Core Curriculum For Neonatal Intensive Care Nursing 6Th Edition M Terese Verklan Full Chapter
Core Curriculum For Neonatal Intensive Care Nursing 6Th Edition M Terese Verklan Full Chapter
19. Discharge Planning and Transition to Home, 329 39. Ethical Issues, 714
20. Genetics: From Bench to Bedside, 346 40. Legal Issues, 720
21. Intrafacility and Interfacility Neonatal Appendix A: Newborn Metric Conversion Tables, 734
Transport, 359 Index, 737
CORE CURRICULUM FOR
Neonatal Intensive
Care Nursing
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CORE CURRICULUM FOR
Neonatal Intensive
Care Nursing
SIXTH EDITION
EDITED BY
M. TERESE VERKLAN, PhD, RNC, CCNS, FAAN
Professor/Neonatal Clinical Nurse Specialist
Graduate School of Biological Sciences
School of Nursing
University of Texas Medical Branch
Galveston, TX, United States
Previous editions copyrighted by Saunders, an imprint of Elsevier, Inc., 2015, 2010, 2004, 1999, 1993
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and using any information, methods, compounds or experiments described herein. Because of rapid
advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages
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contained in the material herein.
ISBN: 978-0-323-55419-0
Debra Armentrout, PhD, APRN, NNP-BC Lindsey Churchman, MSN, RN, NNP-BC
Adjunct Faculty Assistant Director, Neonatal Nurse Practitioners
School of Nursing Neonatology
University of Texas Medical Branch Children’s Mercy Hospital
Galveston, TX, United States Kansas City, MO, United States
Teresa B. Bailey, DNP, APRN, NNP-BC M. Colleen Brand, PhD, APRN, NNP-BC
Neonatal Nurse Practitioner Neonatal Nurse Practitioner
Pediatrix Medical Group Neonatology
Mednax National Medical Group Texas Children’s Hospital
Austin, TX, United States Houston, TX, United States
Assistant Professor
Susan Givens Bell, DNP, MABMH, NNP-BC, RNC-NIC
Neonatology
Neonatal Nurse Practitioner
Baylor College of Medicine
Neonatal Intensive Care Unit
Houston, TX, United States
Asante Rogue Regional Medical Center
Medford, OR, United States Karen D’Apolito, PhD, APRN, NNP-BC, FAAN
Professor & Program Director NNP Specialty
Susan Tucker Blackburn, PhD, RN, FAAN
School of Nursing
Professor Emerita
Vanderbilt University
Department of Family and Child Nursing
Nashville, TN, United States
University of Washington
Seattle, WA, United States William Diehl-Jones, PhD, MSc, BSc, BScN
Associate Professor
Marina Boykova, PhD, RN
Center for Nursing and Health Research
Assistant Professor
Athabasca University
School of Nursing & Allied Health Professions
Athabasca, AB, Canada
Holy Family University
Philadelphia, PA, United States Georgia Ditzenberger, PhD, RNC, NNP-BC
Non-Executive Director Neonatal Nurse Practitioner
Council of International Neonatal Nurses Women and Children’s Department
Yardley, PA, United States Salem Health Hospital & Clinics
Salem, OR, United States
Wanda T. Bradshaw, MSN, RN, NNP-BC
Assistant Professor; Lead Faculty NNP Specialty Christine D. Domonoske, PharmD
School of Nursing Neonatal Clinical Pharmacy Specialist
Duke University Pharmacy
Durham, NC, United States Children’s Memorial Hermann Hospital
Neonatal Nurse Practitioner Houston, TX, United States
Cone Health
Ann Donze, MSN, APN
Greensboro, NC, United States
Neonatal Intensive Care (retired)
Leigh Ann Cates-McGlinn, PhD, APRN, NNP-BC, St. Louis Children’s Hospital
RRT-NPS, CHSE St. Louis, MO, United States
Director
Sharron Forest, DNP, APRN, NNP-BC
McGlinn Institute
Associate Professor
Neonatal Nurse Practitioner
School of Nursing
Atrium Health
The University of Texas Medical Branch
Charlotte, NC, United States
Galveston, TX, United States
Anita Catlin, DNSc, FNP, CNL, FAAN
Manager, Research
Administration
Kaiser Permanente
Vallejo, CA, United States
vii
viii CONTRIBUTORS
Debbie Fraser, MN, CNEON(C) Heather Lynn Maltsberger, MSN, APRN, NNP-BC
Associate Professor Neonatal Nurse Practitioner
Faculty of Health Disciplines Pediatrix Medical Group
Athabasca University Mednax National Medical Group
Athabasca, AB, Canada Austin, TX, United States
Neonatal Nurse Practitioner
Margaret M. Naber, MSN, APN, NNP-BC
NICU
Advanced Practice Registered Nurse/Neonatal Nurse Practitioner
St Boniface Hospital
Pediatrics, Division of Neonatology
Winnigeg, MB, Canada
Ronald McDonald Children’s Hospital at Loyola University
Editor-in-Chief
Medical Center
Neonatal Network
Maywood, IL, United States
Springer Publishing
New York, New York, United States Barbara Elizabeth Pappas, DNP, ARNP, NNP-BC
Neonatal Nurse Practitioner
Jennifer G. Hensley, EdD, CNM, WHNP, LCCE NICU
Professor, Clinical Nursing Coordinator Blank Children’s Hospital
D.N.P. Nurse-Midwifery Program Des Moines, IA, United States
School of Nursing
University Louise Herrington Leslie A. Parker, PhD, APRN, FAAN
Dallas, TX, United States Associate Professor
Certified Nurse-Midwife College of Nursing
Renaissance Women’s Group University of Florida
Austin, TX, United States Gainesville, FL, United States
Alice S. Hill, PhD, RN, FAAN Webra Price-Douglas, PhD, NNP-BC, IBCLC
Professor, Associate Dean of Graduate Programs, Retired Coordinator
School of Nursing Maryland Regional Neonatal Transport Program
University of Texas Medical Branch Johns Hopkins & University of Maryland Medical Centers
Galveston, TX, United States Baltimore, MD, United States
Pat Hummel, PhD, APRN, NNP-BC, PPCNP-BC Deanna Lynn Robey, BSN, RNC-NIC, CLNC
Neonatal/Pediatric Nurse Practitioner Team Leader
Neonatology NICU
Loyola University Medical Center Blank Children’s Hospital
Maywood, IL, United States Des Moines, IA, United States
Certified Legal Nurse Consultant
Helen M. Hurst, DNP, RNC-OB, APRN-CNM Lederer, Weston, Craig, PLC
Department Head and Associate to the Dean, West Des Moines, IA, United States
Associate Professor
Nursing Kathryn M. Rudd, DNP, MSN, RN, NIL, NPT
University of Louisiana at Lafayette Nurse Educator
Lafayette, LA, United States Division of Nursing
Cuyahoga Community College
Carole Kenner, PhD, RN, FAAN, FNAP, ANEF Cleveland, OH, United States
Chief Executive Officer
Council of International Neonatal Nursing, Inc. (COINN) Tammy Rush, MSN, RN, C-NPT, EMT
Yardley, PA, United States Department of Pediatric Trauma
Brenner Children’s Hospital
Lisa A. Lubbers, MSN, APRN, NNP-BC Winston-Salem, NC, United States
Neonatal Nurse Practitioner
NICU Sharyl L. Sadowski, MSN, APN, NNP-BC
Avera McKennan Hospital Clinical Faculty
Sioux Falls, SD, United States Marcella Niehoff School of Nursing
Neonatal Nurse Practitioner Loyola University Chicago
NICU Chicago, IL, United States
Fairview Health Services Patricia Scheans, DNP
Minneapolis, MN, United States Neonatal Nurse Practitioner
Denise Maguire, PhD, RN, CNL, FAAN Pediatrics
Vice Dean, Graduate Programs Legacy Health
Associate Professor, College of Nursing Portland, OR, United States
University of South Florida
Tampa, FL, United States
CONTRIBUTORS ix
Julieanne Heidi Schiefelbein, DNP, MApp Sc, MA(Ed), Tanya Sudia, PhD, RN
NNP-BC, CPNP Dean and Professor
Neonatal Nurse Practitioner College of Nursing
NICU Augusta University
Primary Children’s Hospital Augusta, GA, United States
Salt Lake City, UT, United States
Ellen Tappero, DNP, RN, NNP-BC
Assistant Professor
Neonatal Nurse Practitioner
College of Nursing
Neonatology Associates Practice
University of Utah
Mednax National Medical Group
Salt Lake City, UT, United States
Phoenix, AZ, United States
Holly A. Shippey, MSN, APRN, NNP-BC
Carol Wiltgen Trotter, PhD, NNP-BC
Neonatal Nurse Practitioner
Neonatal Nurse Practitioner
Neonatology
Retired
Texas Children’s Hospital
St. Louis, MO, United States
Houston, TX, United States
Instructor M. Terese Verklan, PhD, RNC, CCNS, FAAN
Neonatology Professor/Neonatal Clinical Nurse Specialist
Baylor College of Medicine Graduate School of Biological Sciences
Houston, TX, United States School of Nursing
University of Texas Medical Branch
Bonita Shviraga, PhD, CNM, RN, FACNM
Galveston, TX, United States
Certified Nurse-Midwife
Adjunct Faculty, Midwifery Institute Marlene Walden, PhD, APRN, NNP-BC, CCNS, FAAN
Thomas Jefferson University Nurse Scientist Manager
Philadelphia, PA, United States Nursing Research Department
Arkansas Children’s Hospital
Joan Renaud Smith, PhD, RN, NNP-BC, FAAN
Little Rock, AR, United States
Director
Quality, Safety & Practice Excellence Catherine Witt, PhD, APRN, NNP-BC
St. Louis Children’s Hospital Dean/Associate Professor
St. Louis, MO, United States Loretto Heights School of Nursing
Regis University
Carol Turnage Spruill, MSN, APRN-CNS, CPHQ
Denver, CO, United States
Clinical Nurse Specialist
Women, Infants and Children
University of Texas Medical Branch
Galveston, TX, United States
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REVIEWERS
Denise Casey, RN, CCRN, CPNP Carie Linder MSN, APRN, NNP
Clinical Nurse Specialist Neonatology
Neonatal Intensive Care Unit Integris Baptist Medical Center
Boston Children’s Hospital Oklahoma City, Oklahoma
Boston, Massachusetts
Caitlin O’Brien
Liz Drake, RNC-NIC, MN, NNP, CNS Boston Children’s Hospital
Clinical Nurse Specialist Stoneham, Massachusetts
Neonatal Intensive Care
CHOC Children’s at Mission Hospital
Mission Viejo, California
xi
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P R E FA C E
The provision of intensive care to the high-risk neonate presented as to how we can assist in the recognition of
challenges every neonatal care provider. Research and re- the high-risk fetus/neonate and plan interventions that
finements in technology have made “high-tech” modalities support the physiologic demands of the neonate during
such as extracorporeal membrane oxygenation (ECMO), transition. Cornerstones of Clinical Practice presents
nitric oxide, and hypothermia available to many more hos- concepts common to the delivery of quality care to all
pitals. The art and science of neonatal nursing are never high-risk newborns and families. The third section,
stochastic. We learn from scientists; researchers; interpro- Pathophysiology: Management and Treatment of Com-
fessional colleagues; and, of course, our infants and their mon Disorders, provides a systems approach to the
families. At a minimum, we are expected to enhance our assessment and management of the disease processes
application of clinical knowledge by utilizing an evidence- high-risk neonates commonly present with. The last
based approach to improve patient outcomes. The role of section, Professional Practice, focuses on the caregiver to
the nurse is frequently to bring together all the pieces of the strengthen competency with respect to research use, in
puzzle to ensure comprehensive, clinically excellent, and addition to providing an overview of universal ethical
compassionate care to sick newborns and their families. and legal issues that may be encountered in the practice
The sixth edition of Core Curriculum for Neonatal of neonatal nursing.
Intensive Care Nursing is intended as a clinical resource This text is the collaborative effort of the three major
and as an aid to prepare the nurse to take the high-risk nursing specialty associations: the Association of Women’s
neonatal nursing certification examination, whether it Health, Obstetric and Neonatal Nurses (AWHONN); the
is the American Association of Critical Care Nurses American Association of Critical-Care Nurses (AACN);
Certification Examination (CCRN-neo) or the National and the National Association of Neonatal Nurses (NANN).
Certification Corporation (RNC-NIC). The book is The book brings together experts in the care of the high-
divided into sections and designed in an outline format risk neonate, all having the common goal of providing a
so that it may be used as an easy reference. The first comprehensive resource for the management and care of
section, Antepartum, Intrapartum, and Transition to sick newborns. We are honored to be the editors of such an
Extrauterine Life, addresses clinical issues related outstanding collaborative effort.
to factors that affect the fetus and the neonate’s ability to
successfully adapt to postnatal life. Information is also M. Terese Verklan
Marlene Walden
Sharron Forest
xiii
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CONTENTS
Assessment of the Gastrointestinal System, 505 Physiology of the Neurologic System, 631
Abdominal Wall Defects, 508 Neurologic Assessment, 632
Obstructions of the Gastrointestinal Tract, 512 Neural Tube Defects (NTDs), 634
Necrotizing Enterocolitis, 522 Neurologic Disorders, 636
Short-Bowel Syndrome, 524 Intracranial Hemorrhages, 644
Biliary Atresia, 526 Seizures, 647
Cholestasis, 527 Hypoxic–Ischemic Encephalopathy, 649
Gastroesophageal Reflux, 528 Periventricular Leukomalacia, 652
Multisystem Disorders With Gastrointestinal Meningitis, 653
Involvement, 530 35. Congenital Anomalies, 654
30. Endocrine Disorders, 543 Lisa A. Lubbers
Susan Tucker Blackburn Specific Disorders, 658
The Endocrine System, 543 Sex Chromosome Abnormalities, 664
Pituitary Gland Disorders, 545 Non-Chromosomal Abnormalities, 665
Thyroid Gland Disorders, 546 Deformation Abnormalities, 671
Adrenal Gland Disorders, 551 Congenital Metabolic Problems, 672
Sexual Development, 556 Disorders of Metabolism, 673
Disorders of Sexual Development, 556 36. Neonatal Dermatology, 678
Pancreas, 564 Catherine Witt
31. Hematologic Disorders, 568 Anatomy and Physiology of the Skin, 678
William Diehl-Jones and Debbie Fraser Care of the Newborn Infant’s Skin, 680
Development of Blood Cells, 568 Assessment of the Newborn Infant’s Skin, 681
Coagulation, 572 Common Skin Lesions, 681
Anemia, 574 37. Ophthalmologic and Auditory Disorders, 691
Hemorrhagic Disease of the Newborn, 577 Debbie Fraser and William Diehl-Jones
Disseminated Intravascular Coagulation, 578 Anatomy of the Eye, 691
Thrombocytopenia, 580 Patient Assessment, 692
Polycythemia, 581 Pathologic Conditions and Management, 693
Inherited Bleeding Disorders, 582 Nasolacrimal Duct Obstruction, 694
Transfusion Therapies, 583 Anatomy of the Ear, 701
Evaluation by Complete Blood Cell Count, 586 Innervation, 702
32. Infectious Diseases in the Neonate, 588 Patient Assessment, 702
Kathryn M. Rudd
Transmission of Infectious Organisms in the PA R T F O U R
Neonate, 588 Professional Practice
Risk Factors, 589
Diagnosis and Treatment, 589
Neonatal Septicemia, 595 38. Foundations of Neonatal Research, 705
Infection With Specific Pathogens, 600 Alice S. Hill
Infection Control, 611 Research and Generation of Nursing Knowledge, 705
33. Renal and Genitourinary Disorders, 617 Research Process and Components of a Research
Denise Maguire Study, 707
Overview, 617 Quantitative Research, 708
Fetal Development of the Kidney, 617 Qualitative Research, 709
Development of the Bladder and Urethra, 618 Areas of Exploration in Neonatal Nursing, 709
Renal Function, 618 Nurses as Consumers of Research, 709
Renal Anatomy, 618 Ethics in Research and Nurses as Advocates, 710
Regulation of Postnatal Renal Hemodynamics, 619 39. Ethical Issues, 714
Clinical Evaluation of Renal and Urinary Tract Tanya Sudia and Anita Catlin
Disease, 621 Examining Ethical Issues in the NICU, 714
Laboratory Evaluation of Renal Function, 622 Principles of Biomedical Ethics, 715
Radiographic Evaluation, 623 Other Approaches to Ethical Issues, 716
Acute Kidney Injury, 623 Case Analysis Model, 717
Renal Tubular Acidosis, 625 The Nurse’s Role in Ethical Issues, 717
Developmental Renal Abnormalities, 625 Assessing Ethical Advisories From Maternal Child
Disorders of the Genitalia, 627 Organizations, 718
34. Neurologic Disorders, 629 Consulting the Hospital Ethics Committee, 718
Georgia Ditzenberger Summary, 718
Anatomy of the Neurologic System, 629
CONTENTS xix
CHAPTER 1
Uncomplicated Antepartum,
Intrapartum, and Postpartum Care
Bonita Shviraga and Jennifer G. Hensley
functional mechanism for folate’s effect on NTDs is compromise during pregnancy. During labor, alkaline
its epigenetic role in DNA methylation and histones phosphatase levels may increase further, and AST,
Part 1
(Ross and Desai, 2017). Routine supplementation of ALT, and lactate dehydrogenase levels may increase as
folic acid 0.4 to 0.8 mg is recommended for women a result of the stress of labor (Cappell, 2017).
of childbearing age or for those planning a pregnancy 9. The gut microbiome changes in pregnancy, with
to assist in the prevention of NTDs (U.S. Preventive an altered bacterial load and composition. These
Services Task Force, 2016). Women with a previously changes resemble the gut microbiome found in
affected child should take folic acid 4 mg daily for proinflammatory and prodiabetogenic states and
1 month prior to conception and throughout the first may promote energy storage and fetal growth
3 months of gestation (Agency for Healthcare Research (Antony et al., 2017).
and Quality [AHRQ], 2017; West et al., 2017). B. Respiratory system.
3. Approximately 50% of pregnancies are affected by 1. The increased vascularity and vascular congestion
morning sickness during the first trimester, which of the upper respiratory tract, resulting from in-
is associated with increased levels of human chori- creased levels of estrogen, causes hypersecretion
onic gonadotropin (hCG) and progesterone (West of mucus from the nasopharynx, which may lead
et al., 2017). to nasal stuffiness, sinus congestion, and epistaxis
4. The stomach loses tone, has decreased motility, and (nosebleed) during pregnancy (Antony et al., 2017).
may have delayed emptying time due to the smooth 2. Maternal oxygen requirements increase during 20%
muscle relaxation effects of progesterone (King during pregnancy (Cunningham et al., 2014).
et al., 2015). Evidence regarding delayed gastric 3. The chest wall profile changes. Increased levels of
emptying is inconclusive; however, there is a delay estrogen and relaxin cause relaxation of intercostal
during labor (Antony et al., 2017). ligaments with resulting increased chest expansion
5. Relaxation of the pyloric sphincter and upward and chest circumference and an increase in the
displacement of the diaphragm, in combination subcostal margin angle (Cunningham et al., 2014).
with increased intra-abdominal pressure from the The diaphragm is elevated by 4 cm in the third
enlarging uterus, can result in gastroesophageal trimester (King et al., 2015).
reflux and heartburn (West et al., 2017). 4. Respiratory changes during pregnancy include a
6. The small bowel has reduced motility and hyper- 30% to 40% increase in tidal volume, a 15% to
trophy of the duodenal villi to increase absorption 20% decrease in expiratory reserve volume,
of nutrients. Constipation is a problem because of a 20% to 25% decrease in residual volume, and a
mechanical obstruction from the uterus, reduced 20% decrease in functional residual capacity
motility, and increased water absorption (King (Antony et al., 2017). Forced expiratory volume
et al., 2015; West et al., 2017). does not change in pregnancy and is a reliable
7. The gallbladder has decreased muscle tone and indicator of respiratory illness, including asthma,
motility after 14 weeks as a result of the effects of in pregnant women (Antony et al., 2017). In-
progesterone. High levels of estrogen may decrease creasing progesterone levels lead to chronic hyper-
water absorption by the gallbladder’s mucosa, lead- ventilation by 8 weeks, as reflected in the increase
ing to dilute bile, with resulting inability to seques- in tidal volume. Maternal Paco2 levels decrease
ter cholesterol. This increase in cholesterol may to 32 mm Hg and oxygen levels rise to 106 mm
lead to gallstone formation during the second and Hg early in pregnancy to allow fetal–placental
third trimesters of pregnancy (Antony et al., 2017). exchange (Antony et al., 2017). As a result of
Decreased gallbladder tone may also lead to in- these cumulative respiratory changes, pregnant
creased retention of bile salts, resulting in pruritus women may experience physiologic dyspnea. To
and cholestasis gravidarum. Cholestasis gravi- prevent the maternal acidosis due to the carbon
darum has been associated with increased risk of dioxide levels from the fetus, mild hyperventila-
stillbirth and preterm deliveries (Cappell, 2017). tion occurs, which may cause a respiratory alka-
8. The liver is displaced upward by the enlarging losis. According to Cunningham et al. (2014),
uterus. Estrogen may cause altered production of progesterone lowers the threshold and increases
plasma proteins, bilirubin, serum enzymes, and chemosensitivity to carbon dioxide; in response
serum lipids. Alterations in laboratory values such to the respiratory alkalosis, plasma bicarbonate
as reduced serum albumin, elevated alkaline phos- levels decrease from 26 to 22 mmol/L, creating a
phatase, and elevated serum cholesterol may mimic slight increase in blood pH that shifts the oxygen
liver disease. Serum levels of bilirubin, aspartate dissociation curve to the left. Although pulmo-
aminotransferase (AST), and alanine aminotrans- nary function is not impaired, respiratory dis-
ferase (ALT) are unchanged in normal pregnancy eases may be more serious during pregnancy
and may be used as an indicator of hepatic (Cunningham et al., 2014).
CHAPTER 1 • Uncomplicated Antepartum, Intrapartum, and Postpartum Care 3
Part 1
sleep profiles, which may extend into the postpar- 7. Changes in the nails are uncommon but may occur
tum period. The majority of pregnant women (66% beginning in the first trimester. Changes include
to 94%) report sleep alterations, which may begin brittleness, distal separation of the nail bed, subun-
as early as the first trimester and worsen as preg- gual hyperkeratosis, whitish discoloration (leuk-
nancy progresses (Antony et al., 2017). onychia), and transverse grooving (Wang and
2. There is a decrease in rapid eye movement (REM) Kroumpouzos, 2017). The cause is unknown.
sleep, which is important for cognition, and a de- 8. There is a change in the vaginal microbiome, with
crease in stage 3 and 4 non-REM sleep, which is decreased diversity and decreased number of spe-
important for rest. By the third month postpartum, cies present and a predominance of Lactobacillus
stage 3 and 4 alterations resolve; however, sleep species. One of the predominant neonatal gastroin-
disruption may occur due to nocturnal infant testinal (GI) species, L. johnsonii, is increased in
awakenings (Antony et al., 2017). the vaginal microbiome and may be important in
3. Restless leg syndrome (RLS) onset or its worsening the establishment of the neonatal GI microbiome
in pregnancy may also contribute to sleep (Antony et al., 2017).
disturbances and should be assessed (Antony E. Urinary system.
et al., 2017). 1. Structural renal changes begin during the first tri-
D. Skin. mester and are a result of progesterone, pressure
1. Because of elevated levels of estrogen, spider angio- from the enlarging uterus, and increase in blood
mas are frequently seen on the neck, face, throat, volume. The kidneys enlarge, the ureters dilate, hy-
and arms. Palmar erythema is common in two perplasia of the smooth muscle walls of the ureters
thirds of white women and one third of African occurs, and the ureters elongate. Hydronephrosis
American women (Antony et al., 2017; Cunning- occurs in 80% of pregnant women (Antony et al.,
ham et al., 2014). 2017; Columbo, 2017).
2. Striae gravidarum occurs in some women due to 2. An increase in asymptomatic bacteriuria (ASB)
the thinning of the elastin fibers in the connective may lead to cystitis and pyelonephritis in preg-
tissue under the skin (King et al., 2015). nancy. The most common pathogen for ASB is
3. Increased pigmentation is due to increased levels of Escherichia coli (Columbo, 2017).
estrogen and melanocyte-stimulating hormone and 3. The renal plasma flow increases by 75%, with a
occurs in approximately 90% of women. This is 25% decrease in the third trimester (Antony et al.,
most marked on the nipples, areolas, perineum, and 2017). The increased renal plasma flow is accompa-
midline of the lower portion of the abdomen (com- nied by an increase in the glomerular filtration rate
monly called the linea nigra) (Antony et al., 2017). of 50%, which leads to an increase in creatinine
4. Hyperpigmentation of the face, known as chloasma clearance and a decrease in nitrogen levels, as re-
or melasma and also referred to as the mask of flected by decreased blood urea nitrogen (BUN)
pregnancy, is caused by melanin deposits in the and serum creatinine levels (Antony et al., 2017).
epidermis and macrophages. The resulting dark, 4. Due to the expansion of plasma volume and water
blotchy appearance of the face, forehead, and retention in pregnancy, even though sodium reten-
upper lip occurs in up to 70% of women and is tion is increased by 900 mEq, serum levels of sodium
exacerbated by ultraviolet light (Wang and decrease by 3 to 4 mmol/L (Antony et al., 2017).
Kroumpouzos, 2017). 5. The reduced threshold for glucose reabsorption
5. During gestation, a greater percentage of the hair may result in glycosuria in pregnancy. Glycosuria
remains in the anagen (growth) phase, which can be detected in up to 90% of pregnant women
decreases normal hair loss. Hair loss commonly with normal blood glucose. However, repetitive
occurs between 2 and 4 months after delivery due glycosuria warrants evaluation (Antony et al.,
to an increase in the telogen (resting) phase of hair 2017). Glucose measurements in the management
growth. The hair returns to a normal growth phase of diabetes mellitus may be affected.
within 1 to 5 months (Wang and Kroumpouzos, 6. A small amount of proteinuria may occur in preg-
2017). nancy due to decreased protein reabsorption (King
6. Changes in secretory glands occur during preg- et al., 2015). Urinary protein excretion increases in
nancy. Sebaceous gland activity alterations are vari- pregnancy, with an upper limit of 300 mg in a
able, and the resulting changes in acne develop- 24-hour period (Antony et al., 2017). Greater than
ment are unpredictable (Wang and Kroumpouzos, trace proteinuria may not indicate pathology, but
2017). Eccrine sweat gland activity increases as a warrants evaluation for urinary tract infection and
result of increased thyroid activity, body weight, preeclampsia.
4 PART 1 • Antepartum, Intrapartum, and Transition to Extrauterine Life
40% to 50% from the end of the first trimester, lactation and therefore become more prominent
peaking at 32 weeks (King et al., 2015). If the (Cunningham et al., 2014).
plasma volume increases faster than red blood cell 3. Estrogen, progesterone, human placental lactogen
(RBC) production, a physiologic anemia may result (hPL), hCG, prolactin, and luteal and placental
(King et al., 2015). hormones cause hyperplasia of the breast tissue
2. There is an increase in maternal heart rate, which and development of lactiferous ducts and lobular
increases by 17% above the nonpregnant state by alveolar tissue during the second and third trimes-
the third trimester. Stroke volume increases by ters (King et al., 2015). Physical examination may
8 weeks’ gestation until 20 weeks at 20% to 30% reveal palpable milk ducts and excretion of colos-
above prepregnancy levels. There is an increase in trum from the nipples.
cardiac output beginning in the first trimester 4. Colostrum, which is a high-protein precursor of
and peaking at 30% to 50% above prepregnancy breast milk, may be expressed toward the end of
levels, with most of the increase in cardiac output pregnancy (King et al., 2015).
to the uterus, placenta, and breast (Antony et al., 5. The breast begins lactogenesis with alveolar cells
2017). changing to a secretory epithelium toward the mid-
3. Because the heart is displaced leftward and upward dle of pregnancy. After delivery, the second stage of
by the enlarging uterus, the cardiac silhouette in- lactogenesis, milk production, begins (King et al.,
creases on x-ray films. It is important to confirm 2015).
cardiomegaly with an echocardiogram and not rely H. Skeletal changes.
solely on x-ray (Antony et al., 2017). 1. Compensating for the anteriorly positioned grow-
4. Altered cardiac sounds in pregnancy include split- ing uterus, the lower portion of the back curves.
ting of the first heart sound, an audible S3 heart This lordosis shifts the center of gravity backward
sound, systolic ejection murmurs (96% of pregnant over the lower extremities and causes low back
women), and transient diastolic murmurs (up to pain, a common complaint in pregnancy (Antony
18% of pregnant women). Diastolic murmurs et al., 2017; King et al., 2015).
should be evaluated (Antony et al., 2017). 2. The sacroiliac and pubic symphysis joints loosen
5. Blood pressure (BP) remains at the prepregnancy during pregnancy due to effects of the hormone
level in the first trimester and drops during the relaxin and may result in pain localized to the
second trimester at approximately 24 weeks of ges- symphysis pubis and radiating down the inner
tation by a mean arterial pressure (MAP) of 5 to thigh (Antony et al., 2017).
10 mm Hg. It returns to normal prepregnancy levels 3. Alteration in the center of gravity, loosening of the
at the end of pregnancy. It is recommended in the joints, and an unsteady gait increase the risk of falls
ambulatory setting that BP be taken in the sitting in pregnancy.
position and that the fifth Korotkoff sound be used 4. Although serum calcium levels decrease during preg-
for diastolic BP measurement (Antony et al., 2017). nancy, serum ionized calcium levels are unchanged.
6. Between 20 and 24 weeks of gestation, pressure on Maternal serum calcium levels are maintained, and
and resulting obstruction of the inferior vena cava fetal calcium needs are met through increased
may occur in the supine position. The resulting maternal intestinal absorption of calcium (Antony
10% to 30% fall in cardiac output, due to the de- et al., 2017).
crease in stroke volume as a result of decreased 5. Bone turnover is low in the first trimester and later
blood in the heart, results in supine hypotension. increases in the third trimester when peak fetal cal-
Positioning the mother in a lateral position or with cium transfer occurs; however, osteoporosis is not
lateral displacement of the uterus with placement associated with pregnancy bone turnover (Antony
of a wedge under her hip assists in the prevention et al., 2017).
of supine hypotension (Antony et al., 2017). I. Hematologic changes.
7. Blood stagnates in the lower extremities because of 1. Plasma volume increases 15% by the end of the
compression of the pelvic veins and the inferior first trimester, undergoes a rapid expansion during
vena cava, contributing to dependent edema and the second trimester, peaks at 32 to 34 weeks, and
the development of varicosities (King et al., 2015). then plateaus near term (Cunningham et al., 2014).
G. Breasts. Plasma volume at or near term is 50% above pre-
1. Early changes in the breasts during the first trimes- pregnancy levels (Antony et al., 2017).
ter include tenderness and paresthesia (Cunningham 2. The white blood cell (WBC) count rises progres-
et al., 2014). The symptoms usually subside at the sively during pregnancy and labor. Prepregnancy
end of the first trimester. levels range from 5000 to 12,000 cells/microliter
CHAPTER 1 • Uncomplicated Antepartum, Intrapartum, and Postpartum Care 5
(mcL) and increases up to 20,000 to 30,000 cells/ second trimester. The hormone hCG has
mcL in labor and the early postpartum period thyrotropic activity and can activate TSH recep-
Part 1
(Antony et al., 2017). tors and increase secretion of T4 (Antony et al.,
3. The RBC count begins to rise during the first tri- 2017).
mester, with an average increase of 18% throughout d. Although T4 and T3 levels begin to increase in
pregnancy without iron supplementation (Antony the first trimester and peak in the middle of
et al., 2017). The increase in plasma volume pregnancy, serum portions of T3 and T4 are
changes the ratio of RBCs to plasma, causing a de- normal, unless a maternal iodine deficiency is
creased hematocrit. This “physiologic anemia of present or there are abnormalities of the thyroid
pregnancy” reaches the lowest levels at 30 to 34 gland (Antony et al., 2017).
weeks. As the hematocrit begins to rise, a closer- e. TSH does not cross the placenta (Antony et al.,
to-normal ratio of RBCs to plasma results in a 2017). There is transplacental transfer of T4,
higher hematocrit near term (Antony et al., 2017). which is necessary for fetal neurologic develop-
4. Iron requirements for a pregnancy are 1000 mg ment in early gestation (Antony et al., 2017).
(Antony et al., 2017; Cunningham et al., 2014). The fetus is dependent on maternal transfer of
Fetal and placental requirements are 300 mg. thyroid hormones until 12 weeks’ gestation and
Serum ferritin levels decline after midpregnancy still has some reliance on maternal transfer after
(Cunningham et al., 2014). the fetal thyroid is functional (Antony et al.,
5. Pregnancy has been called a hypercoagulable state. 2017).
The platelet count decreases slightly as a result of f. Additional research is in progress to evaluate
increased destruction or hemodilution but remains maternal hypothyroidism and universal screen-
within the normal range. About 8% of women have ing of mothers (Antony et al., 2017).
a gestational thrombocytopenia in the third trimes- g. Iodine crosses the placenta and is 75% of the
ter (Antony et al., 2017). Fibrinogen is increased by maternal level (Antony et al., 2017). Also, radio-
50% to 80%, and factors I, II, VII, VIII, IX, and XII active iodine given to the mother crosses the
increase (Antony et al., 2017; King et al., 2015). placenta and can concentrate in the fetal thyroid
Bleeding and clotting times remain normal (Antony after 12 weeks’ gestation and cause adverse fetal
et al., 2017). The incidence of thromboembolism affects (Antony et al., 2017).
increases five- to six-fold and is greatest during the 2. Carbohydrate metabolism.
postpartum period (Antony et al., 2017). a. Pregnancy is characterized by mild fasting
6. Pregnancy is known to result in altered immuno- hypoglycemia, postprandial hyperglycemia,
logic function so that the “foreign fetus” is accom- and hyperinsulinemia (Antony et al., 2017;
modated. Therefore, a decrease in cellular immu- Cunningham et al., 2014).
nity may account for improvement of certain b. The basal metabolic rate is increased by 10% to
autoimmune diseases in pregnancy and an in- 20% by the third trimester (Cunningham et al.,
creased susceptibility to infection. The humoral im- 2014).
mune system, characterized by antibody-mediated c. Peripheral resistance to insulin is referred to as
immunity, remains intact (King et al., 2015). the diabetogenic effect of pregnancy. Its purpose
J. Endocrine and metabolic changes. is to ensure a sustained postprandial supply of
1. Thyroid. glucose for the fetus. By term, there is a 45% to
a. The thyroid remains unchanged or slightly en- 70% reduction in the action of insulin. The hor-
larges during pregnancy, which is detected only mones that may be responsible for this effect are
by ultrasound. Suspected goiter should be evalu- hPL, progesterone, and estrogen. hPL may in-
ated during pregnancy (Antony et al., 2017). crease lipolysis, leading to increased free fatty
b. Thyroid-binding globulin (TBG) increases dur- acids, which increases tissue resistance to insu-
ing the first trimester due to the effect estrogen lin (Cunningham et al., 2014).
has on the liver. TBG plateaus by 12 to 14 weeks’ d. Glucose is actively transported to the fetus;
gestation and results in increases in total T4 and however, insulin and glycogen do not cross the
total T3 levels (Antony et al., 2017). placenta. During pregnancy, hyperglycemic
c. Although there may be changes in laboratory states rapidly change to fasting states, resulting
indices, pregnant women remain euthyroid in hypoglycemia. In this fasting state, there is an
(Antony et al., 2017). Increased hCG levels are increase in levels of fatty acids, triglycerides,
associated with decreased thyroid-stimulating and cholesterol. This switch in fuels from glu-
hormone (TSH) levels in early pregnancy. There cose to lipids is referred to as accelerated starva-
is a transient decrease in TSH during the first tion, and ketonuria rapidly occurs (Cunningham
trimester, with a return to normal levels by the et al., 2014).
6 PART 1 • Antepartum, Intrapartum, and Transition to Extrauterine Life
Table 1.1
Routine Initial Prenatal Tests
Part 1
Standard Test Reason for Screening Test
Blood type and Rh status Identify blood type and Rh status for postpartum hemorrhage and Rh incompati-
bility with fetus
Antibody screen Identify fetuses at risk for hemolytic disease of the newborn/fetus
Complete blood count Baseline laboratory studies
Rule out maternal anemia or thalassemia
Rule out thrombocytopenia; repeated between 24 and 28 weeks
Hemoglobin electrophoresis in patients with Screen at-risk populations to determine carrier status and determine if partner
African/African American ethnicity screening is indicated (women with sickle cell trait have higher risk of bacteriuria
in pregnancy)
Cystic fibrosis carrier testing Determine carrier status and determine if partner screening is indicated
Rubella antibody screen Identify women susceptible to acquiring rubella during pregnancy (immunize
after delivery)
MSQS (maternal serum for AFP, hCG, Genetic screening offered between 15 and 20 weeks
estriol, inhibin-A) AFP screens for neural tube defects
Combination of serum markers sensitive in identifying Down syndrome
Diabetes screen on all women between 24 1-hour glucose screen to determine need for 3-hour GTT to rule out gestational
and 28 weeks; if high risk, do at initial diabetes
obstetrics visit too
Mantoux TB test Rule out need for immediate follow-up
Urine
Urinalysis: Glucose, ketones, protein, nitrite, Screen for diabetes, pregnancy-related hypertension, renal disease, possible
RBCs, WBCs, bacteria urinary tract infection
Culture and sensitivity Rule out asymptomatic bacteriuria (GBS may be identified in heavily colonized
women)
Cervical Cancer Screening
Papanicolaou smear; begin age 21; 30 years Identify cytologic changes that could be precancerous
include high-risk HPV
Sexually Transmitted Infections
Neisseria gonorrhoeae and Chlamydia DNA Identify treatable sexually transmitted diseases, most of which can cause fetal or
by NAAT from cervix or urine neonatal morbidity
Hepatitis B surface antigen Identify women whose offspring can be treated at birth to prevent hepatitis B
infection with HBIg and HB vaccine
Human immunodeficiency virus 1 and 2 Identify women in need of treatment to decrease transmission to the fetus
Hepatitis C antibody Screen at-risk women
Syphilis (VDRL, RPR, or treponemal test) Identify women in need of treatment to reduce fetal/neonatal morbidity (man-
dated by law in most states)
AFP, a-fetoprotein; DNA, deoxyribonucleic acid; GBS, group B streptococcus; GTT, gamma-glutamyl transferase; HB vaccine, hepatitis B vaccine; HBIg, hepatitis B immune
globulin; hCG, human chorionic gonadotropin; HPV, human papilloma virus; MSQS, maternal serum quadruple screen; NAAT, nucleic acid amplification testing; RBCs, red
blood cells; Rh, Rhesus factor; RPR, rapid plasma reagin; TB, tuberculosis; VDRL, Venereal Disease Research Laboratory; WBCs, white blood cells.
From American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG). (2017). Guidelines for Perinatal Care (8th ed.). Elk Grove
Village, IL: American Academy of Pediatrics.
From Gabbe, S. G., Niebyl, J. R., Simpson, J. L., Landon, M. B., Galan, H. L., Jauniaux, R. R. M., et al. (2017). Obstetrics Normal and Problem Pregnancies (7th ed.). Philadel-
phia, PA: Elsevier.
3. At 14 weeks’ gestation, or with a crown–rump length ultrasound examination is between 18 and 22 weeks’
of 84 mm, biparietal diameter (BPD) is more accu- gestation (American Academy of Pediatrics [AAP]
rate and highly reproducible for fetal measurements. and ACOG, 2017).
Four parameters are used to establish gestational C. Pelvic examination and fundal height.
age: BPD, head circumference (HC), abdominal 1. Determination of the size of the uterus during an
circumference (AC), and femur length (FL). early examination (before 12 to 14 weeks) is rela-
4. In the absence of medical conditions or risk factors tively accurate if the mother is of normal height
that could affect the pregnancy, and taking into and not grossly obese.
consideration the cost and for what insurance 2. Fundal height measurements in centimeters
will reimburse, the optimal time for one dating (McDonald’s measurements) from the symphysis
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that nobody can know what is doing, except a very few who, for that
purpose, sit near the clerks’ table; or they leave the House and the
Men of Business, as they call them, to mind such matters.’
In 1728, royalty continued to exhibit itself in a THE KING AND
manner which, now, seems rather unedifying. On QUEEN.
Sundays and Thursdays, in the summer, the city sent
curious multitudes to Hampton Court, to see their Majesties dine in
public. The sight-seers went freely into the gallery, where a strong
barrier divided them from the royalties at table. On all occasions, the
pressure against this barrier was immense; on one, it gave way,
when scores of ladies and gentlemen were sent sprawling at the foot
of the king’s table. Away went perukes and hats; for which there was
a furious scramble, with much misappropriation, more or less
accidental. While it lasted, king and queen held their sides and
laughed aloud, regardless of etiquette, or indeed, of becomingness;
but there was provocation to hilarity, when the worshippers were
rolling and screaming at the feet of the national idols.
One of the latter showed how little he was prejudiced against
Jacobites when they had qualities which outweighed their political
defects. Dr. Freind, the Jacobite physician, whom the Prince of
Wales had taken to St. James’s from the Tower, was, on the Prince’s
accession to the throne, appointed physician to the queen. The
doctor did not escape sneers and inuendoes from his old friends. ‘Dr.
John Freind,’ writes Mr. Morrice (June, 1728), ‘is a very assiduous
courtier, and must grow so more and more every day, since his
quondam friends and acquaintances shun and despise him; and
whenever he happens to fall in the way of them, he looks methinks
very silly.’ Atterbury in exile, on hearing of Freind’s
ATTERBURY
death, in 1728, remarked: ‘I dare say, notwithstanding WEARY OF
his station at Court, he died with the same political EXILE.
opinions with which I left him.’ There was a talk in
London of Atterbury himself being at least weary of exile. His later
letters show some longing to die in his native land; and Walpole
seems to have been aware of the fact. In October 1728, Atterbury’s
son-in-law, Morrice, wrote to the bishop,—‘I was assured near two
months ago, that Sir Robert Walpole had given out that you had
entirely shaken off the affair of a certain person,—were grown
perfectly weary of that drooping cause, and had made some steps,
by means of the Ambassador at Paris, towards not being left out of
the General Act of Grace which, it is every now and then talked, will
pass the next Parliament; and that you desired above all things to
come home, and end your days in your own country.’ The next
Parliament, however, was not disposed to lenity.
In the king’s speech, on opening the Session in January, 1729,
there was no reference to the Pretender. The king, however,
attributed certain delays at the Courts of Vienna and Madrid to
‘hopes given from hence of creating discontents and division’ among
his subjects; but if this hope encouraged these foreign Courts, ‘I am
persuaded,’ said the king, ‘that your known affection for me, and a
just regard for your own honour, and the interest and security of the
nation, will determine you effectually to discourage the unnatural and
injurious practices of some few who suggest the means of
distressing their country, and afterwards clamour at the
inconveniences which they themselves have occasioned.’ In the
usual reply, the Lords lamented that the lenity of the constitution was
daily abused, and that the basest and meanest of mankind ‘escape
the infamous punishment due by the laws of the land to such
crimes.’ The Commons, after some debate, employed terms equally
strong. The Heir Apparent used the opportunity to
THE PRINCE OF
illustrate his fidelity to the Protestant succession. WALES AT
Prince Frederick, to convince all good people of his CHURCH.
Protestant orthodoxy, went a round of the London
churches. He was accompanied by a group of young lords and
gentlemen of good character, and, at this time, his reputation did not
suffer by his being judged according to the company he kept. On the
occasion of his dissipated church-going, the prince and his noble
followers took the Sacrament in public: the doors of the church,
whichever it might be, were set wide open, and the church itself was
packed by a mob of street Whigs and Tories, who made their own
comments on the spectacle, which was not so edifying and
impressive as it was intended to be. Fog’s Jacobite paper hinted that
a family not a hundred miles from St. James’s was split up with petty
domestic quarrelling. The family, indeed, dined together twice a
week in public; but people were reminded that outward appearances
were exceedingly deceptive,—and sacramental partakings (it was
said) proved nothing.
The papers of the year bear witness to the
THE MORALS
wickedness and barbarity of all classes of people, of AND
both sexes. Half the highwaymen and footpads were MANNERS OF
members of his Majesty’s own guards. There was not THE TIME.
a street or suburb of London that was free from their violence and
villany. Small offences being as much a hanging matter as the most
horrible crimes, lawless men found it as cheap to be murderers as
petty-larcenists; and all looked to Tyburn as the last scene, in which
they must necessarily figure. Three or four of these fellows, behind
old Buckingham House, stopped the carriage of the Bishop of
Ossory, who was on his way to Chelsea with his son. They took from
the prelate’s finger his episcopal ring (of great value), and from his
hand what seemed to be a pocket book, but which was a Book of
Common Prayer. When the highwayman who held it saw that it was
a Prayer Book, he handed it back to the bishop. ‘Had you not better
keep it?’ said the prelate. ‘Thank you, no!’ rejoined the Pimlico
Macheath, ‘we have no occasion for it at present, whatever may be
the case at some time hereafter.’ The time alluded to was the hour of
‘hanging Wednesday,’ at Tyburn, when each patient was provided
with a Prayer Book, which he often flung at someone in the crowd of
spectators before he was pinioned. There was always a great variety
of company at the triple tree in Tyburn field, built to accommodate a
score. At a push a couple of dozen could be disposed of on a very
busy hanging morning. The sufferers ranged,—from the most brutal
murderers, men and women, down to timid pickpockets and shy
shoplifters, boys and girls, to all of whom the bloody code of the time
awarded the same measure of vengeance. The London mob were
almost satiated with Tyburn holidays. It was an agreeable change for
them to witness the public military funeral of old Mary Davis, who
had served, both as sutler and soldier, in our wars in Flanders. In her
later years, Mary kept a tavern in King Street, Westminster, bearing
the curious sign of ‘Man’s worst ills.’ The crowd there, and about St.
Margaret’s, where she was buried, was as great as at their
Majesties’ coronation.
The press prosecutions of this year were few. A
vendor of some reprints of former very offensive ATTERBURY,
ON MIST.
numbers of Mist’s Journal lost his liberty for a while;
and a poor servant girl, for delivering to a caller (who may have been
a police agent) an obnoxious pamphlet, was sentenced to
imprisonment in Bridewell, there to receive ‘the correction of the
house,’—which meant a severe whipping.
No better proof of Atterbury’s sympathy with Mist and the enemies
of the established Government can be given than in the following
passage, from a letter written at Montpellier, in March, 1729-30. It is
addressed to Sempill, who was a favoured resident at the
Chevalier’s Court, but really a spy in the service of the Court in
London.—‘I shall be concerned if so honest a man as Mr. Mist
should have any just cause of uneasiness. His sufferings, that were
intended to distress and disgrace him, ought to render him in the
eyes of those for whom he suffered, more valuable; and I hope it will
prove so that others may not be discouraged.’
During the next ten years Jacobitisin in the capital THOMSON’S
made no manifestation, but the Whig poets were ‘SOPHONISBA.
rather ostentatious in their loyalty; and the royal family ’
patronised them accordingly. For instance, on the last
day of February, 1730, Thomson produced at Drury Lane his
tragedy, illustrating the virtue of patriotism, namely, ‘Sophonisba.’
The queen herself had attended the full-dress rehearsals, at which
crowded audiences were not so much delighted as they were told
they ought to be. However, the notice the queen condescended to
take of this essay to keep alive the virtue of patriotism, led the author
to dedicate it to Caroline. In that dedication the poet informed both
Whigs and Jacobites that the queen ‘commands the hearts of a
people more powerful at sea than Carthage, more flourishing in
commerce than those first merchants, more secure against
conquest, and under a monarchy more free than a commonwealth
itself.’ In the prologue it was said of Britain,—
When freedom is the cause, ’tis her’s to fight,
And her’s, when freedom is the theme, to write.
In the play Mrs. Oldfield splendidly illustrated the spirit of
patriotism, in the part of the heroine. Cibber acted the subordinate
part of Scipio, in which he suffered at the hands of the Jacobites.
These had not forgotten the offence in his ‘Nonjuror;’ and joining,
hilariously savage with the critics who laughed at Cibber in tragedy,
they hissed him off the stage and out of the part on the second night.
Williams, a moderately good player, succeeded him as Scipio, and
he, on the third night, looked so like the ultra-Whig actor, that the
Jacobite spectators received him with groans and hisses, which,
however, speedily turned to laughter and applause.
But Colley had his reward. The zeal he had CIBBER MADE
displayed against Jacks and Nonjurors, by producing POET
his famous comedy, now obtained its recompense, LAUREATE.
and his sufferings their consolation. In 1730, Cibber
was appointed to the office of Laureate, with its annual butt of sack,
or the equivalent, 50l. Every Jacobite who could pen a line, printed it
against the laurelled minstrel. Apollo himself was pressed into the
Nonjuring faction:—
‘Well,’ said Apollo, ‘still ’tis mine,
To give the real laurel,
For that, my Pope, my son Divine,
Of rivals end the quarrel.
But, guessing who should have the luck
To be the Birth-day fibber,
I thought of Dennis, Tibbald, Duck,
But never dreamed of Cibber.’
The year was one fruitful in plays; but it was observed that when
nuts are plentiful, they are generally of poor quality; so it was with
the plays of 1730. They are all clean forgotten, including
‘Sophonisba’ itself,—the epilogue to which tragedy had this advice to
ladies who patronised foreign productions:—
To foreign looms no longer owe your charms,
Nor make their trade more fatal than their arms,
Each British dame who courts her country’s praise,
By quitting these outlandish modes, might raise
(Not from yon powder’d band, so thin, so spruce)
Ten able-bodied men, for public use.
There was much meanness in the ill feeling of the JACOBITE
Jacobites at even the little mischances that happened HEARNE.
to the royal family. On a dark evening in November, the king and
queen were returning from Kew to St. James’s, their footmen and
grooms carrying torches. A storm of wind blew out the torches, and
at Parson’s Green the carriage and its royal freight was overturned.
Lord Peterborough’s people came to the rescue, with flambeaux,
and the royal pair went on to town with nothing worse than an
assortment of bruises. Such accidents were kindly attributed to the
drunkenness of servants, but that bitter Jacobite Hearne thought that
the mistress, if not the master, could be as drunk as they. Here is a
sample of both thought and expression.—‘The present Duchess of
Brunswick, commonly called Queen Caroline,’ says Hearne, in his
‘Reliquiæ,’ ‘is a very proud woman, and pretends to great subtlety
and cunning. She drinks so hard that her spirits are continually
inflamed, and she is often drunk. The last summer, she went away
from Orkney House, near Maidenhead (at which she had dined), so
drunk that she was sick in the coach all her journey, as she went
along;—a thing much noted.’
The Tories, on their side, were savagely mauled by A JACOBITE
the Whig press. The old Jacobite fire of Earbery was THREAT.
thereby inflamed, especially by the attacks on the old
Tories in the ‘Craftsman.’ The former Stuart champion, who, in 1717,
fled the country to avoid the consequences of publishing his ‘History
of the Clemency of our English Monarchs,’ but whose sentence of
outlawry was reversed in 1725, gave the ‘Craftsman’ warning, in the
following advertisement, which was in the ‘Evening Post,’ of
September 26, 1730,—‘Whereas the “Craftsman” has, for some time
past, openly declared himself to be a root and branch man, and has
made several unjust and scandalous reflections upon the family of
the Stuarts, not sparing even King Charles I., this is to give notice,
that if he reflects further upon any One of that line, I shall shake his
rotten Commonwealth principles into atoms. Matthias Earbery.’ The
writer kept his word in his ‘Occasional Historian.’
To decline to take the oath of abjuration was still a very serious
matter, involving not merely temporary loss, but life-long professional
ruin. Pope had a nephew, Robert Rackett, whose position affords a
striking illustration of these Jacobite times. The story is thus told by
Pope himself, in a letter to Lord Oxford, Nov. 16, 1730: ‘It happens
that a nephew of mine, who, for his parents’ sins and not his own,
was born a papist, is just coming, after nine or ten years’ study and
hard service under an attorney, to practise in the law. Upon this
depends his whole well-being and fortune in the world, and the
hopes of his parents in his education, all which must inevitably be
frustrated by the severity of a late opinion of the judges, who, for the
major part, have agreed to admit no attorney to be sworn the usual
oath which qualifies them to practise, unless they also give them the
oaths of allegiance and supremacy. This has been
DIFFICULTIES
occasioned solely by the care they take to enforce an IN
Act of Parliament, in the last session but one, against PROFESSION
fraudulent practices of attornies, and to prevent men AL LIFE.
not duly qualified as attornies from practising as such. It is very
evident that the intent of the Act is in no way levelled at papists, nor
in any way demands their being excluded from practising more than
they were formerly. Therefore, I hope the favour of a judge may be
procured, so far as to admit him to take the usual attorney’s oath,
without requiring the religious one.’ Pope hopes one of the judges
will be good-natured enough to do this, and he suggests Judge Price
for Lord Oxford’s manipulation. ‘In one word the poor lad will be
utterly undone in this case, if this contrivance cannot be obtained in
his behalf.’ Lord Oxford applied, not to Price, but to ‘Baron C.’
(Carter or Comyns, as Mr. Elwin suggests). This judge, says Pope
(Dec. 1730), ‘showed him what possible regard he could, and
lamented his inability to admit any in that circumstance, as it really is
a case of compassion.’ Ultimately the obstacle seems to have been
surmounted. Within a few months of half a century later, Pope’s
nephew died in Devonshire Street, London, where he had ‘clerks’ in
his employment. ‘He had, therefore,’ says Mr. Elwin in a note to the
letter from which the above extract is taken, ‘managed to make his
way in some line of business.’
In the year 1731 died a popular and political writer,
DEATH OF
in the announcement of whose death neither his DEFOE.
popular works nor his provocating agency in the
service of Government is referred to. The event is thus recorded in
Read’s ‘Weekly,’ for May 1st, 1731: ‘A few days ago died Mr. Defoe
Sen., a person well known for his numerous and various writings. He
had a great natural genius and understood very well the Trade and
Interest of this Kingdom. His Knowledge of Men, especially of those
in High Life, with whom he was formerly very conversant, had
weakened his Attachment to any Party, but in the Main, he was in
the Interest of Civil and Religious Liberty, in behalf of which he
appeared on several remarkable Occasions.’
In the month of July the Government began to look ‘FALL OF
sharply after political offences on the stage. At the MORTIMER.‘
Haymarket Theatre, an historical tragedy, called ‘The
Fall of Mortimer,’ was announced; and, in the announcement the
Ministry saw an attack on Walpole, and probably on the queen. The
grand jury of the County of Middlesex delivered a long ‘presentment’
to the Court of King’s Bench, in which the new play was described as
‘a false, infamous, scandalous, seditious, and treasonable libel,
written, acted, printed, and published against the peace of our
Sovereign Lord the King, his crown and dignity.’ It is not clear that
the play was ever more than rehearsed. On the night it was to have
been regularly acted, a body of messengers and constables rushed
through the stage door in order to make capture of the players.
These were attired, and ready for the curtain to go up; Mullart, as
Mortimer, stood plumed and gallant at the centre of the stage. At the
first alarm, however, he and his mates took to flight, decked out as
they were, and succeeded in escaping. This play, which some thirty
years later was again turned to political purpose, grew out of the
brief fragment and the sketched-out plot of a play designed by Ben
Jonson. In the few lines he wrote, there are the following against
upstarts and courtiers. These were held to be adverse to Walpole’s
peace as well as the king’s. For example:—
Mortimer
Is a great Lord of late, and a new thing!
* * * * *
At what a divers price do divers men
Act the same things. Another might have had
Perhaps the hurdle, or at least the axe,
For what I have this crownet, robes, and wax.
There is a fate that flies with towering spirits
Home to the mark, and never checks at conscience.
* * * * * We
That draw the subtle and more pleasing air
In that sublimed region of a Court,
Know all is good we make so, and go on,
Secured by the prosperity of our crimes.
This matter passed over. A press war sprang up in another
direction.
Lord Hervey published a pamphlet called, ‘Sedition DUELS AND
and Defamation Displayed.’ An anonymous author SERMONS.
speedily followed it up by ‘a Proper Reply to a late
scandalous libel, called “Sedition and Defamation displayed.”’
Hervey challenged William Pulteney, the reputed author of the
Proper Reply. The parties fought in the new walk in the upper part of
St. James’s Park. Their respective friends, Sir John Rushout and
Henry Fox looked on, while the adversaries made passes at each
other; but, when they closed, the seconds rushed in, parted, and
disarmed them. A little plaister was all the remedy required to cover
all the damage done by a few scratches on Lord Hervey’s person.
Pulteney’s name, however, was struck out of the Council Book, and
he was ignominiously put out of the commission of the peace.
The royal family proceeded to show that there was no prejudice
on their part against the noble art of printing. A printing press and
cases were put up at St. James’s House (as the old palace used to
be called), and the noble art of printing was exhibited before their
majesties. The future victor of Culloden, the Duke of Cumberland,
worked at one of the cases. He set up in type a little book, of which
he was the author, called ‘The Laws of Dodge Hare.’ The duke, at
this time, also took lessons in ivory-turning, which was considered to
be a ‘most healthful exercise.’ Generally on Sunday, while the king
and queen were in the Chapel Royal, one of the Bishop of London’s
chaplains preached to the young Duke and the Princesses Mary and
Louisa in his royal highness’s apartment! As his royal highness had
recently stood godfather, in person, to the son and heir of Lord
Archibald Hamilton, he was supposed to be of importance enough to
be thus preached to. The young princesses were thrown in to make
up a juvenile congregation.
Very much seems to have been made of the young duke this
year, as if he had a mission to perform. A little establishment was set
up for him, and he became a ‘personage.’ The papers solemnly
proclaimed how the Duke of Cumberland appeared in public, for the
first time, with his own coach and livery servants. He paid a visit to
Sir Robert Walpole, in Arlington Street, and went afterwards to Major
Foubert’s Riding House (on the site of what is now called Major
Foubert’s Passage, Regent Street), and there received his first
lesson in riding.
The only manifestation of party feeling this year was made by the
citizens of London. A subscription had been entered into for the
casting of a statue of William III. When it was executed, the city,
influenced by Jacobite feeling, refused to receive it. Bristol was more
loyal. The citizens there bought the effigy that London despised, and
William soon stood erect in the midst of Queen Square.
Among the miscellaneous chronicling of the year, YOUNG LORD
there is one made by most of the Saturday papers to DERWENTWAT
this effect: ‘Yesterday, Friday, August 19th, the Lord ER.
Derwentwater arrived at his house in Poland Street,
from France.’ This was John, the late earl’s only son. He came to
London to consult Chiselden, the great physician. He was hopelessly
ill of dropsy; and a double sympathy attracted crowds of Jacobites to
resort to Poland Street to manifest their respect for the suffering son
of one of the martyrs to the cause of the Stuarts.
When in 1732 the National Defences became a A STANDING
serious matter for consideration, the Jacobites ARMY.
affected to think that an army of 12,000 men would
suffice for the protection of the realm. The Whigs insisted that at
least 17,000 would be required for its defence. The London Whig
papers asserted that 4,000 men would have all their work to do in
keeping Scotland quiet. The fortified towns of England would require
2,000 men. The remainder would not be sufficiently strong in
numbers, for sudden emergencies, if the total was only to be 12,000.
Such insufficiencies would leave many places without defence. This
would encourage Risings. Open insurrection would lead to foreign
invasion, with the Pretender at the head of it. The wind that would
bring over his hostile fleet would shut up our own in our harbours.
Why had Jacobitism increased tenfold in the last four years of Queen
Anne? Because the High Priests had been unmuzzled, and the
necessary forces had been disbanded. The Preston Rebellion, as
the outbreak of 1715 was contemptuously called, would never have
happened at all if we had had 17,000 men under arms. As it was, it
was crushed not by the bravery or ability of our troops and officers,
but by the incapacity and timidity of the rebels themselves. So ran
Whig comments in Parliament.
Unless the Government in London were sure that there were as
many majorities in all Corporations against the Chevalier’s
pretensions as there were ‘in certain places against King William’s
statue,’ the administration was conjured to keep up the numbers of
the army. While the Jacobites had hopes, England must entertain
fears. Had Louis XIV. lived a few months longer, a French army
would have been in full march to seat the Chevalier on a throne at
Westminster. The Regent, Duke of Orleans, did not help the
Pretender, simply because he needed our alliance against Spain
which refused to recognise his Regency.
At home there was a seeming fixed determination THE DUKE’S
that the Duke of Cumberland should be a soldier, and GRENADIERS.
be trained to the ability necessary to meet future
emergencies. The youthful prince had military inclinations. That
military spirit was stimulated by the formation of a company of
youthful grenadiers out of a dozen sons of persons of quality. Their
dress resembled the uniform of the 2nd Foot Guards. ‘His Royal
Highness the Duke,’ say the journals of the day, ‘diverts himself with
acting as corporal, choosing to rise regularly in Preferment. The
number being but twelve, is to be increased.’ Fog’s Jacobite journal
says maliciously,—‘increased in case of War.’
Observance of the solemn anniversary of the 30th of January
used to be considered as a protest that all parties might make
against ‘the sin of rebellion.’ However this may be, reverence for the
Royal Martyr seems to have suffered some diminution in the year
1732.
When Dr. Hare, Bishop of Chichester, preached GENERAL
before the House of Lords, in the Abbey, on the 30th ROGUERY.
of January, the only peers present were the Lord
Chancellor, Lord Onslow, and the Bishops of Peterborough, Lincoln,
Lichfield and Coventry, St. David’s, and Rochester. The sermon was
thoroughly political. The text was from Proverbs xxiv. 21, ‘My son,
fear thou the Lord and the king: and meddle not with them that are
given to change.’ The sermon was described as ‘most extraordinary;
the preacher vindicated the King’s honour and sincerity in his
concessions to the Parliament;’ and he insisted strongly on the uses
of ‘keeping up the day.’
Later, the Jacobites found some little satisfaction in the smart
reprimand delivered by the Speaker of the House of Commons to Sir
John Eyles, for directing the secretary of the Commissioners for the
sale of forfeited estates to set his name to an order for the disposal
of the Earl of Derwentwater’s estates, in the sale of which, great
frauds were discovered. But where was fraud not found at that time?
From the benches of Parliament to the council-room of the Charity
Commissioners, rogues abounded; the country was sold by the
Senate, and the poor were plundered by their trustees. Yet, these
things caused less emotion in the London coffee-houses than the
report which came of the death of Bishop Atterbury at Paris, in
February. The event was simply recorded in the ‘Gentleman’s
Magazine’ in these uncompromising words:—
‘February 15, 1732.—The Revd. Dr. Francis DEATH OF
Atterbury, late Bishop of Rochester, died at Paris, ATTERBURY.
justly esteemed for his great learning and polite
conversation.’ In what sense the Jacobites esteemed him may be
seen in an expression in one of Salkeld’s letters, wherein the writer
laments the loss of ‘that anchor of our hopes, that pillar of our
cause.’
Pope, in a letter to Lord Oxford, referred to Atterbury’s death in
these terms: ‘The trouble which I have received from abroad, on the
news of the death of that much-injured man, could only be mitigated
by the reflection your Lordship suggests to me—his own happiness,
and return into his best country, where only honesty and virtue were
sure of their reward.’ Pope could not have thought the ex-bishop
innocent of the treason, of which he was undoubtedly guilty; for the
poet had knowledge of the treachery before the Jacobite prelate’s
death. Samuel Wesley must have known it too, but he ignored all but
his patron’s virtues in a very long elegy on Atterbury’s decease,
written in very strong language, of which these lines are a sample:—
Should miscreants base their impious malice shed,
To insult the great, the venerable, dead;
Let truth resistless blast their guilty eyes!
—which is a sort of malediction that is now quite discarded by moral
and by fashionable poets.
The ‘Craftsman’ of May 6th announces the arrival of Mr. Morrice,
the High Bailiff of Westminster, at Deal. On landing he was taken into
custody and sent up prisoner to London, where, after being
rigorously examined by one of the Secretaries of State, he was
admitted to bail. The corpse of the ex-bishop was arrested as it
came up the river. It was taken to the Custom House, where, the
coffin being examined for papers, and nothing compromising being
found, the body, according to the facetious ‘Craftsman,’ was
discharged without bail. Great opposition was made to a request for
burial in the Abbey; and when this was granted, the ‘Craftsman’ was
‘not certain as to the usual Church ceremony being read over the
corpse.’
The public were, at all events, kept in the dark, lest BURIAL OF
Jacobite mobs should make riotous demonstrations at ATTERBURY.
the ceremony. ‘On Friday, May 12th,’ says Sylvanus Urban, ‘the
Corpse of Bishop Atterbury was privately interred in his Vault in
Westminster Abbey. On the Urn which contained his Bowels, &c.,
was inscribed: “In hac Urnâ depositi sunt cineres Francisci Atterburi
Episcopi Roffensis.” Among his papers brought over by Mr. Morrice
was “Harmonia Evangelica,” in a new and clearer Method than any
yet publish’d. ’Tis also said he translated Virgil’s “Georgics,” which
he sent to a friend with the following Lines prefix’d,
Haec ego lusi
Ad Sequanæ ripas, Tamesino a flumine longe
Jam senior, fractusque, sed ipsa morte meorum
Quos colui, patriæque memor, neque degener usquam.’
They who were of the prelate’s way of thinking made him, in one
sense, speak, or be felt, even in his grave. The body of the Jacobite
Bishop of Rochester had scarcely been deposited at the west end of
the south aisle of Westminster Abbey, of which he had been the
Dean, when copies of an epigrammatic epitaph were circulating from
hand to hand, and were being read with hilarity or censure in the
various London coffee-houses and taverns. It ran to another tune
than that made upon him by Prior, namely:—
His foes, when dead great Atterbury lay,
Shrunk at his corse, and trembled at his clay.
Ten thousand dangers to their eyes appear,
Great as their guilt and certain as their fear!
T’ insult a deathless corse, alas! is vain;
Well for themselves, and well employ’d their pain,
Could they secure him,—not to rise again!
The printsellers reaped a harvest by selling the Bishop’s portrait.
The most popular was sold by Cholmondely in Holborn, but he was
had up before the Secretary of State, and was terrified by that official
into suppressing the sale.
All London, that is, what Chesterfield called ‘the AT
Quality,’ went seaward in August. The cream of them SCARBOROU
settled on the Scarborough sands. ‘Bathing in the GH.
sea,’ says Chesterfield, ‘is become the general practice of both
sexes.’ He gives an amusing account of how ‘the Quality’ from
London looked, at Scarborough, and he jokes, in his peculiar
fashion, upon plots, Jacobites, and ministers. He writes to the
Countess of Suffolk: ‘The ladies here are innumerable, and I really
believe they all come for their healths, for they look very ill. The men
of pleasure are Lord Carmichael, Colonel Ligonier, and the
celebrated Tom Paget, who attend upon the Duke of Argyle all day,
and dance with the pretty ladies at night. Here are, besides,
hundreds of Yorkshire beaux, who play the inferior parts and, as it
were, only tumble, while those three dance upon the high ropes of
gallantry. The grave people are mostly malignants or, in ministerial
language, “notorious Jacobites,” such as Lord Stair, Marchmont,
Anglesea, and myself, not to mention many of the House of
Commons of equal disaffection. Moreover, Pulteney and Lord
Cartaret are expected here soon; so that if the Ministry do not make
a plot of this meeting, it is plain they do not want one for this year.’
Chesterfield was branded as a ‘notorious Jacobite,’ NOTORIOUS
because he had opposed Walpole’s famous Excise JACOBITES.
Bill, this year. As a consequence, he was deprived of
his staff of office as Lord Steward of the Household. While
Chesterfield was writing so airily to Lady Suffolk, the king was laying
out 3,000l. in repairing the Palace of Holyrood. A dozen years later,
when ‘news frae Moidart’ reached the London Jacobites, they
laughed at the idea of the ‘Duke of Brunswick’ having made
Holyrood suitable for the reception of Charles Edward, Prince of
Wales.
In the meantime a voice here and there from the metropolitan
pulpits ventured to hope the king would be kept by divine guidance,
in a safe groove. The future hero of Culloden was taking lessons in
philosophy from Whiston, and in mathematics from Hawksbee; and,
at a funeral more public than Atterbury’s, the Jacobites assembled in
Poland Street, to pay a last mark of respect to the ‘Earl of
Derwentwater,’ the patient whom great Cheselden could not save,
and whose
corpse was carried to Brussels to be deposited by
THE EARL OF
the side of that of his mother, Anne Webb. The so- DERWENTWAT
called ‘Earl’ John, son of the attainted and beheaded ER.
peer, as a sick man, was left unmolested, though he
called himself by a title unrecognised by the Government.
CHAPTER III.
(1733 to 1740.)
he feverish imagination of Tories who were decided
Jacobites also, saw impossible reasons for every
event. From the 23rd to the 30th of January, 1733,
there raged in the metropolis what would probably now
be called an influenza. The disease was then known as
the ‘London head-ache and fever;’ and it was fatal in very many
cases. Some of the Jacobites at once discovered and proclaimed the
cause and the effect of this visitation, which carried off fifteen
hundred persons in the metropolis. Observe the two dates. ‘On the
23rd of January, 1649, Charles denied the jurisdiction of his Judges,
who, nevertheless, sent him to the block on the 30th.’ The week of
mortal fever and headache was only an instalment of that former
week’s work which ended in the martyrdom of the Chevalier de St.
George’s grandfather! Horace Walpole asserts that George II.
always attended Church on the 30th of January. The king and the
whole Court went thither in mourning. All who had service to perform
at Court, put on sables. The king’s sister, the Queen of Prussia, was
a declared Jacobite, ‘as is more natural,’ says Walpole, ‘for all
princes who do not personally profit by the ruin of the Stuarts.’[2]
The royal speech on opening Parliament was of a
APPROACHIN
peaceful character. The Lords re-echoed it in their G STORM.
address, but in the Commons, both Sir John Barnard
and Shippen moved amendments to the address, from that House.
The speech had recommended an avoidance of all heats and
animosities. The theme of Barnard and Shippen was that the
liberties and the trade of the nation were probably menaced; that a
general terror was spreading of something being about to be
introduced, perilous, nay destructive, to both. Men of all parties being
subject to this terror, ‘they cannot,’ said Shippen, ‘be branded with
the name of Jacobites or Republicans, nor can it be said that this
opposition is made by Jacobites or Republicans. No, the whole
people of England seem to be united in this spirit of jealousy and
opposition.’ The address, of course, was carried. But a storm was
approaching.
This year, 1733, was the year of the famous
WYNDHAM IN
debates on the motions for a permanent increase of PARLIAMENT.
the army, and on the Excise question introduced by
Walpole, who proposed to transfer the duties on wine and tobacco
from the Customs to the Excise. The two propositions set the country
in a flame. The universal cry was that they were two deadly blows at
trade and liberty. The first proposal was carried; Walpole, under
pressure of large minorities against him in the House, and larger
adverse majorities out of it, withdrew the Excise measure. All his
opponents were branded by his partisans as Jacobites and
something more. This gave opportunity to the Jacobites in
Parliament, and increased the vigour of their opposition. It was
against the motion for increasing the number of the Land Forces,
that the ‘Patriot’ Sir William Wyndham spoke with almost fierce
sarcasm. ‘As for the Pretender, he did not believe there was any
considerable party for him in this nation. That pretence had always
been a ministerial device made use of only for accomplishing their
own ends; but it was a mere bugbear, a raw head and bloody bones
fit only to frighten children; for he was very well convinced his
Majesty reigned in the hearts and affections of his people, upon that
his Majesty’s security depended; and if it did not depend on that, the
illustrious family now on the throne could have little security in the
present number, or in any number, of the standing forces.’
A few press prosecutions, a few imprisonments of Jacobite
tipplers who would drink the health of King James in the streets, or
call it out in church services; a weeding-out of disorderly soldiers
from otherwise trustworthy regiments; and a little trouble arising from
pulpit indiscretions, are the only symptoms of yet uncertain times, to
be detected. The ‘Craftsman,’ of August 4th, chronicles the
discharge of ‘several Private Gentlemen out of the Lord Albemarle’s
troop of Life Guards, some as undersized, and others as
superannuated, but such have been allowed fifty guineas each and
their college. His Lordship proposes to give every Private Gentleman
in his Troop a new Surtout and a pair of Buckskin breeches, at his
own Expense.’
Later, in the autumn, preachers took for a subject
POLITICAL
the want of respect manifested, by the mass of SERMON.
people, for their ‘betters,’ including all that were in
authority. On Saturday, October 13th, the ‘Craftsman’ had this
paragraph, showing how the pulpit was lending itself to politics as
well as to morals:—‘Last Sunday a very remarkable sermon was
preached at a Great Church in the City, against speaking evil of
dignities, in which the Preacher endeavoured to show the
unparalleled wickedness and Impudence of Tradesmen meddling in
Politicks, and particularly of their riotous Procession to Westminster
to petition against the late Excise scheme (so evidently calculated for
their good), which he placed among the number of Deadly Sins, and
recommended Passive Obedience and Non-Resistance, for which
the Audience were so unkind as to laugh at him so much that he shut
up his book before he had done and threatened them with a severe
Chastisement.’
The fear of the ‘Pretender,’ the recruiting in back STORMY
parts of London for ‘foreign service,’ and the relations DEBATES.
of England with Continental powers, kept up a
troubled spirit among those who wished to live at home, at ease.
One of the most remarkable debates of the session occurred in the
House of Lords. The king had exercised, and wished to continue to
exercise, a right (such as he supposed himself to possess) of
dismissing officers from the army, without a court martial. The Duke
of Marlborough (Spencer) brought in a Bill to prevent such summary
expulsion, at the king’s pleasure. In the course of the debate the
figure of the Pretender was brought forward. The Duke of Newcastle
warmly supported the king’s ‘prerogative.’ There would be no safety,
he said, unless the king held that right. ‘There is,’ he remarked, ‘at
present a Pretender to the Crown of these realms, and we may
conclude that there will always be plots and contrivances in this
kingdom against the person in possession of the throne. While there