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Of the Management of new-born Children,
with the Diseases to which they are subject.

by William Smellie, M.D.

Volume 1, Book 4, Chapter II of

A Treatise on the
Theory and Practice of Midwifery,
Fourth Edition, London, 1762

 

Note to the reader: The middle English "f" has been changed to "s" for increased ease of reading. All other archaic spellings and punctuations have been preserved as they appear in the original manuscript.

 

William Smellie (1697-1763), a native of Lanark, Scotland, first began to teach midwifery in 1741, after many years successfully practising the subject. The first volume of A Treatise on the Theory and Practice of Midwifery was published in 1742, and Smellie continued to improve the work and to expand it over the next twenty-two years, with the third volume appearing in 1764. He was a friend of Dr. John Gordon and also knew Tobias Smollett, whom Gordon taught. Smollett helped prepare later editions of the first volume of Smellie's work and edited the second volume.

Sect. I.
Of washing and dressing the child.

The child being delivered, the navel-string tied and cut, a warm cloth or flannel cap put on its head, and its body wrapped in a warm receiver, it may be given to the nurse or assistant, in order to be washed clean from that scurf which sometimes covers the whole scarf-skin, and is particularly found upon the hairy scalp, under the arm-pits, and in the groins. This ablution is commonly performed with warm water, mixed with a small quantity of Hungary water, wine, or ale, in which a little pomatum, or fresh butter, hath been dissolved. This composition cleans all the surface, and the oily part, by mixing with, and attenuating the Mucus, prepares it for the linnen cloth, which dries and wipes off the whole: nevertheless, milk and water, or soap and water, is preferable to this mixture.

In laborious or preternatural cases, when considerable force has been used in delivering the child, the whole body ought to be examined; and if there is any mark or contusion on the head, it will disappear, if anointed with pomatum, and gently rubbed or chafed with the accoucheur's hand: if any limb is dislocated or broke, it ought to be reduced immediately: luxations, though they seldom happen, are more incident to the shoulder, than to any other part, the Humerus being easily dislocated, and as easily reduced. The bones of the arm and thigh are more subject to fractures, than any other of the extremities: the first is easily cured, because the limb can be kept from being moved; but a fracture in the thigh bone is a much more troublesome case, because, over and above the difficulty of keeping the bones in a proper situation, the part is often necessarily moved in cleaning the child. In this case, the best method is, to keep the child lying on one side, after the thigh hath been secured by proper bandage, so that the nurse may change the cloth without moving the part; and to lay it upon bolsters or pillows raised above the wet nurse, that it may suck with greater freedom: if any of the bones are bent, they may be brought into their proper form, by a slow, gentle, and proper extension.

The navel-string must be wrapped in a soft linnen rag, and folded up on the belly, over which is to be laid a thick compress, kept moderately tight with a bandage commonly called a belly-band. This compression must be continued for some time, in order to prevent an Exomphalus, or rupture, at the navel; and kept tighter and longer on children that are addicted to crying, than on those that are still and quiet: yet not so tight as to be uneasy to the child, and the bandage must be loosened and the part examined, every second day. The navel-string shrinks, dies, and about the sixth or seventh day, commonly drops off from the belly; though not at the ligature, as some people have imagined. This being separated, a pledgit of dry lint must be applied to the navel, and over it, the thick compress and bandage, to be continued several weeks, for the purpose mentioned above.

During the time of washing and dressing the child, it ought to be kept moderately warm, especially in the head and breast, that the cold air may not obstruct perspiration: the head and body ought also to be kept tolerably tight with the cloaths, for the convenience of handling, and to prevent its catching cold, especially if the child be weakly; but, if it is vigorous and full grown, it cannot be too loosely cloathed, because the brain, Thorax, and Abdomen, suffer by too great compression. The cloathing of new-born children, ought also to be suitable to the season of the year, and the nature of the weather; the extremes of cold and heat being avoided, as equally hurtful and dangerous. Instead of the many superfluous inventions of nurses, and those who make cloaths for children, with a view to make an expensive and pompous appearance, the dress ought to be contrived with all imaginable simplicity: the child being washed, the navel-string secured, and the head covered with a linnen or woolen cap, as already directed, a shirt and waist-coat may be put upon the body, and over it a flannel skirt or petticoat, open before, with a broad head-band, as commonly used, or rather a waistcoat joined to it, so as that they can be put on at once; this ought to be rather tied than pinned before, and, instead of two or more blankets, may be covered with a flannel or fustian gown; while the head is accomodated with another cap, adorned with as much finery as the tire-woman shall think proper to bestow.

In short, the principal aim in this point is, to keep the child's head and body neither too tight nor too slovenly, too hot nor too cold; that it may be warm, though not over-heated, and easy, though not too loose; that respiration may be full and large; that the brain may suffer no compression; and that, while the child is awake, the legs may be at liberty; to reject all unnecessary rollers, cross-cloths, neckcloths, and blankets; and to use as few pins as possible, and those that are absolutely necessary, with the utmost caution.

Sect. II.
How to manage when any of the common passages are locked up, or the tongue tied.

When the child cannot make water, because the passage is filled up with Mucus; after having unsuccessfully practiced the common methods of holding the belly near the fire, and rubbing the parts with Ol. Rutae, &c. we must introduce a probe, or very small catheter along the Urethra, into the bladder; and operation much more easily performed in female than in male children.

In boys, the prepuce alone is sometimes imperforated; in which case, an opening is easily made: but, if there is no passage in the Urethra, or even through the whole length of the Glans, all that can be done is to make an opening, with a lancet or bistory, near the mouth or sphincter of the bladder, in the lower part of the Urethra, where the urine being obstructed, pushes out the parts in form of a tumour: or, if no such tumefaction appears, to perforate the bladder above the Pubis, with a trocar: this, however, is a wretched and ineffectual expedient, and the other can but at best lengthen out a miserable life. If the Anus is imperforated, and the Faeces protrude the parts; or, if it be covered with a thin membrane, and a bluish or livid spot appears, the puncture and incision commonly succeed; but, when the Rectum is altogether wanting, or impervious for a considerable way, the success of the operation is very uncertain: nevertheless it ought to be tried, by making an artificial Anus with a bistory, remembering the course of the Rectum, and the entry in both sexes. For further information on this subject, Mauriceau's and Saviard's observations, and the Memoirs of the academy of surgeons, may be consulted.

In female children, there is a thin membrane, in form of a crescent, called the Hymen, that covers the lower part of the orifice of the Vagina, and is rent in the first coition. The middle of it is sometimes attached to the lower part of the Meatus urinarius, and on each side of the bridge is a small opening, that will only admit the end of a probe, though it is sufficient for the discharge of the Menses. This obstruction is commonly unknown till marriage, and hath often proved fatal to the unfortunate woman, who had concealed it through excess of modesty, and afterwards sunk into a deep melancholy, which cost her her life, rather than submit to inspection, and the early cure of having the attachment snipt with a pair of scissars. On this consideration, Saviard advises all accoucheurs to inspect this part in every female child they deliver; and if there should be such a defect, remedy it during her childhood: or, if the entry is wholly covered with the membrane, make a sufficient perforation, which will prevent great pain and tension in their riper years, when the Menses being denied passage, would accumulate every month, and at last push out this and neighboring parts in form of a large tumor, the cause of which is generally unknown, until it be opened.

Sometimes, a thin membrane rising from the under part of the mouth, stretches almost to the tip of the tongue, bracing it down, so as to hinder the child from taking hold of the nipple and sucking. This disorder, which is called tongue-tying, is easily remedied by introducing the forefinger into the child's mouth, raising up the tongue, and snipping the bridle with a pair of scissars. If, instead of a thin membrane, the tongue is confined by a thick, fleshy substance, the safest method is, to direct the nurse to stretch it frequently and gently with her finger, or if it appears like a soft Fungus, to touch it frequently and cautiously with lunar caustic, or roman vitriol; but we ought to take care that we are not deceived by an inflammation that sometimes happens in the birth, from the accoucheur's helping the head along with his finger in the child's mouth.

Sect. III.
Of Mould-shot Heads, Contusions, and Excoriations.

In laborious and lingering labours, the child's head is often long confined, and so compressed in the Pelvis, that the bones of the upper part of the Cranium are squeezed together, and ride over one another, in different manners, according as the head presented. If the Ossa parietalia rise over the Os Frontis, the case is called the mould-shot; if over the Occiput, it goes by the name of the horse-show mould. When the Fontanelle presents, (though this is seldom the case) and is pushed down, the form of the head is raised up in the shape of a hog's back; whereas, in the former case, the Vertex or crown of the head presented, and the whole was turned from a round to a very long figure. If the held is kept long in the Pelvis, and the child not destroyed by the compression of the brain, either before or soon after delivery, it commonly retains more or less of the shape acquired in that situation, according to the strength or weakness of the child. When the bones begin to ride over one another in this manner, the hairy scalp is felt lax and wrinkled; but by the long pressure and obstructions of the circulating fluids, it gradually swells, and forms a large tumour.

In these cases, when the child is delivered, we ought to allow the navel-string, at cutting, to bleed from one to two or three spoonfuls, especially if the infant be vigorous and full-grown, and to provoke it by whipping and stimulating: for, the more it cries, the sooner and better are the bones of the Cranium forced outwards into their natural situation: or, if the head hath not been long compressed, and is not much inflamed, we can sometimes, with our hands, reduce it into its pristine shape. The Meconium ought also to be purged off as soon as possible, to give freer scope to the circulating fluids in the Abdomen, and make a revulsion from the surcharged and compressed brain. This may be effected with suppositaries, glysters, repeated doses of Ol. Amygdal. d. mixed with Pulv. Rhubarb. or De Althoea, or Syr. de Cichoreo, cum Rheo.

If the child is seized with convulsions soon after delivery, in consequence of this compression; and the vessels of the navel-string have not been allowed to bleed, the jugular vein ought immediately to be opened, and from one to two ounces of blood taken away; an operation easily performed in young children: the urine and Meconium must be discharged, and a small blister applied between the Scapulae. When the scalp is bruised, inflamed, or swelled, let it be anointed, or embrocated, with a mixture of Ol. Chamomel. Acet. and Spt. Vin. Camphorat. and cerates and pultices applied to the parts.

If the tumefaction is large, and we feel a considerable fluctuation of extravasated fluids, which cannot be taken up by the absorbent vessels, assisted with those applications, the tumor must be opened; though generally there is no occasion for a large incision, because after the fluid is once discharged, the hollow scalp, by gentle pressure, is more easily joined in children than in older subjects.

When the head is mishapen, it should not be bound or pressed, but left lax and easy; lest, the brain being compressed, convulsions should ensue.

The body of the child is sometimes covered all over with little red spots, called the red gum, and commonly proceeding from the costiveness of the child, when the Meconium hat not been sufficiently purged off at first. And here it will not be improper to observe, that as the whole tract of the Colon is filled with this viscid excrement, which hath been gradually accumulated for a considerable time; and as the small intestines, stomach, and gullet are lined with a glary fluid or Mucus, the child ought to take no other nourishment than pap as thin as whey, to dilute this fluid, for the first two days; or indeed, till it sucks the mother's milk, which begins to be secreted about the third day, and is at first, sufficiently purgative to discharge these humours; and better adapted for the purpose than any artificial purge.

If the mother's milk cannot be had, a nurse lately delivered is to be found; and if the purgative quality of her milk is decreased, she must be ordered to take repeated small doses of manna or lenitive electuary, by which it will recover its former virtue, and the child be sufficiently purged.

If the child is brought up by hand, the food ought to imitate, as near as possible, the mother's milk: let it consist of loafbread and water boiled up together, in form of panada, and mixed with the same quantity of new cow's milk, and sometimes with the broth of fowl or mutton. When the child is costive, two drachms of manna, or from two to four grains of rhubarb, may be given: and when the stools are green and curdled, it will be proper to absorb the prevailing acid with the testaceous powders, such as the Chel. Cancror. fimp. or Test. Ostrear. given from the quantity of ten grains to a scruple: and for this purpose. the Magnesia alba is recommended from one to two drachms a day, as being both opening and absorbent. The red gum may likewise proceed from the officiousness of the nurse, by which the scarf skin hath been abraded, or rubbed off; in which case, the child must be bathed in warm milk, and the parts softened with pomatum: the same bath may be also used daily in the other kind, and the belly kept open with the aforementioned medicines; with which, some syrup, tincture, or powder of rhubarb, may be mixed, or given by itself, if the stools are of a greenish hue.

Excoriations behind the ears, in the neck and groin of the child, are sometimes, indeed, unavoidable in fat and gross habits; but most commonly proceed from the carelessness of the nurse, who neglects to wash and keep the parts clean: they are, however, easily dried up and healed, with Unguent. Alb. Pulv. e Ceruffa, or fuller's earth. Yet we ought to be cautious in applying drying medicines behind the ears, because a discharge in that part frequently prevents worse diseases.

Sect. IV.
Of the Aptha.

The Aptha, or thrush, is a disease to which new-born children are frequently subject, and is often dangerous, when neglected at the beginning. This disease proceeds from weakness and laxity of the contracting force of the stomach and intestines, by which the ascescent food is not digested; and from a defect in the necessary excretion of bile, with which it ought to be mixed. This prevailing acid in the Primae viae, produces gripings and loose green stools, that weaken the child more and more, deprived of its proper nourishment and rest, and occasion a fever from inanition and irritation. The smallest vessels at the mouths of the excretory ducts in the mouth, gullet, stomach, and intestines, are obstructed and ulcerated in consequence of the child's weakness and acrimonious vomitings, belchings, and stools, and little foul ulcers are formed.

These first appear in small white specks on the lips, mouth, tongue, and at the fundament: they gradually increase in thickness and extent; adopt a yellow colour, which in the progress of the distemper becomes duskish, and the watry stools (called the watry gripes) become more frequent. The whole inner surface of the intestines being thus ulcerated and obstructed, no nourishment enters the lacteal vessels; so that weakness and disease are increased, the milk and pap which are taken in at the mouth, passes off curdled and green, the child is more and more enfeebled, and the brown colour of the Aptha declares a mortification, and death at hand. Sometimes, however, the Aptha are unattended by the watry stools; and sometimes, these last are unaccompanied with the Aptha.

In order to prevent this fatal catastrophe, at the first appearance of the disorder, we ought to prescribe repeated doses of testaceous powders, to absorb and sweeten the predominant acid in the stomach, giving them from ten to twenty grains in the pap, twice or three times a day; and on every third night, from three to five grans of the Pulv. Rhei, Jualp. e Creta; oily and anodyne glysters, with epithems to the stomach, may also be administered. When these, and every other prescription fail, the child, if not much weakened, is sometimes cured by a gentle vomit, consisting of Pulv. Ipecacuan. gr. 1. given in a spoonful of barley-water, and repeated two or three times, at the interval of half an hour between each. When the child is much enfeebled, the Oleo-Saccharum Cinnamoni, or Anifi, mixed with the pap, is sometimes serviceable. If the milk is either too purgative or binding, the nurse should be changed, or take proper medicines to alter its quality: or, if the child has been brought up by hand, woman's milk may be given on this occasion, together with weak broths; but, if the child cannot suck, the milk of cows, mares, or asses, may be substituted in its room, diluted with barley-water.

Sect. V.
Of Teething

Children commonly begin to breed their fore-teeth about the seventh, and sometimes not before the ninth month; nay, in some, the period is still later. Those who are healthy and lax in their bellies, undergo dentition earlier than such as are of a contrary constitution. When the teeth shoot from their sockets, and their sharp points begin to work their way through the Periosteum and gums, they frequently produce great pain and inflammation, which, if they continue violent, bring on feverish symptoms and convulsions, that often prove fatal. In order to prevent these misfortunes, the swelled gum may, at first, be cut down to the tooth, with a bistory or fleam: by which means, the patient is often relieved immediately: but, if the child is strong, the pulse quick, the skin hot and dry, bleeding at the jugular, will be also necessary, and the belly must be kept open with repeated glisters. On the other hand, if the child is low, funk, and emaciated, repeated doses of Spt. C. C. Tinct. Fuligin. and the like, may be prescribed, and blisters applied to the back, or behind the ears.


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