make use of the vectis or lever, except to reqtify malpositions ofthe head. He agrees with Dr. Osborn, that the "vectis never ought, because it never can, be used with safety, when the child's bead is not sufficiently low lo admit the forceps." For a full view ofthe question with respect to the comparative advantages ofthe two instruments, the reader is re- ferred lo Dr. Osborn's Essays on the Practice of Midwifery, in natural and diffi- cult labours. 85. Page 437, line 25. Such are those which are now generally preferred and employed in this city, under the name of Haighlon's Forceps: by increasing the breadth of the blades, and enlarging the fenestra or opening in the blade, which is to be applied over the parietal protuberance, a firmer hold is obtained in consequence of the greater space of the cranium, which is grasped by the instrument. These forceps are also very conveniently portable, which is no trivial advantage,as it regaids prac- titioners in Ihe country. The following are the dimensions of Haighton's Forceps, as made by Henry Schively, Surgeon's Instrument-maker, Philadelphia. The whole length -------- 11* inches. Blade from the angle of the joint ----- 64 Handle to the angle of the joint ----- 54 Breadth between ihe blades in the widest part ofthe curve - 3 Breadth of tho blades near the point ----- If Do. of do. at its centre - - - - - 2f Do. of do. near the handles _ - - - 2\ 86. Page 442, line 23. The rectum likewise, where it passes over or near tho projection of the sacrum, may, by long continued pressure of ihe head, have its life destroyed, and slough- ing take place into the vagina, through which the faeces will be discharged. These deplorable effects sometimes follow cases of impaction, or the locked head, where instruments have not been used. 87. Page 442, line 40. The forceps are to be preferred lo the lever, even in the cases here alluded to ; they will rarely slip if properly, applied. It is generally owing to improper appli. cation, not having first accurately ascertained the precise position of the head, that we hear complaints of the forceps not keeping a firm hold. 88. Page 446, line 12. But when introduced, can il grasp the head so as to act with any effect in bringing it through the brim or superior strait? 89. Page 451, line 21. Where one of the sutures or fontanclles can be conveniently reached, the ope- ration is facilitated by perforating through these, as must occur to every one. 90. Page 45C, line 25. The reader is referred to a case of prematuie labour, artificially induced, where the child lived some time after delivery, relaled in the Eclectic Repertory, vol. I. p. 105, and seq. . The same woman was afterwards prematurely delivered of a child before the expiration of the eighth month, which lived and did well. 91. Page 461, line 12. Mauriceau, Baudelocque. Capuron, Solayres, and the generality ofthe modern French Accoucheurs and Surgeons who have had the greatest success in per- forming the Caesarian operation, prefer making the incision in ihe linea alba. Cooper agrees in recommending this mode. Vide Diet, of Surgery, Dorsey'a edition, vol. I. p. 163. Some of the reasons assigned for this preference are, that 778 the incision is made with greater facility, and is less painful, because there are fewer parts to be divided ; and the haemorrhage is less profuse. The uterus is readily brought into view, and it is cut in its middle portion, and parallel to its principal fibres. 92. Page 462, line 41. It has of late again been recommended, by some French writers of eminence ; vide Capuron,cours iheorique et pratique, &c. p. 673, and seq. Gnidien, Traite" d'Accouchemens, torn. 3, p. ?0. and seq., and J. B. De Mangeon, De ossium pu- bis Synchondrotomia. Parisiis, 1811. 93. Page 469, line 6. Dr. Clarke, of London, thinking it necessary, in a case of convulsions, to turn the child and deliver it, a convulsion occurred whilst his hand was in the uterus, when, of course, he had an opportunity of observing how it was affected.—He remarked, that instead of a regular contraction taking place, the uterus seemed to flutter, or be irregularly and tremulously contracted and relaxed again quickly, and he was disposed to believe that it was in that state during every case of puerperal convulsions. 94. Page 470, line 32. Where this cannot be conveniently accomplished, we should detract blood very freely by cupping from the temples and back part of the neck. I have more than once been witness to the best effects resulting from this practice, and therefore must here strongly recommend it. 95. Page 474, line 6. Dr. Hamilton, in an interesting paper on puerpeial convulsions, which he terms Eclampsia, [in Annols of Medicine for 1800,] says, that no patient to whose as- sistance he had been called, who had taken a dose of opium previously to his arrival, had ever recovered Camphor he strongly recommends, and gives it in doses of from 5 to 10 grains, frequently repeated; he says that every patient tq whom it was possible to give it, recovered.—The digitalis he also used wilh ad- vantage in those cases where oedema existed. This mode of treating the disease has proved so successful iq his hands, that, in the paper above referred to, which is well worthy of perusal, he states, that in 15 months immediately preceding its publication, he had attended twelve cases of the disease, where the fits had occurred previously to his being sent for ; and although in more than a majority of them, every symptom deemed unfavourable concurred, yet every patient recovered.—This is certainly a favourable result,for Mauriceau relates 21 cases of the disease, 13 of which died. Giffard mentions 4 cases, 2 of which perished. 96. Page 475, line 21. Vide a case by the Editor, inserted in the New-York Medical Repository for 1804. Hexade 2, vol, I. * 97. Page 476, line 27. See also a case of similar nature by Dr. M. Anthony. Eclectic Repertorv. vol. IV. p. 496. J 98. Page 477, line 39. Dr. Douglass' patient recovered after the delivery ofthe child. Mr. Haden's patient also recovered, after rupture of the uterus. Vide Med. and Chirurgical Transactions, vol. p. 184, seq. In a case that occurred lo the Editor, the wo- man lived near four days after delivery, and gave flattering hopes of recovery, but unhappily not realized. 99. Page 481, line 38. An interesting case of this nature is related by Dr. Merriman, in Edinburgh Mjid. and Phys. Journal for 1810, and in Eclectic Repertory, vol. I. p. 269, and seq. 779 100. Page 491, line 6. As the most prominent indication in these cases would appear to be to excite powerful contraction of the uterus, the ergot, or secale cornutum, might here be given with advantage, in the manner heretofore mentioned, 101. Page 492, line 22. It appears, from a late publication, that a novel mode of restraining uterine haemorrhage (taking place after parturition) has been attended with success, in Paris. It has been introduced by M. Evrat, and is as follows :—A lemon is de- prived of its rind and skin, and its cells exposed over its whole surface. This is introduced into the cavity of the uterus, in the hand of the operator ; by this means the blood flowing over the surface of the lemon can wash off only the juice that it meets with, but the innumerable cells of which the fruit is composed remain untouched. The contraction of the uterus is soon excited by the presence of the hand, and some drops ofthe citric acid. It is at this instant, that by forci- bly squeezing the lemon, its pure juice flows, without any admixture or dilution; and acts immediately on the internal surface of the uterus. M. Evrat advises, that in withdrawing the hand, the remainder ofthe 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 of the haemorrhage. The uterus, when it contracts completely, will expel the compressed lemon, as happened in a case related in the work alluded to. 102. Page 494, line 29. Le Roy thinks the position of the patient in haemorrhages, is worthy of con- sideration; in uterine haemorrhage, the horizontal position of course must be pre- ferred, and the feet should be more elevated than the head, 103. Page 500, line 13. The acknowledged efficacy of the ergot, in increasing the energy of uterine contractions, would appear to point it out as a proper remedy to be had recourse to in the cases of haemorrhage alluded to in this chapter; and as Dr. Bigelow has well observed, in females habitually subject to profuse haemorrhage at the period of parturition, there is perhaps no better preventive than a full dose of ergot, ad- ministered just before delivery. The editor has been in the practice of exhibit- ing it in powder, in doses of a scruple, mixed in any sirup ; but it may also be given in infusion or decoction; for instance, a drachm ofthe powder may be in- fused in half a gill of boiling water, and a table spoonful ofthe turbid fluid may be given every 20 minutes, till its effects are perceptible. 104. Page 501, line 21. Or probably, by pulling at the cord before that contraction ofthe uterus which is to expel the placenta from its cavity, takes place :—hence may be deduced a general rule worthy ofthe attention of young practitioners, to wait, after the de- livery ofthe child, until the woman complains of pain, (which generally indicates the contraction of the uterine fibres,) before they attempt to co-operate in tho extraction ofthe 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 determined by exami- nation ; and if found to be the case, we proceed to immediate extraction. 105. Page 503, line 29. In cases of partial inversion, where it has been found impracticable to reduce the uterus, it has been advised to grasp the portion which has passed through the os uteri firmly with the hand, and render the inversion complete, by bringing the whole of the uterus into the vagina, and keeping it there. By this means, the danger of strangulation from the stricture occasioned by the contraction of the oi uteri on the body of that viscus, is presumed to be prevented. This plan ap- 5 E 780 pears to have succeeded in a case by Dr. Dewees, in the Philadelphia Medical Musuem, vol. VI. p. 20, and seq. Case 2d. 106. Page 506, line 19. Inversion ofthe uterus may be occasioned by tho weight of an excresoenco of the nature of polypus, depending from the fundus of the uterus. For a case of this kind, together with an illustrative plate, see Denman's Collection of Engra- vings, tending to illustrate the generation and parturition of animals, and of tho human species. The fundus of the uterus was completely inverted, and dragged through the os uteri into the vagina. This case is worthy of consultation. 107r Page 507, line 9. It is frequently necessary to give the opiate in pretty large doses, and repeat it every few hours ; as for instance, 2 grains of purified opium, or 50 or 60 drops of laudanum ; where these fail, the best effects are sometimes experienced from an enema of 80 or 100 drops of laudanum, in four table-spoonfuls of thin starch, or infusion of flaxseed. When these do not succeed, the strong infusion or tincture of hops may be tried, or camphor and opium combined, given by the mouth. 108. Page 542, line 13. 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. 109. Page 543, line 13. 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 Amer- ica, even in our large towns, but more especially so in situations in the country; and that what has by some been considered as that disease, and in which deple- tion has been found so useful, has been a species of peritonitis. Of this tho Edi- tor thinks he has known more than one instance. On tho subject of fevers attack- ing puerperal women, he would particularly recommend to the student, the atten- tive peiusal ofthe excellent essays of Dr. John Oarke, on the Inflammatory and Febrile diseases of lying-in women. Also, the valuable writings of Gordon of Aberdeen, Hey of Leeds, and Armstrong of Sunderland, on the puerperal fever which prevailed as an epidemic in thoso places. 110. Page 544, line 42. It is an opinion entertained by some respectable and experienced practitioners, that this disease is, in fact, a variety of rheumatism, and is lo be managed on the general plan of treatment that is found to be successful in rheumatic fevor. After the inflammatory stage is over, it is by them considered as running into the chronic state of rheumatism, and to be treated accordingly by the remedies ap- propriated to that form of disease. 111. Page 547, line 28. It is the practice at one ofthe best regulated lying-in hospitals in London, 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 beyond those necessary to keep the bowels open, are ever used. [Vide vol. V. of Lond. Med. and Phys. Journ.) The editor can, from experience, add his testimony in favour ofthe beneficial effects of this treatment. Dr. John Clarke recommends laying the whole leg affected in a soft poultice, made as follows: To a peck of well dried bran, he adds an ounce of hot olive oil, and a pint of strong soap lees ; these being well mixed together, says the Doctor, form a poultice, which in these cases may be used with ihe 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. 781 Dr. Hosack, of New-York, in this disease strongly recommends the exhibition of a combination of squills and calomel, which he thinks has often produced the best effects. 112. Page 548, line 22. I have met with but two cases of this strange affection, which I treated, very successfully, by copious bleeding, by very active purging, and by blisters applied to the groin, and extending up the abdomen. In these cases there was every ap- pearance of high inflammatory action, accompanied with much pain. If the pre- ceding remedies should fail, and the disease run on obstinately to the second stage, I would recommend large doses of opium to allay the pain, and calomel in the ordinary quantity, with a view of exciting salivation. C. 113. Page 548, last line. Active purging is very useful in this disease. I have also known much goad to be derived from blisters to the sacrum. C. 114. Page 551, line 4. , _ In the management of this diseaso we are to observe the same rules as are ap- plicable to mania generally. It would seem, however, to be more frequently attended with extreme nervous irritation, than inflammatory action. In the for- mer state, I have seen the most manifest advantage from largo and repeated doses of the tincture of hops, where opium only aggravated the symptoms. In the latter Btate we should bleed and purge as long as there is increased excitement. Blis- ters 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 pro- duce calmness and ease. They are often, especially in mania, if applied in the proper condition ofthe system, which is after the excitement is a little reduced by previous blood-letting, the best of our anodynes. C. "115. Page 554, line 9. There is an intimate connexion between the thyroid gland and the brain. Tt is well known, that, very generally, one of the most remarkable symptoms of bronchocele is a gradual, though certain, decay ofthe intellectual faculties. This is strikingly exemplied in the Cretans ofthe Alps. The goitre, with this mise- rable race of people, is commonly, if not always, attended with idiotism. In the lower animals, if the gland be removed, a train of nervous affections will speedily follow, and finally fatuity, or a total extinction of mind. This has been proved by a series of experiments, made, as I have understood, by the celebrated Mr. Cooper, of London. As soon as I heard of these facts, it occurred to me as being not at all improbable, that one ofthe hitherto unknown uses of this organ might be to stay the circulation in eases of undue determination of blood to the head. I was assisted to this inference by the recollection of having seen it somewhere remarked, that in the cases alluded to, the gland is uniformly swelled more or less with blood. If, as it now seems to be admitted, that the brain acquires a certain proportion of blood for the regular performance of its functions, and that these will be equally impaired by any excess or deficiency of it, we can have no diffi- culty in conceiving how the brain becomes affected, either by an enlargement or total extirpation of the gland. With respect to the production of peurperal bronchocele we have an obvious ex- planation. During parturition, and particularly if it be laborious, there is very frequently an efflux of blood to the head, and, as may be observed, a considerable distention of the thyroid gland. By this distention, which occasionally is so great as to induce the woman to believe " that something has given way about her throat," the gland is relaxed ; it receives thereby a larger quantity of blood, which neces- sarily nourishes a morbid growth ofthe part. C. 116. Page 556, line 22. I know of nothing so good in these cases as bathing the breaBt with a mixture of laudanum, brandy, and hartshorn. C. 782 117. Page 559, line 35. fn 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 pre- ceding 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 unpleasant preventive, yet is certainly worthy ofthe attention of those who have often expe- rienced the extreme anguish arising from this variety of disease. 118. Page 560, line 7. Richter recommends touching the ulceration ofthe nipple with tho lunar caus- tic, and Dr. Hartshorne informs me that he has tried this wilh success in several cases, where every other application had failed giving relief. The caustic should be applied once every two days. 119. Page 565, line 5. This is rather too near the navel, for in case of the ligature cutting through the cord, and haemorrhage 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 ofthe child. It is best, therefore, to ap- ply the ligature, in a general way, at about three fingers breadth from the na- vel : this leaves sufficient space for the application of another ligature, if neces- sary. 120. Page 570, last line of note. The reader is also referred to an Inaugural Dissertation on Infanticide, by Dr. John Beck, of New-York, published in 1817. 121. Page 572, line 26. Or what is much better, a little mild oleum ricini, or even olive oil. 122. Page 574, line 9. Or a very good substitute may be found in the combination of equal parts of barley-water and fresh cow's milk, sweetened with the best refined loaf sugar. And here we may mention, that brown sugar should never be used in the food of infants, as it readily runs on into fermentation, generating gaseous flatulency in the primae viae, and often producing great uneasiness and colicy pains. When the child is habitually costive, the food may be sweetened with manna instead of sugar. 123. Page 579, line 27. The Very ingenious Astley Cooper, in some observations published in the Medi- co-Chirurgical Transactions, vol. II., has recommended two modes of treating spina bifida, which in his hands have been attended with very encouraging suc- cess ; one mode may be considered as palliative only, the other as radical. The first consists in treating the case as a hernia, and applying a truss to pre- vent its descent. This truss, in the first instance, may consist of a piece of plas- ter of Paris, somewhat hollowed, and that hollow partly filled with a piece of lint, which is to be placed upon the surface of the tumour; a strip of adhesive plaster is then to be applied, to prevent its changing its situation, and a roller is to be carried round the waist, to bind the plaster of Paris firmly upon the back, and to compress the tumour as much as the child will bear ; after some months, a truss may be applied, similar in form to that which is sometimes used for umbilical hernia in children, which must be constantly worn. The second mode of treatment, which is to be considered as rad*ca/,con-istsin producing adhesion ofthe sides of the sac, so as to close the opening from the spine, and stop the disease altogether. This is done by puncturing the tumour with a needle, or any very fine pointed instrument, and thus discharging the fluid contained in it. Pressure by means of a roller, &c. is then to be applied, and the operation of puncturing is to be repeated as often as the fluid re-collects. 783 The first mode, Mr. Cooper observes, is attended with no risk. The truss forms an artificial vertebra, when the natural is defective—a buttress which supports the part, and prevents the increase of the disease; but in this mode of treatment, the truss is required in future life ; for if discontinued, the tumour re-appears, and will grow as hernia does, to great magnitude, but with more fatal consequences. On the contrary, the adhesive mode of cure exposes the patient to much consti- tutional irritation, but leaves him without the apprehension ofthe future return of the disease. It may also be observed, that this mode does not prevent the sub- sequent attempt at the palliative treatment, if the radical should not be success- ful. Nevertheless, it is confessed that there are many cases of spina bifida which do not admit of a cure by these, or any other means. See Eclectic Repertory, vol. III. p. 438, and seq. 124. Page 580, line 32. This is a good test; for if, upon the insertion of the finger into the child's mouth, it sucks it readily, division of the fraenum cannot be, necessary. 125. Page 583, line 37. A very mild and useful application in burns, particularly in those of children, is a liniment composed of equal parts of mild olive oil and lime water, well mix- ed together by agitation ; this may be laid on with a feather, and afterwards a piece of fine old linen, dipt in the liniment, applied to the part, which is to be constantly kept moist by means ofthe feather. 126. Page 585, line 32. Blisters are sometimes applied in these cases to the temples, and even occasion- ally over the closed eyelids, with the best effects. 127. Page 636, line 2. Vide Alley on Hydrargyria, and Mathias on the Mercurial Disease ; also Spens on Erythema Mercuriale, in Edin. Med. and Surg. Journal, vol. I., and M'Mul- lin's in same work, vol. II. 128. Page 643, line 5. In so far as they operate as laxatives, their effects occasionally must be benefi- cial, and children are more easily induced to take them, as they are not so nau- seous as some other cathartics. 129. Page 645, line 2. It has been satisfactorily determined by the experience of the physicians of this city that the genuine Vaccine scab, after the usual process of separation from the arm, will, when properly used, communicate the real Vaccine disease. This valuable fact was first brought before the medical public in the year 1802, bv James Bryce, of Edinburgh, surgeon to the Vaccine Institution of that place. The student is also referred to a paper on this subject, with directions for the proper mode of using the scab, or crust, by Dr. Samuel Powel Griffitts, Eclectic Repertory, vol. I. p. 362. Dr. G. has used with success a scab which he had possessed for eleven months. As it appears to be a matter of importance to the voung practitioner to understand this subject well, we shall take the liberty of subjoining, from the paper above alluded to, the most essential circumstances to be observed in the use ofthe scab in vaccinating. " The most perfect vesicles which go on to the state of crust, or scab, without anv deviation frem the proper character, and which when they fall off are some- what transparent, smooth, of a mahogany colour, and rather brittle than tenacious in their texture, are to be chosen to propagate the infection. It should be the first seab 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, inter- nal part is to be shaved off, reduced to powder on a piece of glass and moistened wUh a small quantity of cold water, mixing it well together, and then mtroducmg 784 it in the arm on the point of a lancet, leaving also a small portion of the scab on the scratched part. No more of the 6cab must bo 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 bet- ter by continuing in the undetached state. It is believed that the livid vesicle, and especially the unopened one, is most powerful." 130. Page 647, line 8. Numerous cases have of late years been undeniably adduced, of the variolous virus producing its full effects twice in the same system, so that a similar objec- tion 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 pit- ted with the first attack, and he died nearly fifty years afterwards, in consequenco of the second. See also a case of secondary small-pox, with reference to some cases of a similar nature, by T. Bateman, M. D.F. L. S., Physician to Ihe public Dispensary, and to the Fever Institution. Medico-Chirurgical Transactions, vol. II. p. 31, and seq. » 131. Page 648, line 2. The following note is extracted from the Eclectic Repertory for July, 1813. The interesting nature of the information it contains, it is presumed, precludes the necessity of apologizing for introducing it here. " The following important statement, from the annual official Reports of the Board of Health of Philadelphia, with the accounts of persons vaccinated by the society for promoting vaccination, must be peculiarly interesting and conclusive in respect to the benefits of this invaluable discovery. By the Reports ofthe Board of Health, it appears that there have died of inoculated and natural small-pox, in the city of Philadelphia and its neighbourhood, In 1807 .. 32 persons. 1808..145 1809..101 1810..140 1811..117 1812.. none. In 1809.. 11C2 "1 Persons were successfully 1810.. 955 vaccinated by the Physi- 1811.. 1277 i ciansof the Society for pro- 1812.. 1255 j moting vaccination in tho ---- city and neighbourhood of Total, 4589 J Philadelphia." 132. Page 662, line 26. Of all the eruptive diseases, the measles are undoubtedly the most inflamma- tory. They therefore require to be treated by depletion. Bleeding, even pretty copiously, can rarely be dispensed with. I speak now of the disease as it appears in this country. To this remedy may bo added, occasionally, purging wilh the neutral salts, and the antimonial preparations, with a view not less of diminish- ing arterial action, than overcoming the structure on the surface ofthe body. The whole antiphlogistic plan is indeed to be pursued. If there be much local affec- tion, either in the lungs or head, blisters should be employed. Change of air, especially by removal to the country, will be found most speedily and certainly to subdue those distressing effects which too often follow the disease, such as diarrhoea, cough, Sic. C. 133. Page 691, line 25. It is not at all uncommon in hydrocephalus, at the expiration of eight or ten days, especially if its progress has been rapid, for the more violent symptoms to subside, so as to induce a very sanguine expectation of a speedy recovery. This is often a most treaoherous and fatal calm, as it results from an effusion in the ventricles ofthe brain. The vessels in this way become relieved, and the disease is suspended. After a short time, however, the extraneous fluid acts as a re- exciting cause, and the disease returns with redoubled force. Under such circum- 785 stances, It is perhaps incurable. Effusions in other cavities ofthe body mav be taken up, but as far as we know, the ventricles are destitute of absorbents or if they exist, they act incompletely in these cases. ' q 134. Page 702, line 28. Dr. Armstrong was the first, I believe, who called the attention of physicians to this complaint. He has written very elaborately upon it, and deems it much more formidable than it is commonly represented lo be. Where it is neglected ja"jV it/,wi11 degenerate into an almost constant drowsiness, which is suc- ceeded by a fever and thrush, or else it terminates in vomitings, sour curdled or green stools, the watery gripes, and convulsions." The antimonial wine, given as an emetic, is the chief remedy which he has suggested. Notwithstanding the preceding frightful picture, f cannot help considering " in- wards fits" as a very trifling sort of complaint, too trifling, indeed, to get a place among the diseases of infants. That ve/y young children often exhibit the symp- toms described by Mr. Burns, is undoubtedly true. These, however, will be found to proceed from uneasiness, the consequence of an overloaded and distended stomach. The mild carminatives will generally give relief. But if they fail, the stomach must be emptied by a puke or purge. It is better, however, to prevent this complaint altogether by a proper regulation of the child's diet. C. 135. Page 702, line 35. At this very early stage of life, I would prefer purging with castor oil to calo- mel. Q 136. Page 709, line 24. I oan bear testimony to the decisive and superior efficacy of active and con- tinued purging in chorea. Two cases of the disease in boys, which had been pre- viously treated for several months by stimulants and antispasmodics, without the least advantage, were perfectly cured by me in a very few weeks, by administer- ing, every two days, a powerful purge. C. 137. Page 712, line 32. Croup sometimes occurs even among people of advanced age. Cases of this kind have been repeatedly notieed by different practitioners in this country. C. 138. Page 713, line 15. During the growth ofthe body, the fluids, and especially the blood, in relation to the solids, are larger in quantity, as it is distinctly shown by a variety of cir- cumstances. This fulness of their vessels, and the greater excitability of their systems, render children peculiarly liable to inflammatory affections. Nearly all their diseases partake, in some degree, of this character. It follows, 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 chil- dren, than in those of adults. If, too, they do not at the time bear the loss of blood better, they undoubtedly recover much sooner from its effects. The preju- dice against bleeding in children, seems to have arisen out of the too prevalent opinion, that, owing to an extreme delicacy and frailty of constitution, they can- not bear any vigorous impression. As a natural consequence of this opinion, the general practice in their complaints is extremely feeble, exactly, indeed, of that kind 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 nor partial observation, I am thoroughly persuaded that the very contrary of this opinion is true. Children, I have remarked, display an uncommon tena- city of life, and strength of constitution. They often survive under circumstances which destroy adults. They have been found living at a » 3 c o-S 2«2 w1' Eh ^ @ ^, The fore part of tho Neck, or the Throat, 1 presenting | to the Os Uteri. The Breast presenting I at the ( Os Uteri. . The abdomen presenting at the | Os Uteri. The fore part ofthe Thighs and the! Pelvis, or the Sexual Parts, presenting at the Os Uteri. kofthe ) k- I 'tmg f i Uteri. J The Back Neck presenting at the Os Ute The Back presenting at the | Os Uteri. I TheLumbar Region presenting I at the t Os Uteri. ' The Side of the Nock presenting at the Os Uteri. The Shoulder, Elbow, or Arm and Hand, presenting at the Os Uteri. One of the Sides ofthe Child presenting at the Os Uteri. One of the Hips ofthe Child presenting at the Os Uteri. Of which there are IV. positions, viz. Of which there are IV. positions, viz. Of which there are IV. positions, viz. Of which there are . IV. positions, viz.. Of which thero are IV. positions, viz. Of which there are IV. positions, viz. Of which there are IV. positions, viz. Of which there are IV. positions, viz. Of which there are IV. positions, viz. Of which there are IV. positions, viz. Of which there are JV. positions, viz. 2d. [Accoig to BAUDELOCQUE.] t the Pubes ; the upper part ofthe Breast the projection of the Sacrum. d the Face towards the Sacrum. - , - - - - of tho left Ilium, and the Breast on theriglium. -*' - ofthe right Ilium, and the Breast on the le - - - r the Pubes, and the Abdomen "over the Sam, -" i r the base ofthe Sacrum, and the Abdomever the Pubes. ) ■ ■ « ! i the left Ilium, and the Abdomen on the nt Ilium. :' " ' > the right Ilium, and tho Abdomen on the!. - - - the inferior Pktremities above the Sacrum..... Xne Breast above the Sacrum; the inferior Extremities above the Pubes <*'-• - 1 he Breast resting on the left Ilium ; the Thighs and Knees on the rightum, - - - * - The Breast resting on the right Ilium; the Thighs and Knees on the lefl' *..... Ihe Knees above, or on one side of the projection ofthe Sacrum ;■' the domen above the Pubes ; the ) Breast and Face to the anterior portion of the Uterus. ft \ Tt?te™TeS °Ver ^ anteri°r brhnoflhePeJvis; the Breast andtwjhe posterior portion of the The Knees to the concavity ofthe right Ilium ; the Breast to the left IhV - - - - i. The Knees to the concavity ofthe left Ilium; the Breast to the righ|Ilii.-- - ' - * Jho^cciPutoverthemargin of the Pubes: the Back above the Sacrum..... The Occiput on one side of the projection of the Sacrum ; the back alovdie Pubes. - The Occiput on the left Ilium ; the Back to the right Ilium. I ..--... . The Occiput to the right Ilium; the Back to the left Ilium. - - ..... " rX/16 Tback.of lJB Neck °ver the margin of the Pubes ; the Lumbar Regi, above the Sacrum. The Lumbar Reg.ori over the Pubes ; tho back of the Neck over the pos ior margin of the Pelvis. - ■ The Occiput on the left Ilium ; the Lumbar Region on tho rio-ht Ilium - - . The Occiput to the right Ilium ; the Lumbar Region on tho Teft Ilium' - ;- - - -' ■ Tho Back above the fubes ; the Thighs above the Sacrum - •-'..... The Thighs and Feet above the Pubes; the Back and Head towards the acrum...... The Back on the left Ilium ; the Thighs and Feet ori the right Ilium. - - - - * - The Back on the right Ilium; the Thighs and Feet on the left Ilium., ...... The Ear and angle ofthe Lower Jaw to the Pubes; the Shoulder towardshe Sacrum. The Face towards ) the left sido of the mother when the right side of the Neck presents, an vice versa. \ The Ear and angle of tho Lower Jaw towards the Sacrum ; tho SWoukielowards the Pubes. The Face > towards the right side of the mother when the right side of the Neck prients, and vice versa. \ The side of the Head upon the left Ilium, and tho Shoulder on the rigMlium. The Face towards the > Sacrum when the right side of the Nock presents ; towards the Pubes hen the left. \ The side of the Head upon the right Ilium, and the Shoulder on the leftliuai. The Face towards the ) Pubes when the right side of the Neck presents; towards the Sacrum iven the left. $ The side of thei Am* on the Pubes, and the Side over the Sacrum. ThtBreast towards the left Ilium J when the right Shoulder or Arm presents ; and towards the rigtit Iliumwhen the left Shoulder or Arm \ presents. V TljieBreist towards the right Ilium > Ilium. JThe back to the fore part \ The Neck and Head on the right Ilium ;'the Side and Hip on the'left Ilium? ffhe I roast to the fore part \ of the Uterus when the right Shoulder and Arm present, and vice versa T ) The Axilla over the Pubes ; the Hip over the Sacrum. The Bre&t towards tie left Ilium when tho right ) Side presents, and vice1 versa. :j j c the Axilla over the Sacrum ; the Hip over the Pubes. The Breast towards thfright Ilium when the right ) Side presents, and vicfi versa. . - fT I The Axilla on the left Ilium ; the Hip on the right Ilium. The Brkst tow rus when the right Side, and vice versa. The Axilla on the right Ilium ; the Hip on the left Ilium j rus when the right Side presents, and vice1 versa.' The Thighs towards the Sacrum ; the Spine of theJIium towards.lbe Pube i left Side ofthe Uterus when the right Hip presents, and vice- versa The Thighs towards the Pubes ; the Spine of the Ilium towards the Sacjrr , side of the Uterus when the right Hip presents, and vic6 versa U JThe Thighs towards the right Side ; the Spine of the Ilium towardsthe left posterior part of the Uterus when the right Hip presents, and vice versal - The Thighs towards the left Side ; the Spine of the Ilium towards the right Side. anterior part ofthe Uterus when the right Hip presents, and vice versa. The side of the Neck over the Sacrum, and the Side over the Pubes when the,right Shoulder presents, and vic6 yersa. The Neck and Head on the left Ilium; the Sido and Hip on the) right m"[ Vt!J?1!™8 "h™ th° figlU ?h°ulder PresentSi and to the back.partwfien tie left presents. * J TheB s the back part of the Ute- st towj|'ds the fore part of the Ute- The Breast towards the The Breast towards the The Breast towards the The Breast towards the Either the right or left hand of Ihe practitioner, indifferently, to be introduced to The right hand to be introduced when the Face is on the right side of the vert The left hand to be introduced to reach the Feet and turn the Child, &c. The right hand to be introduced, &c. &c. Either the right or left hand, indifferently, to be introduced. The right hand to be introduced when ihe Face is on the right side of the ver i The left hand to be introduced, &c. &c. The right hand to be introduced, Sic. Sic. The right or left hand may be introduced, indifferently, &c. The right or left hand, indifferently, may be introduced. The left' hand to be introduced towards the right side ofthe Uterus. The right hand to be introduced towards tho left side of the Uterus. The right or left hand, indifferently, may be introduced. The right or left hand, indifferently, may be introduced. The left hand to be introduced towards the right side ofthe Uteru?. The right hand to bo introduced towards the left side of the Uterus. Either tho right or left hand, indifferently, to be introduced, &c. Either the right or lefl hand, indifferently, to be introduced. The right hand to be introduced towards the left side ofthe Uterus'. The left hand to be introduced towards ihe right side ofthe Uterus. The right hand to be introduced towards the left side ofthe Uterus, The right hand, &c. &c. > The right or left hand, indifferently, &c. &c. The right or left hand, indifferently, &c. The right hand to be introduced, &c. The right hand, &c. The left hand to be introduced towards the right Ilium. The right hand to be introduced towards the left Ilium. The right hand to be introduced when the right side of the Neck presents ; the left hand when the left side, &c. The left hand to be introduced when the right side ofthe Neck presents ; the right hand when the left side. The right hand to be introduced when the right side ofthe Neck presents, &c. The left hand to be introduced, &c. The right hand to be introduced when the right Shoulder; the left when the left Shoulder presents. The left hand to be introduced when the right Shoulder presents ; the right hand when the left Shoulder, fee. The right hand to be introduced when the right Shoulder presents ; tho left hand when the left Shoulder, Sic. The right hand to be introduced.when the right Shoulder presents ; the left hand when the left Shoulder, Szc. The right hand to be introduced if the right Side presents ; the left hand if the left Side presents. The left hand to be introduced Jf the right Side presents ; the right hand if the left Side presents. The right hand to be introduced if the right side presents ; the left hand if the left Side presents. Tho right hand if right Side; the left hand if left Side. The right hand to be introduced when the right Hip presents ; tho left hand whan the left Hip, &c. The left hand to be introduced when the right Hip presents ; the right hand when the left Hip, &c. The left hand to be introduced in both varieties of the position. The right hand to be introduced in both varieties of the position. r . ^/u'T1^i8 t0.u6 ob,se"ed that Baudelocque, and the French practitioners generally in preternatural Labours, or where the opjration of Turning, or the application of the Forceps becomes necessary, place the Woman in a Supine Position, with the Breech brought to the edg* or foot of the bed, so that the Coccyx and Pennamm may be free, the Thighs and Legs half extended, the Feet resting on two chairs Jaced properly, or supported by assistants. Plate 1. 7tCxmpe>eJl Sc '-*. PI ah 2. ILCampbeH Sc A SERIES OF EJTGRAVIXGS, Waaa ai5i2>^3Ir'8£!'i?J]S>SJ3o SELECTED FROM SMELLIE'S PLATES, PLATE I.—Represents, in a front view, the Bones of a well-formed Pelvis. The five vertebrae of the loins, The os sacrum, A The-os coccygis, B The os ilium. C.C The ossa ischia. D The ossa pubis, E The foramina magna. F The acetabula. G.G.G The brim ofthe pelvis, or that circumference of its cavity, which is described at the sides by the inferior parts ofthe ossa ilium, and at the back and fore parts by the superior parts of the ossa pubis and sacrum. In this Table, besides the general structure and figure ofthe sever ral bones, the dimensions ofthe brim of the pelvis, and tbe distaace between the under part of the ossa ischium, are particularly to be attended to ; from which it will appear thit the cavity ofthe brim is commonly wider from side to side than from the back to the fore part, but that the sides below are in the contrary proportion. The reader, however, ought not from this to conclude, that every pelvis is similar in figure and dimensions; since even well formed ones differ ki some degree from each other In general, the brim ofthe pelvis measures about five inches and a quarter from side lo side, and four inches and a quarter from the back to the fore part ; there being likewise the same distance between the inferior parts of the ossa ischium. All these measures, however, must be understood as taken from the skeleton ; for, in the subject, the cavity of the pelvis is sition in the former plate) backwards to the os sacrum, and the occiput below the pubes; by which means the narrow part of the head is to the narrow part ofthe pelvis, that w, between the inferior parts of the ossa ischium. Hence if may be ob- [ PLATES. 1 strvedi that, though ihe distance between the inferior parts of the Itisi mentioned bones is much the same as between the coccyx and pubes; yet, as the cavity of the pelvis is much shallower at ihe anterior than lateral part, ihe occiput of the fcetus, when come down to the inferior part of either os ischium, turns out below the fubes. This answers the same end as if the pelvis itself had been wider from the posterior part than from side lo side ; the head likewise enlarging the. canty by forcing back the coccyx, and pushing out the external parts inform of a large tumour. The uterus contracted closely to the fcetus after the waters are evacuated. The vertebrae of the loins, or sacrum, and coccyx* A The anus. B The left hip; C The perinaeum. D The os externum beginning to dilate; E The os pubis ofthe left side. F The remaining portion of the bladder; G The posterior part of the os uteri. PLATE VI.—Shows iri what manner ihe head ofihefaXus is helped along with the forceps, as artificial hands, when it is necessary to as- sist with the same for the safety ofeitJier mother or child. The vertebrae ofthe loins, os sacrum, and coccyx* A The os pubis of the left side. B The remaining part of the bladder* C The intestinum redtutri. D The mons veneris. E The clitoris, with the left nympha. F The corpus cavernosum clitoridis* )C The meatus urinarius. H The left labium pudendi. I The anus. K The perinaeum. L.M The left hip and thigh. The patient, in this case, may be placed, as in this plate, on her side; With her breech a little over the side or foot of the bed, her knees be- ing likewise pulled up to her abdomen, and a pillow placed between them, care being taken, at the same time, that the parts are, by a pro- per covering, defended from the external air. If the hairy scalp of* the fetus is so swelled, that the situation ofthe head cannot be dis- tinguished by the sutures, as in plate III. ; or if, by introducing a fin- ger between the head ofthe child and the pubes^ or groihs* the ear or back part of the neck cannot be felt, the os externum must be gra. dually dilated in the time ofthe pains, with the operator's fingers, L'troduc^in:^"catedwith hog's "lard,) til. the whole hand Jn be mtroduced into the vagina, and slipped up, in a flattish form, between Plate ti. I ♦ / K RCzmpheU Se» 43 Flatt 7. [ PLATES. ] Hie posterior part of the pelvis and the child's head. This last is then to be raised up as high as possible, to allow room for the fingers to reach the ear and posterior part ofthe neck. When the position of the head is known, the operator must withdraw his hand, and wait to see if the stretching ofthe parts will renew or increase the labour- pains, and allow more space for the advancement ofthe head in the- pelvis. If this, however, proves of no effect, the fingers are again to be introduced as before, and one ofthe blades ofthe forceps (lubri-j cated with lard) is then to be applied along the inside ofthe hand or' fingers, and left ear of the child, as represented in the plate. But, if the pelvis is distorted, and projects forward at the superior part of the os sacrum, and the forehead, therefore, cannot be moved a little back- wards, in order to turn the ear from that part of the pelvis which prevents the etid ofthe forceps to pass the same ; in that case, the blade must be introduced along the posterior part of the ear at the side ofthe distorted bone. The hand that was introduced is then to be withdrawn, and the handle ofthe introduced blade held with it as far back as the perinaeum will allow, whilst the fingers of the other hand are introduced to the os uteri, at the pubes or right groin, and the other blade placed exactly opposite to the former. This done, the handles being taken hold of and joined together, the head is to be pulled lower and lower every pain, till the vertex, as in this plate, is brought down to the inferior part ofthe left ischium, or below the same. The wide part ofthe bead being now advanced to the narrow part ofthe pelvis betwixt the tuberosities ofthe ossa ischium, it is to be turned from the left ischium, out below the pubes, and the fore- head backwards to the concave part of the os sacrum and coccyx, and afterwards the head brought along and delivered as in plates VII. and Vltl. But, if it is found that the delivery will require a con* siderable degree of force, from the head being large, or the pelvis narrow, the handles of the forceps are to be tied together with a fillet, as represented in this table, to prevent their position being changed, whilst the woman is turned on her back, which is then more conve- nient for delivering the head, than when laying on the side. This plate shows .that the handles of the forceps ought to beheld as far back as the os externum will allow, that the blades may be id an imaginary line between that and the middle space between the umbilicus and the scrobiculus cordis. When the forceps are applied along the ears and sides ofthe head, they are nearer to one another, have a better hold, and mark less, than when over the occipital and frontal bones. PLATE VII.—In this, the os externum is open, the occiput comeslou) down from below the pubes, and the forehead fast the coccyx, by which both the anus and perinmum are stretched out inform of a large tumour. When the head is so far advanced, the operator ought to extract with great caution, lest the parts should be torn. If the labour-paina [ PLATES. ] are sufficient, the forehead may be kept down, and helped along, in a slow manner, by pressing against it with the fingers on the exter- nal parts below the coccyx ; at the same time, the forceps being taken off, the head may be allowed to stretch the os externum more and more, in a gradual manner, from the force of the labour-pains, as well as assistance of the fingers. But, if the former are weak and insufficient, the assistance ofthe forceps must be continued. (Vide the description ofthe parts in plate VI.) S. T. in this, represent the lefl side ofthe os uteri. The dotted lines demonstrate the situation ofthe bones ofthe pelvis on ihe right side, and may serve as an ex- ample for all the lateral views ofthe same. A.B.C.H The outlines of the os ilium. D.E.F The same ofthe pubis and ischium. M.N The foramen magnum. PLATE VIII.—In the same section ofthe parts, but with a view of the right side, shows the head of the fcetus in the contrary position to the three last figures, the vertex being here in the concavity of the sacrum, and the forehead turned lo the pubes. A The anus. B The os externum not yet begun to stretch. C The nympha. D The labium pudendi ofthe right side. When the head is small, and the pelvis large, the parietal bones and the forehead will, in this case, as they are forced downwards by the labour-pains, gradually dilate the os externum, and stretch the parts between that and the coccyx, in form of a large tumour, till the face comes down below the pubes, when the head will be safely de- livered. But, if the same be large, and the pelvis narrow, the diffi- culty will be greater, and the child in danger ; as in the following plate. PLATE IX.—Shows, in a lateral view, the face of the child present. ing, and forced down into the lower part of the pelvis, the chin being below the pubes, and the vertex in the concavity of the os sacrum ; the waters likewise being all discharged, the uterus appears closely joined to the body of the child, round the neck of which is one circumvolution of the funis. A The inferior part ofthe rectum. B The perinaeum. C The left labium pudendi. When the pelvis is large, the head, if small, will come along in this position, and the child be saved ; for, as the head advances Plak 8. / Pl.t* 9. Plate UK Plate/I. Tt.Qimf>b4l. Sc [ PLATES. ] lower, the face and forehead will stretch the parts between the frse- num labiorum and coccyx, in form of a large tumour. As the os externum likewise is dilated, the face will be forced through it ; the under part ofthe chin will rise upwards over the anterior part ofthe pubes ; and the forehead, vertex, and occiput, turn from the parts below. If the head, however, is large, it will be detained, either when higher, or in this position. In this case, if the position cannot be altered to the natural, the child ought to be turned and delivered footling. PLATE X.—Shows, in a front view ofthe parts, the forehead of the fcetus presenting at the brim of the pelvis, the face being turned to , one side, the fontanelle to the other, and the feet and breech stretched toward the fundus uteri. A The perinaeum. B The os externum ; the thickness ofthe posterior part be- fore it is stretched with the head of the child. C.C.C The vagina. D The os uteri not yet fully dilated. • If the face is not forced down, the head will sometimes come along in this manner ; in which case the vertex will be flattened, and the forehead raised in a conical form ; and when the head comes cfown to the lower p^rl ofthe pelvis, the face or occiput will be turned from the side, and come out below the pubes. But, if the head is large, and cannot be delivered by the pains, or if the wrong position cannot be altered, the child must be delivered with the forceps. PLATE XI.—Shows, in a lateral view ofthe right side, the face of the f ailus presenting, as in plate IX., but in a contrary position; that is, with the chin lo the os sacrum, and the bregma to the pubes, the waters evacuated, and the uterus contracted. In such cases, as well as in those described in the last Plate, if the child is small, the head will be pushed lower with the labour-pains, and gradually stretch the lower part ofthe vagina and the external parts ; by which means the os externum will be more and more dila- ted, till the vertex comes out below the pubes, and rises up on the outside ; in which case the delivery is then the same as in natural labours. But, if the head is large, it will pass along with great diffi- culty, whence the brain, and vessels of the neck, will be so much compressed and obstructed, as to destroy the child. To prevent which, if called in time, before the head is far advanced in the pel- vis, the child ought to be turned, and brought footling. If the head, however, is low down, and cannot be turned, the delivery is then to be performed with the forceps, either by bringing along the head as it presents, or as in the following Plate, bee the references in Plate IX. [ PLATES. ] PLATE XII.—"Represents, in a front view of the pelvis, the breech of the fcetus presenting, and dilating the os internum, the membranes being too soon broken. The fore parts of the child are to the poste. rior part of the uterus ; and the funis, with a knot upon it, surrounds the neck, arm, and body. Some time after this and the other Plates were engraved, Doctor Kelly showed me a subject he had opened, where the breech pre. sented, and the child lay much in the same position with its body as in tbe second plate, supposing the breech in that figure turned down to the pelvis, and the head up to the fundus uteri. I have sometimes felt, in these cases, (when labour was begun, and before the breech was advanced into the pelvis,) one hip at the sacrum, the other resting above the os pubis, and the private parts to one side ; but, before they could advance lower, the nates were turn- ed to the sides and wide part of the brim ofthe pelvis, with the pri. yate parts to the sacrum, as in this plate ; though sometimes to the pubes. As soon as the breech advances to the lower part of the ba, sin, the hips again return to their former position, viz, one hip turned out below the os pubis, and the other at the back parts ofthe os ex, ternum. • In this case, the child, if not very large, or the pelvis narrow, may be o£te« delivered alive by the labour-pains ; but, if long detained at the inferior part ofthe pelvis, the long pressure ofthe funis may ob- struct the circulation. In most cases where the breech presents, the effect of the labour-pains ought to be waited for, till at least they have fully dilated the os i ternum and vagina, if the same have not been stretched before with the waters and membranes. In the mean time, whilst the breech advances, the os externum may be dilated gently during every pain, to allow room for introducing a finger or two of each hand to the outside of each groin ofthe foetus, in order to assist the delivery when the nates are advanced to the lower part of the vagina. But, if the foetus is larger than usual, or the pelvis narrow, and after a long time, and many repeated pains, the breech is not forced down into the pelvis, the patient's strength at the same time failing, the operator must, in a gradual manner, open the parts, and, having introduced a hand into the vagina, raise or push up the breech ofthe fcetus, and bring down the legs and thighs. If the uterus is so strongly contracted that the legs cannot be got down, the largest end of the blunt hook is to be introduced. As soon as the breech or legs are brought down, the body and head are to be delivered, as descri, bed elsewhere, only there is no necessity here to alter the position ofthe child's body. The description of the parts in this plate is the same as that of plate XI. only the dotted lines in this describe the place ofthe ossa pubis, and anterior parts ofthe ossa ischium which are removed, and may serve in this respect as an example for all the other front views, where, without disfiguring the plate, they could not be so well put in. Flatel2 . / INDEX. Abortion, 266—difference in symptoms of, according to age of foetus, 268— great diversity in symptoms and dura- tion of, 269—in some cases child ap- pears dead for some time before, 270 —divided into accidental and habitual, 271—most apt to occur in those who have married late in life, 272—apt to occur after having miscarried once, ib. —exciting causes of, 274 predispos- ing causes of, 279—excitement of ori- gin of spinal nerves, ib.—fatigue, a cause of, 282—death of child, a cause of, ib.—when threatened, treatment of, 286—when it cannot be prevented, treatment of, 294—principal means for restraining haemorrhage in, 296— manual assistance in, 297—effect of, on stomach, 299. Absorbents, medicines supposed to act as such, 107. After-pains distinguished from inflam- mation of uterus or peritonaeum, 506 __great attention to be paid to situa- tion and duration of, 507. Alopecia, 615. Amenorrhcea, 160. Amnion, 207. Amnii, liquor, in too great quantity, 246 —how distinguished from ascites, 247. Antiversion of uterus, 262. Anus, imperforate, 576. Apoplexy, 242—during labour, 474. Aphtha?, 625—divided into mild and se- vere, ib.—source of danger in bad cases of, 626—cause of, 627—treat- ment of, ib.—local applications to, 628 —on tonsil, with or without fever, 619 —malignant and infectious species of, constituting putrid sore throat, ib. Arrest of head, 423. Ascites, 245. Baldness, 615. Bladder,56—diseases of, 95—stone in,ib. —contraction of orifice of,96—indura- tion and scirrhus of, ib.—chronic in- flammation of mucous membrane of, 97—polypous tumours in, ib.—gan- grene of, ib.—prolapsus vesicaB, 99— hernia vesicalis, ib.—treatment of, 100 5 —affected by pregnancy, 236—dis- tended, effect on retroversion, 261. Boils, 597. Bronchocele, 553—treatment of, 554. Bronchotomy in croup, 715. Bronchitis, 72o—treatment of, 726. Burns and scalds, 583. Cffisarian operation, 458—cause of dan- ger of, 459—direction for the perform- ance of, 461—when the mother dies in end of pregnancy, proper to per- form the operation, 462. Catarrh in infants, 725. Catheter, introduction of, 56. Calculus,95—in uterus, 120. Cerebral and spinal irritation, 157, 664 —different modes of affoeting action of brain, ib.—effects produced on brain, 666—consequences of, 667—on stomach and intestines, ib.—cough, 669. Chicken-pox, 648—description of, ib.— lenticular, 649—conoidj.1, ib.—swine or bleb pox, ib.—management of, ib. Child, head of, and progress through pelvis in labour, 39—dimensions of, 40—compared to pelvis, 41—passage of, in labour, 356. Child alive before quickening, 222— motion of, amounting to disease, 242 —delivery of, after flooding, 325— birth of, and application of ligature to cord, 366—dead, signs of, in note, 450. Chorea sancti Viti, 697—treatment of, 708—variety of, generally attacking females, 709. Chlorosis, 160. Chorion, 207. Clitoris, 55—scirrhus of, 77—elonga- tion of, ib. Colic, 802. Conception, 181. Convulsions, tetanic, during gestation, 242—hysterical, during gestation, 2 .3 __during labour, 465—hysterical, 4 i6 __of nature of tetanus, succeedc d oy stupor, ib.—symptoms indicating ap. proach of, 467—arising from uteiine irritation, 468—treatment of, 470— 11 delivery in, 471—internal remedies, 472—preventives, 473. Convulsions of children, 708—divided into those from primary affection of brain, and those from sympathy with some other organ, ib.—inward fits of infants, 702—description of, 703— treatment of, ib.—stupor after, 705— near time of puberty, 706—during hooping-cough, 724. Cord, umbilical, 198—length of, 199— varicose state of vessels of, 200—rup- ture of, ib.—varieties of, ib.—ligature of, 367—presentation of, 392. Corpora lutea, 181. Crotchet, application of, 453—directions in operating with, 455. Croup, 711—description of, ib.—dissec- tion, appearances on, 712—treatment of, ib.—bleeding in, ib.—emetics in, 713—blisters in, ib.—calomel in, ib.— bronchotomy in, 715—spasmodic, 716 —causes of, 717—treatment, 718. Costiveness during pregnancy, 233—in children, 741—hereditary, ib.—treat- ment of, ib. Cutaneous diseases, 591. Dandriff, 607. Death, sudden, after delivery, 488, 515. Delivery during uterine haemorrhage, 325—circumstances under which to be performed, 326—when os uteri is firm and unyielding, to trust to plugging, cold, &c. and delay, 327—when pa- tient has lost much blood, and is very much debilitated, to deliver or not ? 331 Delirium, puerperal, 549. Dentition, 587—bad effects of, 589—to allay local irritation in, 590—to alle- viate urgent symptoms, ib.—to sup- port the strength in, 591—convulsions during cutting second set, 706—spasm about windpipe during, 720. Despondency of women during preg- nancy, 254. Diarrhoea, 235—after delivery, 554—in children, 731—appearance of stools in, 733—how injurious, 734—appearan- ces on dissection, ib.—exciting causes of, 736—treatment of, 737—calomel, &c, 738—necessary to support strength in, 739—recapitulation of practice, 740. Dietetic treatment of pregnant women, 228. Diet of children when not suckled, 574. Distortion of feet, 580. Dress of children, 575. Dysmenorrhea, 170. Dyspnoea, 235. Earach in children, 584. Eczema mercuriale, 635. Ergot, 168, 297, 399. Eruptions, anomalous, arising from den. tition or irritation of bowels, 596— from deficient nourishment, 597—like millet seed, in children, 599. Erysipelas,617—milder, and worst kinds of, 618—treatment of, ib. Erythema, 619. Excoriations behind ears, 620—treat. ment of, ib.—superficial on tongue, gums, and inside of lips, during den- tition, 631. Extremities, spasms of lower, 251. Eye, inflammation of, in infants, 585— spongoid disease of, ib. Fallopian tubes, 64—wanting or imper- vious, 152. Faeces, indurated, 234. Febrile state during pregnancy, treat- ment of, 229. Fever.appearing in middle of pregnancy, assuming appearance of hectic, 229— ephemeral and remittent, 516—causes of, ib.—commencement of attack, 518 —treatment in cold stage, 519—to check a recurrence of fit, 520—milk, 521—miliary, ib.—intestinal, 523— symptoms of, ib.—treatment of, 524 —puerperal, 534—symptoms and his- tory of, ib.—attacks generally second or third day, 536—appearances on dis- section, 53 7—less fatal in private prac- tice than in hospitals, ib.—how dis- tinguished from peritonitis, ib.—treat- ment of, by different practitioners, in note, 538—on first appearance of, 542 —remittent infantile, 679—symp- toms, and treatment of, 680—of older children, produced after eating some indigestible substance, 681—brought on more gradually by irritation of ac- cumulated faeces, 682—description of, ib.—mild cases of, ib.—bearing strong resemblance to hydrocephalus, 684 —generally produced by disorder of bowels irritating the brain, ib.—treat- ment of, 685—venesection in, 686 —liver apt to have its function im- paired, 688. Fever, typhus, 753—symptoms of, ib.— treatment of, 754. Fluor albus, 90—proceeding from ute- rus, ib.—alternating with menses, ib. —divided into three species, 92— treatment of, 93. iii Foetus, appearance and growth of, 190— proportion between weight of, and in- volucra,192—twins,193— proportions of single births to plurality of child. ren, 194—peculiarities of, ib.—liver, gall-bladder, &c. of, 195—blood of, ib.—stomach, intestines of, ib.—lungs of, 196—structure of heart of, ib.— head and brain of, 197—difference between male and female, ib.—posi- tion of, in utero, ib. Forceps, arguments for use of, 425— observations on application of, 429— patients generally disinclined to use of, 432—ancient practice, 433—Cham- berlain's, 434—-directions for applica- tion of, 437—movement of, in delive- ry, 441—application of long, 444—di- rections for, 446. Frenum linguse too short, 570. Generation, external organs of, 54— labia, ib.—clitoris, 55—orifice of ure- thra, 57—vagina, orifice of, ib.—pe- rinaeum, 58—internal organs of, 59— diseases of, 69. Gestation, duration of, 84—how reck- oned, ib.—laws of this country with regard to, in note, ib. Gonorrhoea, 95. Gums, spongy and ulcerated during den- tition, 621—when neglected become fungous, and is called scorbutic, ib.— corroding disease of, beginning in cheek, 622. Headach, during gestation, 241. Head, dimensions of, &c. 40—presenta- tion of, but improperly situated, 289 —forehead to acetabulum, ib.—fonta- nelle, 390—crown of, with face to pubis, ib.—side of, 391—occiput, ib.— face with chin directed to acetabulum, pubis, sacrum, or sacro-iliac junction, ib.—advice to turn the child, 392— child's, size of, or firmness of, making it necessary to destroy the child, 449 —sometimes required to break down the, 454. Harelip, 576. Heart, malformation of, 581. Heartburn, 232. Haemorrhage, effects of, 173—causes of, 171. Haemorrhage, (menorrhagia), 171— uterine, 301—umbilical, 582. Haemoptysis, 241. Haematemesis, ib. Hernia, pudendal, 74—perinaeal, 86— inguinal, ofuterus, 141—umbilical, of pregnant women, 253—of bladder, t« be reduced in commencement of la- bour, 254—umbilical after birth, 578— other species of, to be treated on gene- ral principles, ib. Herpes, 602—varieties of, ib.—treat- ment of, 604—orbiculare, ib.—crusta- ceous, in note, ib. Hooping-cough, 721—treatment of, 722 —for relief of cough, 723—convul- sions during, 724—cough mistaken for, ib. Hydatids, 128. Hydrocele in children, 581. Hydrocephalus, 688—acute symptoms of, 689—divided into three stages, 691 —duration of, ib.—diagnosis in in- fants,692—appearances on dissection, 693—predisposition to, ib.—exciting causes of, ib.—state occasioning, 694 —treatment of, in first stage, 696— second, 697—when known to be a fa- mily disease, to strengthen constitu- tion, 698—chronic, ib.—affection lia. ble to be confounded with, 699—dis- section, ib.—treatment of, 700—se- condary, ib. Hymen, 57—imperforation of, 78. Hysteria, 156—paroxysm of, ib—causes of, 157—treatment of, 158. Hysteralgia, 508—cause and symptoms of, 509—treatment of, ib. Hysteritis before delivery, 104—in the puerperal state, 525. Icthiosis, 605. Impaction, 420. Impetigo, 609—varieties and description of, ib.—treatment of, 610. Inflammation of peritonaeum, 530—cau- ses and symptoms of, ib.—treatment of, bleeding chiefly to be relied on, 531—of mucous coat of intestines, 533. Inoculation, 642—vaccine, 643—-spu- rious cowpox, 644—although vesicle runs its course with distinctness, some- times inefficacious, 645. Insanity, temporary, brought on by spi- nal irritation, 677—in infancy, 678. Intertrigo, 596. Intussusceptio, in diarrhoea, 734. Jaundice, 238—of infants, divided into two species, 739—symptoms of first, 740—of second, ib. Labia, pudendi, 54—phlegmonoid, in- flammation of, 69—excoriation of in- ternal surface of, 70—chancre on, ib. iv phagedcena of, 71—excrescences on, 72—solid tumours on, 73—polypous tumours on, ib.—oedematous tumour of, 74—erysipelatous affection of, 623. Labours, classification of, 341—calcula- tion ofthe proportion these bear to one another, 312—natural, 344—divided into three stages, ib.—pains, ib.—du- ration of, 347—progress of, to be as- certained by examination,358—os ute- ri in, position and dilatation of, 352— head, position of at different periods of, 356—the stages of, generally mark- ed by the different modes of expressing pain, 358—why coming on at end of ninth month, 359—delivery produced principally by efforts of uterus, 360 mental, 419—protracted, danger aris- ing from, 424—results of delay in, de- duced from Hospital Reports, 428— premature, proposed as a mean of preventing necessity of an operation on child, when pelvis is deformed, 4£6 —methods of procuring, ib.—dilata- tion of os uteri, ib.—evacuation of liquor amnii, 457—impracticable, 458 —complicated with haemorrhage, 463 —haemorrhage from lungs or stomach, to be treated as in common cases, if increased by the pains, prompt deli- very, 464—with convulsion, 465— hysterical convulsions, 466—sudden death after, in note, 488. Larynx, necrosis of cartilages of, 720. preparation for, and dress of patient, Leucorrhcea. See fluor albus, 608. 362—premature, 372—wherein differ- Lepra, lepra alphoides, 608. ing from natural, ib.—causes of, ib.— Lever, application of, not so easy for treatment of, 373 —presentation of young practitioners, as forceps, 435 breech,375—process of delivery in,376 —directions for, 436. —when thighs are directed to back Lichen, description of, bearing a resem- pirt of pelvis, ib.—thighs directed to blance in its different stages to itch pubis, 377—bring down the feet when and measles, 595—urticatus of Bate- pelvis is contracted,378—presentation man 596. of feet, 379 —of shoulder or arm, ib-— Ligiment round, suffering in inflamma- how distinguished from breech, ib.— tion of uterus, treatment of, 529. position of feet in, 380—proposal to Linea alba, rupture of, allowing por- turn, and bring down head in, ib.—not tions of uterus to protrude, 253. to rupture membranes in, 381—strong Liver, diseased, 751 —inflammation of, contraction of uterus on child, allayed in infancy, ibi—appearances on dis- by an opiate, 383—when turning is section, ib.—in older children, symp- impracticable, proposed to cut os ute- toms of, 752—treatment of, ib.— ri, 385—spontaneous evolution, ib.— chronic, ib. opinions as to mode of expulsion, of Liquor amnii, premature discharge of, Dr. Denman, Dr. Douglas, and Dr. 404. Gooch, 386—presentation of hips, Locked head, 420—effect of, on patient, back, belly, sides, treatment of, 388— on soft parts, ib.—on foetus, 421. of head, 391. Lungs, floating of, in water, a certain sign child has breathed, 569—appear- ance of, when child has not breathed, in note, 568—weight of, in compari- son to rest of body, 570. Longings of women during pregnancy, 233. Labour, tedious, 397—under what cir- cumstances it may occur, ib.—causes of, and means of overcoming, 398— from inefficient action of uterine fibres, 402 —venesection, when to be employ- ed in, 403—from absolute debility or exhaustion, 404—erect position, a mean of accelerating, 408—over ac- tion in first stage, a cause of, 412— accession of fever, 413-prolapsus uteri, 414—second order, 415—aris- ing from size of head or smallness of pelvi*, ib.—from malposition ofhead, ib.—from rigidity of soft parts, ib.— blood-letting in, 416—from smallness of os uteri, 417—contraction and ci- catrices in vagina, ib.—excrescences in os uteri, hernia of bladder, great obliquity of uterus, malformation of organs of generation, 418—instru- Mamma, pain and tension of, attending gestation, 244—inflammation of, 555 —of fascia, ib.— of deeper parts, 556, —treatment of, ib.—in scrofulous constitutions productive of very pro- tracted disease, 557—sinuses in, 558. Management of children, 565—applica- tion of ligature to cord, ib.—no crite- rion of death of child at first, but pu. trefaction, ib.—when cord pulsates at time of birth not to divide imme- diately, 567—inflation of lungs, ib.— treatment of child when separated V from placenta, 570—washing, dress. ing, &c. 571—food and medicine be- fore being put to the breast, 572. Mania, puerperal, 549. Marks on bodies of children, 579. Marasmus, 742—symptoms of, ib.— treatment of, 743. Measles, 658—symptoms of, ib.—erup- tion, ib.—membranes apt to be affect- ed in, 660—treatment of, ib.—whf-n pneumonic symptoms considerable, bleeding and blisters, 661—coma, often an attendant on, ib. Membrana decidua, 207—opinions of Hunter and Haller, ib.—structure of, ib. Membranes, protrusion of, during la- bour, 355—bursting of, 356—allow- able sometimes to pierce, 364—when allowable to rupture, 408. Menstruation, 153—at what age com- mencing, 154—when ceasing, ib.— whence derived, ib. Menstrual action, diseased states of, 160. Menses, retention of, 161—causes of, ib. —treatment of, 163—often attended with symptoms of phthisis, 164—sup- pression of, 165—causes of, and treat- ment, 166. Menses, a membranous substance, ex- pelled instead of, 169. Menstruation, too copious or frequent, 171. Menses, cessation of, 180. Menorrhagia, 171—lochialis,497—treat- ment of, 499. Milk, different kinds of, 573—cow's, preparation of, to resemble woman's, 574. Moles, 127. Monstrosity, 396. Muscles, pain of, during pregnancy, 250 —abdominal, yielding too much, or irregularly, 252. Navel, excoriation of, 581—haemorrhage from, 582. Nerves, affections of, origins of, 92,155, 157—excitement of origin of spinal, a predisposing cause of abortion, 279— affection of spinal, 515—reaction of extremities of, upon origin, productive of fever, 516. Nipple, excoriation of, 559—artificial, 560. Nostril, foetid mucous secretion of, 584 Noma, 623. Nursing, causes disqualifying a woman for, 560. Nurse, choice of, in note, 572. Nymphae, 54—elongation of, 75—tu- mour of, 75, 76. Nymphomania, 89. Ovaria, 65—diseases of, 141—dropsy of, ib.—to what source, effects, and symptoms referable, 142—case of Ma- dam de Rosney, 144—treatment of, 146 —tapping, 148—laying open tumour of, 149—extirpation of, 150—adhesion to the intestines, ib.—bones, hair, &,c. found in, 151— scrofulous affection of, ib.—enlarged, 152—wanting, ib. Ovarium, diseased, mistaken for preg- nancy, 224. Ovum, appearance and growth of, 188. —coats of, 206. Ova, of fowls, in note, 201—of fishes, in note, 203—of serpents, in note, ib.__ of turtle, in note, ib.—of the frog, in note, 2U4—of vegetables, 205. ffidema, 245. Pains, false, 337—how distinguished from real, 338—treatment of, 339. Paralysis after delivery, 548—in child- ren, 710. Palpitation, 243. Pelvis, bones of, 17—articulations of, 22 —separation of, 24—soft parts which line the, 29—muscles, &c. ib.—iliac artery, 32—nerves, ib.—lymphatics, 34—dimensions of, ib.—diminished capacity and deformity of, 43—causes of, 44—rickets, ib.—malacosteon, 45 —exostosis, 47—tumours, 48—to as- certain degree of deformity, 52—aug, mented capacity of, 53—deformed, de, livery in, 417—dimensions of, under 3 inches impossible to deliver without destruction of child, 448. Perinaeum, 58—laceration of, 80—sup, port of, during labour, 365, Peritonaeal inflammation, 729—treat, ment of, ib. Perforator, directions for application of, 451. Petechiae sine febre, 616. Pessaries, 137, Phagedaena, 109. Phrenitis, 552. Pityriasis, 607—treatment of, 608. Placenta, 201—size and shape of, 204— junction of umbilical cord with, ib.— use of, 206—change in structure of, ib.—attachment of, 332—retention of, 297, 368—practice in, 369—when re. tained by spasm, 370—adhesion of, 371—retention of part of, 510—symp. VI toms arising from, ib...-treatment of, Retroversion of uterus, 254—symptoms 511—extraction of, ib. injections, ib. of, 255—causes of, 256,260—attempt Pleurisy, 512—in children, 726—termi- to replace, 259—effect of rectum in nations of, 727. producing, 260. Plurality of children, 393. Rickets, 589. Pneumonia, 512. Ringworm of scalp, 614. Polypous tumours in vagina, 85—in Roseola, 662—mistaken for measles, uterus, 121. ib.—eruption of, 663—infectious, ib. Polypi, different kinds of, 123—how —treatment of, ib.—autumnalis, ib. hurtful, ib.—means for removal of, —infantilis, 664. 124—ligature in, ib. Pompholyx, 598. Salivation, 243. Porrigo, 610--larvalis, 611—treatment Scarlatina, 651—simplex, ib.—descrip- of, 612—furfurans, 613—lupinosa, tion of, ib.—anginosa, 652—maligna, treatment of, ib.—scutulata, 614. 653—description of, ib.—seldom at- Pregnancy, extra-uterine, 211—tubal tacks twice, 654—treatment of sim- most frequent, ib—termination of, plex and anginosa, ib.—maligna, 656. 213—combined with ordinary preg- Scrofula, 58r. nancy, 214—case of, by Mr. Hay of Scrofulous children, fretting, and in- Leeds, 216—tubal, 217—ovarian, ib. flammation of nostrils, upper lip, and —ventral, ib,—treatment of, 218— labia pudendi in, 623. Caesarian operation in, cases, in note, Scabies, 600—varieties of, ib.—cure of, 218, 219. 601. Pregnancy, signs of, 220—period of Scabs, bloody, in head of children, 615. quickening, 221—examination of ute- Scirrho-cancer of uterus, 105—treat- rus in, 223—duration of, 184—effects ment of, 115.—extirpation of, 116. of, on system, 227—quickness of pulse Secale cornutum, 168, 297, 399. during, 228—treatment of febrile state Sinking after delivery, 488, 515. during, 229—vomiting a frequent Signs of a woman having been recently effect of, 230—during, relieved by delivered, 562—of life of child at leeching, 231—heartburn, during, 232 birth, 568. —longings of women during, 233— Skin-bound, 636—description of, ib.— spasm of stomach during, ib.—costive- more chronic in private practice, ib. ness, ib.—diarrhoea, 235—piles, 236 —treatment of, 637. —jaundice, 238. Small-pox, 638—symptoms of, ib.— Pregnant women, diseases of, 224. eruption, ib.—progress of, ib.—con- Presentations. See Labour. fluent, 640—treatment of distinct, ib. Prolapsus vesicae, 99—uteri,132—symp- —of confluent, 641—treatment, if toms of, ib.—examination in, 134— eruption suddenly subside, ib. during pregnancy, 140—ani in child- Spasm of stomach and duodenum, 243. ren, 581. Spasmodic affection or colic pains mis- Prurigo, 89—affecting anus, ib.—mitis, taken for puerperal inflammation, 507. 599. —and nervous diseases, 513—palpita- Psoriasis, description of, 605—varieties tion, ib.—hysteric fits, hiccough, syn- of, 606—excoriation about anus mis- cope, &,c. ib.—dyspnoea from ex- taken for syphilis, ib.—treatment of, ertion of muscles of respiration dur- ib. ing labour, ib.—colic, cramp of sto- Pubis, proposal to divide symphysis of, mach, &c. 514. 462. Spina bifida, 578. Puerperal mania, 549—description of, Sphincter ani, 66—spasm of, 67. ib.—treatment of, 550—variety of, Spongoid tumour, 88—of uterus, 119. 551. Spinal irritation, 93,108,157,515,664— Purpura attended with haemorrhage symptoms of inflammation of spinal from different parts, as nose, mouth, marrow, 669—disease produced by, &c. 617. 670—at times passes for hysteria, 671 Putrid sore throat, 629—symptoms of, —treatment, 672—anomalous and ib.—treatment, 630. protracted symptoms succeeding par- Pyrosis, 232. tial cure of, 673—treatment of these, n , __ , . , „ 674—another modification, 676—is. Rectum 66—schirrhous, 68. sues, best remedies, 677—temporary vii mental aberration a symptom of, ib.- Urine, incontinence of, 98-common in d!nAe5Tf0™ of' attacki«S children end of gestation, 238U«ZSSof during labour, 481. Uterus, 60—shape of, ib.—substance of, I—arteries of, ib.—veins of, ib.- and adults, 679. Spleen enlarged, 753. Sterility, 209. Stomach, effect of abortion on, 299__ inflammation of, 727—treatment of, 723—softness of, ib. Strangury, 512. Strophulus intertrinctus, 592—dcscrip nerves of, ib.—lymphatics of, 62— connexion of, with bladder and rec- tum, ib.—round ligaments of, 64.__va- rieties, in size of, 102—wanting, 103__ double, ib.—divided by septum, ib.— tion of ib.-treatment of, 593-albi- Uteri, os, almost or altogether shut up ™s. ib.—confertus, ib.—candidus, 104. F Uterus, varicose vessels of, 104—inflam- mation of, before parturition, ib 59 Syphilis in infants, 631—appearance of child in, 632—inflammation of eyes, &c. in, 633—genitals and anus be- come ulcerated, ib.—may exist not only under its own form, but also un- der that of some of the eruptions of children, 034—proposed to be treated by giving nurse mercury, 635—treat- ment of, ib. Sympathy of abdominal viscera and ute- rus with nerves, 224. Syncope, 240. Swelled leg, 543—symptoms and histo- ry of, ib.—causes of, 546—treatment of, 547. Swelling of breast of children after birth, 581. Tabes mesenterica, 744—symptoms of, ib.—accompanied by swelling of thy- mus gland, ib.—treatment of, 745— diet in, 746. Tapping, 148—uterus, 248. Teeth, how formed, 588—number of, in infancy, ib.—permanent, ib.—cut the gum, when, 589. Treatment after delivery, 483. Trismus nascentium, 706. Toothach during pregnancy, 245. Tubercles in uterus, 117—how distin- guished from diseased ovarium, 118— treatment of, ib. Tumours in pelvis, 48—case of Mrs. Broadfoot, 49 cause of scirrho-cancer, 105—chronic inflammation of, ib.—wounds of, 109 —ulceration of, ib.—phagedena, ib. —smooth ulcer of, 110—excrescences °f» HI—cauliflower excrescences, ib. —venereal, ib—scirrho-cancer, 112__ treatment of, 115—extirpation of, 116 —tubercles in, 117—enlarged and cartilaginous state of, 119—strumous affections of, ib.—spongoid tumour of, ib.—earthy concretions in, 120— polypous tumours, 121—soft tumour with broad base, 126—moles, 127__ hydatids, 128—increased secretion from, 131—worms in, 132—air se- creted by vessels of, ib.—prolapsus, ib.—extirpation of, 139—lengthening of cervix of, 141—inguinal hernia of, ib.—gravid, 184—size of, in ninth month, ib.—and shape of, in different months, 185—ascent of, out of pelvis, 18(3—development of cervix of, ib.__ muscular fibres of, 187—increased size of, not owing to muscle so much as to blood vessels and cellular tex- ture, ib—change in situation of liga- ments of, ib.—increased size of ves- sels of, 188—preternatural sensibility of, and spasm, 251—retroversion of, 254—antiversion of, 262—rupture of, 263—opened by ulceration, 266—con- traction of, brought on by stopping the action of gestation, 280. Tumour on head of child after tedious UtfP> os> in labour, dilatation of, 352, labour, 580. Twins, 393—practice in cases of, 394, —expulsion of placenta, 395—cases of, in note, 396. Tympanitis, 561—acute with fever, 562. Urethra, irritability of, 96—excrescen- ces in, 100—inversion of, 102—vari- cose state of vessels of mucous coat of, ib.—imperforate, 577. Ureter, spasm of, 251. 406. Uterus, inefficient action of, from sym- pathy, 409—irregular action of, cause of tedious labour, 411—spasm of, ib. —treatment of, 412—rupture of, dur- ing labour, 475—causes of, ib.—those who are subject to cramp most liable to,476—symptoms of,477—treatment of, 478—Caesarian operation, 479— cases of, in note, 480—hour-glass, 489—inversion of, 500—symptonii of, 501—often caused by pulling cord, viii 501—terminations of, 502—if disco- vered early it may be replaced, 503— when not observed in time, difficult from contraction of os uteri, ib.— when it cannot be replaced, palliative treatment, 504—how distinguished from prolapsus or polypus, 505—in- flammation of, after delivery, 525— symptoms of slight, ib.—treatment of, 526__symptoms of severe, ib__treat- ment of, 529. Uterine uneasiness, from state of nerves, 108—haemorrhage, 301—causes of, 305—alterations taking place in sys- tem during, 309—opinion to be form- ed respecting immediate danger of pa- tient in, 312—treatment of, 313— blood-letting when to be employed in, 315—application of cold in, ib__plug- ging vagina, 316—danger of internal, 318—probability of patient going on to full time after, ib__best means to prevent return of, 320—to diminish action of system, ib.—to remove every irritation, 322—syncope from, 323— delivery in, 325—greater risk of, in cases of twins, 395. Uterine haemorrhage after delivery, 486 —causes of, 487— effect of, on patient, 488—sudden expulsion of child, a cause of, 489— treatment of, 490 — friction in, 491—application of cold in, 492—spasm of uterus in, ib.—re- tention of placenta in, 493—state of siomach to be watched in, 494—syn- cope in, 495—extraction of coagula, 498. Urticaria, 650—acute and chronic, ib.™ treatment of, 651. Vagina, orifice of, 57—spasmodic con- traction of sphincter, ib.—vagina, 59—smallness of, 82—impervious, ib. —gangrene of, 83—abscess and sinus of, 84—scirrhous glands in, 85—fo- reign bodies in, ib.—polypous tumours of, ib.—inverted or prolapsed, ib.— water collected between rectum and. ib.—protrusion of rectum into, 87— indolent abscess and encysted tumours, ib.—varicose tumours, 88—erysipe- latous inflammation, ib. Varicose tumours on legs, 250. Vomiting often an effect of pregnancy, 230—relieved by leeching, efferves- cing draughts, &c. 231—brought on by state of stomach approaching to inflammation, ib.—from morbid con- dition of uterus, 232—in children, 730. Watery fluid, discharges of, from vagi- na during gestation, 248. Weed, 516. Windpipe, spasm about, during denti- tion, 720. Worms in uterus, 132—ascarides, 747— treatment of, 748—lumbrici, ib— treatment of, ib.—thread, 749.—tae- nia, ib. THE END. VALUABLE WORKS LATELY PUBLISHED BY CHARLES S. FRANCIS, 252 Broadway, New-York. ANATOMICAL PLATES. ILLUSTRATIONS of the principal Regions ofthe human Body, in relatiop to SURGICAL ANATOMY. Twelve Folio Plates, with Letter Press Explanations. The follow- ing is a list of the Subjects of the Plates ; which may be had either coloured or plain. PLATE I. Inferior Lamina ofthe Perinaeum in the Male. PLATE II. An interior view of the Perinaeum, and of the lesser Pelvis; more particularly to show the pelvic and superior Perineal Aponeurosis. PLATE III. A Dissection of Inguinal and Crural Hernia, by Sir Astlej Cooper.' PLATE IV. Anterior part of the region of the Elbow ; the Veins being strongly injected, to show their nodosities, and the comparative number of valves in the superficial and deep seated Veins. PLATE V. Superior Clavicular Region ; with the external part of the Sterno Mastoid Region. PLATE VI. View ofthe upper Hyoidean,the inferior Hyoidean, and Carotid Regions. PLATE VII. View of the Axilla, the arm being raised up. PLATE VIII. A Parallel Section ofthe Axis ofthe Perinaeum—ofthe hypo- gastric portion ofthe anterior Walls of the Abdomen—and ofthe Sacral Re- gion, posteriorly a little to one side of the Median Line. PLATE IX. Exterior view ofthe Inguinal and Crural Canals. PLATE X. Posterior view of the anterior Abdominal Parietes, to show the superior surface of the Inguinal and Crural Canals ; and, at the same time, a perpendicular and transverse section of the Pelvis—to display the external Iliac Region, and the connexions of the Perineal Aponeurosis with those ofthe Walls ofthe lesser Pelvis. PLATE XI. A view of the part posterior to the Knee, or Popliteal Space. PLATE XII. The Fingers. " Well worthy the attention of every student of Medicine."—JV. Y. Medical Journal. MANUAL OF MIDWIFERY. Compendium of Operative Midwifery ; or, the Manual and Instrumental Operations of Preternatural Labours re- duced to the greatest simplicity : preceded by an Investiga- 5 II • fiouofthc Mechanism of Natural Labour. From the French of Julius Hatiu, Doctor of the Medical Faculty of Pari:*, etc. etc. by Richard Tuite, M. D. "Under the form of a Manual, this work embraces the whole system of prac-" tical obstetrics—While it is calculated to prove a useful pocket companion tr> the practitioner, it is also designed as a guide to the student, who is ambitious of obtaining* practical knowledge of the obstetric art."—j\ tic-York Midical and Physical Journal. A PRACTICAL FORMULARY OF THE PARI- SIAN HOSPITALS, exhibiting the prescriptions employ- ed by the Physicians and Surgeons of those establishments; with Remarks, illustrative of their doses, mode of adminis- tration, and appropriate applications ; also, General Notices of each Hospital, the diseases it especially receives, and medical doctrines ofthe practitioners who preside in it. . By F. S. Ratier, M.D.