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[Illustration:

  And Adam knew Eve his wife,
  and she conceived, and bare Cain.
  _Chapter IV_ GENESIS. _1st verse_]




  THE
  MATRON'S MANUAL
  OF
  MIDWIFERY,
  AND THE
  DISEASES OF WOMEN DURING PREGNANCY
  AND IN
  CHILDBED,

  BEING A FAMILIAR AND PRACTICAL TREATISE, MORE
  ESPECIALLY INTENDED FOR THE INSTRUCTION OF
  FEMALES THEMSELVES, BUT ADAPTED ALSO
  FOR POPULAR USE AMONG STUDENTS
  AND PRACTITIONERS OF MEDICINE.

  By FREDERICK HOLLICK, M. D.,

  LECTURER ON PHYSIOLOGY AND FEMALE DISEASES,--AND
  AUTHOR OF THE DISEASES OF WOMAN,--OUTLINES
  OF ANATOMY AND PHYSIOLOGY
  FOR POPULAR USE,--NEUROPATHY,--AND
  THE ORIGIN OF LIFE.

  ILLUSTRATED BY OVER 50 SPLENDID ENGRAVINGS.

  NEW YORK:
  PUBLISHED BY T. W. STRONG,
  NO. 98 NASSAU STREET.
  BOSTON:--NO. 64 CORNHILL.
  1849.




  Entered according to Act of Congress, in the year 1848,
  By FREDERICK HOLLICK, M. D.,
  in the Clerk's office of the District Court of the United States for the
  Southern District of New York.

  The price of this Book is One Dollar.--It may be obtained of all
  Booksellers, or of T. W. STRONG, 98 Nassau-st., N. Y., who will also
  send it by Post to any part of the country, on receiving One Dollar
  and the Address.--N. B. All Dr. Hollick's other Books will be sent by
  T. W. Strong in the same way.




PREFACE.


A short time ago I published a popular treatise on _The Diseases of
Woman_, in the non pregnant state, and in that work I announced my
intention of shortly publishing a similar one on _Pregnancy and its
diseases_. This book is the fulfilment of that promise.

Being the first _popular_, and yet strictly _scientific_ and
_practical_ book on Midwifery ever published, its preparation has
necessarily been a work of great labour and difficulty. Everything
had to be simplified; familiar explanations had to be given of
complicated processes, and illustrations had to be designed that could
be understood by my readers. Little or no assistance could be obtained
from other works on the subject, because they were either designed for
professional men; and therefore too technical, or else were too general
in their explanations, and too unsystematical, to be of any practical
use. I therefore had to write every part afresh myself, and plan a new
arrangement; and so difficult was this to do, satisfactorily, that I
have _twice before_ completed the whole work, and then commenced at the
beginning again, before I was satisfied with my own production.

As it now stands, I trust this treatise answers the purposes for
which it was intended. I have taken care to make it so complete, and
scientific, that a medical student may take it for his text book; and
at the same time I have endeavoured to so simplify it that any female,
of ordinary capacity, can fully understand both its explanations and
practical directions. All purely technical words have been avoided, or,
when absolutely necessary, they have been carefully explained. Every
topic connected with the main subjects has been discussed, and the
latest information given on every point, and from every source.

Such a work as this has long been needed. Females have been kept in
shameful ignorance, of everything connected with their own systems, and
of the wonderful phenomena in which they play so important a part. That
ignorance has led to untold evils, which can never be corrected till
they become more enlightened respecting themselves. Fortunately many
of them begin to see this, and they request, in behalf of themselves
and their sisters, that such knowledge be no longer withheld. I have
been now, for a long time, engaged in this pleasing task of female
instruction, both by my Lectures and books, and in my daily communion
with them as patients; I am therefore aware both of their great lack of
proper information, and of their strong desire for it, and I flatter
myself I also know, from experience and careful observation, the
best mode of imparting it to them. In fact, I have made it a matter
of careful study, not only to render my subject _plain_, but also
_pleasing_ and _unobjectionable_; so that the most unreflecting shall
feel an interest in it, and the most sensitive be able to study it
without pain or repugnance.

The object of this book is not to make _every_ woman a professional
Midwife, nor to induce her to dispense with proper assistance in her
hour of difficulty, but simply to explain to her the nature and manner
of child-birth, and the means by which she is to be assisted. This will
disabuse her mind of many pernicious errors--make her more patient
under her unavoidable difficulties and pains--more docile to what is
required of her, since she will see the _reason_ for it--and it will
also enable her to avoid much positive suffering, and to render great
help, in many cases, to her attendant.--In a case of emergency also,
when other assistance cannot be procured time enough, or not at all,
it will teach one female how to assist another in delivery, which
every one of them ought to be able to do. Very often it happens that a
case of this kind occurs, and the Females around, instead of knowing
how to help the sufferer, are utterly useless, and even make her
worse by their evident terror and ignorance. I have known women _die_
in child-bed, for want of the most trivial assistance, which even a
child could understand how to give, though there were elderly females,
mothers themselves, around her; but they knew not what to do. Such a
state of things is disgraceful to the boasted intelligence of the age,
and should be remedied as speedily as possible. Every Adult female, or
at least every married one, should be instructed in these things, so
that she may know how to regulate her own conduct and how to render
useful assistance to others in case of need. Ill informed women are
generally as apprehensive of danger as they are incapable of avoiding
it; and as regardless of proper advice as they are ignorant of the
reason for it.

The time, I trust, is fast coming, when every female will be taught,
as of paramount importance, everything which concerns her own welfare;
and when ignorance will no longer be considered necessary to propriety
and virtue, nor useful knowledge incompatible with the most refined
delicacy and the strictest morality. I consider it my duty to assist
in hastening that time, and I feel much pleased that my previous
efforts have been so much commended. This book I hope will be equally
acceptable, and, if possible, more useful, than those which have
preceded it.

    F. HOLLICK, M. D.,

    New York




INTRODUCTION.


Parturition, or the expulsion of the perfectly formed human being from
the body of its mother, is a most wonderful natural function, for
the complete and safe performance of which at the proper time, every
requisite is found to exist. Notwithstanding the contrary experience
of society, as it now exists, it is well known that extreme suffering,
and danger to life, are not necessary nor even probable accompaniments
to child-birth; for it is invariably found, when females live under
circumstances favourable to their full physical development and health,
that it occurs speedily, and with little or no difficulty or pain.
Numerous proofs of this could be given in accounts of the Indians, and
other uncivilized females, among whom parturition is regarded as an
ordinary occurrence, for which no preparation need be made, and about
which no apprehension need be felt; such facts, however, are so well
known that they only need be referred to here.

As the organization and requirements of society changes, by the
adoption of what is called civilization, the condition of woman becomes
very different to what it was originally. In many respects her lot
is much meliorated, and she has great reason to be pleased with the
change, but in other respects she has not been so fortunate.

One great evil resulting from her altered position is, a neglect of
proper physical education while young, and of the various requirements
for bodily health in after life. In consequence of which she becomes
constitutionally weaker, and more sensitive to various injurious
influences, which she possesses diminished powers to withstand.
This evil increases in proportion as civilization advances, until
at last females become so imperfectly organized, and so enervated,
that they are utterly unable to fulfil the duties assigned them, and
they either die prematurely, or pass their whole lives in suffering
and complaint. So universally is this the case at the present time,
particularly in cities, that the exempt are very rare exceptions
to a rule most lamentably general. Unfortunately, custom and false
notions have given this melancholy state the stamp of propriety, and
thrown around it the charm of fashion. The suffering invalid is called
_interesting_, and the pale faced debilitated creature, scarcely able
to crawl about, is styled _genteel_, while robust health and physical
capability is termed _coarseness_ and _vulgarity_. So infatuated,
and weak minded, have females been made on this point, that I have
actually known some of them quite chagrined because people could see
they were well and strong; and I have known others quite alarmed for
fear that they should _look_ so. A short time ago I knew a lady who,
by the adoption of a proper course of training and treatment, passed
through her confinement so quickly, and with so little exhaustion,
that she was up and travelling about in three days after, not only
without inconvenience but with pleasure and advantage. But what was
the impression made on her female friends by such a speedy recovery?
did they feel quite pleased at it, and desirous that all others should
be equally fortunate? No; but quite the contrary! She was actually
thought deserving of _reprehension_, and was stigmatized as _vulgar_ in
the extreme. One person even made the remark, that she must be _a very
common person, and no Lady_! Now what a pitiable state of ignorance,
and mental imbecility, these females must be in, to be actually _proud
of their infirmities_; and yet they are but like the majority of
their sex. If they were not so _unfortunate_ in not knowing their true
interests, they would be highly culpable, but as it is they are truly
deserving of our pity.

It must be admitted, however, that though civilization has, so far,
entailed these evils on women, it has also done much to alleviate them.
Many diseases are beneficially modified, and some are even _cured_, by
medical treatment; surgical science has also attained a high point of
perfection; and the difficulties attendant on child birth are overcome
to a great extent by obstetrical skill. But notwithstanding all this
alleviation, these evils are still deplorably great. The utmost
scientific skill to which society can ever attain, will do but little
towards effectually relieving human suffering, and removing disease,
so long as it is entirely devoted to the mere art of _curing_ and
_palliating_ as it chiefly is now. Our knowledge of the human system,
and of the causes which produce in it disease and deterioration, must
be universally disseminated, so that the whole people may see _how
these evils arise_, and how they should live, and conduct themselves,
so as to _avoid them altogether!_ or, in other words, science should
teach us how to _prevent_ disease and suffering, instead of merely how
to alleviate them. Eventually this will be done, and our females will
then pass through their travail as easily as their savage sisters do
now. Let us hope that time will soon come; and let every one esteem it
his duty, who possesses the ability, to hasten its coming, by doing all
he can to spread the necessary information to those who need it.

The happy exemption from difficulty and suffering which females enjoy
in more uncultivated states of society, and which we believe they will
ultimately enjoy universally, does not however obviate the necessity
for assistance _now_, in our state of society, and we have therefore to
explain how it can best be rendered.

It has often been a matter of dispute, both with medical men and with
moralists, whether _Men_ or _Women_ ought to assist in child-birth.
The discussion has called forth a great deal of declamation, but very
little has been said to the point on either side. It appears to me,
however, that the question may be very easily settled, if it be rightly
considered. The first requisite, and the most indispensable, in those
who are to assist in child birth is, that they should _know how to
assist_. This is paramount to every thing else. Now, if females really
did know what to do in such cases, and were fully competent to do it,
I think there is no question but they would be the _best_ assistants,
to say nothing of their being the most _proper_. There are many
things experienced by females in such situations, which can never be
understood by a man at all, though they are readily appreciated by one
of their own sex, particularly if she has been a mother herself. With
each other also there would be less disposition and less occasion for
reserve in delicate communications, and less repugnance to necessary
examination or manipulation, which could therefore be more efficiently
practised. In short, if women were undoubtedly equally competent with
men in this art, and full confidence was felt in them by their own sex,
I think it is evident they would, in every respect, be the most fitting
practitioners, and I have no doubt but they would be preferred. The
question simply arises then, whether they are so competent? And every
one able to judge, who speaks honestly, must admit that very few, if
any of them really are so. It has not been possible for them to acquire
the requisite information, nor to pursue the necessary investigations,
and therefore we cannot expect that they can be equal to those who
have. There are some women I know, who have been careful observers,
and who have had great experience, that can render all needful help _in
most cases_, but even they are apt to meet with difficulties, which
require more skill than they possess to overcome; therefore very few
like to depend upon them altogether. It is naturally argued that, as a
physician _may_ be needed, it is better to have him at first, and so be
ready for every contingency.

That females can make competent _Accoucheurs_ is proved by numerous
well known instances, among which I need only refer to MADAME
BOIVIN, and MADAME LACHAPELLE, both of whom, as practitioners and as
authors, stand in the very highest rank. These ladies are referred
to as authorities, and their works are quoted by the most eminent
Professors of the day; in fact, on many points, they have surpassed all
competitors. Further on in our work we shall have occasion to refer to
their labours, the value of which will then be seen.

It is therefore evident that females can officiate, if they are
properly instructed, which I think they ought to be, independent of the
reasons already given. That they will eventually be competent I have no
doubt, and I am proud to throw my mite of instruction in their way to
assist in making them so.

In regard to the alledged _immorality_ resulting from the present
system of men acting as Midwives, there is much exaggeration, and
much unnecessary alarm. That it is, in some respects, indelicate, and
only to be justified by necessity is true, but there is no foundation
for saying, as some do, that it leads to wide spread Profligacy
and Adultery. I should prefer to see females always able to assist
each other; but I cannot nevertheless consider the present system a
necessary cause of licentiousness.

That females were always depended upon in old times, and are now in
certain rude communities, is true, but that is no reason why they
should be depended upon under all circumstances. In our present
highly artificial state there are numerous causes at work, and
numerous difficulties experienced, unknown to more primitive times and
conditions, and we therefore require greater skill and more extensive
resources. Females have in fact become more in want of help, and less
able to assist.

At what time, and in what country, men first began to assist in cases
of labour is not recorded. They have done so however for a long time,
much longer than most people suppose. In the time of _Hippocrates_,
called the Father of Medicine, who lived _more than four hundred years
before Christ_, it appears that physicians were commonly resorted to.
In his writings we find cases described, which show that he was well
acquainted with the process of parturition, and even with some of the
most difficult operations now practised. The Israelites appear to have
employed women, as most eastern nations in fact do at the present day.

Midwifery, however, did not attract much attention, nor make much
progress, till about the middle of the sixteenth century, since when
it has been studied and practised by the most eminent Physicians and
Surgeons, and has arrived at great perfection.

Many new discoveries have been made lately, which enable us to
facilitate delivery and ease its pains, so that it is now robbed of
many of its former terrors and dangers. Some of these discoveries are
of easy application, and promise much future good; I shall carefully
describe them all, in the following pages.

    F. H.




ILLUSTRATIONS.


FRONTISPIECE, Eve in the Garden of Eden.

PLATE I.--Lateral Section, of the Female Pelvis, to show the position
of the Organs in their natural state, 5. PLATE II.--Front View of the
Female Pelvis, with the External Walls removed, 9. PLATE III.--The
Uterus and its Appendages, 13. PLATE IV.--Vertical Section of the
Womb and Vagina, natural size, 18. PLATE V.--The Muscular Fibres
of the Womb, 23. PLATE VI.--Muscular Fibres of the Womb, 27. PLATE
VII.--Bones of the Pelvis, 33. PLATE VII.-_a._--Male Pelvis, to show
the difference in structure, 35. PLATE VIII.--Section of the Pelvis,
37. PLATE IX.--Diameters of the Upper Strait, 41. PLATE X.--The
Bones of the Pelvis viewed from below, 45. PLATE XI.--The Direction
of the Pelvis, 49. PLATE XII.--Section of the Uterus, with the Ovum
and appendages, at about one month, 65. PLATE XII.-_a._--Female
Breast, 77. PLATE XIII.--Breast about the Fourth Month, 90. PLATE
XIV.--Womb, at about the third, seventh and ninth months, 99. PLATE
XV.--Primipara, or the First Pregnancy.--Woman who has borne children
before, 101. PLATE XVI.--Mode of performing the Ballotment, to detect
Pregnancy, 107. PLATE XVII.--At the end of the Fifth Month, 111. PLATE
XVIII.--The neck of the Womb in a first pregnancy, and in a female
who has borne children before, at the end of the seventh month, 116.
PLATE XIX.--Fœtus in the most usual position, 121. PLATE XX.--Fœtus
in the next most frequent position, 125. PLATE XXI.--Presentation of
the Pelvis, or breech, 129. PLATE XXII.--The position of Twins, as
most usually observed, 133. PLATE XXIII.--End of the Ninth Month,
135. PLATE XXIV.--The Fœtal head, 147. PLATE XXV.--Diameters of the
Head, 151. PLATE XXVI.--Attitude of the Fœtus, 153. PLATE XXVII.--Head
just entering the upper strait, 173. PLATE XXVIII.--Head lower in
the Pelvis, 177. PLATE XXIX.--Head beginning to Rotate, 181. PLATE
XXX.--Rotation of the Head, 183. PLATE XXXI.--Head in the _right_
anterior occipito iliac position, 187. PLATE XXXII.--Delivery in a
breech presentation, 194. PLATE XXXIII.--Anterior posterior position of
the head, 195. PLATE XXXIV.--The chin just passed in presentation of
the face, 200. PLATE XXXV.--Presentation of right shoulder, 205. PLATE
XXXVI.--Descent of shoulder, 206. PLATE XXXVII.--Descent of shoulder,
207. PLATE XXXVIII.--Trunk descended, 208. PLATE XXXVIII.-_a._--State
of the parts at beginning of labor, 215. PLATE XXXIX.--Manner of
supporting the perineum, 233. PLATE XL.--Standard form of Pelvis,
271. PLATE XLI.--Masculine Pelvis, 271. PLATES XLII, XLIII, XLIV,
XLV.--Deformed Pelves, 275-279. PLATE XLVI.--Head fixed in a narrow
pelvis, 282. PLATE XLVII.--Case of Tumor, 289. PLATE XLVIII.--Case
of Polypus, 293. PLATE XLIX.--Limbs cut off by the Cord, 301. PLATE
L.--Forceps, 346. PLATE LI.--Head extracted by Forceps, 353.




TABLE OF CONTENTS.


  PART I.--MIDWIFERY.


  Section I.

  POSITION AND USES OF THE FEMALE ORGANS.

                                                               _Page_

  CHAPTER I.--Position of the Organs and Parts,                    13
              Internal Organs,                                     14
              External Organs,                                     16

  CHAPTER II.--Structure of the Principal Organs and Parts,        18
               The Womb,                                           19
               The Vagina.--Vulva.--Perineum,                      29
               The Pelvis,                                         30

  CHAPTER III.--Functions of the Principal Female Organs,          50
                The Womb,                                          50
                The Ovaries.--Menstruation,                        51
                Conception,                                        54

  CHAPTER IV.--Fœtal Development,                                  57
               Fœtal Nutrition,                                    67
               Peculiarities of the Fœtal Circulation,             70
               The Breast,                                         74


  Section II.

  SIGNS OF PREGNANCY, AND THE MEANS OF DETECTING IT; ITS DURATION,
  AND THE PERIOD AT WHICH THE FŒTUS CAN LIVE.

  CHAPTER V.--Presumptive Signs,                                   83
              Probable Signs,                                      94

  CHAPTER VI.--Duration of Pregnancy,                             137

  CHAPTER VII.--Period when the Child can live,                   142


  Section III.

  THE FORM, SIZE AND POSITION OF THE FŒTUS, AND ITS APPENDAGES, AT
  FULL TERM.

  CHAPTER VIII.--Form and Size of the Body,                       144
                 Size and Form of the Head,                       144
                 Attitude of the Fœtus at Full term,              152

  CHAPTER IX.--The Appendages of the Fœtus at term,               155

  CHAPTER IX.--The Membranes,                                     155
               The Placenta,                                      156
               The Umbilical Cord,                                157


  Section IV.

  THE MECHANISM OF DELIVERY IN ALL THE DIFFERENT PRESENTATIONS
  AND POSITIONS OF THE FŒTUS.

  CHAPTER X.--Presentations,                                      160
              Positions,                                          161
              Mode of ascertaining the Presentation and
                  Position,                                       164

  CHAPTER XI.--The Mechanism of Delivery, in a Presentation
                   of the Head,                                   170
               The Left Anterior Occipito Iliac Position,         170
               Mechanism of Delivery in all other Positions
                   of the Head,                                   185
               General Remarks on the Different Positions
                   of the Head,                                   189

  CHAPTER XII.--Mechanism of Delivery in Presentations of
                    the Lower Extremities,                        191
                Delivery in a Breech Presentation in the left
                    Anterior Sacro-Iliac Position,                192
                Delivery by the Breech in the Right Posterior
                    Sacro Iliac Position,                         196
                Delivery by the Breech in the Full Posterior,
                    or Sacro Sacral Position,                     196
                General Remarks on the Presentation of the
                    Lower Extremities,                            197

  CHAPTER XIII.--Mechanism of Delivery in Presentations of
                     the Face,                                    199
                 Delivery in the Right Posterior Mento Iliac
                     Position of the Face,                        199
                 Delivery in other positions of the face,         200

  CHAPTER XIV.--Mechanism of Delivery in Presentations of
                    the Trunk,                                    203
                Mechanism of Delivery in Presentations of
                    the Trunk by Spontaneous Evolution,           204


  Section V.

  THE PHYSIOLOGY OF SPONTANEOUS DELIVERY, OR CHILDBIRTH, AND THE
  MANNER OF CONDUCTING A NATURAL LABOR.

  CHAPTER XV.--Of Delivery in General.--Different Kinds of
                   Delivery.--Causes of Labor,                    211
               Signs of Delivery,                                 212

  CHAPTER XVI.--The Progress, Phenomena, and Duration of
                    Natural Labor.--First Period,                 214
                Second Period,                                    216
                Duration of Natural Labor,                        220

  CHAPTER XVII.--The Conduct or Management of a Natural
                     Labor.--Preliminary Requisites,              222
                 Preliminary Proceedings,                         223
                 Preparations for the Delivery,                   226
                 Attendance after the Preparations are made,
                     and during the Delivery,                     229

  CHAPTER XVII.--Delivery of the After Birth, or Placenta and
                     Membranes,                                   239
                 Attentions to the Female after the Delivery
                     of the After Birth,                          242
                 Attentions to the Child,                         243
                 Accidents which may happen,                      246
                 Subsequent Attentions to Mother and Child,       249
                 Concluding Remarks,                              255


  Section VI.

  PROTRACTED AND DIFFICULT LABORS.

  CHAPTER XVIII.--The Causes and Consequences of Prolonged
                      Labor to both Mother and Child,             259
                  The Consequences of Prolonged Labor,            259

  CHAPTER XIX.--Causes connected with the Mother which
                    may impede labor, or make it difficult,       260
                Inertia, or Want of sufficiently Powerful
                    Contraction in the Womb,                      260
                Rigidity of the Mouth of the Womb, Vagina
                    and Vulva,                                    264
                Obliquities of the Womb,                          266
                Prolapsus Uteri.--Smallness or Deformity of
                    the Pelvis,                                   267
                Tumors in the Pelvis,                             286
                Tumors externally.--Obstructions in the Vagina,   295

  CHAPTER XX.--Causes connected with the child, or children,
                   which may impede delivery.                     297
               Procidentia of the Umbilical Cord,                 297
               Shortness of the Cord,                             300
               Descent of other parts with the head,              301
               Twins and Triplets,                                302
               Excessive size of the Fœtus, or the diseased
                   development of certain parts,                  304
               Ossification of the Head,                          305
               Various presentations and positions of the
                   Fœtus,                                         306
               Presentations of the Lower Extremities,            307
               Presentations of the Shoulder,                     311


  Section VII.

  ACCIDENTS DURING LABOR WHICH MAY COMPROMISE THE MOTHER'S LIFE.

  CHAPTER XXI.--Uterine Hemorrhage, or Flooding, during
                    Labor,                                        315

  CHAPTER XXII.--Eclampsia, or Convulsions during Labor,          336

  CHAPTER XXIII.--Rupture of the Womb or Vagina,                  341


  Section VIII.

  OPERATIONS WITH THE HAND AND WITH INSTRUMENTS.

  CHAPTER XXIV.--Operations with Instruments.--The Forceps,       345
                 Other Instruments,                               355

  CHAPTER XXV.--Operations with the Hand.--Turning,               357


  PART II.

  THE DISEASES OF WOMEN DURING PREGNANCY, AND IN CHILDBED.


  Section IX.

  THE DISEASES OF PREGNANCY.

  CHAPTER XXVI.--Sympathetic Diseases occurring during
                     Pregnancy.--Sickness and Vomiting,           366
                 Ptyalism, or Excessive Salivation,               369
                 Odontalgia, or Toothache,                        369
                 Derangements of the Appetite,                    371
                 Pyrosis.--Dysphagia,                             374
                 Gastralgia,                                      375
                 Constipation,                                    377
                 Dysentery and Diarrhœa,                          378
                 Dyspnœa, or Difficulty of Breathing,             380
                 Cough,                                           381
                 Palpitation of the Heart,                        383
                 Syncope, or Fainting,                            384
                 Headache and Dizziness in the Head,              386
                 Insomnia, or Sleeplessness,                      388
                 Temporary Affection of the Sight, Hearing,
                     and Smell,                                   389
                 Disordered Judgment, Inclinations, and
                     Propensities,                                391
                 Hæmoptysis, Hæmatemesis and Epistaxis,           393
                 Varicose Veins,                                  395
                 Hæmorrhoids, or Piles,                           397
                 Œdema, or Watery Swellings,                      399
                 Hydrorrhea, or Profuse Discharge of Water,       400
                 Pustules, and Mucous Discharges,                 400
                 Derangements of the Urinary Organs,              401
                 Cramps.--Pruritus, or Itching of the External
                     Parts,                                       403

  CHAPTER XXVII.--Idiopathic, or Primary Diseases Incident
                      to Pregnancy.--Flooding,                    406
                  Abortion, or Miscarriage,                       409


  Section X.

  THE DISEASES OF WOMEN IN CHILDBED, AFTER LYING IN.

  CHAPTER XXVIII.--Diseases of Childbed.--Puerperal Fever,
                       or Childbed Fever,                         420
                   Affections of the Breast occurring after
                       Pregnancy,                                 430
                   Bronchocele, or swelling in the Throat,        438
                   Phlegmasia Alba Dolens, or Milk Leg,           439
                   Trouble with the Urine,                        441


  APPENDIX.

  ON PREVENTING PAIN IN CHILDBIRTH,                               443




PART I.

MIDWIFERY.


  PLATE I.

  Lateral Section, or side view of the Female Pelvis, to show the
  position of the Organs.

  A. The Bladder.
  B. The Womb.
  C. The Vagina.
  D. The Rectum.
  _e._ The Right Ovary.
  _f._ The Right Fallopian Tube.
  _g._ The Os Tincæ, or Mouth of the Womb.
  _h._ The Meatus Urinarius, or Mouth of the Bladder.
  _i. i._ The Small Intestines.
  _j. j._ The Back Bone.
  _k._ The Pubic or Front Bone.
  _l._ The Right External Lip, or Labium.
  _m._ The Right Internal Lip, or Nymphæ.
  _n._ The Hymen.
  _o._ The Opening through the Hymen.
  _q._ The Perineum.
  _p._ The Clitoris.

  (This of course shows the half of all the single Organs and the right
  one only of those that are double.)

[Illustration: Plate I.

Lateral Section, or side view of the Female Pelvis, to show the
position of the Organs in their natural state.]


  PLATE II.

  Front View of the Female Pelvis, with the External Walls removed.

  A. The Bladder.
  B. The Womb.
  D. The Rectum.
  _e. e._ The Ovaries.
  _f. f._ The Fallopian Tubes.
  _i. i._ The Small Intestines.
  _r. r._ The Round Ligaments.

[Illustration: Plate II.

Front View of the Female Pelvis, with the External Walls removed.]




MIDWIFERY.




SECTION I.

POSITION, STRUCTURE, AND FUNCTIONS OF THE ORGANS AND PARTS OF THE
FEMALE BODY CONCERNED IN GENERATION AND PARTURITION.


To understand the subjects treated upon in the present work, it is
necessary to have at least a general acquaintance with the structure,
position, and special uses of the principal organs and parts of the
female system. A complete acquaintance, so far as our knowledge
extends, would be advisable, but is not absolutely required, and
could not with convenience be given here. The following explanations
therefore, chiefly taken from my book on the Diseases of Woman, are
merely sufficient for the present occasion, and for reference--full
details being reserved for a separate and complete work, now preparing,
on the _Philosophy and Physiology of the Reproductive Functions_.




CHAPTER I.

POSITION OF THE ORGANS AND PARTS.


Plate I, represents one half of the Female body, supposing it to be cut
down the middle, and gives an accurate representation of the relative
position of the different organs.

Plate II, represents a front view of the Female body, with the external
walls removed, to show the relative position of the organs.

Plate III, represents the uterus and its appendages removed from the
body, so that their connections with each other may be seen.

[Illustration: PLATE III.

B. The Womb.--C. The Vagina.--_e. e._ The Ovaries.--_f. f._ The
Fallopian Tubes.--_s._ The left broad Ligament, the right one being
removed.--_r. r._ The Round Ligaments.--_g._ The Os Tincæ, or Mouth of
the Womb.]


INTERNAL ORGANS.

_The Ovaries._--(_e. e._ Plates I, II and III.)--These are two oval
shaped bodies, about the size of an almond nut, placed one on each
side, nearly in the groin. They contain a number of small round grains,
or granules, called the _ovæ_, or eggs, which are the germs of human
beings, as the eggs of birds are of their particular kind. They are
connected with the uterus by two short arms, or prolongations, and are
enclosed in the folds of the broad ligaments.

_The Fallopian Tubes._--(_f. f._ Plates I and II.)--These are two
Tubes, one on each side, beneath the Ovaries, and extending farther.
Each of them has a small passage which opens into the uterus at one
end, and opposite the Ovaries at the other. Their use is to convey the
impregnating principle to the Ovaries, at the time of conception, and
to convey the Ovæ, when impregnated, to the interior of the Womb.

_The Uterus, or Womb._--(B. Plates I, II.)--This is a hollow organ,
placed between the Bladder, which is in front, and the Rectum, which is
behind. It is connected with the Vagina, and opens into it by the small
orifice called the mouth of the womb.--(_g._ Plate I.)--The Uterus
is the organ which receives the impregnated ovum, and in which it is
developed into the human being. It is connected with the Ovaries by the
Fallopian Tubes, and with the Vagina by the Os Tincæ, and is retained
in its situation partly by its connections with other organs, and
partly by the round and broad ligaments.

_The Vagina._--(C. Plate I.)--This is the passage which leads to the
Womb from the external opening.

_The Os Tincæ, or Mouth of the Womb._--(_g._ Plates I and II.)--This is
the small orifice, opening into the Vagina, by which communication is
established with the Uterus from without.

_The Bladder._--(A. Plates I and II.)--The Receptacle of the Urine. It
is placed immediately in front, on the pubic bone, the Uterus lying
nearly on the top of it.

_The Rectum, or Termination of the large Intestine._ (D. Plates I and
II.)--This is situated behind the Vagina, and between it and the back
bone.

_The Broad Ligaments._--(_s._ Plate III.)--These are two broad folds
of membrane, which serve partly to enclose the Fallopian Tubes and
Ovaries, and partly to sustain the Womb in its place. They adhere to
the Uterus and to the walls of the Pelvis.

_The Round Ligaments._--(_r. r._ Plates II and III.) These two cords
arise from each upper corner of the Uterus, and curving downwards are
fixed by their other extremities to the pubic bone. They are partly
enclosed in the Broad Ligaments. They assist in sustaining the Uterus
in its position, and probably also they strengthen the Broad Ligaments
and prevent their rupture when the strain upon them is too great.

_Fimbriæ of the Fallopian Tubes._--(_t. t._ Plate III.) These Fimbriæ
are like Tentaculæ, or fingers, springing from the extreme ends of the
Tubes, and floating loosely in the cavity of the pelvis. Their use is
to clasp hold of the ovaries at the time of conception, so that the
fecundating principle can reach them, and also to take up the ovæ when
impregnated, and convey them into the Tube, down which they pass into
the Womb.


EXTERNAL ORGANS.

_The External Lips._--(_l._ Plate I.)--These are commonly termed the
_Labiæ externa_. They are two broad folds of membranous and adipose
substance, forming the portals to the Vulva, or entrance to the Vagina.

_The Internal Lips._--(_m._ Plate I.)--These are two smaller labiæ,
sometimes called the Nymphæ, within the first, the chief use of which
appears to be to direct the flow of the urine from the urethra.

_The Hymen._--(_n._ Plate I.)--This is a membrane generally found
in virgins, which grows over and closes more or less completely the
entrance to the Vagina. Use unknown. When it exists there is generally
a small orifice through it, by which the menses escape at each monthly
period.--(_o._ Plate I.)

_The Clitoris._--(_p._ Plate I.)--This is a small prominent organ,
about the size of a large pea, placed in the upper part of the opening
between the external lips, and immediately above the Meatus Urinarius.
It is the principal seat of venereal excitement, and is subject to many
annoying diseases.

_The Perineum._--(_q._ Plate I.)--The part between the Vulva, or
entrance to the Vagina, and the fundament. It is chiefly composed of
the muscles belonging to the neighboring parts, and assists very much
in supporting the womb.

_The Meatus Urinarius_, or Mouth of the Bladder, (_h._ Plate I.)--A
small opening by which the urine escapes, placed between the lips, and
immediately above the Vulva, or entrance to the Vagina.

These organs are all placed within, or in contact with, the lower part
of the Trunk, called the pelvis. They are all intimately connected
with each other, and some of them have most extensive and strong
sympathies with almost every other part of the system. So much so is
this the case in fact, that probably the great majority of diseases to
which females are liable arise, directly or indirectly, from Uterine or
Ovarian derangement. Very often the heart, the stomach, or some other
organ, though perfectly healthy, is thought to be diseased, and appears
to be so, merely from its sympathy with the diseased womb.




CHAPTER II.

STRUCTURE OF THE PRINCIPAL ORGANS AND PARTS.


[Illustration: PLATE IV.

Vertical Section of the Womb and Vagina, natural size.

_a. a. a._ The solid walls of the Womb cut through. _b._ That part of
the cavity, or hollow of the Womb, which is in the fundus, or top. _c._
That part of the cavity which is in the lower part, or neck, of the
Womb. _d._ The Vagina. _e. e._ The cut edges of the Vagina. _f. f._
The positions of the Fallopian Tubes, which are cut off, and down the
passages of which two needles are passed. _g._ The Os Tincæ, or Mouth
of the Womb.]

In addition to the general explanation already given, there are some of
the Female organs whose peculiar structure requires to be more fully
noticed, on account of its important influence on some of the processes
hereafter to be described.


THE WOMB.

The external appearance of the womb, viewed in front, and in connection
with its appendages, is shown in Plate III. It is placed in the Pelvis,
between the bladder and the Rectum, and at the top of the Vagina, as
seen in Plates I and II. Its internal structure is represented in
Plate IV.

The length of the Womb, after puberty, is about three inches; its
breadth at the upper part, or fundus, about two inches; and at the
cervix, or neck, about one inch. The cavity in the interior is small,
owing to the thickness of the walls, and its form is triangular. The
shape of the Womb resembles a pear, somewhat flattened, from before
backward. Previous to puberty its size is much smaller, and with those
who have had children it often exceeds the dimensions we have given.

The _Neck_, or narrow part, (_c._ Plate IV.) is much changed by
pregnancy. In virgins it is long and pointed, and somewhat enlarged
in the middle. In those who have borne children it is considerably
shorter, more obtuse, and less regular in its form. The cavity in the
Neck is larger in the middle than at either end, as will be seen in
Plate IV.

The _Os Tincæ_, or mouth of the Womb, also undergoes considerable
change from the same cause. In the young person it is merely like a
small slit, scarcely to be felt, but after pregnancy it much enlarges,
and remains more or less permanently open. The anterior lip, or the one
in front, is somewhat larger than the posterior one.

The body of the Uterus is formed of a very dense, gray colored,
muscular substance, possessing astonishing contractile power. The
interior is lined, like the Vagina, with a mucus membrane, and the
whole organ is plentifully supplied with arteries, veins, and nerves.

One of the most remarkable properties of the Womb is that of being
able to distend to an extraordinary degree, and then retract again to
nearly its original size. The force which it sometimes exhibits during
its contraction is very great, being sufficient to separate, and even
break, the bones of the mother's pelvis, and paralyze the hand of the
operator when introduced. The Muscular Fibres on which this contractile
force depends are most obvious during gestation; they then appear
very numerous, and very curiously disposed, some of them ramifying in
almost every direction, as will be seen by Plates V, VI. It is owing to
this that the Womb contracts in every conceivable direction, and thus
presses, during labor, on every part of the child's body.


  PLATE V.

  Figures 1 and 2.

  Fig. 1. In this plate represents the Muscular Fibres a little
  exaggerated, so that they can be more distinctly seen.--_a. a._ are
  the orifices of the Fallopian Tubes.

  Fig. 2. Represents the natural appearance, the fibres not being quite
  so distinct, though sufficiently obvious.--_a. a._ The orifices of
  the Fallopian Tubes.

  In both Figures the Womb is supposed to be turned inside out, its
  peculiar structure being more readily seen interiorly than exteriorly.

[Illustration: Plate V.

The Muscular Fibres of the Womb.]


  PLATE VI.

  Figures 1 and 2.

  Fig 1. This represents the appearance of the Fibres externally, and
  shows how they terminate in the round ligament a. b.

  Fig. 2. The lines _a. b._ represent the direction of the force of the
  Fundul Fibres; _c. d._ That of the Circular Muscles of the body of
  the Uterus; _d. e._ The combined force of the Muscles.

  The dotted lines represent the force reflected by the liquor amnii.
  The dotted curved lines the direction of the circular fibres of the
  body of the Uterus.

[Illustration: Plate VI.

The Muscular Fibres of the Womb.]


THE VAGINA.

The Vagina (_c._ Plate I.) is a membranous canal, lined with a mucus
membrane like the Uterus. By its upper part it is attached to the neck
of the Womb, at about two-thirds of its height--so that two-thirds of
the neck hang within the Vagina. Below, it terminates in the Vulva,
or external mouth. The upper part of the Vagina is much larger than
the lower part, particularly in those who have borne children. It is
capable of considerable distension, and after retraction, to allow of
the child passing down it from the Womb. The external mouth is called
the _Vulva_, and is usually partly closed, in the virgin state, by the
membrane called the Hymen, (_n._ Plate I.) The length of the Vagina is
from three to five inches, and its diameter from one inch to one and a
half, or even two inches in those who have borne many children.


THE VULVA.

This is the external opening, or mouth of the Vagina, through which
the child has to pass at the termination of delivery. The external and
internal lips, with the muscular and membranous tissue surrounding it,
are all capable of great distension, without injury, to allow of the
passage of the child.


THE PERINEUM.

This is the part situated between the Vulva and the Rectum. (_p._
Plate I.) It is composed of a somewhat dense and firm substance,
chiefly muscular, and, like all the other parts mentioned, is capable
of great distension. It is important, in many of the manipulations
during labor, to be well acquainted with it; and when the child's head
is passing the perineum requires supporting, to prevent its being
lacerated or broken through, an accident which often happens from want
of due attention, and which leads to the most serious consequences.


THE PELVIS.

The Pelvis is that part of the bony structure, or skeleton, of the
female, in which the generative organs are placed, and through which
the process of parturition is effected. An acquaintance with its
natural structure, and with the changes which may be produced in its
form and size, by disease and other accidents, is indispensable to
those who wish to practise or understand midwifery.

In early life the Pelvis is composed of several bones, many of which,
after puberty, grow together. In the adult female it is customary
to speak of but _four_ bones, the sacrum, the coccygis, and the two
innominata, or hip bones, (see Plates VII, VIII.) In the young female
these are divided into several distinct parts.


  PLATE VII.

  _Bones of the Pelvis._

  _The four principal bones, as found in Mature life._--A. A. The
  Ossa Ilii, or Ossa Innominata, commonly called the haunch, or hip
  bones.--B. The Os Sacrum, or lower part of the back bone.--C. The
  extreme termination of the back bone, called the Os Coccygis.

  _The divisions into parts, as in Early life._--The Ilium, A, on each
  side, is in three parts; the Ilium, properly so called, marked _a.
  a._; the Pubis, marked _b. b._; and the Ischium, marked _c. c._ The
  Sacrum is in five parts, marked 1, 2, 3, 4, 5.

  _d._ Is the last bone of the spine, which joins the Sacrum.--_e. e._
  Are the Sockets in which the upper parts of the thigh bones fit,
  forming the hip joints.--_g. g._ The two rings, formed by the bones
  of the Pubis and Ischium, each called the Foramen Magnum.

[Illustration: Plate VII.

Bones of the Pelvis.]

[Illustration: PLATE VII.--_a._

This represents the Male Pelvis, to show the difference in structure.

The letters correspond with those in Plate VII.]

[Illustration: PLATE VIII.

Section of the Pelvis, to show the shape and connection of those parts
not distinctly visible in the full view. The section is made down the
middle of the back bone, and through the symphysis pubes, in front. The
letters correspond with those in Plate VII.

A. The right Ilium.--B. The Sacrum.--C. The Coccygis.--_b._ The Os
Pubis.--_c._ The Os Ischinum.--_g._ The Foramen Magnum.--_o._ shows the
manner in which the coccygis is bent back through labor.]

These bones are all firmly bound together by a cartilaginous substance,
which is placed between where they touch, and is firmly attached to
each one. This union is called a _symphysis_. The one at front which
joins the pubic bones is called the symphysis pubis; the two which join
the Ossa Illii to the Sacrum are called the sacro iliac symphyses;
and that which joins the Coccygis to the Sacrum, is called the Sacro
coccygeal symphysis. The two pubic bones are separated a little in
Plate VIII, simply to show them better. The reader will bear in mind
that they are naturally connected by the cartilaginous substance which
forms the symphysis.

These articulations, or joinings, become much softened during labor,
and give way a little, but not to any extent sufficient to assist
delivery. It is a mistake to suppose that the bones separate at that
time. The only part which gives way is the sacro coccygeal symphysis,
which does relax, and allows the Os Coccygis to be pushed back by
the child's head a full inch or more, thus enlarging the inferior
strait.--(See _c._ and _o._ Plate VIII.) Sometimes this little bone
will be even broken off, when there is great disproportion between the
head and the strait. I have heard it snap like a stick breaking. There
is nothing serious nor alarming in this, however, unless it be _a first
delivery late in life_, though it may cause some pain at the time, and
a little difficulty in _sitting_ for some time after. In young persons
the symphysis is soft, and gives way easily, so that they have little
difficulty during delivery from this cause; but if a female marry late
in life, after it becomes hardened, she may suffer considerably. In
this case the coccygis is usually curved inwards considerably, and
being firmly fixed the head cannot push it back, and on that account
cannot pass, without great difficulty, and with the risk of rupturing
some of the soft parts, or breaking the coccygis completely off. There
is in fact great difficulty, and some danger, if the first pregnancy
takes place late in life.

The Pelvis is usually divided into two parts,--the _great pelvis_, or
upper part, enclosed between the wide flanges of the Ossa illii and
the upper part of the sacrum; and the _small pelvis_, or basin, which
is enclosed between the lower part of the sacrum and coccygis behind,
and the ossa ischii and ossa pubes in front. The basin is nearly
cylindrical, larger in the middle, and curved towards the front.

_The Straits of the Pelvis._--The bones of the Pelvis, it will be seen,
form a kind of broad ring, or cylinder, particularly in the basin; and
the straits are two passages, one by which the child passes into the
basin from the upper Pelvis, and the other by which it passes out from
the basin into the world.

In Plate VIII. the line marked † is the antero posterior diameter of
the _upper strait_, through which the child first passes, called also
the brim, or entrance to the Pelvis. The line marked ‡ is the diameter
of the _lower_ strait, through which the child passes into the world,
called also the outlet of the Pelvis. In Plate VII. the line marked †
crosses the upper strait, or brim of the Pelvis.

_The diameters of the Pelvis_ are the distances between the prominent
points of each strait, and are four in number for each, _those for the
upper_ strait being represented below.


  PLATE IX.

  _Diameters of the Upper Strait._

  A B, which extends from the most prominent point of the Sacrum, to
  the top of the Symphysis pubes, is called the _antero posterior_
  diameter, or that from before to behind.--C D, and E F, are called
  the two _oblique diameters_; they extend from each sacro iliac
  symphysis, to the most prominent point of the Os Ilium on the
  opposite side.--G H, is called the Transverse, or _bis iliac_
  diameter, it crosses the Pelvis nearly from one hip joint to the
  other.

  The Sacro Antero posterior diameter measures _four inches_. The
  two oblique diameters _four inches and a half_ each. The bis iliac
  diameter measures _five inches_.

  (By comparing this with Plate VII. the various points will be still
  more apparent.)

  The inferior strait has also four diameters, represented in Plate X.

[Illustration: Plate IX.

Diameters of the Upper Strait.]


  PLATE X.

  The Bones of the Pelvis viewed from below, looking through the
  inferior strait, to show its diameters.

  A B, which extends from the end of the Coccygis to the lower part
  of the Symphysis Pubis, is called the _antero posterior_ diameter;
  it measures _four inches_, like that of the upper strait, but is
  increased a little by the bending back of the Coccygis.--C D, and E
  F, are the two _oblique diameters_, also corresponding to those in
  the upper strait; they measure _four inches_, but are increased a
  little by the giving way of the soft parts.--G H, is the transverse,
  or bis-ischiatic diameter; it measures _four inches_.

[Illustration: Plate X.

The Bones of the Pelvis viewed from below, looking through the inferior
strait, to show its diameters.]

It will thus be seen that the diameters only average from four to five
inches, but it must be remembered that the soft parts, and even one of
the bones, very readily give way, and thus they are slightly increased.

When we come to describe the form and size of the fœtal child's head,
it will be found that its diameters correspond very nearly with those
of the pelvic straits through which it has to pass, so that ordinarily
labor presents no serious difficulty. If the head be larger than
natural, from any cause, or if the Pelvis be too small, or deformed,
this mutual adaptation does not exist, and delivery of course becomes
difficult, or dangerous, and sometimes impossible. The only obstacle
therefore, which can seriously impede the expulsion of the fœtus,
or prevent it altogether, is this want of conformity, in size and
shape, between its head and the bones of the Pelvis. The _soft parts_
may retard labor considerably, by being contracted or rigid, but can
generally be made to give way, either by the efforts of nature or
by manual assistance; and the fœtal head can be reduced in size if
necessary; but insufficient size, or faulty form, in the _bones_, is
irremediable.

The various causes which produce deformity, or imperfect development,
in the Pelvis, and unnatural growth of the child's head, will be stated
in a subsequent section. For the present, we have only to do with both
in the normal state.

The importance of an accurate knowledge of the structure of the
Pelvis, and of the changes which may be induced in it, will now be
obvious; neither the theory nor the practice of Midwifery can in fact
be understood without such knowledge. It is also frequently of the
first importance to know, _previous to marriage_, whether the pelvis
of a young person is so formed that delivery can be safely effected!
Inattention to this has sacrificed the lives of many, and caused others
to live for years suffering and helpless. In another place we shall
give some plain rules and directions by which this important point may
be determined.

_The floor of the Pelvis._--The soft parts at the bottom of the basin
of the Pelvis, consisting of the perineum and various muscles, are
called the floor of the Pelvis--the only passage through which is by
the Vulva, or mouth of the Vagina. As the head of the child descends
to the bottom of the basin, it presses upon this floor, and gradually
distends it, until the Vulva is sufficiently enlarged. This delay is
advantageous, for if the passage was always large enough, or increased
in size without any difficulty, the child would pass too suddenly, and
much mischief might often result from its sudden expulsion--such as
pulling down of the womb, flooding, and the falling of the child upon
the ground.

_Direction of the passage of the Pelvis._--In most of the lower animals
the passage of the Pelvis is straight, and on a line with the body,
the two straits being opposite each other, which makes delivery much
more easy with them. Even in the negroes, and other inferior races, the
passage is much straighter than in the whites. The more perfect the
organization therefore, the more difficult is parturition; and the more
imperfect or simple the organization, the more easy is parturition.
The dotted line in Plate XI. shows the direction of the passage of the
Pelvis, in the human female, to be a curve, so that the child has to
move, during its passage, in a circle.

[Illustration: PLATE XI.

The axis, or direction, of the upper strait is denoted by the line A,
that of the lower strait by the line B, and that of the Vulva by the
line C. The force of expulsion tending to push the child in _each_
direction, it has to traverse a path intermediate with them all, or
compounded of them all, not being able to move in either alone. This
aggregate direction is denoted by the dotted curved line, which shows
the direction in which the child passes, and in which the hand must be
passed when introduced.

I is the Perineum.--The dotted line which crosses A denotes the upper
strait, and the line I the lower strait.]




CHAPTER III.

FUNCTIONS OF THE PRINCIPAL FEMALE ORGANS.


The great object for which the whole of the Female organs perform their
several functions is, _that of bringing into existence a new being_!
For this purpose they act both separately and conjointly, each one
having its specific part to play in the grand phenomenon. As already
remarked, it would not be in place here to give all the details of this
wonderful event, but merely such a description of its principal stages,
as will suffice for an understanding of the main subject of the present
treatise. I shall therefore, first give the uses of the principal
organs separately, and then explain the processes of conception, and
fœtal development.


THE WOMB.

The Womb is nothing more than the receptacle in which the impregnated
egg is placed, and in which it undergoes all the wonderful changes by
which it eventually is developed into a perfect human being. The womb
is not therefore absolutely needed in _conception_, and indeed several
cases have been known where the new being was formed without the
womb altogether, though not perfectly. Its principal use is in fœtal
development, which cannot take place perfectly in any other part of the
body.


THE OVARIES.

The Ovaries, as already remarked, are two oval-shaped bodies, placed
one on each side of the womb, and connected with it, whose use is to
form the germ or rudiment, called the ovum, or egg, from which the new
being is developed. The structure of the Ovaries is very simple, and
the manner in which they produce the ovum is not very well understood.
It is certain however, that they are indispensable to conception, being
in fact the most essential parts of the female generative system.


MENSTRUATION.

Menstruation appears to be a process resulting from the development
and healthy action of the Female organs, and is essential to their
well being. The following brief account of its nature and origin is
extracted from my _Diseases of Woman_, page 152 to 155:

 "Until very recently but little was known, with any certainty,
 respecting this remarkable and important phenomenon of the female
 system. The most crude and visionary theories have been advanced to
 explain it, and our works on medicine and physiology do nothing more
 than repeat them, one after the other. The investigations of several
 distinguished physiologists however, within the last few years, have
 thrown a new light on this hitherto obscure subject, and explained
 much that was previously unknown, or, at best, merely conjectured
 upon. A brief statement of the result of those investigations will not
 only be highly interesting in itself, but will materially assist in
 explaining what we shall afterwards speak upon.

 "It is well known that the female organs are liable, at regular
 periods, to assume a peculiar action, which results in the discharge
 of a fluid termed the menses. The secretion and excretion of which
 are highly essential, both to the proper performance of many other
 functions, and to the maintenance of the general health. Whence
 comes this fluid, and what causes it to flow? These were questions
 unanswered, except by mere supposition, previous to the discoveries
 referred to, which we now proceed to make known.

 "In the first chapter it was stated that the _Ovæ_, or eggs, contained
 the rudiments or germs, from which, when impregnated by the male
 principle, new human beings were developed. These ovæ, however, are
 not prepared to undergo this development before the age of puberty,
 nor after the change of life, nor are the whole of them fit for
 conception even during the prolific period. It appears that they
 become fit for fecundation in succession, during the menstrual period,
 _one ovum,_ or more, _being ripened every month_! When fully perfected
 it separates from the ovary and is lost, unless conception occurs, in
 which case it passes along the fallopian tube into the Womb, and then
 develops into the fœtus. Here then we see the cause of the menses; the
 ripening of the ovum causes a local excitement, and congestion, in the
 ovary and womb, which increases till the period when it is thrown off,
 and then the accumulated fluid is discharged, the excitement subsides,
 and a new development commences.

 "This curious process is termed by some physiologists the monthly
 _ponte_, or _laying of eggs_, and by others the _Ovarian labor_, or
 _birth_! A small scar is left on the ovary at the point where the ovum
 separates, which fades away after a time, but a number of them may
 always be observed on the ovaries of those who have long menstruated.
 In those who die during menstruation the ovaries are found very red,
 and full of blood, and sometimes one of the ovæ will be found swelled,
 and just ready to burst through, or the ruptured opening may be seen
 through which it has actually escaped.

 "Precisely the same phenomenon occurs in the lower animals, excepting
 that their periods are more extended; some of them occurring annually,
 and others at still longer intervals. Some of the monkeys even have a
 species of real menstruation.

 "These important facts, by enabling us to understand what causes
 menstruation, give us an insight also into the nature of its
 derangements, and the conditions required for their regulation. When
 we call to mind also the close sympathy between the uterine organs and
 every other part of the system, it shows us how important a proper
 menstruation is to the general health, because without it those organs
 must be diseased, and consequently every other part of the system
 liable to suffer with them.

 "Formerly many absurd notions prevailed respecting menstruation, which
 in fact are not quite removed even now. Thus some authors asserted
 that a female, while unwell, could cause various diseases, by merely
 _touching_ persons! Others supposed they would curdle milk, and nearly
 all believed that the menstrual fluid itself was highly poisonous,
 so that females, at those times, were compelled to live apart and
 approach no one. In the Old Testament there are many regulations
 given, for females while menstruating, which show the prevalence of
 such notions in olden times. It is scarcely necessary to say that
 there is no foundation whatever for all this, as the fluid itself
 differs but little from ordinary blood, and is equally innocuous.

 "In like manner it was supposed, that menstruation was influenced by
 the _Moon_, and only occurred at a certain period of her age. We know,
 however, that females are unwell almost every hour of every day in the
 year.

 "The due establishment of the menstrual function is absolutely
 necessary, to the perfection both of mind and body, and its regular
 performance is quite as essential to the continuance of health, for
 there is scarcely a single disease that its derangement will not
 either cause, or at least seriously aggravate.

 "It is therefore _vitally important_ to attend to this matter,
 _particularly in young persons approaching puberty_! A little care
 at that time, properly bestowed, may prevent years of disease and
 suffering, if not untimely _death_!"


CONCEPTION.

Conception is the union of the male principle with the female ovum, or
egg, after that is perfected in the manner described in the article on
Menstruation. The precise manner in which this union is effected is
unknown, though our information in regard to it is much more extensive,
and precise, than formerly. As nearly as can be stated it occurs in the
following way:

At the time of a fruitful connection, which can only occur, it must
be remembered, when the ovum is ripe, the male principle is carried
into the Womb, (B, Plates I. and III.) and is then supposed, by some,
to meet with the ovum which has descended down the Fallopian Tube
(_f_, Plates I. and III.) from the Ovary, so that the union of the two
takes place, according to this view, either in the Fallopian Tube or
in the Womb. Others, however, suppose that the ovum does not leave the
Ovary before conception, but that the male principle passes down the
Fallopian Tube and meets it there, and that it is several days after
before it reaches the Womb. There are many facts and arguments brought
forward in support of each view, all of which will be set forth in my
forthcoming work on the reproductive functions. All that is known for
certain is, that the two principles must unite in one place or the
other, and that the ovum must pass down the Tube into the Womb, either
before impregnation, or after.

The union of the two principles in the Womb appears so likely an event
that it is scarcely possible to avoid thinking that it really does then
take place, but at the same time there are very strong reasons for
adopting the opinion that it takes place in the Ovary. Among others may
be mentioned the phenomenon of _extra uterine conception_, which will
be more fully alluded to in another place. In these cases the fœtus is
found _outside_ of the Womb, in the Tube, or the Ovary, or even in the
Abdomen, among the intestines. Such an occurrence seems to render it
almost certain that the ovum must have been fecundated in the Ovary,
because we cannot well conceive, if it were not so, how it could reach
the outside of the Womb. This difficulty is not, however, regarded
as insuperable, by the advocates of the opposite theory. Possibly
conception may occur _in both ways_.

There are many causes which prevent conception, or, in other words,
which produce _barrenness_ and _sterility_. These various causes
cannot be all explained, except in connection with a full explanation
of the process of reproduction, and of the nature of many female
diseases. In my work on "_The Diseases of Woman_," I have given a
chapter on this subject, and have also referred to the present work as
one in which it would be more fully treated. This reference, however,
was made in mistake; the subject is not needed here, but will be in
the other work, on the _reproductive functions_ in which it will be
discussed at length.




CHAPTER IV.

FŒTAL DEVELOPMENT.


The last Chapter brought us up to the point of conception, or the first
commencement of the new being. The next step is to exhibit its various
stages of development, and to show how it is nourished and maintained
in its proper position. This is requisite in order to understand the
origin of many diseases and accidents which occur during gestation, and
also to explain the various signs by which it is determined whether a
female is pregnant or not.


FŒTAL DEVELOPMENT.

The development of a perfectly formed human being from the egg in which
it originates, is one of the most astonishing phenomena that can come
under our observation, and is eminently deserving the study of every
rational being. The present explanation of it must necessarily be
brief, being merely intended to make the main subject more clear.

It has already been remarked that it is uncertain whether the ovum is
impregnated before it is brought into the Uterus, or after it arrives
there; but be that as it may, nothing has yet been discovered in the
Womb till several days after conception. Some physiologists tell us
that the rudiment of the new being may be found there about the _sixth_
day; but others again assure us that it cannot be found before the
_twelfth_, at which period our explanation of its development will
commence.

_At the twelfth day_ the ovum is about the size of a large pea, it is
composed of a vesicle containing a thick fluid, called the _germ_,
which corresponds to the opaque substance seen in the white of a
fecundated bird's egg, and of a yellowish substance, in which it
floats, called the _vitellus_, which answers to the yelk. The whole
being surrounded by two membranous coverings, the outer one called
the _chorion_, and the inner one the _amnion_. Between these is a
gelatinous substance, and within the amnion is a fluid, called the
liquor amnii. The two membranes, the liquor amnii, and the inclosed
ovum, are called the _ovulum_! Immediately after conception the uterus
begins to secrete, from its inner walls, another membrane, very
delicate, called the _decidua_. This lines the whole cavity, so that
when the ovulum passes out of the tube it is met by this lining which
seems to prevent its entrance into the womb. The ovulum, however,
presses upon it and so makes a depression, like a nest, in which it
lies. This prevents its moving about, or falling to the bottom of the
womb.

The weight of the entire ovulum is about one grain. The embryo
commences in the germ, and may now be seen about the size of a pin's
point. The vitellus removes away from it, but remains connected by a
small pedicel or thread-like tube, down which it is gradually absorbed
as nutriment. A small white thread, scarcely perceptible, may be seen
sometimes as early as this period, being the commencement of the brain
and spinal marrow. The mouth is visible also from the twelfth to the
twentieth day, and frequently the eyes. These are placed at first on
the side of the head, like those of quadrupeds, and move round to the
front afterwards.

_At twenty-five days_, the embryo is about the size of a large ant,
which it also resembles in form. It begins to have a little more
consistence, and the future bones begin to resemble cartilage, or
gristle. A small groove may be seen denoting the neck, which thus
indicates the separation of the head from the trunk. The weight is
three or four grains.

_The first month_, it is about the size of a Bee, and is somewhat like
a small worm bent together. The arms may be seen like two little warts.
They are first formed under the skin, and shoot out like buds, growing
straight from the body; afterwards they become folded together, in
a curious manner, upon the breast. The head is as large as the rest
of the body, and upon it we can now see distinctly the eyes, like
two black dots, the mouth, like a line, and also the nose. The lower
extremity is lengthened out like a tail. Weight about ten grains.

_The second month._ Every part has now become much more developed, and
the general form is that of a human being. The superior members are
much more elongated, and the inferior ones begin to be distinguished,
forming in the same manner as the others. The fingers are united
together by a membrane, like the web on a Frog's foot. In the ribs,
clavicles, and jaw bones, a few points can be seen ossified, the
cartilage beginning; to harden into bone. The rudiments of the first
teeth are also visible. The weight is about one drachm, and the length
one inch.

_At about seventy days_ the eyelids are visible, the nose becomes
prominent, the mouth enlarges, and the external ear may be seen. The
neck is well defined. The brain is soft and pulpy, and the heart is
perfectly developed.

Every organ is originally formed without either blood or blood vessels.
The circulation which afterwards takes place in them is merely for
their subsequent development. The heart is perfect in all its parts,
and even has a slight motion, before the blood is found in it.

_Three months._ All the essential parts are well defined. The eyelids
distinct, but firmly closed. The lips perfect, but drawn tightly
together. The heart beats forcibly, and in the larger vessels red blood
is seen. The fingers and toes are defined, and the muscles begin to be
apparent. The organs of generation are remarkably prominent, but still
it is somewhat difficult, at first, to distinguish the sex by these
organs, notwithstanding their development, as the principal parts in
both are nearly identical in form. It can, however, be ascertained by
other circumstances, as the form of the head, dorsal spine, thorax, and
abdomen. It now weighs about two ounces and a half, and measures four
or five inches in length.

_Four months._ The development is remarkably increased. The brain
and spinal marrow becomes firmer, the muscles distinct, and a little
cellular tissue is formed. The abdomen is fully covered in and the
intestines are no longer visible. A little of the substance called
_meconium_ even collects in the intestines, the same as is found in at
birth. It now weighs seven or eight ounces, and measures six or seven
inches. The bones are ossified in a great part of their extent, and the
rudiments of the second set of teeth are visible, under the first.

The uterus now is so large that it can no longer remain in the lower
part of the pelvis, but is compelled to rise up into the abdomen for
more room. This change of position is improperly called _quickening_!
Sometimes it takes place very gradually, so that it is scarcely
noticed, but more frequently it rises suddenly, disturbing all the
internal organs, and causing in them considerable derangement till
they accommodate themselves to the change. This occurrence often
causes unnecessary alarm, though the sickness, and other unpleasant
sensations, are always sufficiently annoying.

This stage corresponds with that in which the young of oviparous
animals breaks the shell and escapes. The human being however,
undergoes a remarkable change, and remains in the womb for a period
longer than that already past, in order to become more perfected.

From four to nine months the development is proportionally much more
rapid than during the first four months, owing to the circulation of
perfect red blood, which is now found the same as in the adult, and is
probably derived from the mother's blood vessels.

_Five months._ Every part is considerably increased in size, and become
more perfect. The lungs enlarge, and are even capable of being, to a
certain extent, dilated. The skin becomes much stronger. The situation
of the nails can be discerned. The meconium is more abundant, and lower
down in the intestines. The length is now eight or ten inches, and the
weight fifteen or sixteen ounces.

_Six months._ The nails are marked. The head becomes downy, from the
first development of the hair. A little fat is formed. Length twelve
inches, weight from one and a half to two pounds. No indications of
intellectual faculties.

_Seven months._ The whole being has rapidly progressed. The nails
are formed, the hair is perfect, in the male the testicles descend
to the scrotum, and in the female the ovaries reach the brim of the
pelvis. The bones are tolerably firm, and the meconium collects in the
large intestines. Length fourteen inches, weight about three pounds.
Intellectual functions not yet exercised.

The two remaining months are merely devoted to further increase in size
and weight. No new phenomena present themselves.

_Nine months._ Every function has become active. The skin becomes
colored, and perspiration occurs. There are no indications of the
intellectual functions, but the animal functions are remarkably active,
particularly that of _taste_, which no doubt leads to the act of
sucking, from the natural desire for its gratification. The child can
now experience all the ordinary sensations of pain, hunger, heat, and
cold, and is capable of preserving an independent existence if brought
into the world.

Plate XII. represents a section of the Uterus at about one month of
gestation, so as to show all the parts in their proper situation.


  PLATE XII.

  Section of the Uterus, with the Ovum and appendages, at about one
  month of gestation.--_a. a. a._ The substance of the walls of the
  Womb.--_b. b._ The Embryo.--_c._ The different vessels by which it
  is connected with the Placenta.--_d. d._ The Placenta.--_e._ The
  Vitellus.--_f. f. f._ The Membrane lining the Uterus, called the
  Decidua; it is seen to be bent double, or reflected, the Embryo being
  on the outside of it.--_g. g._ The Chorion, or Middle Membrane, which
  is studded over with villosities, or small blood vessels.--_h. h._
  The Amnion, or inner membrane, which contains the fluid called the
  liquor amnii, in which the Embryo floats.--_i. i._ The blood vessels
  which connect the Placenta with the Womb.--_j._ Is a plug of Mucus,
  by which the mouth of the Womb is now blocked up.--_k. k._ The ends
  of the Fallopian Tubes, which are cut off; these are also blocked up
  with mucus, the same as the Os Tincæ.--_l._ The Os Tincæ, or mouth of
  the Womb.--_m._ The Vagina.

[Illustration: Plate XII.

Section of the Uterus, with the Ovum and appendages, at about one month
of gestation.]


FŒTAL NUTRITION.

The manner in which the new being derives its nutriment, or the
material by which it grows, is, in a great measure, unknown to us,
though we certainly obtain some little information about it by a study
of the apparatus employed in the process.

For the first fifteen or twenty days the substance called the
_Vitellus_, (_e._ Plate XII.) which is analagous to the yelk of the
ordinary egg, appears to supply most, if not all of the material
that is required in the formation of the new being; and indeed this
substance does not totally disappear till after the third month, though
we cannot suppose it to be the sole source of nutriment then. It is
also supposed, by some, that the amniotic liquor, in which the fœtus
floats, may afford some nutriment, either by being swallowed, or by
being absorbed through the skin. It is certain that this fluid is
nutritive, and there is nothing impossible in its absorption, though it
is not very likely to occur to a sufficient extent. The idea that it
can be swallowed however, is erroneous, because the mouth of the Fœtus
is firmly closed while in the Womb; and besides, children have been
born alive without _mouths_, and even without _heads_, and of course
they could not have swallowed anything. It is now generally conceded
by physiologists that the material required by the Fœtus, for its
nutrition, is obtained from the blood of the mother, through the medium
of the Placenta, and the vessels in the Umbilical cord. It is, however,
a matter of dispute whether the maternal blood is sent directly, in
its ordinary state, into the body of the child, or whether it first
undergoes a preparatory process, which most modern authors suppose it
does.

From the earliest period of gestation, the middle membrane, called the
chorion, (_g. g._ P. XII.) is covered, on its outer surface, with a
number of small protuberances called _villosities_, which subsequently
become true blood vessels. About the fourth month these have increased
very much in size and number, and have all become conglomerated into
one mass, in form like a mushroom. This is called the _Placenta_.
It is almost entirely formed of blood vessels, which seem to attach
themselves at one end, by open mouths, to the open mouths of other
blood vessels on the inner walls of the uterus (_i. i._ Plate XII.)
At the other end these vessels are drawn together and lengthened out
into a long tube, called the _umbilical cord_, or _navel string_, which
finally enters the body of the child at the navel and so establishes
the connexion between it and the mother.--(_c._ Plate XII.)

The blood vessels in the placenta, umbilicus, and fœtus, like those
in the maternal body, are of two kinds, _Arteries_ and _veins_. The
arteries, which come from the _left_ side of the heart, carry the pure
blood, which contains all the materials for forming and nourishing
every part of the system. The veins contain the blood in its impure
state, and take it to the _right_ side of the heart, from whence it is
forced into the lungs to be purified by the act of breathing. The blood
is made impure by some of its constituents being absorbed, to form the
different parts of the body, and by having thrown into it a quantity of
waste and poisonous matter no longer needed.

The course of the blood, therefore, is from the left side of the
mother's heart along her arteries till it reaches the arteries of the
uterus, from them it passes into those of the placenta, and thence into
those of the umbilicus which convey it into the body of the child.
When there it circulates in its arteries, supplies the material for
its further increase and development, becomes in consequence impure,
and passes into its veins, the same as in the maternal body. From
these veins it passes into those of the umbilicus and placenta, and,
apparently, into those of the mother, by which it is conveyed to the
right side of her heart, and by its action to her lungs, to be again
purified when she breathes. This explains what was previously stated,
that the child uses the mother's heart, lungs, and stomach, while in
the womb, and has, therefore, no occasion to use its own.

The diameter of the placenta is about six inches, and its thickness
about one inch and a half. The length of the umbilical cord is from
eighteen to twenty-four inches, its diameter about half an inch. These
dimensions are, however, subject to great variation. Instances are
mentioned of the cord being five feet long, and as thick as the child's
arm. I have seen one myself four feet long. Sometimes it will be very
short, not more than eight or ten inches. It is composed of one artery
and two veins, twisted together like the strands of a cable, and of a
sheath surrounding them composed of the chorion and amnion. Between the
sheath and the vessels is a thick gelatinous fluid called the Gelatine
of Wharton.

This explanation, it must be remembered, is in fact merely
hypothetical. The direct passage of the blood through the Placenta,
from the mother's vessels into those of the cord, is denied by many
physiologists, who contend that there is an intermediate set of vessels
in the Placenta, in which it first undergoes important changes.
They also contend that the impure blood does not pass through into
the mother's veins at all, but is purified in the Placenta, and
immediately returned. Some have even averred that the Placenta is not
required at all, to supply nourishment, but is merely a purifying
organ. It is now known, however, that it is not absolutely essential
to either process, for children have been born alive, and perfectly
formed, which merely floated loosely in the amniotic liquor, having
neither Placenta nor cord, nor any other connection with the mother.
How they were nourished we cannot tell. These, however, must be
regarded merely as curious exceptions, there being little doubt but
that fœtal nutrition is ordinarily effected through the Placenta and
cord, by means of the mother's blood, somewhat in the manner we have
described.


PECULIARITIES OF THE FŒTAL CIRCULATION.

From the circumstance of the fœtus not using its heart and lungs, like
the adult, its circulation has several modifications.

The engine by which the blood is forced along its vessels is the
_heart_! This is divided into two distinct parts, each of which has
two cavities, the upper one called the _auricle_, and the lower one
the _ventricle_, which communicate with each other by curious valves.
In the adult the whole of the impure blood is poured into the right
auricle, that from the lower part of the body by the _inferior vena
cava_, and that from the upper part by the _superior vena cava_. From
the right auricle it passes into the right ventricle, which pumps it
into the lungs, by way of the pulmonary artery; here it is purified by
the act of respiration, and then brought, when pure, by the pulmonary
veins, into the left auricle, and passes from thence into the left
ventricle, which pumps it into the great aorta, and from thence into
the smaller arteries all over the body. The two sides of the heart,
therefore, do not communicate directly with each other, but there is
a strong partition between them. In the fœtus the arterial blood from
the mother, when it leaves the umbilical artery, enters first the
liver, runs through its vessels, gives off the bile found in it, and
then joins the vena cava inferior. By this passage it is taken into the
right auricle, along with the impure blood of the vena cava. From the
right auricle it passes through a hole in the partition directly into
the left auricle, instead of taking the indirect route by the lungs as
in the adult. From the left auricle it passes into the left ventricle,
and is from thence distributed by the arteries all over the body. This
opening in the partition is called the _foramen ovale_!

After birth, when the blood begins to pass through the lungs, this
passage closes up. By the eighth day it is generally obliterated, often
much sooner, though occasionally it has remained open longer without
inconvenience. In some cases the foramen ovale does not close at all.
The child then has what is called the _blue disease_! The whole body is
of a uniform leaden, or blue color, and the whole system is generally
languid and sluggish. The blue color is caused by the dark blood of
the veins mixing with that of the arteries. These children mostly die
early, but some live to be five or six years old, and one I saw twelve,
but this is rare. No remedy can be had for this affliction, and I have
never known it to cure spontaneously. Some children are so very dark
for a few days after birth as to cause great alarm. This is owing to
the foramen ovale being very open and closing slowly. No apprehension
need be experienced in such cases, as it soon subsides.

The impure blood from the upper part of the fœtal body, which is
brought down by the superior vena cava, also enters the right auricle,
but does not pass from thence through the foramen, like that from the
inferior vena cava. By a peculiar arrangement this blood is made to
pass down into the right ventricle, and from thence along the pulmonary
artery, the same as in the adult state. Only a very small portion,
however, passes into the lungs, the great part being taken along a
tube called the _ductus arteriosus_ into the great artery called the
aorta, where it begins to turn down to the lower part of the body. In
consequence of this, the arterial blood going down to the lower part of
the body, is mixed with this portion of impure, venous blood, brought
by the ductus arteriosus from the superior vena cava; while that going
to the head, and upper part of the body remains pure. And this is the
reason why the lower part is always so much smaller than the upper
part, previous to birth; it receives less pure nourishment. The head
and chest appear, at an early period, almost as large as the rest of
the body.

This circumstance also explains why, in the great majority of cases,
the _right_ arm is preferred to the _left_, and has more real power.
The place where the ductus arteriosus pours the impure blood into the
aorta, is almost immediately opposite to where the artery is given
off which feeds the left arm. In consequence of which, in most cases,
a small portion of this impure blood becomes mixed with the arterial
blood, and the left arm is, therefore, in the same situation as the
lower limbs, and like them is comparatively imperfectly developed.
The right arm is not liable to any such deprivation. In some cases
the insertion of the ductus arteriosus is lower down, so that no such
mixture occurs. Both arms are then equal, and this accounts for the
fact that in some persons there appears to be no difference. In some
cases, no doubt, early habit, or imitation, may overcome this natural
inferiority, and even give the preference to the left arm; but such
instances are rare; the general rule is the contrary, and for the
reason stated.

The ductus arteriosus closes up about the same time as the foramen
ovale.

The two veins which convey the impure blood back to the mother, to be
purified, originate from the iliac artery, in the pelvis. They pass up
the sides of the bladder towards the navel, enter the sheath of the
cord, and so reach the placenta. These vessels are obliterated about
the third or fourth day after birth, and remain afterwards in the form
of a fibrous cord.

The real source of _all_ the blood in the body of the child is a
mystery; it would certainly appear most likely for the whole of it to
be derived from the mother's vessels, but there are many circumstances
which make it probable that the child may form some itself, by
digesting the fluid it is supposed to absorb. This view is supported by
the fact that there is found in its bowels at birth, and even before,
a greenish substance like excrement, called _Meconium_. This has every
appearance of being the product of digestion, though some suppose it
to be derived from the liver. It occasionally contains hair, and other
anomalous substances.




CHAPTER IV.

THE BREAST.


The Breasts, or _Mammæ_, are not needed in the process of generation,
nor are they absolutely necessary even after birth; but as they
are naturally associated, in the majority of cases, with infantile
nutrition, and are besides liable to many derangements and diseases
during pregnancy and child-birth, it is advisable to give some account
of them.

When one of the breasts is dissected it is found to be composed chiefly
of a singular body called the _Mammary Gland_, which resembles somewhat
a very firm piece of fat, of a yellowish drab color. In the substance
of this Gland are an immense number of little cells, or vessels, in
which, by some unexplainable process, the milk is secreted, or made
from the blood. From these little vessels there proceeds small tubes
which gradually unite into larger ones, and these again into larger
ones still, until at last all the milk is poured into a few tubes,
or canals, which terminate in the nipple. The outer mouths of these
terminal canals are only slightly contracted together, so that the
suction of the child's mouth, or even the pressure of the milk, when
the breast is full, will force them open and allow the fluid to flow
out.

The following plate represents the structure of the Breast, and
explains, as far as it can be explained, the manner in which it
performs its functions.


  PLATE XII.--_a._

  _a. a._ The cut edges of the skin.--_b. b._ The flaps of the skin
  thrown back.--_c. c. c._ The fat which covers the breast.--_d. d._
  The cells of the Mammary gland.--_e. e. e._ The Tubes or canals,
  which convey the milk from the Gland to the Nipple.--_f._ The Nipple,
  cut down the middle, to show the ends of the milk tubes terminating
  in it; these are usually about fifteen or eighteen in number.--_x._
  Shows a bunch of the little cells, with the tubes proceeding from
  them, as they appear when injected.

[Illustration: THE FEMALE BREAST.

Plate XII.--_a._

This Plate represents the structure of the Breast, and explains the
manner in which it performs its functions.]

Sometimes there has been seen two and even three nipples on one breast,
and in a few cases one of the breasts has had no nipple at all. The
two glands are not immediately connected, but have a very intimate
sympathy with each other. The size of the breast depends more upon the
thickness of the layer of fatty substance, than upon the development
of the gland, so that one female, with a very full bosom, may have
but little milk, while another, whose breast is but little prominent,
may have a superabundance. The graceful swell of the fully developed
breast is, however, a matter of positive utility, as well as of beauty,
because it better adapts it to the use of the child, and probably
also adds to its _pleasure_, as any one may readily conceive who will
observe the delight with which an infant, even when not nursing, will
often caress it. Sir Astley Cooper says, "The natural obliquity of the
Mamella, or nipple, forwards and outwards, with a slight turn of the
nipple upwards, is one of the most beautiful provisions in nature, both
for the mother and the child. To the mother, because the child rests
upon her arm and lap in the most convenient position for sucking; for
if the nipple and breast had projected directly forwards, the child
must have been supported before her, in the mother's hands, in a most
inconvenient and fatiguing position, instead of it reclining upon her
side and arm. But it is wisely provided by nature, that when the child
reposes upon its mother's arm it has its mouth directly applied to the
nipple, which is turned outwards to receive it, whilst the lower part
of the breast forms a _cushion_, upon which the cheek of the infant
tranquilly reposes."

With the exception of the dark _areola_, or circle, and the little
tubercles around the nipple, the breast is of the most delicate
structure and color, so that it blushes, or reddens, like the cheek,
from any sudden emotion, and goes pale during fainting.

As a general rule no milk is secreted in those who have not become
pregnant, nor in those who have passed the turn of life, but
occasionally exceptions are observed to this rule.

Bandelocque tells us of a girl only _eight_ years of age, who suckled
her little brother more than a month! And Sir Hans Sloane tells us of
a lady aged _sixty eight_, who nursed several of her grandchildren,
though she had had no child herself for twenty years! Dr. Francis, of
New York, describes the case of a lady who continued to secrete milk
regularly for _fourteen years_ after having lost her child, so that
she could always nurse an infant; and Dr. Kennedy relates an instance
of another who continued to suckle children, uninterruptedly, for
_forty-seven years_, and who had milk perfectly sweet and good even
when _eighty-one years old_! Dr. Clark, of Alabama, informs us that
a married lady, who had never been pregnant, was requested to take
charge of an infant during the night, and that to quiet it she had put
her nipple in its mouth. This was done frequently, and to the great
surprise of all it induced a flow of milk. A singular circumstance
connected with this was that the lady soon after became _pregnant_,
though previously barren! This will not appear so surprising, however,
to those who know the connection between the breasts and the womb,
and who have observed the mysterious bond of sympathy by which their
functions are united.--(See the articles on _Menstruation_, and on
_Sterility_, in my "Diseases of Woman," for other instances of this
kind.)

The structure of the male breast is precisely the same as that of
the female, but it is seldom developed. Instances have been known,
however, of the milk being secreted in men, and of children having
been nourished by it! Humboldt gives us an instance of this kind, and
Professor Hull, of Maryland, exhibited a colored man to his class, in
the year 1827, who had a large full bosom, like a female, and who had
often officiated as _wet nurse_ in the family of his mistress. The
secretion appears to have been established by his putting the children
that he had to nurse to the nipple, to quiet them. When the milk was
not needed it was found as difficult to dry it up as it is in some
females, but it was soon made to flow again, by applying a child to the
breast for a few times. This man differed _in no other respect_ from
any other man!

In the females of some races of the human kind, the mammæ attain a
surprising length, and become very flaccid, so that they hang down
to the hips, or lower, and may be thrown over the shoulder for the
child to nurse from while carried on the back. Some suppose this to
constitute a real variety of the human race, but others suppose it to
result merely from habit, which is probably correct.

When the breasts are small sized in young females, their growth may
often be promoted, but the means need not be pointed out here.




SECTION II.

SIGNS OF PREGNANCY, AND THE MEANS OF DETECTING IT; ITS DURATION, AND
THE PERIOD AT WHICH THE FŒTUS CAN LIVE.


It is always desirable, and frequently of the first importance, to
be able to know whether a female is pregnant or not, both to the
accoucheur and to the individual, or even to be able to judge whether
she is probably or possibly so, or not. Sometimes this can be decided
positively, but more frequently it is a matter of great uncertainty.
The presumptive and positive signs on which a judgment can be formed
are of various kinds, most of which can be readily observed, and easily
made use of by any person in possession of the information already
given in the preceding section. They will be set forth in the following
Chapters, together with such other matter as appertains to this part of
the subject, in such a manner as will make them available either for
professional or for private use.




CHAPTER V.

SIGNS OF PREGNANCY, AND THE MEANS OF DETECTING IT.


The signs of Pregnancy are of three kinds--Presumptive, Probable, and
Certain.


PRESUMPTIVE SIGNS.

The presumptive signs of pregnancy are only of value in the first
_three months_. They consist mainly of certain nervous and organic
derangements, and of certain changes in personal appearance. It is
scarcely possible to enumerate all these, nor is it necessary; we shall
therefore only specify those most important, and most generally met
with.

Colic pains, and creeping of the skin, with shuddering and fainting
fits, very frequently follow _immediately on conception_, and in many
females inform them when that event occurs. Some persons speak of
other sensations, of a peculiar nature, by which they _always_ know,
in their own cases, when they conceive; but these sensations are felt
by so few, and are so little capable of being explained or observed,
that they are of no general use. In most cases, within the first
three months, and sometimes in the first three days, the face changes
remarkably. The eyes are sunk and dull, and surrounded by a black
circle, the nose seems pinched up, the skin turns pale, and red spots,
or freckles, frequently appear. Many females also complain of a husky
dry throat, numbness in the hands and feet, and a sudden sinking at
the heart. These signs, however, are very uncertain guides; very often
none of these are felt at all during pregnancy, and sometimes they are
all experienced from other causes. One of the most constant signs,
according to some, and the most to be relied upon, is an _increase in
the size of the neck_. This I know is often very apparent, and at a
very early period. I am acquainted with females who, by simply keeping
the measure of their necks, can always tell when they are pregnant.
The increase is often considerable in a few days. In young persons of
a certain temperament however, the neck is apt to swell merely from
_marriage_, though they do not conceive; and some old nurses, we are
told, being acquainted with this fact, judge of the honesty of their
unmarried charges by such admeasurements!

This singular development is owing, probably, to a sympathetic
connection between the uterine organs and certain parts of the brain,
and large nerves in the neck.

_Suppression of the Menses_ is one of the strongest presumptive signs
of pregnancy that can be observed, but does not always _accompany_
it, and frequently arises from other causes. In the great majority of
cases, it is true, the menses cease to flow, immediately conception
occurs; sometimes they will continue for one or more periods after, and
occasionally during the whole time of gestation, even up to a few days
before delivery. This, however, is a very unusual occurrence, and the
stoppage of the menses is by no means so strong a sign that pregnancy
_has_ occurred, as their continuance is that it has _not_. Some females
are always irregular, so that pregnancy makes little difference, and
in them of course these signs are even less to be depended upon than
usual. There have cases been known even of women who have conceived
without having _menstruated_, and of others who never menstruated
except when they were pregnant; and it is not at all unusual to see
others who will conceive while nursing, and never menstruate between
the two pregnancies. Therefore we can only say that the menses
_usually_ stop when conception occurs, and that their continuance is
strong evidence that it has not occurred, but still both signs may fail.

It is also proper to remark that several medical men have advanced
the opinion that the discharge which appears during pregnancy is not
the menstrual fluid, but real blood. It has however been accurately
examined, and found in no respect to differ from the usual discharge.
In my own opinion there is no doubt but that some females really do
menstruate while pregnant.

As an instance that the presence of the menses is no proof that
pregnancy has _not_ occurred, I give the following case:--Not long
since I was requested to see a lady who was supposed to labor under
a polypus in the womb. She had been married six years, but had no
offspring. On seeing her I suggested, from certain peculiarities in
her appearance and manner, that _possibly_ she might be pregnant. The
suggestion was met with a smile, particularly by the medical attendant
who was present, and I was told that there was no sign of such a thing,
and moreover it _could not be_, for she had never stopped menstruating,
nor was there the slightest change in the breasts, nor any disturbance
in the stomach, mind, or feelings. On making the usual examination
however, I felt fully _convinced_ I was right, and told them so, but
my opinion had no other effect than to induce them not to interfere
for a time. They had been talking of an _operation_ immediately. She
still continued to menstruate for three months after, but in six weeks
from her last period was safely delivered, without assistance, of a
very fine living child. No part of the body had undergone any material
change, except the abdomen, though many of the usual changes occurred
after delivery. In this case the delay probably saved the lives of both
mother and child, and deeply grateful they all were for the escape.
In my work on the Diseases of Woman many fatal cases will be found of
pregnant females who have been killed from mistakes of this kind, owing
to a blind reliance on such uncertain signs.

_Disturbance of the Digestive Functions._--It is very seldom, indeed,
that pregnancy does not produce more or less disturbance in these
functions, though it must be remarked that _marriage_ also does the
same sometimes, even without conception. These disturbances are
generally manifested by loss of appetite; sickness, particularly in
the morning; vomiting, and depraved taste; the individual frequently
taking a fancy to the most extraordinary articles, and making herself
extremely unhappy if she cannot obtain them. Thus some have eaten
flies, spiders, mice, and other living things, and others again have
regaled themselves upon charcoal, chalk, slate pencils, and even earth
or ashes. Such freaks are called _longings_, and it is thought highly
improper not to indulge them, which is certainly right when they are
for articles not positively injurious; but I have known this notion
carried to a very injurious and absurd extent. There is no doubt but
these vagaries of the stomach arise, mainly, from its sympathy with the
uterus, but it is highly probable that they are often exaggerated, and
frequently even produced, by a morbid state of the sensibilities, and
by vacuity of mind. The tendency to imitation also, so strong in most
females, often leads to the same result. A young female who is declared
to be, or who fancies herself, pregnant, listens eagerly to all that
is said about that interesting state, by older acquaintances, and when
told that _they_ always _longed_, immediately begins to long also. I
have known young persons considerably advanced in gestation, who had
never longed at all before, do so immediately after a conversation of
this kind. It must be remembered however, that the sympathies of the
digestive organs with the womb are very strong, and that the appetite
and taste are frequently rendered very capricious at this time, so
that the female really likes or dislikes many things that she did not
before; but still I feel convinced that the absurd ways in which this
caprice exhibits itself, are often owing to the causes I have stated.
The wondering ignorance, in which most females are kept, makes them
disposed to be led away by a morbid imagination, and constantly liable
to be imposed upon by silly and erroneous statements, which they of
course implicitly believe. These longings are always the strangest, and
most frequently met with, among the most uninformed and unthinking,
though they are occasionally met with under all circumstances. As a
sign of pregnancy this longing is not much to be relied upon alone,
because marriage alone often produces it, and so do many uterine
derangements.

Usually all these disturbances disappear by the third or fourth month,
the appetite becomes regular, and sometimes even voracious, and the
digestion improves, so that the individual may become quite fat, though
previously she was very thin.

Some suffer from constipation, and others from diarrhœa, but this is
more rare.

_Nervous Derangements._--The changes produced in the minds and feelings
of pregnant females are sometimes of the most extraordinary character.
Individuals who possess, ordinarily, the most agreeable tempers, and
the most amiable dispositions, will become peevish and fretful, and
often even violently passionate and malicious. Some have even been
known to have a disposition to commit various crimes, of which they had
the greatest horror in their natural state. Others, on the contrary,
who are usually ill-tempered and unhappy, attain a charming tenderness
of manner, and a most pleasing serenity of mind. Their likings and
dislikings also change very much, so that their most valued friends
will become hateful to them, and those whom they habitually dislike
will seem endowed with every loveable quality. Some will become perfect
misanthropes, or weep and fret without intermission, while others will
exhibit the most reckless and boisterous gaiety. I have known some much
disposed to study while pregnant, and others who would draw, or paint,
most excellently, though at other times they were but indifferent
artists. In short, it is impossible to denote half the singular changes
of this kind that are thus produced. Suffice it to say that, when well
marked, they are strong presumptive signs of pregnancy, especially
when coming in connection with other evidences. It must be remembered
however, that hysteria, and some other uterine diseases, are often
accompanied by similar changes.

_Alteration in the appearance of the Breast._--The direct, and
sympathetic connection between the womb and the breast is so great that
pregnancy usually causes corresponding changes in both, though not
always. In most cases however, the breasts swell, and become painful.
The nipple becomes elevated, and the circle around it assumes a dark
brown color, and is dotted with small tubercles, from which a thin
watery liquor may often be pressed. The nipple will also enlarge, or
become erect on being rubbed, and, as gestation advances, milk may
be forced from it. Most of these signs however, may be wanting in
pregnancy, and may arise independent of it. Chronic inflammation, and
other diseases of the womb, will frequently produce them, as may be
seen in my "Diseases of Woman." _Marriage_ alone frequently causes
such symptoms, particularly in certain temperaments, and deranged
menstruation will frequently produce them.

The alteration in the color of the areola, or circle round the nipple,
is a sign much relied upon by some, but is frequently a deceptive one,
merely from want of close observation. I have known many females,
though frequently mothers, whose breasts always retained the bright
rosy color they had previous to marriage; and I have known young
unmarried females with the breasts quite dark. The peculiar hue that
arises from pregnancy however, is different from anything I ever saw in
non-pregnant females; and, though not always to be met with, is, in my
opinion, an infallible sign when present. The celebrated John Hunter
regarded this sign as an unmistakeable one, and he gave a remarkable
instance of it in his lectures. In making a _post mortem_ examination
of the body of a young female, he observed this peculiar color, and
at once proclaimed her pregnant, _though the hymen was unbroken_.
On dissection he was found to be correct--she was four months
advanced. If this sign were constant, pregnancy could nearly always be
ascertained, but frequently it does not appear. The peculiar color must
be seen to be recognized, as it cannot be accurately described; perhaps
the nearest approach to it is the shell of a fresh _ripe chestnut_, but
it is much darker in some than in others. The dark circle is nearly
always more elevated than the rest of the breast, as may be seen by
taking a profile view.

[Illustration: PLATE XIII.

_View of the Breast about the Fourth Month._--_a. a._ The Breast.--_b._
The Nipple.--_c._ The Areola, or part which becomes brown; it is
elevated above the rest of the Breast, as may be seen.--_d. d._ The
little Tubercles.]

Most frequently the breasts do not swell, nor the areola change color,
nor the tubercles appear, till about the fourth month, and frequently
much later.

All these changes in the breast are also liable to become more or less
permanent, after the first pregnancy, so that they are of much less
service, and less to be depended upon, in all succeeding ones. They
also remain, with most females, during nursing, and are therefore not
available in those who conceive while they are nursing. On the whole
however, these signs, especially in those not previously pregnant,
may be pretty confidently relied upon, and will seldom deceive an
experienced observer.

_The secretion of milk_ is, by most persons, considered a positive sign
of pregnancy, but it is not so, for it sometimes takes place in young
girls merely from the establishment of puberty, and in some females
it always occurs at each monthly period, though they have never been
pregnant. Instances have been known of women nursing other people's
children though they had never conceived themselves.

_Miscellaneous signs._--There are a few other presumptive signs, not
easily classified, some of which are of value, while others are so
uncertain, or so little available, as to be almost worthless. All these
however, it is necessary to point out, because some of them may be made
use of in cases where the more ordinary signs are absent.

In the unimpregnated state the mucus membrane, which lines the Vagina,
is of a bright rose color, but in nearly every case of pregnancy it
changes to a bluish, or purplish hue. I do not recollect a single
instance, in the course of my own observation, in which this change
has not occurred, and the same statement is made by several eminent
authors. It is true that in some young females the mucus lining is
naturally darker than it is in others, but, like the areola round the
nipple, this natural tinge is not like that produced by pregnancy. It
is of course impossible to say whether this blue tinge is _always_
produced, though I am inclined to think it is, and I should certainly
consider it an almost infallible sign when present. Parent Duchatelet
states that he was present when M. Jacquemin proved this, without a
single failure, _in four thousand five hundred cases_.

Many females are also warned of their condition by pains in various
parts of their bodies, the most frequent of which is one felt at _the
top of the head_. Some always have palpitation at the heart, and others
experience a singular kind of _fluttering_ in the womb.

Many medical men rely altogether on certain peculiarities in the
_urine_, and as this sign is really a valuable one, in some cases, I
will describe the mode of examination fully. The urine is put in a
clean vessel, and allowed to stand perfectly still. In a short time,
varying from two to six days, a number of little opaque bodies begin to
rise from the bottom, like flocks of cotton, which unite together at
the top into a thin but firm layer, or pellicle, like cream on the top
of milk. This layer is frequently so consistent that it can almost be
raised out of the vessel, by taking hold of one edge, and may be easily
drawn out by passing the finger under it. This substance is called
_kyestein_. It is of a whitish color, semi-transparent, and looks as if
it were partly crystalized. After a few days, if left undisturbed, the
urine becomes thick and muddy, and the pellicle of kyestein breaks up
and falls to the bottom. According to the experience of many medical
men, and so far as I have seen myself, this peculiar substance is
_always_ to be found in the urine of pregnant females, after the first
month, and frequently even earlier. Sometimes a substance _similar_ to
it is observed in the urine of those not pregnant, but there is, in
most of these cases, sufficient difference between them to enable any
one, who has seen both, to distinguish one from the other. The only
time, except during gestation, when real kyestein appears to be formed,
is while the milk is being secreted and not freely discharged. Thus it
may often be found when the female is weaning, and, some writers assure
us, in some cases during the whole period of nursing. On the whole
this sign is a very valuable one, and may be much relied upon.

The changes in the pulse, on which some persons rely, are of no value
whatever as a sign of pregnancy, since they are no more frequent, and
not at all different, so far as I have seen, from what ordinarily occur
from other causes.

The development of the abdomen, though an invariable accompaniment
of pregnancy, is by no means a certain sign of it, since it may be
produced by other causes; and besides, it is sometimes but little to
be observed till a late period. The peculiar manner of the development
however, is usually somewhat different from that produced by tumors,
and other diseases. Very often the abdomen will be tolerably large by
the second month, and then again become so much smaller that the female
will think she is certainly not pregnant. This is owing chiefly to
flatulence, produced by digestive disturbance during the early periods,
but which afterwards subsides. In a short time however, the uterus not
only enlarges more, but rises, and the development becomes permanent.
This circumstance of there being often _two_ developments has deceived
many, and I have known females declared to be not pregnant, simply
because the development of the abdomen went down, who, in a short time
after, exhibited unequivocal evidences of being in that condition.
The first development, or swelling, is merely similar to what often
arises from indigestion, and other causes, and is therefore no sign of
pregnancy; but the second development is accompanied by other changes,
besides being more permanent.

The linea alba, or white line, which may be seen extending from the
navel to the pubis, in the ordinary state, becomes much darker, the
skin of the abdomen wrinkles, and the umbilicus, or navel, becomes
prominent.

Swelling of the eyelids, and puffing of the face, are experienced by
some females, but are not very general, and so frequently result from
other causes that they are of little value as evidences in this case.

This, I believe, comprises all the presumptive signs of Pregnancy that
are worthy of notice. Some of them are valuable and may be depended
upon, particularly the presence of kyestein in the urine, which may
almost be called a _certain_ sign. Others of them are of little value
alone, but are useful in the way of corroboration. The more there are
of them observed together, in any case, of course the more grounds
there are for the _presumption_ that pregnancy exists, and the reverse.

It must be carefully remembered however, that these presumptive signs
are precisely those most likely to be produced by other causes,
particularly by _marriage only_; they must therefore be well weighed,
and unless very numerous, or very distinctly marked, must not be
regarded as conclusive. As already remarked, it is only during _the
first three months_ that most of these presumptive signs are taken much
notice of; after that we have others that can be more depended upon,
and which will be described in the succeeding articles.


PROBABLE SIGNS.

_End of the third month._--The probable signs now to be described are
seldom recognized before this time, and not generally with distinctness
till a still later period. They chiefly consist of certain changes in
the form, development, and position of different parts of the uterus,
to ascertain which requires an internal examination. These changes are
not observable till the end of the third month, previous to which time
we cannot be certain that the womb has really increased beyond its
normal size. And even then, when the increase is obvious, we cannot
tell how it has been produced; it is not till a much later period, till
five or six, or even seven months are elapsed, that pregnancy can be
ascertained with anything like certainty.

The changes to be noticed are in the form, and size, of the neck and
body of the womb, and in its mouth, and also in the weight of the whole
organ. No one, of course, can expect to recognize these changes who is
not acquainted with the parts in the unimpregnated state, both in the
virgin and in those who have borne children.

The mode of conducting the requisite examination is, by introducing
the index finger of the right hand, covered with oil or mucilage,
into the Vagina, and then carrying it upwards till it reaches the Os
Tincæ. By means of this finger the position and length of the neck of
the womb are ascertained, and also the state of its mouth, whether it
is opened or closed, and to what extent. If it be then placed at the
top of the neck, on the under side, and the other hand upon the fundus
of the womb externally, and pressing firmly upon it, the organ is
enclosed as it were between the two hands, so that its size and form
may be pretty accurately ascertained, and also its degree of firmness,
by which a judgment may be formed as to whether it is occupied by any
solid body, or fluid, or whether it is empty. In addition to this a
pretty accurate estimate may be made of its comparative _weight_, by
_balancing_, and raising it up on the finger. This is called by the
French _Ballotment_, and, as will be shown further on, is a valuable
means, at certain stages, of ascertaining pregnancy.--(See Plate XVI.)

The female may be examined either standing or lying down, though the
recumbent position is best, except in certain displacements of the
womb, when it is most likely to be thrown into a position in which
the neck can easily be reached by the female standing. The position
of the neck is very different in many of these displacements, and
during pregnancy, to what it is in the ordinary state, and a person not
acquainted with these changes might frequently be much puzzled to find
it. As we have already remarked, also, there are certain differences
between those who have had children and those who have not. The
following three diagrams represent the changes just spoken of at three
different periods:--


  PLATE XIV.

  _Figure 1_, represents the form and size of the body, neck, and mouth
  of the Womb, at about the third month.

  _Figure 2_, the same at about the seventh month.

  _Figure 3_, the same at the ninth month.

  The references are the same in all. _a._ The Neck of the Womb.--_b.
  b._ The Body of the Womb.--_c._ The Os Tincæ, or Mouth of the
  Womb.--_d. d._ The cut edges of the Vagina.

[Illustration: Fig. 1.

Fig. 2.

Fig. 3.

Plate XIV.

The form and size of the body, neck, and mouth of the Womb, at about
the third, seventh and ninth months.]

It will readily be seen by these diagrams that the alterations in
the neck and mouth of the womb are very marked, and of a character
easily to be ascertained by the touch. These three should be compared
with the section of the womb in Plate IV, which represents it in the
unimpregnated state.

The difference between those who have borne children, and those
who have not, is well represented in Plate XV,--the drawings being
one-third of the natural size, and representing the appearance at about
three months.

[Illustration: PLATE XV.

Primipara, or the first Pregnancy.

Woman who has borne children before.

_a. a._ The neck of the Womb.--_b. b. b._ The body of the Womb.--_c._
The Os Tincæ, or mouth of the Womb.--_d. d._ The cut edges of the
Vagina.--_e_. The Fœtus.--_f. f._ The Fallopian Tubes, Ovaries, and
Round Ligaments.--_g._ The Placenta.]

Most of the changes produced can be readily distinguished by the
finger, after seeing this representation, and making a proper
comparison between it and the natural state in Plate IV.

The Neck is not much enlarged at this period, but its lower part is
somewhat soft to the feeling. The Os Tincæ is more _rounded_ than in
the unimpregnated state, particularly in the Primipara, in whom in fact
it is nearly circular, the lips being quite smooth and closed. In the
female who has already borne children it is somewhat open, so that the
finger may often be introduced; and the lips feel rough, owing to scars
and laceration in previous deliveries. It is also larger altogether,
and softer, than in the primipara. The whole length of the neck at this
stage is about two inches.

The body of the uterus, when pressed between the two hands, will be
found much larger than ordinary, and more round, and it will feel heavy
when pushed up by the finger.

In regard to the precise value of these probable signs, it can only
be said, when they are observed, that it is certain that the womb
is enlarged, and _most probably_ from pregnancy. But at the same
time it must be remembered that several diseases, and particularly
suppressed and irregular menstruation, or the development of tumors and
polypi, will effect very similar changes, and that it is not _always_
possible to say whether they arise from these abnormal growths or from
pregnancy, though it can generally be done. But though we cannot,
in every case, say when these signs exist, that the female must be
pregnant, we can nearly always say, when they do not exist, that she
cannot be so, particularly if the other usual signs are absent.

_End of the fourth month._--By this time the neck has become a little
shorter still, and the mouth more open, but on the whole there is
not much change to be felt internally. The body of the womb however,
has now ascended above the superior strait of the Pelvis, and begins
permanently to enlarge the Abdomen. It may be distinctly felt between
the two hands, like a firm round ball, somewhat elastic, and resisting
when pressed. This is the period when the motions of the fœtus are
usually felt first, and these motions, with the ascension of the womb,
are sometimes experienced very suddenly, so as to alarm the female,
and produce certain curious sensations, with much nervous derangement.
This is called _quickening_, and, with some persons, is always so well
marked as to indicate not only their condition, but the very period,
with great precision. Many however, never experience anything at all
peculiar at this time.

It is customary for the medical attendant, as a means of making the
child move, to put his hand first in cold water, and then over the
fundus of the uterus; the sensation of cold thus conveyed usually
causing it to move immediately. Great care must be taken however,
that other motions be not mistaken for those of the child, an error
not at all uncommon. Many a female, and many a medical man also, has
been deceived in this way, particularly in cases of uterine or ovarian
dropsy, and tumor, and even in ordinary flatulence and hysteria.
Females who much desire offspring frequently deceive themselves in this
way, and it is sometimes next to impossible to convince them of their
error. Some women possess the power of _imitating_ the movements of
the child, with great exactness; and instances have been known where
they have successfully imposed, both on their friends and medical
attendants, for a long time, in this way. Mr. Dubois mentions instances
of females who possessed this extraordinary power, and who, though not
pregnant, used to present themselves to his class, for the pupils to
_ascertain the motions of the child_. In short, this sign must not be
too much relied upon, nor too confidently expected, for many females
observe no fœtal motions at all till the sixth or seventh month,
and even then very indistinctly. Sometimes also, after having been
distinctly felt, these motions will altogether stop for a long time,
and then appear again.

At this time however, _Ballotment_ can begin to be practised, though it
is not quite so certain as at a month later. The manner of performing
this important manipulation has already been partly described, and by
examining Plate XVI, and attending to the following remarks, it may be
readily understood and practised.


  PLATE XVI.

  This Plate represents the mode of performing the Ballotment, to
  detect pregnancy. The outline of the figure is the same as in Plate
  I, and most of the organs are lettered the same.

  The index finger of the right hand is passed into the Vagina till it
  touches the body of the Womb, the neck being thrown back, owing to
  the tilting of the Fundus forward. The left hand is pressed firmly
  upon the Abdomen, just over the pubic bone.

  1, Is the Fœtus.--2, The Placenta, connected with the Fœtus by
  the cord.--3, Is the index finger of the right hand, within the
  Vagina.--4, Is the left hand.

  The development of the Womb, and the change in its position, are very
  well represented in the Plate, and so are the alterations in some of
  the other organs. The manner in which the Bladder, A, is pressed out
  of its usual shape and size, may be seen by comparing this with Plate
  I. The shortening of the Vagina, and the expansion of its upper part,
  are also equally obvious, and the manner in which the mouth of the
  Womb is thrown back against the Rectum.

[Illustration: Plate XVI.

This Plate represents the mode of performing the Ballotment, to detect
pregnancy. The outline of the figure is the same as in Plate I, and
most of the organs are lettered the same.]

When the right hand finger (1 Plate XVI,) is carried to the top of the
Vagina, it meets with a round soft tumor, which is the head of the
child felt through the walls of the womb. As soon as this is distinctly
felt, the finger must be withdrawn a little, and then pushed suddenly
against the tumor with a jerk; this will displace the fœtus, and cause
it to rise in the liquor amnii towards the Fundus, so that the round
tumor will have disappeared. In a few moments it will sink down and
may be again felt, and again displaced in the same manner. This is
called the _Ballotment_, or balancing it on the end of the finger. The
sensation conveyed on touching the Fœtus, and when it rises after being
pushed, are so peculiar that they are not likely to be overlooked, or
mistaken for anything else, after being once experienced. The jerk is
not required to be at all violent, and had better be made at first
very slight, as it can easily be repeated a little more forcibly if
the tumor does not rise at first. Some practitioners practice the
Ballotment in this way, using the one hand only; but others place the
left hand also on the Abdomen, (4 Plate XVI,) at the same time, and
immediately after jerking _upwards_ with the right hand, they suddenly
depress the Abdomen, just over the pubes, with the fingers of the left,
so as to send the Fœtus down again more quickly and more forcibly. This
is seldom needed, but if the first way does not succeed the two hands
may be tried.

A species of ballotment may even be practised externally, in the
following way:--The fingers of the right hand are placed on the
Abdomen, just over the fundus of the womb, like the left hand in Plate
XVI, and a smart jerk is given downwards and backwards, several times
in quick succession. This also displaces the Fœtus, which may be
distinctly felt to float away, each time the percussion is made. No one
can mistake this peculiar motion who has once felt it.

Sometimes one of these manœuvres will succeed when the other fails, so
that it is well to practise them all. They may be performed with the
female either standing or lying down, and will sometimes succeed one
way when they will not the other.

It is requisite to remember that in presentations of the breech,
or trunk, the ballotment may not succeed as well as when the head
presents; or it may even fail altogether, so that when it is
unsuccessful we must not immediately conclude there is no pregnancy.
Tumors in the womb, stone in the bladder, and various uterine
displacements, may also create uncertainty, or cause failure, but these
accidents are rarely met with, and only interfere materially at an
early stage; afterwards ballotment can be practised notwithstanding
them, or auscultation may be resorted to.

In short, this mode of detecting pregnancy is one of the most certain,
and the most generally applicable, that we possess.

_End of the fifth month._--At this time the Uterus has increased
considerably in size, and has ascended so high in the Abdomen that the
Fundus is level with the umbilicus, or navel, in a first pregnancy,
though somewhat lower in those who have borne children before. This
rising of the womb makes the Vagina longer, and brings the neck of the
womb nearer to its centre. In the previous stage the neck was thrown
so far back that it was difficult to reach, but now it is much more
favorably situated, though much higher. Its substance is softer than
before, and the two lips are nearly on a level, and somewhat opened,
particularly in those who have borne children before. Indeed, in them
the point of the finger may be introduced, as seen below:--

[Illustration: PLATE XVII.

Neck of the Womb in a first Pregnancy, very slightly opened.

Neck of the Womb in a female who has borne children before, showing how
it admits of the introduction of the finger.

This is at the end of the Fifth Month, and the drawings are about
one-third of the natural size.]

Ballotment is now much more easily practised, and is more conclusive.
A new sign is also to be distinguished, by which we are furnished with
another valuable means of detecting pregnancy. The child's heart begins
to beat so strongly, and its circulation is so vigorous, that the
_sound_ of it can be _heard_ externally. The same means are taken to
ascertain this that are used in sounding the chest of an adult. If the
ear be placed on the Abdomen, over the womb, the beating of the fœtal
heart may be heard quite plainly; and if the stethoscope be used it
will be still more distinct. This practice is called _Auscultation_.
The signs furnished by it are certainly of the greatest value, and
frequently enable us to detect pregnancy with unerring certainty.
Indeed, not only can we tell by them that a child is in the womb, but
often even _the very position in which it lies_, and whether there be
_twins_, _or more_. This is done by noting where the heart is situated,
by the sound, and whether the beating is single or double.

The nature of these sounds, and the manner of detecting them, require
to be carefully explained.

If the person wishing to notice this sign is not already familiar with
the beating of the adult heart, he had better become so first. The ear
should be placed on the left side of a grown up person, on the skin,
just beneath the breast, and held very still. The heart will then be
heard to beat very distinctly, there being two sounds, a long one and a
short one, alternating with each other. When this has been listened to
for some time, the ear will be able to catch any similar sound, and the
auscultation may then be practised to detect pregnancy.

The ear must be placed on the Abdomen, about midway between the Pubes
and the umbilicus, and towards the left side. No weight should be borne
on the body, but the ear must be laid sufficiently close to exclude all
external sounds, and no motion should take place, particularly with the
clothes. If the sound be not heard in the position first assumed, move
a little, in different directions, till that point is attained where it
is most distinct. It can scarcely fail to be heard, with ordinary care.
A practised ear will sometimes distinguish the sound as early as the
fourth month, but generally it cannot be heard before the end of the
fifth, or even till the sixth month. There are several sounds that may
either be mistaken for it, or that may confuse the ear. The beating of
the mother's heart will sometimes be very distinct, as far as the lower
part of the Abdomen, but it is much slower; the child's heart throbbing
nearly twice as fast. The movements of the Fœtus, and the rumbling of
the intestines, will also interfere; but when once the proper sound has
been caught it may be kept independently of all these.

The manner in which the child lies in the womb will determine where the
heart shall be opposite, and as its position frequently varies, both in
different individuals, and at different periods, in the same person,
the sound must be sought for at several points, till the right one is
found. The most usual position will be seen in several of our plates,
and they will give sufficient indication to enable almost any one to
practise this mode of detection with success. During the early months
the child moves about a good deal, so that the sound may be heard one
day in one place, and the next in another. About the seventh month
however, it becomes more fixed, so that the place of the heart can be
pretty certainly ascertained, and thus the _position_ of the whole body
is made out, whether the head is downwards or upward, and a tolerable
idea can be formed even as to the direction of each part.

Many persons have failed in their attempts to hear the Fœtal pulsation,
but I cannot but think it must have been either from inattention, or
from not being acquainted with the sound of the heart at all. I never
recollect an instance when I could not do so, at the proper time. M.
Chailly says he does not hesitate to affirm that in every instance
they can be detected; and M. P. Dubois distinctly heard them in one
hundred and eighty-five females, out of one hundred and ninety-five,
in the other ten the child being probably dead. Indeed, the absence of
this sound is the most certain sign of the death of the Fœtus, as its
existence is of its being alive; and medical men now tell whether the
child is dead or not by these very means.

In conducting the auscultation the female must recline, and keep as
still as possible, breathing low. The Abdomen may be covered with a
single thin garment, if absolutely insisted upon; but the judgment
will be so much the more uncertain, owing both to the deadening of the
sound and to the friction of the material. The experimenter must also
recollect that if the head be held down too long, the blood will rush
to it, and cause a humming in the ears, which will confuse him; it will
therefore be better if the bed be high.

It is always best to use the _stethoscope_, as it covers only a small
space, conveys the sound more directly, and shuts out external noises
more effectually. This instrument is extremely simple, consisting
merely of a tube of wood, glass, metal, gum elastic, or almost any
other material. One end should be expanded a little, like a bell, and
the other made small, so as to fit close in the ear--the large end
being placed on the Abdomen. It may be about a foot in length, though
a little shorter or longer will not make much difference. I once used
a child's _tin trumpet_, having no regular stethoscope with me, and
succeeded with it perfectly. The large end should be pressed on the
Abdomen, and the smaller one into the ear, sufficiently close to shut
out all other sounds but those coming from the body. This is the same
instrument that the lungs are sounded with, when we want to judge of
their action and condition.

This is an invaluable means of detecting pregnancy; in fact, at the
proper time, and with due care, it may be said to be _certain_.

_End of the sixth month._--This is the period when, according to the
law, the child can live. There are no new signs at this time, but those
previously noticed are now more distinct. The neck of the womb is still
softer and shorter, and the finger can penetrate further in the passage
than before. The fundus of the womb is now above the umbilicus, in
primipara, though not so high in those who have borne children; and the
bladder is above the superior strait.

Ballotment can now be practised with certainty, the falling and rising
of the Fœtus being very distinct.

Auscultation also becomes more positive, the sounds being louder and
more easily ascertained.

_End of the seventh month._--The fundus of the womb has now risen still
higher, and the Bladder is pushed completely above the upper strait,
so that the whole length of the Urethra lies behind the pubic bone. It
is then much pressed upon and swollen, and being much longer, and bent
out of its usual course, the urine is often passed with difficulty, and
the catheter can scarcely be introduced. The upper part of the Womb
now lies over towards the _right side_ of the body, very evidently.
This direction is nearly constant, in all females, but the reason for
it is not known. There have been many theories to account for the
peculiarity, but none of them are either so plausible, or so well
supported by facts, as to be generally adopted.

The upper part of the Womb being tilted to the right side, the neck
of course points to the left, and backwards. It is now very short,
even in primipara, but in those who have borne children it is scarcely
to be distinguished at all. The finger may now be introduced, even in
primipara, half way up the neck; and in others it will reach even into
the uterine cavity.

[Illustration: PLATE XVIII.

First child.

Woman who has borne children.

The neck of the Womb in a first pregnancy, and in a female who has
borne children before, at the end of the seventh month.]

The part below the lower line here, shows that part of the neck which
is contained in the Vagina. It will easily be seen how much shorter
this part is, and how much more open the passage is, in the female who
has borne children, than in a first pregnancy.

Ballotment and Auscultation both, now afford unmistakeable evidences as
to the condition of the patient.

_End of the eighth month._--By referring to the preceding Plates, it
will be seen that the part of the neck of the Womb _above_ the Vagina,
which is placed between the two dotted cross lines, remains almost
unchanged, while the part _within_ the Vagina, or that below the lowest
line, becomes less and less, till at this time, in those who have borne
children, it can scarcely be felt at all; and even in a primipara it is
merely like a small tubercle. About this time however, the upper part
of the neck begins to shorten also, though that is not so obvious, and
therefore not so useful for our present purpose.

On making an examination, the mouth of the Womb itself may now be felt,
at the upper part of the Vagina, and far back. It is however, very
difficult to reach, on account of its position. The finger will now
pass, in those who have previously borne children, into the cavity of
the Womb itself, but in others it will scarcely reach so far.

The linea alba becomes darker at this period, and so does the areola
around the nipple. Certain peculiar marks also appear on the Abdomen,
and upper part of the thighs, almost like the _pits_ from small pox.
They are usually diamond shaped, slightly depressed, and dark in
color. They appear to be owing to the over stretching of some of the
parts under the cuticle, and which give way in consequence. In first
pregnancies, and in those who enlarge very much, these marks are
sometimes very numerous, and remain for a long time after delivery,
sometimes even they never disappear. As signs of pregnancy however,
they are but of little value, because they are often produced by other
causes that distend the Womb. None of these presumptive signs are now
needed, and therefore they are of little consequence, because there are
others more certain.

The motions of the child itself can now be generally both felt and
seen, and an experienced observer may even predicate from them, with
tolerable certainty, the position in which it lies. Ballotment, by
one hand on the Abdomen, may still be practised with success; but in
the Vagina it is difficult, because the Fœtus is both more fixed and
heavier.

Auscultation is now the surest dependence however, and may be
advantageously resorted to also as a means of determining beforehand
the position of the child. This may be done even a month earlier, but
not so certainly as now.

To understand how this important point is determined, it is only
necessary to recollect, as will be very evident, that the pulsation
will be heard the loudest immediately over the heart; and as we know
the form and general size of the Fœtus, and the manner in which it
usually lies, it becomes possible, when the position of its heart is
discovered, to trace out, from that, the position of every other part.
This will be evident by referring to Plates XIX, XX, and XXI. It will
then be seen that, if a line be drawn across the middle of the Abdomen,
the heart will be _above_ that line when the breech presents, and
_below_ it when the head presents, and on the right or left side, as
the case may be, in each position.

In case of twins there will be two pulsations, and they so much
interfere with each other that it is difficult to distinguish either.
The two children being generally disposed with the head of one to the
heels of the other, one heart will be _above_ the line, and the other
_below_, on opposite sides, as shown in Plate XXII.


  PLATE XIX.

  This Plate represents the Fœtus in the most usual position, the head
  downwards, and the back of it presenting to the _left_ side.

  The black spot _a_, shows the situation of the heart; usually
  immediately under that part where the sound is heard the
  strongest.--It is below the line.

[Illustration: Plate XIX.

This Plate represents the Fœtus in the most usual position, the head
downwards, and the back of it presenting to the _left_ side.]


  PLATE XX.

  This Plate represents the Fœtus in the next most frequent position,
  the head downwards, but the back of it presenting to the _right_ side.

  The black spot _a_, shows the situation of the heart as in the
  previous Plate. It is now below the line, as before, but on the
  opposite side.

[Illustration: Plate XX.

This Plate represents the Fœtus in the next most frequent position, the
head downwards, but the back of it presenting to the _right_ side.]


  PLATE XXI.

  This Plate shows the position of the Fœtus in a presentation of the
  Pelvis, or breech, which happens, comparatively, but seldom.

  The black spot _a_, denotes the situation of the heart, which is here
  _above_ the line, instead of below.

  In this case, as in the others, the heart may be on either side of
  the body, according as the child faces, but always above the line.

[Illustration: Plate XXI.

This Plate shows the position of the Fœtus in a presentation of the
Pelvis, or breech, which happens, comparatively, but seldom.]


  PLATE XXII.

  This represents the position of Twins, as most usually observed, one
  having a head presentation, and the other a breech.

  The black spot _a_, on both, denotes the position of the heart, which
  in one case is above the line, and in the other below.

  The head however, may be on the right side instead of the left, and
  so reverse the position of the two hearts, but this is very seldom
  the case.

  When there are more than two, the confusion and uncertainty becomes
  still greater.

[Illustration: Plate XXII.

This represents the position of Twins, as most usually observed, one
having a head presentation, and the other a breech.]

At this period the signs previously observed become more distinct, but
there are few new ones. The external lips sometimes swell, and the
breathing becomes more difficult, owing to pressure on the diaphragm.
The trouble with the urine is also apt to increase, and little mucus
tubercles, like pimples, occasionally form around the Os Tincæ, and on
the upper part of the Vagina.

_End of the ninth month._--There is but little difference between this
and the previous period. The mouth of the Uterus is more open, and,
in those who have had children, the finger will pass directly into
the Womb, and feel the child, but in primipara there is still a small
portion of the neck left.

[Illustration: PLATE XXIII.

Fig. 1.

The neck of the Womb, at near the end of nine months in a primipara.

Fig. 2.

The neck of the Womb, at near the end of nine months, in a woman who
has previously borne children.]

Ballotment is now more obscure than before, as the Fœtus is very heavy,
and quite low down, and pretty firmly fixed. Auscultation is distinct
enough, but not more so than at the previous period. The swelling of
the lips, and of the veins of the legs, may increase, and so may the
difficulty with the urine; but the breathing generally becomes easier,
owing to the Womb having descended a little, and so pressing the
diaphragm less.

These comprise all the signs and indications of pregnancy that possess
any real value. Some of them, at certain times, and under particular
circumstances, may be called _positive_; such as those discovered by
Ballotment and Auscultation, and also the presence of Kyestein in the
urine. Most of the others merely make it _probable_ that pregnancy
exists, or warrant us in presuming as much. They are not to be depended
on implicitly alone, but when many of them are observed together, and
no other cause can be assigned for their production, the presumption
becomes so well supported as almost to be called a moral certainty. A
person of experience, who is familiar with all these signs, and with
the others produced by disease which resemble them, will seldom find
it difficult to decide; but still there are cases in which pregnancy
proceeds, even to its termination, with but few unusual symptoms, so
that both patient and attendant are completely at fault. This however
is very rare, and many eminent authors contend that it is _always_
possible to detect pregnancy, _after the sixth month_, and I think so
myself, unless the child be dead, in which case it will soon be evident
in another way.




CHAPTER VI.

DURATION OF PREGNANCY.


The duration of pregnancy, or the precise term of Utero Gestation, is
not fixed. It appears, from accurate observation, that there is no
absolute period determined by natural laws, and therefore there is
none laid down by human enactments. An approximation can be made, by
taking the average of a number of cases, and the period of limitation
may also be determined in the same way. The most usual period is about
nine months, or from thirty-five to forty weeks, some females going
beyond the thirty-six weeks, and others not so long. First children
are frequently born under the nine months, and more so than those that
come after; this is a fact not generally known, and ignorance of it
has often given rise to unjust suspicions. It is quite possible for
a female to be delivered, with the child at full period, in a little
over eight months after marriage, without there being any just grounds
whatever for suspecting unfaithfulness.

Dr. R. Lee, in his Lectures on the Theory and Practice of Midwifery,
gives the best summary that we have in the language, of our information
on this subject; I will therefore quote from his work, making such
comments and additions as I may think advisable.

 "The Roman law fixed the period of gestation at ten lunar months. The
 civil code of Prussia ordains that a child born 302 days after the
 death of the husband shall be considered legitimate. By the law of
 France, the legitimacy of a child cannot be called in question who is
 born 300 days after the death or departure of the husband. The laws
 of England declare that the usual period of human utero-gestation is
 nine calendar months, or forty weeks; farther than this they do not
 fix a definite period: the law is not exact as to a few days. Nine
 calendar months contain only 275 days, and only 273 or 272 if February
 be included. To fix bastardy on a child in Scotland, absence must
 continue till within six months of the birth, and a child born after
 the tenth month is accounted illegitimate.

 "The difficulty of determining the precise time when impregnation
 takes place in the human subject, renders it almost impossible, in any
 case, to calculate with absolute certainty the duration of pregnancy.
 We are, however, in possession of a sufficient number of observations
 to establish the fact that the ordinary period is about forty weeks,
 or 280 days; but it is certain that it does occasionally exceed
 or fall short of this period by several days. As we can never be
 certain of the precise day, between the periods of menstruation, when
 conception occurs--whether it takes place immediately after the last
 period, or before the expected period, or midway between these--it
 is obvious that all calculations founded upon the cessation of the
 catamenia must be extremely uncertain. The error of the calculation
 will be still greater if the catamenia should have appeared, or a
 discharge like the catamenia should have occurred once or twice after
 conception. Impregnation most frequently takes place soon after
 menstruation, but in others it does not happen till a few days before
 the expected period; so that two women may have menstruated at the
 same time, and one may have reached the full period three weeks before
 the other; and to this extent, or nearly so, an opinion founded on the
 disappearance of the catamenia may be erroneous.

 "Calculations of the duration of pregnancy, founded upon what has been
 observed to occur after casual intercourse, or perhaps a single act,
 in individuals who can have no motive to tell us what is false, are
 likely to be much more correct; and the conclusion to be drawn from
 these is, that labor usually, but not invariably, comes on about 280
 days after conception, a mature child being sometimes born before
 the expiration of forty weeks, and at other times not until the
 forty weeks have been exceeded by several days. A case came under my
 observation very lately, in which I had no doubt the pregnancy existed
 287 days: the labor did not take place till 287 days had elapsed
 from the departure of the husband of this lady for the East Indies.
 Some women are always delivered before the end of the forty weeks,
 according to the usual calculation, and their children are mature.

 "In the evidence given on the Gardner Peerage cause, the period
 of utero-gestation was limited, but not strictly, by some of the
 witnesses, to forty weeks, or 280 days; by others it was extended
 to 311 days. Dr. Merriman, whose opinion is always entitled to much
 respect, thinks the greatest number of women complete gestation in
 the 40th week, and next to that in the 41st. Of 114 pregnancies,
 calculated by him from the last day of menstruation, and in which the
 children appeared to be mature, 3 deliveries took place at the end of
 the 37th week; 13 in the 38th; 14 in the 39th; 33 in the 40th; 22 in
 the 41st; 15 in the 42d; 10 in the 43d; and 4 in the 44th week.

 "How long before the expiration of the 40 weeks a child may be born
 with the power of supporting life has not been determined. Where I
 have induced premature labor for distortion of the pelvis before the
 end of the seventh calendar month from the last menstruation, I have
 never seen a child reared. The lady of the clergyman in Fife, whose
 case has lately given rise to so much discussion, was delivered 175
 days after marriage, and the child lived five months. To what extent
 gestation may be protracted in some cases beyond the 280 days it is
 very difficult to determine, and the opinions of the most eminent
 writers differ upon the subject. I should suspect some great error in
 the calculation where the period of gestation exceeded 300 days. But
 the experiments made on the lower animals prove that there exists in
 them a great variation between the shortest and the longest gestation;
 and it is difficult to comprehend why there should be a difference in
 this respect in the human species."

In a trial which took place in this country, in the county of
Lancaster, Pa., as reported in the _Medical Examiner_ for June, 1846,
it was decided that Gestation may be prolonged to _three hundred and
thirteen days_! The female swore that conception must have taken place
on the twenty-third of March, 1845, and the child was not born till the
thirtieth of January, 1846, or over _eleven months_. The judge directed
the jury to return a verdict in her favor, and I suppose this case
establishes a precedent for America.

In a recent number of the _Medical Gazette_, I find a case reported
wherein the period was said to be prolonged still farther. A man left
his wife in New South Wales, he coming to England, and _twelve months_
after he left she was delivered of a child, which she claimed to be
legitimate. He denied this however, and the judge in the Consistory
Court decided, without hesitation, in his favor. Taking the medium
between these two cases therefore, it appears to be decided that the
_extreme limits_ is somewhere between _eleven_ and _twelve_ months! It
must be recollected however, that both were perfectly arbitrary, and
that, for anything known positively on the subject, both may be either
right or wrong.

Except when labor is brought on prematurely by violence, it always
commences at what would have been one of the monthly periods; or in
other words, after a certain number of _full months_, and never at any
time between! If therefore a female passes over the _ninth_ month, she
will probably go to the _tenth_. This has been proved by extensive
observation, and is only another proof of the regular method in which
nature conducts all her operations. The same law is also observed in
abortions, which generally take place at one of the months, unless
brought on suddenly by violence.




CHAPTER VII.

PERIOD WHEN THE CHILD CAN LIVE.


The precise period when the child can live, if brought into the world,
is not determined, any more than the time it may remain in the Womb.
Some children may be able to live a considerable time before the full
period of Gestation, and others may not till some time after, there
being a great difference in regard to their development.

One may be as fully developed at six, as another at seven months. The
common opinion is that the child cannot live if born before _seven
months_. This, however, is incorrect. Many instances have been known
of births at six months, and even earlier, in which the child lived,
and became strong and healthy. Van Swieten mentions the case of one
Fortunio Liceti, who was born before the sixth month. He was not
larger than the hand, but grew to the average size, and lived to be
seventy-one years old. Dr. Gunning Bedford mentions a similar case, in
his translation of Chailly's Midwifery. There are even cases mentioned
of children living at five months, but it must be borne in mind that
it is seldom possible to determine the exact period. As a general rule
however, the child does not live till after the seventh month, though
there undoubtedly have been cases where it has lived before the end
of the sixth month. The law adopts the medium period, and declares
the child capable of living at _the end of the sixth month_, and not
before. There is no reason whatever for supposing that it is less
likely to live at eight months than at seven, or that it will not live
at all at eight months, as some do.




SECTION III.

THE FORM, SIZE, AND POSITION OF THE FŒTUS, AND ITS APPENDAGES, AT FULL
TERM.




CHAPTER VIII.

FORM AND SIZE OF THE FŒTUS AT FULL TERM.


SIZE AND FORM OF THE BODY.

The average length of the Fœtus, at full term, is about twelve inches
from the head to the breech, and about eighteen inches from the head
to the feet. Its weight varies from five to eight pounds, perhaps
averaging about six, though some have been born weighing only three
pounds, or less, and some even as high as twelve. The breadth across
the shoulders is about four inches, and the same across the hips, but
both are so easily compressed that during delivery they only measure
about three inches, or three and a half at most.


SIZE AND FORM OF THE HEAD.

The head is the most important part, because it is the largest, and
usually present first. It is therefore necessary to describe it fully,
and with special reference to its importance, in the early stages of
labor, as the part by which the position is usually determined.


  PLATE XXIV.

  The head is generally divided into the Cranium, or that part which
  contains the brain, and the Face.

  _The Bones of the Cranium._--These are seven in number, viz., two
  _Frontal_ Bones, or those forming the forehead; 1, 1, Figs. 1 and 2,
  (Plate XXIV.)--Two _Parietal_ bones, or those forming the sides of
  the head; 2, 2, Figs. 1 and 2.--The _Occipital_ bone, or that forming
  the back of the head; 3, 3, Figs. 1 and 2.--And two _Temporal_ bones,
  which lie over and between the ear and the eye; 4, Fig. 2.

  _The Bones of the Face._--These are five in number, viz., two
  _Superior Maxillary_, or upper jaw bones; 5, Fig. 2.--Two _Malar_, or
  cheek bones; 6, Fig. 2.--And one _Inferior Maxillary_, or lower jaw
  bone; 7, Fig. 2.

[Illustration: THE FŒTAL HEAD.

Plate XXIV.

The head is generally divided into the Cranium, or that part which
contains the brain, and the Face.]

The bones of the cranium are not closed together, as they are in the
adult, but are separated to a considerable distance, in certain parts,
and connected by a strong membrane. These membranous spaces are called
_Sutures_ and _Fontanelles_, and a knowledge of them is absolutely
necessary, as a means of ascertaining the position of the head.

_The Sutures._--The first of these spaces, which extends from the
lowest part of the middle of the forehead to the occipital bone, is
called the _Sagittal Suture_, or antero posterior Suture: A, B, C,
Figs. 1 and 2. It separates the two frontal, and the two parietal
bones. The spaces between the two frontal and the two parietal bones
are called the _Frontal Parietal Sutures_, _o. o._ Fig. 1; and those
between the two parietal bones and the occipital, _l. l._ Figs. 1 and
2, are called the _Lambdoidal Sutures_.

_The Fontanelles._--When the different Sutures meet at a point,
the membranous space is greater than at other parts, and is called
a Fontanelle. Thus when the two Frontal Parietal Sutures meet the
Sagittal Suture, at B, Figs. 1 and 2, there is quite a large diamond
shaped space between the different bones, filled up with membrane. This
is called the _Anterior Fontanelle_, or bregma. Where the Sagittal
Suture joins the two Lambdoidal there is another space, not so large,
and different in shape, being triangular; this is called the _Posterior
Fontanelle_, _c._ Figs. 1 and 2. And where each of the temporal bones
joins the parietal there are two other spaces, called the _Temporal
Fontanelles_, _t._ Fig. 2, which are also irregularly diamond shaped,
but not nearly so large as the anterior fontanelle.

It is evident that if a person can distinguish these Fontanelles, when
he touches them with his finger, he can tell what part of the head is
presenting, and hence their use.

These spaces allow of the bones lapping over each other, during
delivery, and thus the head is made smaller. They do not disappear
till sometime after birth, and in very young children the brain may be
felt, and seen to work, at the anterior fontanelle. Eventually however,
the bones come close together, and are joined by a curious kind of
dovetailing. The two frontal bones however, completely coalesce, and
form but one, in the adult.

Sometimes the bones will be very perfectly formed, and the fontanelles
nearly filled up, before birth, and then the head cannot be crushed
much smaller, and so the labor becomes both painful and difficult. This
is usually called an ossified, or solid head.

_Diameters of the Head._--The diameters of the head are the distances
between its most prominent points. They are necessary to be known
before we can judge as to the possibility of its passing the straits of
the Pelvis, in the various positions.

Generally there are reckoned _ten_ diameters, and they are represented
in the following Plate:--

[Illustration: PLATE XXV.

_Diameters of the Head._

1. The _Occipito Mental_, or from the back of the head to the chin, M,
O, Fig. 1, five inches.

2. The _Mento Bregmatic_, or from the chin to the anterior fontanelle
at the top of the head, M, O, Fig. 1, four inches.

3. The _Occipito Frontal_, or from the back of the head to the top of
the forehead, O, F, Fig. 1, four inches.

4. The _Trachelo Occipital_, or from the throat to the back of the
head, T, O, Fig. 1, four inches.

5. The _Sub Occipito Bregmatic_, or from the nape of the neck to the
top of the head, S, B, Fig. 1, three inches and a half.

6. The _Trachelo Bregmatic_, or from the top of the throat to the top
of the head, T, B, Fig. 1, about three inches and a half.

7. The _Trachelo Frontal_, or from the top of the throat to the top of
the forehead, T, F, Fig. 1, about three inches.

8. The _Sub Occipito Frontal_, or from the nape of the neck to the top
of the forehead, S, F, Fig. 1, about three inches.

9. The _Bi Parietal_, or across the head from one side to the other at
the middle of the parietal bones, the widest part, B, P, Fig. 2, three
inches and a quarter to three and a half.

10. The _Bi Temporal_, or across the head from one temporal bone to the
other, B, T, Fig. 2, about two inches and a half.]

The necessity for knowing these diameters will be obvious. It is only
by being acquainted with them, and with the straits of the Pelvis,
already described, that we can tell whether the child can pass or
not in certain positions, and how we must change its position, when
possible, to give relief.

On comparing the diameters of the head with those of the Pelvis, it
will be seen that some of them correspond in size while others do
not, so that in one position delivery can take place spontaneously,
while in another it will be difficult, and in some nearly impossible,
without assistance. Thus, for instance, if the head should present by
the occipito mental diameter, (O, M, Fig. 1,) it evidently could not
pass while in that position, because by this diameter it is five inches
in width, and the greatest diameter of the Pelvis is only about four
inches and a half. Its position must therefore be changed, and the
accoucheur must know how to change it with advantage.


ATTITUDE OF THE FŒTUS AT FULL TERM.

The attitude of the Fœtus is represented in the following Plate:--

[Illustration: PLATE XXVI.

_Attitude of the Fœtus._

The arms, it will be seen, are crossed on the breast, upon which the
chin is also bent; the thighs are close together, and brought against
the Abdomen; the legs are close bent on the Thighs, and the feet are
turned up against the front of the legs, the whole body being curved
forward.]

The position in which the Fœtus most usually lies in the Womb has
already been shown, particularly in Plate XII, and in Plate XVI. The
head is downwards, and the back part of it turned to the mother's
left side. What is the cause of this almost universal position is
not certainly known. It was formerly thought to depend on the head
being heavier than the other parts, and thus sinking down; but this
supposition has been shown to be entirely without foundation. M. P.
Dubois has lately advanced the notion that it depends on an instinctive
feeling in the Fœtus itself, which directs it to take that position
by which it can most easily make its exit. This opinion appears very
reasonable, and is apparently well founded. It is well known that the
Fœtus is susceptible of various impressions while in the Womb, and
impelled by unerring instinct to take the breast immediately it is
born; nay, it has even been known to suck the finger of the assistant,
in cases of face presentation, even before birth! We can readily
believe, therefore, that it is directed to place itself in the Womb, in
the best position, the same as it is directed to take the finger in its
mouth.

In the young of many of the lower animals this is also strikingly
exemplified. The young duck in the shell taps with its little beak
against the part that is to be broken, and rushes into the water even
with a part of the shell still on its back. The young oppossums, who
are born imperfect from the Womb, shelter themselves, immediately they
come into the world, in the pouch on the mother's breast, and fasten
themselves to the mammæ till they are more perfectly grown.

It must be remarked however, that the head does not _always_ present
first, though it usually does so. Occasionally we have the breech
present, and still rarer even other parts; but these are merely
exceptional deviations, the causes of which are unknown. Out of every
sixteen children born, _fifteen_ usually come head first. This however,
will be shown better further on.




CHAPTER IX.

THE APPENDAGES OF THE FŒTUS AT TERM.


THE MEMBRANES.

The uses and arrangements of the membranes surrounding the Fœtus have
already been explained, so that little more is needed to be said here,
because they are not much different at the full term from what they are
at an earlier period, excepting perhaps that the _amnion_ is a little
more dense and firm. This membrane appears not only to surround the
Fœtus like a bag, to contain the waters, but is also reflected close on
to its body, like its skin, with which in fact it is thought by some to
be connected. The child is certainly born with this membrane still on
its body, and does not part with it till some days after birth, when it
peels off like a thin dead skin, or powder.

The _waters_, enclosed within the Amnion, (see Plate XII,) have now
increased to their greatest quantity; and there is also, in most cases,
a second body of fluid between the Amnion and the Chorion, which coming
away before the real discharge, is called the _false waters_.--(See
Plate XII.)

The quantity of the true waters, at birth, is about twenty, or from
that to thirty ounces, but is very variable. It is of a greenish color,
rather muddy, and heavier than water. It contains albumen, (white of
egg,) sulphate of soda, and lime. Ninety-eight per cent. of it however,
is pure water. It appears to be excreted, like perspiration, from the
surface of the membranes, and most likely is merely the watery portion
of the blood exuded through. The uses of this fluid are various. As
already stated, it probably supplies some nutriment to the fœtus,
which it also protects, in a great measure, from pressure and from
concussions. It also prevents the limbs from adhering, and helps to
distend the mouth of the Womb, in the earlier stages of labor, besides
affording an abundant slippery fluid for the purpose of lubricating the
passages, thus making the passage of the child more easy.--(See Plate
XII.)

The other two membranes, the Chorion and Decidua, are not of much
importance in our present explanation; and practically, in fact, the
whole three may be regarded as _one envelope_, surrounding the child
and the waters in which it floats.


THE PLACENTA.

At the full term the Placenta, (See Plate XII,) is about six or seven
inches in diameter, and nearly circular, though often irregular. Its
thickness varies from one to two inches, and is greatest where the cord
is inserted. Sometimes it is very large, or very thick, and may then be
difficult to extract, and even cause serious accidents.

As already explained the Placenta is composed of a mass of
blood-vessels, by means of which the blood of the fœtus is, in some
way, brought into contact, or commingled with that of the mother. Its
uterine face is irregular, being broken into lobes, or cotyledons,
on which may be seen a vast number of little veins and arteries,
corresponding with others on the inner surface of the Womb. Its outer
surface is of a grey red color, and covered with the fœtal membranes,
under which the large blood-vessels can be traced. The Placenta is
usually attached to one side of the Uterus, near the fundus, or at the
fundus, but sometimes it grows wholly, or in part, over the mouth of
the Womb; an occurrence which may cause serious consequences.

When there is more than one child each usually has a separate placenta,
and they are all intimately connected. In some rare cases however, one
placenta only exists with twins. Each child has also a separate amnion,
and waters; but there may be only one chorion and decidua for the
whole, or each may have a complete set of membranes itself. Instances
have been known however, of two children being enclosed in the same
amnion, and surrounded by the same waters, having but one placenta
between them.

These possible diversities show the accoucheur how necessary it is
for him, in any case of multiple pregnancy, to be sure that he has
abstracted _all_ the after birth; and they also caution him not to
proceed to unnecessary manipulations merely because it is not the same
as in other cases.


THE UMBILICAL CORD.

This is composed, as already stated, of an artery and two veins, which
twist round the artery, like the strands of a rope. These are all
enclosed in a sheath, and surrounded by a thick kind of mucus, called
the _Gelatine of Wharton_. Its thickness is about that of the little
finger, though it may be much larger, having been seen as thick as the
child's body. Its usual length is about eighteen or twenty inches, but
it has measured as much as five feet. Then again it has been found
so small that the vessels in it could not nourish the child. These
exceptional variations however, are very rare. The veins may also be
enlarged, or full of knots, and the circulation may be so much impeded
thereby as to cause abortion. The various accidents which may result
from anomalies in the cord will however, engage our attention in
another place.




SECTION IV.

THE MECHANISM OF DELIVERY IN ALL THE DIFFERENT PRESENTATIONS AND
POSITIONS OF THE FŒTUS.




CHAPTER X.

PRESENTATIONS AND POSITIONS OF THE FŒTUS.


The child may present several different parts of its body, at the
commencement of delivery, and they may be in different positions
relatively to the different parts of the Pelvis. All these require to
be known.

Different authors have made different classifications of the
presentations and positions, and have differently named them; but this
is of little consequence, since they are still the same, no matter how
they are named. I shall follow the arrangement of M. Chailly, because I
think it equally perfect, and much more simple and practical, than any
other yet proposed.


PRESENTATIONS.

The fœtus may present at the mouth of the Womb either by the _head_,
the most usual way--by the lower extremities, which is the most
frequent way after the head--or by various parts of the trunk, which is
the least frequent way of all.

In each of these _three_ full presentations there may be certain
variations, which require to be noticed. The head, for instance, may
present either by the _cranium_ or by the _face_; the lower part of the
body may present either by the _feet_, the _knees_, or the _breech_,
according as the legs and thighs are flexed or extended; and the trunk
may present either on the _right_ or _left_ side, and inclined towards
the _back_ or towards the _chest_, though neither the back nor abdomen
ever fully present.

Each of these variations may also have slight variations again. Thus
the face may present full, or by one or the other cheek, and so on.
These variations however, are of little practical consequence, because
we only find them at the very commencement of the labor, and they
always change to the full presentation.

Practically speaking therefore, there are _five full presentations_,
viz., _the Cranium_, _the Face_, _the Breech_, _the Feet_, or knees,
and the _Trunk_, either by the right or left side.

The _varieties_ of these, as already remarked, not requiring any
special attention from the accoucheur, providing he is not puzzled or
misled by them.


POSITIONS.

The position means the particular direction in which the presenting
part of the Fœtus is placed in relation to the Pelvic straits. The
Pelvis itself is supposed to be divided into two similar halves, the
_right_ and the _left_, and each presenting part has one particular
place which is referred to as the indicating point. Thus, for
instance, in the Cranium the Occipit, or behind part of the head, is
the indicating point; and we therefore say, in Cranium presentations,
that it is a _right or left Occipital position_, according as the
back of the head is to the right or left side of the Pelvis. In face
presentations, the chin (_mentor_) is the indicating point, and we
therefore say it is a _right or left mento position_, according as the
chin is towards the right or left side. In breech presentations, the
child's sacrum is the indicating point, and we then say it is a _right
or left sacral position_, according as the Sacrum is towards the right
or left side of the Pelvis. In trunk presentations, which are always
crosswise, the head (cephalo) is the indicating point, and we therefore
say it is a _right or left cephalo position_, according as the head
lies towards the right or left side of the mother's body.

In Cranium presentations also, the back of the head is not merely on
the right or left side, but may be at two different points on each
side. It may be either nearest to the Sacrum (posterior), or nearest
to the pubes (anterior), but still against the Ilium; it is therefore
called a _right or left anterior_, _or posterior_, _occipito iliac
position_, as the case may be. Sometimes also, the occiput lodges
immediately on the pubis, instead of going to either side, and that is
called an _occipito pubic position_; at other times, on the contrary,
it is placed against the Sacrum, instead of being on either side, and
that is called an _occipito sacral position_.

In presentations of the head therefore, we may reckon _six_
positions--the right and left anterior and posterior occipito iliac,
and the pubic and sacral.

In presentations of the face the same; they being _mento_ iliac and so
on, instead of occipito.

In presentations of the lower extremities also the same, excepting that
they are _sacro_ iliac and so on, instead of occipito.

In presentations of the trunk we have but two positions for each side,
the right and left cephalo iliac; according as the head is on the
right or left side of the mother's body. The child always lying, in
presentations of the trunk, crosswise--the feet on one side and the
head on the other.

Most authors enumerate many more presentations and positions, but they
are of little practical utility. When the head presents, for instance,
the delivery takes place in nearly the same manner, let it be in what
position it may. And in presentations of the face, or of the lower
extremities, the particular position is of little consequence, the
delivery being usually effected much the same in them all. Some of
the positions are, it is true, much more favorable than others, but a
spontaneous delivery, generally speaking, occurs in all of them, when
the head, face, or lower extremities presents. Very frequently indeed,
the less favorable positions are changed to the more favorable ones,
and the worst seldom do more than impede delivery for a time, unless
there be some malformation, or loss of power. I therefore refer to them
more for convenience in future explanations, and to enable my readers
to know what is meant by them, when they read other books; not because
they are really necessary to be understood, or of any great practical
use.

The celebrated Baudelocque admitted _seventy-four positions_, and
_twenty-two presentations_; and the number might be made still greater,
if all the variations were to be enumerated. Such classifications
however, are more ingenious than useful, and they are but little
noticed even by medical men.

I shall merely describe the mechanism of labor in the most frequent
positions, in each presentation, because the others usually change
into these; and even when they do not, the process of delivery is
essentially the same, and also the mode of assisting it.


MODE OF ASCERTAINING THE PRESENTATION AND POSITION.

_The Presentation._--Although in general it is not possible to
ascertain with certainty, what part of the fœtus presents to the
mouth of the Womb, until labor commences, yet a tolerable judgment
can frequently be formed before. In head presentations, on performing
ballotment, the head is felt, like a firm round tumor, occupying all
the space which the finger can reach, very differently from any other
part. The peculiar cramps in the female's lower limbs, and frequent
inclination to urinate, mentioned in the signs of labor, are also
strong indications of this presentation, being seldom experienced in
any other. When the labor has actually commenced there can be but
little uncertainty in these cases, for, immediately the mouth of the
Womb is sufficiently open, the finger can be introduced, and the head
felt like a smooth, round, and elastic bony tumor, not likely to be
mistaken for anything else, if ordinary care be taken. After the waters
have escaped, it can of course be felt still more distinctly. If even
an inexperienced person bears in mind the _shape_ of the head, and
reflects how it must _fill up_ the passage, and how it must feel, from
being composed of separated thin bony plates, lying on a soft yielding
substance like the brain, he can scarcely fail to recognize it. The
sensation is very much like that of pressing a piece of firm card board
on an inflated bladder, which forms a tolerable representative of the
fœtal head. Sometimes there is a difficulty from a great quantity
of water being intruded between the membranes and the head, which
somewhat obscures the touch, but this only necessitates greater care.
The water however, may be in such quantity as to entirely prevent the
touch, in which case nothing can be done till the membranes break; the
presentation can then be ascertained with certainty, and it will be
quite early enough to render assistance, if it should be an unfavorable
one. I have known some inexperienced persons mistake the bag of water
itself for the head, and commit great errors in consequence.

The Face can seldom be mistaken, because the nose, or mouth, may be
felt; and, by passing the finger up the side of the head, the ears also.

The trunk is in general easy of recognition. Nearly always the right
or left shoulder occupies the passage, or is near to it, so that the
finger may be readily passed under the arm pit. The shoulder joints,
the ribs, or the shoulder blade bone, all feel very different to the
head, and are not likely to be taken for it.

In presentations of the lower extremities there is still less danger of
error. If the feet, or knees, occupy the passage, they can scarcely be
mistaken. The breech is certainly something like the head in its form,
but feels different, and is divided down the middle by the indentation
between the two cheeks, along which the finger can be passed till it
enters between the limbs.

In irregular presentations, as of the arms for instance, or of one
leg, or an arm and leg, it is only necessary to carefully feel them,
so as to ascertain their form, and the relation of their parts. Thus
the fingers can be distinguished from the toes, and the feet from the
hands, particularly if the ankle can be felt.

The accoucheur should ascertain the particular presentation _as early
as possible_, because he may sometimes be of service in correcting
an unfavorable one, if he is certain of it in time, and knows what he
is about. He should not however, use any degree of force to ascertain
it, in case he cannot do so without, but wait till the conditions are
more favorable. Neither should he, with the same object, rupture the
membranes too soon, for he may thereby cause considerable delay and
difficulty, without any good to counterbalance it.

All the above-named presentations may, and usually do, terminate
spontaneously, except those of the trunk, and even they do
occasionally, though more frequently they require assistance.

_Relative frequency of the different presentations._--The most
favorable presentations, and positions also, are always the most
frequent, while the unfavorable ones are but seldom met with.
According to Madame Lachapelle, in _fifteen thousand six hundred and
fifty-two labors_ there are about _fourteen thousand seven hundred
and forty-nine_ presentations of the head and face; about _five
hundred and eighty-six_ of the breech, knees, and feet; and only about
_sixty-eight_ of the trunk, or shoulders.

_Positions._--The position is generally of but little consequence,
because in all the favorable presentations spontaneous delivery occurs
in every position alike, and in the unfavorable presentations the same
assistance is required in one position as in another. In some cases an
unfavorable position of the head may be changed however, to a better
one; and therefore, so far as the head is concerned, the positions are
worth ascertaining.

The mode of determining the position is by feeling for the _sutures_
and _fontanelles_, described in Chapter VIII; and this cannot be
usually done till after the membranes are broken, when the head can be
distinctly touched. By referring to Plate XXIV, the shape and position
of the Fontanelles will be seen, and if the head be supposed placed
with the top downwards, and the back of it to the mother's left side,
they may be readily found with the finger.

In the left anterior occipito iliac position, or that when the back
of the child's head is against the left side of the mother's pelvis,
and nearest the pubes, while its forehead is against the right side,
and nearest the sacrum,--the sagittal suture, or opening along the
top, will of course run across from right to left. This opening may
be distinctly felt with the finger, which should be passed along
it towards the right side, and it will then reach the _anterior
fontanelle_; afterwards it should also be passed to the left side, and
then it will reach the _posterior fontanelle_. The difference between
these two openings, in shape and size, is shown in Plate XXIV, and even
if a person has never seen, or felt, the head of a newborn child, they
can scarcely be taken for each other, after noticing that Plate.

If the anterior fontanelle should be felt on the left side instead
of the right, and near the pubes, while the posterior fontanelles is
to the right, and near the sacrum, the position must be the _right
posterior occipito iliac_, or just the reverse of the former.

If the sagittal suture should be found to run across from the pubes
to the sacrum, instead of from one side to the other, it will then
indicate either an occipito pubic, or occipito sacral position,
according as the back of the head is behind or before; and this can be
readily ascertained by finding either of the fontanelles.

In short, if the relative position, forms, and directions of these
openings in the child's head be clearly understood, the position of
the head can nearly always be determined by feeling them, as will be
evident by referring to our former explanation of them.

Sometimes however, the bones overlap a good deal, from the head being
pressed, and then instead of an opening along the top, a _seam_ will be
felt. And sometimes, from long continued pressure, a quantity of blood,
and watery fluid, will be effused under the scalp, so as to prevent
the bone being distinctly touched. But these accidents seldom happen,
and with ordinary care and perseverance, need not prevent the position
being determined, after a little delay.

The position of other presenting parts is easily ascertained, by
feeling for some known point--as the _nose_, or the face, the
depression between the cheeks, or the breech, and so on.

_Relative frequency of the different positions._--The most favorable
positions, like the most favorable presentations, are also the most
frequent. According to Baudelocque, in _ten thousand three hundred and
twenty-two cases_, of head presentation, there were _eight thousand
five hundred and twenty-two_ cases when the back of the child's head
was on the mother's left side, and towards the front, (or in the left
anterior occipito iliac position); _one thousand seven hundred and
fifty-four_ when it was on the _right_ side towards the front, (right
anterior occipito iliac); _twenty-five times_ to the right side, but
towards the Sacrum, (right posterior occipito iliac); and _nineteen
times_ on the left, but towards the Sacrum, (left posterior occipito
iliac.) Being most frequently with the back of the head _towards the
front on the left side_, as shown in Plate XXVII; next towards the
front on the right side; and but seldom towards the Sacrum, or back,
on either side. In all these ten thousand cases we do not find a
single instance of the head lying from back to front, in the _occipito
pubic_, or _occipito sacral_ positions, commonly called transverse;
neither do we find a single instance in _fifteen thousand six hundred
and fifty-two cases_ recorded by Madame Lachapelle; which will show
how rare such unfortunate positions must be. What this great frequency
of one particular position depends upon we do not know--possibly on
that cause, previously alluded to, which determines the most frequent
presentation.

In the next Chapter, the mechanism of delivery, or the manner in which
the child escapes out of the body, as it most frequently occurs, will
be fully explained.




CHAPTER XI.

THE MECHANISM OF DELIVERY, IN A PRESENTATION OF THE HEAD.


THE LEFT ANTERIOR OCCIPITO ILIAC POSITION.

This is the presentation and position most frequently observed, perhaps
fifteen out of sixteen times. In most Obstetrical works it is called
the _first_ position.

By observing the following Plates, and referring to the previous
explanations of the diameters of the Pelvis, and fœtal head, in Plates
IX and XXV, it will be seen that through all its changes of position,
while making its exit, the head always presents by one of its shortest
diameters to one of the largest diameters of the Pelvis, so that the
relation between them is invariably the best that could be established;
and many peculiar turnings and revolutions occur, apparently for the
express purpose of bringing this about.

Before the rupture of the membranes the head presents its occipito
frontal diameter, which measures four inches, to the right oblique
diameter of the Pelvis, which measures four inches and a half; while
its bi-parietal diameter, which measures only about three inches and
a half, is presented to the other oblique diameter, also measuring
four and a half--(See Plate XIX.) Even here it will be seen that the
passage is larger than the head which has to pass through it, but a
more favorable position still can be obtained, by a slight movement of
the Fœtus, which nature accordingly accomplishes, and also follows by
others, to preserve the advantage, which will next be described.

_Movements of the Fœtal Head._--There are three of these peculiar
movements, each of which takes place at a particular period of the
labor, and must be described separately.

_First movement, flexion, and descent._--Immediately after the
Membranes are broken, the contractions of the Uterus force the head
into the upper strait, by the occipito frontal diameter of four inches,
as already shown; but then commences the first movement, which consists
in a bending of the child's chin down upon its breast, so that the
forehead is carried up into the Womb; and the most prominent point of
the back of the head presents to the middle of the passage, by the
_occipito bregmatic_ diameter, which is only about _three inches_
instead of four. This of course makes the passage so much easier, and
generally, immediately after this change, the head descends into the
basin of the Pelvis.

It is not absolutely necessary however, for this movement to occur, for
in a well formed Pelvis the head can descend without it, though not so
easily; and sometimes, in fact, it does not take place, but this is
unusual.

It must be recollected that this shifting of the head alters the
position of the _fontanelles_--the posterior one being brought more
to the centre of the strait, and the anterior one carried up out of
reach, while previous to the movement they were both on a level. If an
examination is not made therefore, till after this change, it may be
difficult to determine the position, unless this is borne in mind. The
following Plates show this very well.


  PLATE XXVII.

  It will be seen here that the neck is straightened out, and that the
  two fontanelles are on a line with each other.

  _Note._--The front of the bones are represented in this and the two
  following Plates, as if transparent, so that the head may be seen
  through them.

[Illustration: Plate XXVII.

This Plate represents the head just entering the upper Strait.]


  PLATE XXVIII.

  At this time the anterior fontanelle can scarcely be reached, but the
  posterior one is easily to be reached, being in the open passage, on
  the left side. The head is now fairly within the Pelvic cavity, but
  still lies across from right to left.

  _Second Movement, Rotation of the Head._--When the Fœtus is thus
  brought to the bottom of the Pelvis, its head turns completely round,
  the back of it being brought to the front, or under the pubes of the
  mother, and its forehead turned against her Sacrum, as represented in
  Plate XXIX.

[Illustration: Plate XXVIII.

This Plate represents the head descended still lower in the Pelvis.]


  PLATE XXIX.

  Here the head is seen just beginning to turn--the right side, and
  part of the back of it, just passing under the pubes. As the rotation
  becomes complete the neck straightens, so that the two fontanelles
  are again found on the same level. Finally the back of the head fully
  emerges from under the pubic arch, and the chin slides gradually out
  after it beneath, so that the neck of the child is encircled by the
  ring of the Vulva.

[Illustration: Plate XXIX.

This Plate represents the head still further down, and beginning to
Rotate.]

[Illustration: PLATE XXX.

In _Fig. 1_, the back of the head is nearly under the pubic bone, while
the forehead is just passing the external opening below.

In _Fig. 2_, the back of the head is completely extruded, and also the
chin, so that the whole head is now born.--(_p._ is the pubic bone, in
front.)]

In Fig. 1 it will be seen how the Os Coccygis, or lowest part of the
back bone, (c,) is straitened out, backward, while the head is passing,
as I explained before; and in Fig. 2 it has returned again to its
natural position.

The reason for this rotation of the head will be obvious on calling
to mind the form of the Pelvis and the external opening. On examining
Plates IX and X, it will be seen that the longest diameter of the
Vulva, or external opening, the _antero posterior_, is nearly at right
angles to the longest diameters of the upper strait, the _oblique_.
Now the longest diameter of the head is adapted to this oblique
diameter, on _entering_ the upper strait, as already explained, and it
is necessary for it also to be adapted to the longest diameter of the
external opening, the anterior posterior when making its _exit_; but
as the two are not parallel the head is compelled to turn, or rotate,
in order to pass from one to the other. To accomplish this however,
the neck has to be twisted considerably. But when the head is fully
delivered, it is immediately straitened again, by the back of the head
turning towards the mother's left side, so that its proper relations
with the trunk is re-established.

_Third Movement, Rotation of the Shoulders._--When the head is
delivered the shoulders come next, which also require to turn round a
little, to adjust themselves to the long diameter of the lower strait;
and as they turn within the Pelvis the head also turns, to correspond,
and thus the back of it is brought opposite the middle of the mother's
left thigh. Immediately this movement is effected, the shoulders
rapidly escape through the external opening, the right one being in
front, a little to the left of the symphysis pubes, and the left one
behind, a little to the right of the os coccygis. The body then curves
upwards, to accommodate itself to the curved axis of the Pelvis, and
speedily follows the shoulders.

These curious movements cause the child to pass in a spiral direction,
so that each part may pass through the Pelvis in the most favorable
position. Sometimes all these movements are not effected, and yet the
delivery may occur, though not so speedily, or safely, as when they
are. The shoulders do not always fully rotate, but may nevertheless
pass the opening, if the parts be large, and well relaxed. It is
questionable however, if the head can ever pass the lower strait
without rotating, when it enters the Pelvis diagonally, the occipit on
one side and the forehead on the other; as it is necessary for either
one or the other of these parts to pass under the pubes.


MECHANISM OF DELIVERY IN ALL OTHER POSITIONS OF THE HEAD.

_The right posterior occipital position._--This position, called the
_second_ by some authors, and the _fourth_ by others, is exactly
the reverse of the one just described, the head lying in the same
direction, but the back of it being behind, to the right of the Sacrum,
and the forehead to the left of the pubes.

Precisely the same movements are gone through in this position as in
the other, excepting that the head has to rotate considerably further.
In the former position the back of the head is only a _little_ to the
left of the pubis, and therefore has not far to turn to pass under it;
but in this position the back of the head is _behind_, and therefore
has to turn very far round to reach the same position. The rotation is
therefore more difficult, not so soon effected, and sometimes likely to
be dangerous to the child.

In the other movements there are no difference worthy of notice, but it
must be borne in mind that they all occur the reverse way, to what they
do in the first position, because the occiput is on the _right_ side
instead of the left.

_The right anterior occipital position._--This position is precisely
the same as the first, but on the other side. The back of the head
is in front, but to the _right_ of the pubis instead of the left,
while the forehead is behind, to the left of the Sacrum. This will be
apparent enough by observing Plate XXXI.


  PLATE XXXI.

  This is the second most frequent position; the left anterior occipito
  iliac being the _most_ frequent.

  _a._ The Acetabulum, or socket of the hip joint.
  _c._ The cut edge of the Womb.
  c. The Foramen Ovale.
  _d._ The top of the ilium bone, called the _crest_.
  _h._ The Symphysis Pubes.
  _i._ The ischium.
  K. K. The pubic bones.

[Illustration: Plate XXXI.

Head in the _right_ anterior occiput iliac position.]

The mechanism of delivery is precisely the same, and all the movements
occur in the same order and manner, as in the first position, but the
reverse way. The rotation, for instance, being from right to left,
instead of from left to right, and so of all the others.

_The left posterior occipital position._--Delivery is effected the same
in this as in the left anterior, or first position, excepting that
the rotation is more extended, owing to the occiput being behind, as
explained in the right posterior occipital position.


GENERAL REMARKS ON THE DIFFERENT POSITIONS OF THE HEAD.

In all the other positions, and their varieties, there is nothing that
calls for special notice, or that is material in practice, the delivery
being nearly the same in them all. No matter what position the head is
placed in, the back of it nearly _always_ comes to the front, under
the pubes, even though it have to turn half round to do so. The cause
of this is supposed to be the peculiar form of the parts, which give
it a screw like motion, in its descent, and the shape of the external
opening, which, being longest from before to behind, can only allow the
long diameter of the head to pass through in the same direction.

Sometimes, it is true, the occiput passes behind, instead of coming to
the front, and then the _chin_ comes under the pubes, while the occiput
presses on the coccygis. This is very seldom observed, and when it
occurs the labor is more difficult and tedious, though it may still
terminate spontaneously.

The resistance of the soft parts, externally, appears to be the chief
cause of the head turning; for when they are much relaxed, and the
child's head small, it will sometimes pass without, or in the anterior
posterior position. And sometimes, when the head is large, so that it
distends the parts very much, the shoulders will pass cross wise, there
being room enough for them without turning. In some females, formed
large, whose organs are excessively relaxed, and whose children are
small, the delivery takes place without _any_ of the movements being
effected, the child passing straight through in whatever position it
may happen to be: this is rarely seen however.

When there are twins they do not usually both present by the head, but
one by the feet; and frequently the parts are so relaxed by the passage
of the first, that the second is delivered without rotating at all,
though in general it follows precisely the same movements. It sometimes
happens however, that the second birth does not take place till some
hours, or even days, after the first.

It may be said, in general, that all positions of the head are
favorable to both mother and child, and may terminate spontaneously. It
is seldom that anything more than ordinary assistance is required in
any of them, and they could in general terminate without any at all,
though sometimes with difficulty. The worst cases are those in which
the head does not turn round, but remains across, or where the back
of it turns behind, instead of coming to the front. In these cases
there is great danger of the perineum, or external lips, being much
lacerated, or even of an artificial passage being torn through the
perineum, leading to the most serious after results. About one child
also, out of every fifty, is lost in these unfavorable positions.




CHAPTER XII.

MECHANISM OF DELIVERY IN PRESENTATIONS OF THE LOWER EXTREMITIES.


This presentation includes the feet, the knees, the breech, and also
the hips, there being no difference in the delivery for all these
parts. It is the same also whether there be one foot, or knee, or both
feet and knees.

There are but two positions worthy of notice in this presentation,
and they are determined by the child's sacrum. If the sacrum, or
posteriors, are to the right of the mother's Pelvis, it is called the
_right sacro iliac position_; but if they are on the left side it is
called the _left sacro iliac position_. The direction in which the
child's pelvis is placed, is analagous to that of the head, the sacrum
answering to the occiput. Thus most frequently the sacrum is on the
left side, a little to the left of the pubes, (_left anterior_) while
the abdomen faces the right side near the sacrum. When on the right
side however, it is most usually nearest the sacrum, with the abdomen
facing the left side near the pubes.

The lower extremities present most frequently next after the head, but
still they are but seldom met with. M. P. Dubois tells us that out of
_twenty thousand labors_ he only met with _eighty-five_ such cases. In
these eighty-five cases the breech presented _fifty-four_ times, and
the feet _twenty-six_, the knees being found _but once_.

A presentation of the lower extremities may generally be recognized
at an early stage, by the head being felt at the _fundus_ of the
Uterus, and by the pulsations of the fœtal heart being heard above the
umbilicus, as explained in the section on Auscultation. After labor has
commenced the part felt at the mouth of the Womb is irregular, and so
different from the head, that it is not likely to be mistaken for it.
If the knees or feet present, they can always be distinguished; and
if the breech presents it can easily be recognized by its form, and
particularly by the os coccygis, which can be distinctly felt at the
bottom of the depression between the two cheeks. The side on which it
is felt of course determines the position, and the same with the front
of the knees, or the heels. The Rectum can also be reached with the
finger, when the breech is touched; but great care must be taken not
to intrude it too far, because with a female child the _Vulva_ might
be mistaken for it, and thus the hymen be broken, and other injury
committed. The genitals of a male child are more obvious, so that the
sex of the child may be usually ascertained, along with the position.

For want of proper care the breech has been mistaken for the head, and
face, but this can scarcely happen if the accoucheur is attentive.
It is simply necessary to call to mind what _must_ be felt in each
presentation, as the _nose_ and _mouth_ with the face; the two cheeks
of the posteriors, with the opening between them; and also the
genitals, with the breech; and it can be certainly ascertained which of
these parts are really at the opening. With the knees or feet there can
scarcely be a doubt.


DELIVERY IN A BREECH PRESENTATION IN THE LEFT ANTERIOR SACRO-ILIAC
POSITION.

In this position the legs and thighs are turned up against the
abdomen, the breech in full occupying the passage, with the sacrum to
the left and in front of the mother's pelvis.

The descent of the breech usually takes place without much difficulty,
into the Pelvis, it being small and easily compressed. It descends in
the same direction in which it first presents--that is diagonally, like
the head--and also rotates, or turns round, so that the left buttock
comes in front, just to the right of the pubis, while the right one
goes behind, to the left of the sacrum. The left buttock reaches the
mouth of the Vulva first, in this position, and then remains stationary
there while the right one slides along the curve of the sacrum and
perineum, and passes out first at the lower part of the external
opening. The left however, speedily follows, and when the whole breech
is born it rotates again, one hip coming immediately in front, and
the other going immediately behind. Owing to this movement the long
diameter of the breech is adapted to the long diameter of the Pelvis,
as in the case of the head. This will be evident from the following
Plate:--

[Illustration: PLATE XXXII.

 Delivery in a breech presentation, the buttocks having just passed the
 Vulva.

  _c._ The Coccygis, much straightened.
  _p._ The pubic bone, in front.]

The rest of the body then rotates in the same way, and the arms and
shoulders pass through the external opening in the same direction as
the hips. The left shoulder first moves to the right of the pubes,
while the left passes behind; and then, just when they are both passing
out, one comes immediately in front, and the other immediately behind,
placing themselves in the long diameter of the Vulva.

The head passes through the superior strait in the left, anterior
occipital position, and is often delivered in that way; but sometimes
it rotates, and the forehead passes into the curve of the sacrum, while
the occiput is placed behind the pubes. When this occurs the body also
rotates, to accompany the head. This state of the parts is represented
in the following Plate:--

[Illustration: PLATE XXXIII.

 Anterior posterior position of the head, the occiput being in front,
 after the delivery of the body.

  _c._ The Coccygis.
  _p._ The pubic bone, in front.]

At this period the head is passed the uterus, and there is therefore
little or no contraction to expel it, so that it often remains a
long time undelivered. It will be seen that the position is very
unfavorable, the longest diameter of the head, the occipito frontal,
being the presenting one, which makes it lie immoveably across. The
means of assisting in such a case are plain enough, the forehead must
be brought down while the body is _raised_, towards the mother's
abdomen; this will throw the top of the head back, towards the sacrum,
and change the presenting diameter. The forehead and bregma rapidly
escape below, and the occiput passes out last. This is the way in which
nature herself also completes the delivery in such cases, when she has
the power.


DELIVERY BY THE BREECH IN THE RIGHT POSTERIOR SACRO ILIAC POSITION.

This position is the reverse of the preceding one, the Sacrum being
behind, and to the right, while the Abdomen is to the left in front.
The same movements are performed as in the first position, and the
whole process is similar, only the reverse way. The Sacrum being behind
however, has to rotate much further to come in front, precisely the
same as with the head when in the posterior position.

The head generally follows the Sacrum, and the occiput comes under the
pubes, as already explained; but sometimes only at the moment when
being disengaged.


DELIVERY BY THE BREECH IN THE FULL POSTERIOR, OR SACRO SACRAL POSITION.

In this position there is no rotation at all, the back of the child
being turned full to the back of the mother, and the whole body,
and head, being expelled in that position. In general there is no
particular difficulty from this position, but on the contrary it is
thought by some to be rather favorable than otherwise. The longest
diameter of the fœtal pelvis, and shoulders, are adapted to the longest
diameter of the mother's pelvis, at the upper strait, and easily pass
it. They will also generally pass the external opening in the same
direction, unless it be very unyielding, or the child very large; and
if they pass the head usually follows, because the parts have been so
much dilated by the passage of the body that they offer but little
resistance.


GENERAL REMARKS ON THE PRESENTATION OF THE LOWER EXTREMITIES.

As a general rule delivery by the breech, or by any other position of
the lower extremities, is less favorable than by the head. The labor is
usually longer, more painful, and more exhausting; still however, it is
generally spontaneous, and not necessarily dangerous to the mother. To
the child, on the contrary, it is dangerous, on many accounts.

It appears, from the observations of M. P. Dubois, that in this
presentation _one child is lost out of every twelve_, while only one
out of _fifty_ is lost in head presentations! The chief cause for this
greater mortality appears to be _the compression of the umbilical
cord_, which is greater, and lasts much longer, than when the head
presents, as will be evident on examining the circumstances under which
delivery is effected in each case. When the head presents it passes,
and also the shoulders, before the umbilicus is reached; the mother's
organs are therefore much dilated, and only the smallest parts of the
fœtus are left, when the cord is engaged in the passage; it cannot
therefore be much compressed, nor for any long time, because the labor
is then soon over. When the lower extremities present this is not the
case, the _smallest_ parts then pass before the umbilicus is reached,
so that the cord has to pass along with the head and shoulders,
which are both the largest and the longest in being delivered. This
compression of the cord stops the circulation of blood between the
fœtus and the Placenta, as will be evident on referring to the
description formerly given of _Fœtal nutrition_; and the stopping of
this circulation is as fatal, to it, as stopping the breath is to an
adult. When the breech presents altogether, there is not so much danger
as with the feet, or knees, because it is large, and in its passage
dilates the parts so much that the rest of the body, and the head,
follow more quickly. There is, of course, no danger till after the hips
have passed, because the cord is not reached before; but the delivery
should be completed as soon after they are born as possible, for every
minute's delay makes the chances for the child's life so much less.




CHAPTER XIII.

MECHANISM OF DELIVERY IN PRESENTATIONS OF THE FACE.


Presentations of the face appear to result from the head being bent
backwards, instead of forwards upon the chest. They are easily
recognized, because the face has so many peculiar parts, as the nose
and mouth, for instance, which are altogether unlike what can be felt
in any other presentation. In a very early stage the forehead may be
taken for the vortex, unless care be used, because it _feels_ round and
soft like it, but the mistake cannot last long.

The positions in this presentation, as formerly explained, are
determined by the chin, and in practice only two are noticed--the
_right posterior mento iliac_, and the _left anterior mento iliac_.
In the first the chin is on the right side, near the sacrum, and in
the second it is on the left side, near the pubes. These answer, it
will be seen, to the two principal positions of the head itself. It
is generally considered that, though the chin, like the head, may
assume other positions, yet it does so in but very few cases, and these
presenting no peculiarities which require special notice.


DELIVERY IN THE RIGHT POSTERIOR MENTO ILIAC POSITION OF THE FACE.

The head descends with the forehead and chin nearly on a level, and the
nose occupying the middle of the passage. When fairly in the cavity
it rotates, the chin being brought under the pubes, while the back of
the head passes into the curve of the sacrum. This is nearly always the
process; no matter where the chin may be when the labor commences, it
seldom fails to move under the pubes before it concludes. Occasionally
it may rotate the other way, and pass into the hollow of the sacrum,
while the occiput comes in front, but this is very rare.

The chin is born first, and then follows, below, the forehead, top of
the head, and finally the occiput--the face turning upwards towards
the mother's abdomen, as each part is successively delivered. When the
head is fully born, the body rotates inside the same as in the head
presentation, and the delivery concludes in precisely the same way.

[Illustration: PLATE XXXIV.

Fig. 1.--The chin just passed, in presentation of the face.

Fig. 2.--The head full born in presentation of the face.--_p._ The
Pubic bone.--_c._ The Coccygis.]


DELIVERY IN OTHER POSITIONS OF THE FACE.

The delivery is precisely the same in all the other positions of the
face, excepting that in some of them the chin has further to rotate
before it can pass under the pubes. In all cases however, it may
be safely calculated that it will do so, there having been so few
instances known in which it has rotated the other way, into the hollow
of the sacrum, which is fortunate, for there is always more or less
difficulty and danger when it does so.

Sometimes the rotation does not take place at all, but the face
descends diagonally, as the head occasionally does.

On the whole presentations of the face are not particularly to be
feared, as regards the mother. Some authors even consider them quite
favorable, and reckon them only as varieties of the head presentation.
Madame Lachapelle states as a principle, that face presentations should
always be left to nature. And M. Chailly says he must admit that, in
all positions of the face, the labor may terminate spontaneously,
excepting when the chin passes behind, in which case it will be
protracted, and most likely fatal to the child. The labor is generally
a little longer, and more painful, owing to the face not being so
perfectly adapted to the passage as the head is; but still it must
be regarded as favorable to the mother, though assistance is oftener
required than with the head. There is more or less danger to the child
however, owing to the head being kept under pressure for an unusual
time, which produces congestion. The neck is also forced against the
pubic bone, as will be seen by Figs. 1 and 2, Plate XXXIV, and thus the
jugular veins are compressed. If there be any delay, it is customary
to observe the face closely, after the chin is born; and if it appears
from any indications that congestion is taking place, assistance is
rendered at once. The face will sometimes become so tumefied, and
engorged with blood, from this prolonged pressure, that it will not
appear natural till several days after birth.

Probably about one child is lost in ten or twelve deliveries in these
cases; and if the chin pass behind its death is almost certain.

It was formerly the practice to endeavor to turn the face upwards,
when at the superior strait, and so change the presentation to one
of the head. This however, is now abandoned, because the attempt is
seldom successful, and does not materially improve the condition of
things, besides being painful to the mother. The only extra danger
with the face presenting is to the child, and this is not removed by
the operation; to the mother the face is nearly as favorable as the
cranium. In regard to the frequency of face presentations, we find that
Madame Lachapelle met with but _seventy-two_ cases in _fifteen thousand
six hundred and fifty-two deliveries_.




CHAPTER XIV.

MECHANISM OF DELIVERY IN PRESENTATIONS OF THE TRUNK.


It has already been stated that in presentations of the Trunk it is
nearly always the right or left shoulder which occupies the passage. It
is stated, by some authors, that they have felt the back, and abdomen,
but others think they were mistaken; and most certainly such positions
are extremely rare, if they actually do ever exist.

There are two presentations of the Trunk, determined by the side on
which the fœtus lies, and denominated accordingly _right_ or _left
lateral presentations_.

Each of these presentations has two corresponding positions, determined
by the side on which the child's head lies. If the head be on the
mother's right side it is called the _right cephalo iliac position_,
and if it be on the left side it is denominated the _left cephalo
iliac position_. The mechanism of spontaneous delivery is the same in
them both, and in all their varieties, and so is the mode of rendering
assistance, so that a description of one will suffice.

Sometimes, when the labor has lasted long without assistance, one arm
will be forced down first, and even appear externally. This used to
be considered a separate presentation, and described as such, under
the name of _presentation of the hand and arm_. There is no reason for
describing it separately however, and no utility in doing so, as it
differs in no essential particular from ordinary presentation of the
shoulders, and must receive the same assistance.

What it is that produces presentations of the Trunk, and other
unfavorable parts, is not known, though they are generally thought to
be owing to excessive motion in the child, or obliquities of the Womb.

M. Lachapelle met with _sixty-eight_ cases of Trunk presentation in
_fifteen thousand six hundred and fifty-two labors_, which is nearly
the same as the face. The right side presents more frequently than the
left, and the head is on the left side oftener than on the right, as it
is in ordinary head presentations.

As a general rule assistance is always rendered in presentations of
the Trunk, and is generally considered absolutely necessary. It is
undoubtedly true however, that nature has effected delivery in such
cases unaided, though rarely, and such instances are considered as
extremely fortunate exceptions to the general rule. M. Chailly says
that the accoucheur should never leave such cases to nature alone, but
always aid her; but other authors trust to her a little more. The most
usual mode of rendering assistance is to _turn the child_, and bring
down the feet, a manœuvre which will be fully described hereafter.

In some cases the child turns itself, from the contractions of the
Womb, before it enters the upper strait; and in other cases, when very
small, or long dead, it will pass folded double. This self-turning
however, cannot take place after the escape of the waters, so that it
seldom occurs when the membranes are broken.


MECHANISM OF DELIVERY IN PRESENTATIONS OF THE TRUNK BY SPONTANEOUS
EVOLUTION.

This is the most usual mode for the fœtus to escape, in each
presentation, and in every position. By referring to the following
Plates, and the accompanying descriptions, it will be readily
understood.

[Illustration: PLATE XXXV.

_Position of the Fœtus in a presentation of the right shoulder, and in
the left cephalo iliac position._]

Previous to the rupture of the membranes the child's body lies
_across_, as formerly explained; but immediately after the rupture the
shoulders descend into the Pelvis, as seen in the above Plate, while
the head remains above the pubes; the arm frequently, but not always,
protruding externally.

The shoulder then continues to descend, the body following, bent up
against the face, as seen in Plate XXXVI.

[Illustration: PLATE XXXVI.

_Descent of the shoulder in a Trunk presentation, at a more advanced
period._]

Here the shoulder is protruded from the Vulva, the back being nearly
folded, and the knees turned up against the face.

[Illustration: PLATE XXXVII.

_Descent of the shoulder and trunk at a still later period._]

The whole Trunk is now fully delivered, folded almost double, and the
legs and feet are turned up against the face. They speedily follow
however, and then nothing is left but the head, and perhaps one or both
arms, placed against the sides of it, as shown in Plate XXXVIII.

[Illustration: PLATE XXXVIII.

_The Trunk has fully descended, and only the head is left, with one
arm._]

The arm is generally very easily brought down, or it may remain and
come with the head. The delivery of the head is effected the same
as in presentations of the pelvis, and is seldom attended with much
difficulty, the parts having been so much distended. The body always
rotates so that the back comes in front, and the chin passes into the
curve of the Sacrum.

This is the way in which the delivery is effected by nature in such
cases, and it will readily be conceived how dangerous it is to both
mother and child, and how seldom it can be accomplished. If the Fœtus
be of a full size, and the mother's pelvis no larger than ordinary,
it is almost impossible for this spontaneous evolution to take place;
and even when it does, it is with the greatest difficulty, the mother
suffering in an extreme degree, and running great risk, not only of the
most serious after results, but even of death. To the child the danger
is equally great, owing to the severe and long-continued compression
it receives, and the unnatural position it assumes. M. Velpeau tells
us that in _one hundred and thirty-seven_ such cases, _one hundred and
twenty-five_ of the children died. The number of the mothers also,
who either died or were made sufferers all their future lives, was
undoubtedly great, though unknown.

It is evident therefore, that presentations of the Trunk are the most
unfavorable known, and labor in them is but rarely spontaneous. Nature
can but very seldom effect the delivery of the Fœtus herself, and even
when she does it is with the greatest risk, both to it and the mother.
The accoucheur should _always_ assist therefore, if he can, because
even if nature can complete the delivery it is with such danger. The
means of assisting, by turning, will be described in another Chapter.

If the fœtus is not at full term, and of course is under the full size,
its expulsion may be left to nature safely, but not otherwise.




SECTION V.

THE PHYSIOLOGY OF SPONTANEOUS DELIVERY, OR CHILDBIRTH, AND THE MANNER
OF CONDUCTING A NATURAL LABOR.


Having now completed the description of the _Mechanism of Delivery_, in
all the various presentations and positions, it is necessary to explain
the physiological phenomena attending a natural labor, and the duties
of the accoucheur when conducting it, and to show what assistance he
can render, and when he should or should not interfere.




CHAPTER XV.

OF DELIVERY IN GENERAL.


DIFFERENT KINDS OF DELIVERY.

When the child is brought into the world by the unaided efforts of
nature, and without any accident to itself or the mother, it is called
a _Natural Delivery_. When it occurs by the efforts of nature alone,
but not advantageously for both, it is not called natural, but simply
_Spontaneous Delivery_. And when assistance is required it is called an
_Artificial_, or _difficult Delivery_. It is also called _precocious_,
or _tardy_, according as it comes before or after the full term.


CAUSES OF LABOR.

What it is that causes labor to commence, and proceed, is not fully
known. At the proper time the Uterus prepares to cast out the fœtus it
has so long retained, in the same manner that the tree casts off its
fruit, and from some efficient cause which we have not yet discovered.

It is probable that, when the fœtus attains a certain size, it presses
upon the nerves of the neck of the Uterus and irritates them, and
they react again upon the muscular fibres of the Womb and cause them
to contract, and so expel its contents. This is much the same action,
in fact, as vomiting. When any body very repugnant to the stomach
is swallowed, it irritates the nerves of that organ, and then they
excite its muscular fibres, which, by forcible contractions, expel the
offender.

It is possible, also, that the fœtus itself may instinctively assist in
bringing about its own delivery, as was supposed of old by Hippocrates,
and more lately by Harvey and others. It is certain that labor is both
more difficult, and more dangerous, when the child is dead; though it
may take place as usual after the death of the mother, providing the
child be still alive. Several instances of this kind have been known,
when the living child was expelled from the Womb, by the natural
process, sometime after the mother had ceased to breathe.

The contraction of the muscular fibres of the Womb however, must be
regarded as the immediate or efficient cause of fœtal expulsion, let
them be brought on how they may. The muscles of the Abdomen, and the
diaphragm, also assist, in the last stage, but are not essential.

The young of some of the lower animals are observed to perform certain
peculiar motions, during delivery, by which it is much facilitated;
and this is considered a proof, by some, that voluntary movements of
the fœtus assist in the process. Certainly if it be supposed, as we
have shown there is good grounds for doing, that the child assists in
placing itself in the best _position_, it is equally probable that it
also assists in its own expulsion, in other ways.


SIGNS OF DELIVERY.

_Premonitory Signs._--A few days before delivery the Uterus descends
much lower, so that the diaphragm and stomach are less pressed upon,
and the breathing and digestion becomes easier in consequence. The
ease which is thus experienced is sometimes so great that the female
becomes unusually animated and cheerful, and cannot think she is so
near her travail. This is not always the case however, for some on
the contrary feel very uncomfortable and melancholy. The lips of the
Vulva are also apt to swell and become painful, and the lower limbs
numbed and cramped, owing to the child's head pressing on the large
nerves. The neck of the bladder is also very liable to be compressed,
so that a constant desire is felt to urinate, and a similar trouble may
also be experienced in the Rectum. Most of these inconveniences, but
particularly the numbness and cramps in the limbs, are not likely to be
experienced except when the head presents, because no other part is so
formed as to be able to descend sufficiently low; when they are felt
therefore, the female may console herself by the reflection that they
indicate, with tolerable certainty, that the child is presenting in the
best position it can for a safe and speedy delivery.

Standing, or walking, usually become more difficult, and swelling of
the external parts, or piles, are apt to occur. With some females also,
a sudden diarrhœa, or vomiting, takes place, and troubles them up to
the period when labor commences.

Finally the Uterus begins to contract, though insensibly at first;
the Abdomen becomes unusually hard, and flying pains are experienced,
particularly with first children. This continues with more or less
of intermission, up to the actual period of labor, which is usually
divided into _three_ periods, each of which must be considered
separately.




CHAPTER XVI.

THE PROGRESS, PHENOMENA, AND DURATION OF NATURAL LABOR.


FIRST PERIOD.

On making an examination the mouth of the Womb will be found to
be dilating, and a discharge of mucus, tinged with blood, issuing
from it. The membranes may also be felt protruding into the Vagina,
and distended, like a bladder. The female complains of being drawn
powerfully together in the inside; she trembles, and gasps for breath;
her pulse sinks, and she often becomes sick and deadly faint; she
complains of great thirst, and breaks out into profuse perspiration;
frequently she will weep, and apparently suffer from some terrible
apprehension, while her strength will be completely exhausted.
Occasionally however, she will be perfectly passive, and almost
immoveable, appearing as if in a dream.

The pains however, gradually become more and more acute, and closer
together; the patient is excited and irritable; her pulse becomes
quicker again, the thirst increases, and vomiting frequently ensues.
Before each pain she frequently experiences a severe chill, with
chattering of the teeth, and not unfrequently becomes perfectly
delirious.

With each pain the mouth of the Womb expands more and more, till at
last it totally disappears, and the cavity of the Uterus and the Vagina
form but one uniform passage, which is completely occupied with the
distended membranes, or bag of waters, which may be felt like a soft
round tumor. This is well represented in the following Plate:--

[Illustration: PLATE XXXVIII.--_a._

  Fig. 1.      Fig. 2.

Fig. 1 shows the state of the parts at the beginning of labor. The
mouth of the Womb is considerably dilated, and the Membranes, A, are
protruding slightly.

Fig. 2 shows the state of the parts at the end of the first period. The
neck of the Womb is now so fully dilated that it forms a continuous
passage with the Vagina, while the bag of waters, A, projects far down
and occupies the whole width of the canal.]

The first period may be much protracted, and is generally very
exhausting, though not attended with any danger or special difficulty.


SECOND PERIOD.

At this stage all the previous symptoms become much exaggerated. The
contractions are more powerful, and the pains more acute, but with
a perfect period of repose between them, during which the female
will feel quite easy, and even sometimes fall asleep, but only to be
aroused by the pains coming on again. The muscles of the Abdomen,
and the diaphragm, are now called into play; the patient strains, or
violently bears down, and pants with exertion, while the perspiration
streams from every pore, the pulse quickens, and the expression of the
countenance betrays the wildest anxiety and excitement.

The bag of waters now descends, and enlarges more and more, until
at last, being unable any longer to bear the strain to which it is
subject, it bursts, and the waters flow away in a profuse gush.
Immediately this takes place the head descends, and closes up the
passage; the pains cease for a time, and the patient again has a
respite, while the uterus apparently gains fresh power. Very soon the
contractions recommence, more energetically even than before, the
head passes the mouth of the Womb and enters the Vagina, which keeps
enlarging as it descends, till it reaches the lower part, or floor of
the pelvis. The pains now become more violent than ever, the patient
screams with agony, clutches hold of any object near her, throws
herself back, draws in her breath, and bears down with all the force
she can command.

The fearful cries which most females emit at this time appear to
assist the delivery, by the convulsive efforts at breathing which they
necessitate, and the expulsive straining also does the same. These
natural efforts are much assisted by providing a firm support for the
patient's feet, against which she can push, which she will do with
tremendous force.

The head now presses, at each pain, against the perineum, which begins
to project outwards, as also does the Rectum. The Vulva begins to
dilate, the lips separate wider and wider, and part of the child's head
becomes visible. Gradually the lips become thinner and thinner, and at
last disappear nearly altogether, so that the mouth of the Vulva is
only composed of thin ring, which seems ready to give way every moment.
The head however recedes, and the parts again assume something like
their natural condition for a short time, when the same process again
takes place, and the distension proceeds still further, while the head
does not retire so far. This alternate action is repeated perhaps many
times, so that the external mouth is opened gradually, and without the
lips or perineum being torn, which they would be if the head were to
pass suddenly, before they were softened and dilated.

After this has been continued for a sufficient period a strong
expulsive pain is felt, the female screams, the head passes clean
through the external opening, and the lips close round the neck.
This however, is only for an instant, the rest of the body speedily
following the head, in the manner hereafter to be explained. Most
usually, in fact, the whole body follows the head without any stoppage
at all, but sometimes there is a delay of a few seconds.

_The Third period of delivery_ comprises the delivery of the Placenta,
which will occupy our attention in another place.

_Differences in the process of Labor._--Although, in most cases, labor
proceeds much in the way I have just explained, and is attended with
similar phenomena, yet still we occasionally see marked exceptions.
This is particularly the case with regard to _pain_. Most females
suffer severely at this time, and some even the most torturing agony,
while others again experience scarcely anything to complain of, and
some even feel nothing at all. I am acquainted with a lady at the
present time, the mother of several children, who assures me she never
felt any pain at all in her labors, nor was she in any ways exhausted
by them. I have known her rise from her bed in the night, from feeling
indications of the approaching event, make all her arrangements, and
send for the nurse, as if it was the most ordinary affair imaginable.
On one of these occasions, before her husband returned with the
assistants, she was delivered while alone, without any difficulty, and
they found her sitting up in bed nursing the child. She had cut it
loose, and tied up the cord herself, having heard how to do so at one
of my Lectures, and actually brought away the Placenta with her own
hand. In two days after she was about as usual. And yet this lady was
by no means strong, nor remarkably healthy; and what is very singular,
she suffered severe pains at most of her monthly periods; much more,
as she assured me, than from all her labors put together. M. Chailly
also mentions an instance of a young girl of sixteen, with her first
pregnancy, whose Vagina was also partly closed by an internal membrane,
whose delivery nevertheless was almost painless. She woke up, he tells
us, about four o'clock in the morning, with some very slight pains,
which scarcely disturbed her, but which continued till about six, when
the child was born suddenly and safely, without any assistance, and
with scarcely any increase of pain to the mother. I have known many
other such cases as these, and plenty of them can be found recorded;
but what this fortunate exemption from suffering, in such cases,
depends upon, is not known.

The nature, and the seat of the pains, is also very variable. Some
only feel a dull sort of aching, with powerful contraction, or drawing
together, while others call it _grinding_, _cutting_, and _burning_
pain. Some feel it in the back, and some at front, while others feel
it most in the groins, and others again experience it in all these
parts at once. The peculiar sharp pain which results from the extreme
dilatation of the external mouth, when the head passes, is perhaps the
most constantly felt, and the most alike in all.

The manner in which the mouth of the Womb opens, and the time required
for its dilatation, differ much in different cases. In females who have
previously borne children, as before explained, the mouth is always
considerably opened at the full term, while in a first pregnancy it is
nearly closed, even till some time after the labor actually commences.
Sometimes the dilatation takes place rapidly, and at others very
slowly; it is especially liable to be delayed if the Membranes break
too soon, because then the pressure of the bag of waters is lost, and
that is an important agent in expanding the Os Uteri. In some cases
the neck of the Womb is very hard and rigid, so that a long time
is required to make it give way. When any other part than the head
presents also, the opening of the mouth will not take place so soon,
because no other part so completely fills up the passage.

The breaking of the bag of waters will sometimes occur very early,
almost as soon as it protrudes; while at other times it will be
delayed till the whole Vagina is filled up by it, or even till it
appears externally. The quantity of the water discharged at the time of
the rupture is also variable; if the presenting part of the fœtus does
not completely block up the passage, the whole may pass away when the
rupture takes place; but if it does, as is usually the case when the
head presents, only a part flows then, and the rest comes in gushes, as
the head is raised, and when the child is born. The too early escape of
the waters, as already explained, may retard the delivery, by delaying
the expansion of the mouth of the Womb; and in this way unskilful
accoucheurs have caused lingering labors, by breaking the membranes too
soon.

It is important to recollect also, as I explained before, that a
portion of fluid sometimes exists between the amnion and chorion,
which may pass first, and induce the belief that the true waters have
escaped, when they have not. This is called the _false waters_, or
_shows_, and is not connected with the true waters at all.

The _general_ physiological phenomena of a natural delivery having thus
been explained, we have now to state its duration, and then proceed to
its conduct or management.


DURATION OF NATURAL LABOR.

The duration of natural labor is not by any means constantly the same,
nor can it be predicted with anything like certainty in any case;
but still by keeping careful records, and by duly observing a vast
number of cases, a tolerable approximation can be made. There are
various circumstances that tend to lengthen the duration of labor, some
general, and others belonging to the individual. The mode of life and
early habits of the female, the climate in which she lives, and the
manner in which she has conducted herself during gestation, all have
an important influence. As a general rule, the period becomes longer
in proportion to the civilization of the community in which she lives.
The first labor is generally more tedious than the succeeding ones,
owing to the slower dilatation of the parts. It is also thought by
some, that the labor is longer in proportion to the age of the female,
particularly with the first child; but this opinion is not well founded.

The average duration of labor in our country, is _from eight to twelve
hours_. In some parts it is longer than this, and in others again it is
much shorter. I have good reason also to think, that it is longer in
cities than in the country.

An experienced practitioner can sometimes predict with tolerable
certainty, when called to a labor, how long it will be before it is
over; but this is seldom the case, and most frequently his success is
owing more to chance than to judgment. If the mouth of the womb be well
dilated, the contractions powerful, and the patient vigorous, with the
presentation natural, he is of course justified in predicting a speedy
delivery; or the reverse, if these favorable conditions do not exist.
Many unforeseen conditions may exist, however, and many accidents
arise, that may falsify an apparently safe conclusion. No judicious
practitioner, except in a few rare cases, will hazard his reputation by
fixing any _time_, and no well informed patient would _ask_ him to do
so, because she would know that it was out of his power.




CHAPTER XVII.

THE CONDUCT OR MANAGEMENT OF A NATURAL LABOR.


PRELIMINARY REQUISITES.

In most cases of natural labor there is not much assistance needed.
The assistant should, however, possess a certain _tact_, or _manner_,
calculated to make a favorable impression on the patient. This is
especially needed _when a man officiates_. It must be recollected,
that the situation of the female at such times is a very peculiar one,
and that the presence of one of the other sex, however necessary, must
be more or less objectionable to her. He should, therefore, carefully
exhibit in his behavior the most refined delicacy, combined with a
warm sympathy and kind consideration; thus soothing her scruples and
enlisting her gratitude. He must also appear perfectly self-possessed
under all circumstances, and then she will have full confidence in
his skill and judgment. It may seem scarcely necessary to state
these things, but I have often known men officiate without such
qualifications, and also be perfectly unaware of their deficiencies.
Such accoucheurs never officiate well; they may be skillful and
attentive, but yet unsuccessful, and unappreciated. They are only
_tolerated_, but not respected, and are never fully confided in.

When requested to see a woman supposed to be in labor, it is always
advisable to be prompt in paying the visit, because delivery sometimes
comes on suddenly and unexpectedly, and both mother and child may be
in great danger if no one is near to assist.

Some time before the event is expected, it is advisable to provide
certain articles, which will or may be needed at the time, and which
should not have to be looked for at the last moment. A pair of sharp
scissors, with a piece of strong thread or cord, are indispensable, and
a female catheter may be needed. A quill with the feather part on, may
also be useful; and some pure lard or sweet oil is frequently called
for. The professional accoucheur will also find it a good precaution
to have his stethoscope in his pocket, and a lancet, if he ever relies
upon bleeding in any contingency. A small box of extract of Belladonna
also, may often be of great and immediate service.


PRELIMINARY PROCEEDINGS.

The first thing required when visiting the patient, is of course
to ascertain positively whether she be pregnant, and whether labor
is really commenced, and if so how far it has progressed. This
necessitates an examination, the proposal and making of which require
the most delicate tact, particularly if it be with a comparative
stranger, or in a first labor. No allusion to it should be made to the
patient herself by the assistant; he should converse with _her_ about
indifferent matters, or merely upon her health, and state his wishes to
the _nurse_ or female friend, and then retire. This gives them time to
inform her of what is required, and to make the necessary preparation.
On entering the room again, he should not proceed abruptly, but resume
the conversation, and make some of the necessary arrangements while
carrying it on. He should seat himself by the side of the bed, with
his right hand next her, and his face opposite hers. Then passing
his hand under the bed clothes, after having lubricated it with lard
or oil, he can proceed with the examination as if it were a simple
ordinary proceeding. By exhibiting no hurry, and appearing to think it
nothing unusual or in any way strange, the female herself will cease to
think it so, and will not be flurried or shocked.

The hand must be passed under the female's right thigh, her knees being
elevated. She should, of course, lie on her back, and as near to the
edge of the bed as convenient. Not the slightest exposure is necessary,
nor allowable under ordinary circumstances.

The fore-finger being introduced, _ballotment_ may be practised, to
ascertain if pregnancy really exists; and if the evidence from this
source is not sufficient, auscultation must be resorted to. After
being satisfied on this point, the mouth of the womb must be carefully
examined, and its degree of dilatation noticed. If the female has
pains, their character and frequency must also be noticed, and the
effects they produce on the parts. It will generally be possible by
these means, to discover how far the labor has progressed, and even
to form an opinion how long it is likely to last. The general form of
the parts and their size, should also be noticed; particularly of the
pelvis, so that any deformity or deficiency may be discovered. And
lastly, the _presentation_ should be ascertained, if possible, so that
it may be known in time whether nature will be sufficient herself or
will require helping. The _position_ need not be cared for at present,
because it is of little consequence when the presentation is favorable.

The time required to make the examination need not be long, and should
always be as short as possible.

While conversing with the patient, much useful information may be
gained. The general state of her health, the nature of her pains, and
the time they first commenced, should all be known; and if she has
had children before, it will be highly useful to know what kind of a
labor she had; whether it was long or short, easy or difficult, and
particularly if attended with any accident likely to occur again.

It need scarcely be remarked that great caution is needed in these
cases, many eminent men having been deceived as to the patient's
condition, as already stated in our chapter on the signs of pregnancy.
And many times the doctor has been summoned under the supposition that
labor had begun, while it was yet far off. The pains may be false ones,
such as frequently occur towards the end of pregnancy, and may all
pass away. These false pains, however, can usually be distinguished,
being continuous and irregular, while the true ones intermit with
periods of almost perfect ease, and are tolerably regular. The false
pains are also felt in various parts, while the true ones are chiefly
fixed in the uterus and vagina. Sometimes, however, the difficulty
in distinguishing them is very great, and the accoucheur has often
waited for several hours and even days; the labor meanwhile making
no progress; and eventually all has passed off, and the patient has
risen again from her bed. I know one case, where a gentleman attended
nearly _three days_, at the end of which time the patient _rose and
walked down stairs_. She was not put to bed till _six weeks after_.
I can scarcely think, however, that these mistakes can happen very
frequently, if the examination be properly conducted.


PREPARATIONS FOR THE DELIVERY.

If it appears from the examination that labor has really commenced, or
is about to do so, everything should be at once prepared. All useless
persons should leave the room, and also those who would be likely to
alarm or grieve the patient by uttering cries, or exhibiting fear; but
no objection should be made to any one being present whom she wishes
to see, unless they cannot be depended upon. Thus some females always
wish to have their husbands with them, but others do not, though they
are averse to saying so. In these cases the accoucheur, if he be
an attentive observer, will soon see what is really desired by his
patient, and will manage matters accordingly.

The dress of the female should be perfectly loose, consisting of a
wrapper or night-gown, but sufficiently complete and warm to allow
of her getting up to walk in the chamber, if she desires it, as some
do. No corsets, garters, or other tight bandages, however, should be
allowed.

The bed should be prepared by placing the mattress on the top, or by
removing all from it; and then placing a thick layer of blankets or
quilts, with a folded sheet over them. This is to provide a firm level
surface, in which the body will not sink, and also to prevent the
fluids soaking through. It is an excellent plan, if the material can
be obtained, to place a thin oil-skin or India-rubber cloth under the
folded sheets, as this keeps all perfectly dry underneath. Some persons
also place another folded sheet, or a cushion, under the pelvis, to
keep it elevated; but this is not necessary, unless the bed sinks in
very much. It is also advisable to leave a foot-board or other firm
body, against which the female can press her feet when bearing down;
and a long towel folded lengthways should be passed under the back, so
that it can be raised up by a person lifting at each end. This will
often be found a better mode of _pressing the back_, which nearly all
patients call for, than by merely forcing the hand against it, which is
both tiresome and insufficient. Another towel may also be firmly fixed
to the bottom of the bed, so that she can _pull_ by it, at the same
time that she pushes with her feet.

Some persons are confined on a cot, but this is not a very good
arrangement, because it sinks in too much in the middle, and is not
sufficiently large and firm. It is advantageous in one respect,
however, as it can be placed by the side of the bed, into which the
patient can be lifted when all is over, and be comparatively dry and
comfortable. This is the most frequent plan in France. If the bed be
properly arranged however, the under sheet can be withdrawn, and clean
warm napkins then passed under the body, which will be equally as good.
The covering should consist of a sheet, with blanket or coverlid,
according to temperature, and should, of course, never be removed,
except under peculiar circumstances.

The chamber itself should be as quiet as possible, _well ventilated_,
and not too warm. Nothing distresses the patient more than a close, hot
atmosphere.

The accoucheur need not, of course, be present while these arrangements
are being made; and when he retires he should suggest to the nurse that
the female may attend to the bowels and bladder during his absence.
This precaution may both facilitate the labor, and prevent much future
annoyance. It would even be advisable to administer an injection if
necessary, of thin starch and a little castor oil, rather than leave
the bowels unmoved.

In regard to nourishment, nothing is needed or proper in the shape of
solid food; because all the energies of the system are concentrated
in the uterus, and as digestion cannot therefore go on, it would only
be an evil. If the labor is much protracted however, some broth or
soup may be taken, or a little milk. As a general rule, no spirituous
liquors or stimulating drinks of any kind should be taken; because they
impart no real strength, and may produce inflammation, or congestion on
the brain. Some females always prefer tea to drink, others lemonade,
toast water, gruel, or barley water, and others again simple cold
water, which is perhaps the best of all. In cases of great exhaustion
it is sometimes advisable, and even necessary, to give a little wine,
or brandy and water, but it should always be cautiously administered.

In some parts it is customary for the female to lie on her side during
delivery, with a pillow between the knees; some even choose this mode,
and others will desire to stand, or place themselves on their knees.
The most frequent position however, and certainly the most convenient,
is on the back, though it may often be changed with advantage under
peculiar circumstances. In the early stages of labor she can lie, or
move about, as she chooses, or even rise if more agreeable.


ATTENDANCE AFTER THE PREPARATIONS ARE MADE, AND DURING THE DELIVERY.

When everything is arranged the assistant should take his seat on the
right hand of his patient and repeat the examination. If the head
presents, he need not concern himself much further at present, but
if it be any other part, he should prepare at once to change it, or
assist, as the case may be. At this second examination the parties
present, and the female herself are usually anxious to know if the
child is _coming right_, and how long the labor is likely to last. The
answer to these inquiries should be guarded and circumspect in regard
to the duration, because of its uncertainty, but if the presentation
is right, it is well to say so at once, because this gives great
comfort and encouragement. If it be unfortunately wrong, it is best not
to say so abruptly, but remark that it is rather obscure, or cannot
yet be fully distinguished, and so keep up the spirits of the female
while you await the proper time, or make the necessary arrangements,
to interfere; and then tell her there is a little difficulty which
requires to be righted, but which will not be serious, nor cause much
delay.

If the labor steadily progresses it is necessary to remain with the
female and attend to it; but if it be delayed, and everything remains
natural, she may be left for a time with advantage. When the second
stage is fairly commenced however, and especially after the membranes
are broken, the attention should be unremitting. The state of the parts
should be ascertained frequently, so that the actual progress may be
known, and any necessary assistance rendered. The state of the bladder
especially should be observed, and if it be full and the female unable
to urinate, the catheter should be passed. Neglect of this precaution
may lead to serious accidents. While making the examinations, the hand
should be introduced with great care, so as not to bruise or lacerate
the parts, and it should not remain longer than absolutely necessary.

Many females exhaust themselves unnecessarily by bearing down, and
straining, with great force, from the very commencement of labor,
under the mistaken idea that it is necessary to do so, or will assist.
They should be told not to do so however, till after the membranes are
broken, and not even then unless the neck of the womb begins to dilate.
They should also be told not to make any effort except _during a pain_,
as it will not assist at any other time.

No attempt should be made, under ordinary circumstances, to rupture the
membranes, or dilate the mouth of the womb, even though nature may be
slow in doing so. Patience must be practised, both by the female and by
her assistant, and sometimes it is severely tried.

When the waters have escaped, and the orifice is opened, an examination
must be made, to discover whether the cord has descended, or either of
the arms, as is sometimes the case, and if so, they must be returned if
possible.

As the head descends to the bottom of the pelvis it compresses the
rectum, and produces a feeling as if the bowels must be moved, or even
causes them to be so. This is apt to distress the female, and make her
wish to rise, which cannot be permitted. If anything of the kind occurs
no notice should be taken of it, or she may even be assured she is
mistaken, while a clean napkin may be interposed. This, as Dr. Chailly
observes, will soothe her delicacy. Such an accident is very apt to
occur towards the end of the labor.

When the head has rotated, and presents at the external opening, or
vulva, and begins to distend it, the greatest care is required. This
is a critical period, during which the accoucheur can render more real
assistance than at almost any other. There is danger at this time, as
formerly explained, of the head passing through too quickly, before
the parts are sufficiently relaxed, and so causing them to rupture.
This is particularly the case with the perineum, against which the head
presses with great force. It is necessary therefore to _support the
perineum_, as it is termed, to prevent this accident. This is done by
passing the right arm under the patient's right thigh, and placing the
palm of the hand flat against the perineum, with the thumb encircling
one side of the vulva, and the forefinger the other. The hand is then
gently, but firmly, pressed against the part during every pain, so as
to prevent the head passing too quickly, and also to _elevate it_, and
thus relieve the perineum of part of the strain, and throw the occiput
under the pubes.

Some practitioners also pass the left hand over the thigh, at the same
time, and grasp the back of the head with it, thus holding the head as
it were between the two hands, so as to direct it at pleasure.

The manner of doing this is represented in plate XXXIX.


  PLATE XXXIX.

  The manner of supporting the perineum, during the passage of the head.

  The right hand is placed underneath, so as to push the head gently
  back, when it presses on the perineum too forcibly, before it is
  dilated; and also to elevate it towards the pubes.

  The left hand is seen above, grasping the top of the head, to assist.
  This may be done or not, according to the necessities of the case, or
  the custom of the assistant.

[Illustration: Plate XXXIX.

The manner of supporting the perineum, during the passage of the
head.]

It is also necessary to request the female at this time to moderate her
efforts, and not bear down too strongly. If however she be too excited,
and eager to do so, more care must be used, and the head pressed back
still more forcibly, till the parts are fully relaxed. For want of
these precautions there is often serious lacerations of the perineum
and vulva, particularly in first labors, and when the parts are
unusually rigid. If proper care be bestowed however, these accidents
ought to occur but seldom, even in the worst cases, and nothing can
be more hurtful to the reputation of an accoucheur than for them to
happen. Sometimes it is necessary to support the perineum for hours,
and to bestow constant attention the whole time. It is often useful
to keep applying a little simple ointment, or lard, in the intervals
of the pains, mixed with the extract of Belladonna, which will soften
and relax the parts. Dr. Lee also advises the application of a sponge,
dipped in warm water, and which would probably do much good in many
cases.

It will of course be understood that the pressure only needs to be
made _during the pains_; when the head draws back the ointment or warm
sponge may be applied. The knees of the female should be held up by
some one, if she bears down too much, so as to prevent her from doing
so too powerfully.

When it is felt that the parts are fully relaxed, and sufficiently
distended, the head is left at liberty, during a strong pain, and it
immediately passes the outer ring, or is born.

It should then be held up, towards the pubes, and the mucus should be
cleaned from the mouth with one of the fingers, so that the child may
breathe. A careful examination should also be made round the neck,
to see if the umbilical cord is around it. If it be so, but is not
tight, it may be left alone, or pulled a little over one shoulder, or
even passed clean over the head, if it can be _easily_ drawn out long
enough. When it is very tight, and cannot be eased, it must be cut
through, or it will strangle the child.

In most cases the shoulders follow immediately after the head, the
uterus resting only a few moments; but if they do not the head may
be _slightly_ drawn upon, or the fore-finger of the right hand may
be linked under the arm, and a _little_ force employed, though very
carefully. It is better however to wait even two or three minutes, and
only resort to these means when there is evidently a partial suspension
of the natural efforts. Sometimes also the contractions may be brought
on again by merely pressing the hand over the fundus of the uterus, and
this should therefore be tried first. In all cases it being better to
let the uterus expel the child than to bring it away by manual force.

During the passage of the shoulders the perineum needs as much care as
during the passage of the head, and must be supported in the same way.
Indeed some authors are of opinion that most cases of laceration are
caused by the shoulders.

After the shoulders are expelled the limbs and body speedily follow.
The child should be received in the hands of the accoucheur, and laid
on its side, at a little distance from the vulva, so that it may not
be suffocated by the discharged fluids. He should then take a strong
ligature and pass it _twice_ round the umbilical cord, about two inches
from the navel, and also at about four inches, and then cut the cord
through, between the two bands, with a pair of sharp scissors. The
child may then be handed to the nurse.

The tying of the cord is by some deemed unnecessary, and in most cases
probably is so, but as children have been known to bleed to death,
when it was not done, it should never be neglected. Some practitioners
only tie it once, leaving that part open which is still attached to
the placenta, and they suppose this is advantageous, inasmuch as it
partly empties the placenta of its blood, and so helps to detach it.
There is little or no fear, as some suppose, that this bleeding can be
extensive enough to hurt the female, or second child if there be one,
and even if it were likely to be so it could soon be stopped; it has
the inconvenience however of soiling the bed more, and this is probably
one great reason why the second ligature is applied, which certainly is
not _necessary_.

In my directions I have said that the cord may be tied about two inches
from the abdomen, and this will be sufficient if the child breathes;
but if not it should be left about four inches long, so as to give room
to cut it again, which is occasionally needed, as will be seen further
on. The knot should be drawn very tight, and great care must be taken
never to tie it so near as to pinch the skin of the abdomen, which
passes a little distance up it. A small portion of the intestine will
enter the cord sometimes, and swell it out for an inch or more; this
must be pressed back with the thumb and finger, and carefully avoided
by the ligature. Some practitioners cut the cord first and tie it
after, but I think the other plan is decidedly the safest and the best.

After this is accomplished the accoucheur should place his hand again
over the fundus of the uterus, to discover whether it contracts, and
also to judge whether there be another fœtus. If the womb is felt
drawn up into _a hard round ball_, in the middle of the abdomen, all is
right, and no apprehension need be felt; but if it remains unaltered in
size, and is soft, _flooding_ is to be feared, and the hand should be
firmly pressed, or kneaded, over the fundus, to bring on contraction.

If there be another fœtus, the womb will remain much the same as before
labor, and the child may also be felt. It is better however to make
an examination internally, and then, in most cases, the membranes and
presenting part of the second fœtus will be found at the upper strait.
If there be any doubt after this it is even better to carry the hand
a little way into the womb, than to remain in ignorance on such an
important point. The delivery of the second fœtus usually follows close
upon the first, though sometimes there will be a delay of some hours,
or even days. And in general there is little or no difficulty with the
second, owing to the parts having been already prepared; but the longer
it is delayed the less easy it becomes.

Immediately the birth is fully effected the female feels, as most of
them express it, _in heaven_; there is an almost instantaneous change,
from the most agonizing pain to a state of perfect ease. She ceases
her cries, and falls into a quiet and pleasing languor, strikingly at
variance with the state of intense excitement she was in but a few
moments before. This repose however, does not last long; the Placenta
yet remains, and a new effort is required to expel that.


DELIVERY OF THE AFTER BIRTH, OR PLACENTA AND MEMBRANES.

Unlike the Fœtus the Placenta is fast to the walls of the Womb, and can
only become separated from them by the contraction of their substance,
which usually commences soon after the birth of the child, and is
indicated by new pains, and a slight discharge of blood. In about a
quarter of an hour, or twenty minutes, the accoucheur should enquire
of the patient whether she has felt any of these pains, and he should
also examine whether the Placenta has reached the mouth of the Womb, or
Vagina, so that he may remove it. If the pains have not yet come on,
and the Placenta is not in the passage, he should press one hand on
the fundus of the Womb, to promote its contraction still further, and
then gently draw upon the cord with the other, holding it as high up as
possible, either by a piece of linen around it, or by looping it around
the finger. It should be pulled very gently, but steadily, downwards
and backwards. If it be snatched, or drawn too hard, it may break,
and cause great trouble; or it may _pull down the Womb_, and either
invert it or bring on falling of the Womb afterwards. The hand placed
over the fundus can detect this accident, and if the uterus be felt to
_sink down_ the cord must not be drawn upon any longer. Pulling away
the Placenta too soon, and with rudeness, has often led to deplorable
accidents. In nearly every case it will gradually separate itself, and
be delivered in about half an hour, and should only be assisted by
_slight_ drawing on the cord, and by pressing the fundus.

When the Placenta is completely detached there is seldom any difficulty
in its passing the neck of the Womb, and down the Vagina, but it
usually requires to be drawn through the external opening by the hand.
In doing this the membranes may be twisted round the cord, so as to
wind them altogether, and strengthen the cord.

In case the separation does not take place we must wait, and continue
the slight strain on the cord and the friction over the fundus. It is
not reckoned safe however, by most authors, to wait more than an hour;
and if there is no sign of its coming by that time artificial delivery
is resorted to. This is accomplished by carrying the hand carefully
up into the Womb, and separating the Placenta from its walls with the
fingers, and then bringing it down at once.

When the afterbirth has passed the Vulva, a careful examination should
be made of it, to see that no part is left behind; and for still
greater security it is advisable to explore the Vagina thoroughly, so
that any detached portion may be removed. The membranes are very apt to
become broken, and fragments of them left, which though ever so small
may cause trouble. The finger should also be passed into the mouth of
the Womb, so as to clear it; for sometimes a large clot of blood, or a
piece of the membranes, will remain and keep it open, and thus cause
severe flooding.

It is generally considered, by those who have bestowed attention on the
subject, that assistance should always be rendered, if the afterbirth
does not come very soon. There is danger, if it be left too long, of
the mouth of the Womb contracting and retaining it; in which case it
becomes absolutely necessary to abstract it, but exceedingly difficult,
and even dangerous, to do so. Dr. Lee says it should never be left
more than _an hour_ at most, and that it is best never to delay
removing it even so long as that.

When left purposely, for observation, it is found to be expelled
spontaneously, and soon, only in a few cases; usually it remains
several hours, and most frequently it requires to be removed by hand.
No doubt it is _natural_ for it to be expelled unaided, but it must be
borne in mind that our females are usually too weak, and deficient in
energy, to perform any unusual natural function without assistance. The
accoucheur must use great caution, so as neither to intrude his help
when not required, nor yet to refuse it when really needed; and above
all he must not substitute _violence_ for _skill_.

When the afterbirth is brought away, a bandage should be passed round
the body of the female, made of soft linen, twelve or fourteen inches
wide. It should be drawn moderately tight, and fastened securely. If it
pass round twice it will be all the better, and it should be drawn down
as near the pubes as possible. I know many ladies who prefer the India
Rubber bands, recently invented, as they press more equally and firmly,
and are put on with less trouble, being all in one piece and drawn over
the feet and limbs.

Some accoucheurs put on the wrapper immediately the child is born,
before the afterbirth passes away; but I think this is not the best
plan. When properly adjusted, the supporting band gives great comfort
to the female, and is very useful.

Some ladies provide a curious kind of _corset_ to put on, invented for
the purpose, which however, as a celebrated author recently remarked,
"Are usually stiff and unyielding, like the prejudices of their
patrons, and often prove injurious." None of them are equal to the
simple contrivances above-mentioned.


ATTENTIONS TO THE FEMALE AFTER THE DELIVERY OF THE AFTERBIRTH.

When the afterbirth is removed the patient should be left to repose
herself for about a quarter of an hour, during which time most of the
blood escapes, and then she must be made as comfortable as possible.
In France, and with many persons here, it is customary to cleanse the
patient with a sponge dipped in warm water, pass a clean warm sheet
under her, and then put on clean linen, after which she is lifted into
the clean bed, previously well warmed; the accoucheur himself carrying
her there. Most frequently however, the sponging is dispensed with
till some time after, and also the changing of beds--the under sheet
merely being withdrawn, and a warm dry one passed in its place, while
the female's limbs are gently wiped. In either case the female should
be disturbed as little as possible, particularly if there be danger
of flooding, and she should be carefully guarded from cold. When the
soiled and wet clothes are removed, as completely as possible, warm
napkins should be placed under the Pelvis and between the limbs, to
soak up the discharge, and they should be carefully changed as often
as needed, without uncovering the patient. If she be disposed to sleep
however, and is much exhausted, these attentions need not be pressed
too much till she is recovered a little.

Many persons here have a dread of using the sponge immediately, and
of being carried to another bed; but there is no danger from either
practice, in ordinary cases, when carefully performed; and it is so
productive of _comfort_, that I never knew one but what was pleased
with and benefitted by it, and desirous of its being done in their
subsequent labors.

Some females will even rise and take a _cold bath_, or be wrapped
in a _wet sheet_, not only without evil effect but with _positive
advantage_. I would not advise any one to do this however,
_particularly if they are the least timid at it_, _or doubtful of its
propriety_. Without the mental stimulus of _faith_ and _hope_ it may be
hazardous. It shows however, that many of the popular notions, as to
the requirements and susceptibilities of females, in this state, are
entirely unfounded.

The patient may either experience great comfort after being thus
attended to, or she may complain very much. Some will even be attacked
with a kind of chill. Their teeth will chatter, and their hands and
feet grow quite cold. This however usually passes off, and she falls
asleep. The accoucheur ought to remain for an hour or two, even though
she sleeps soundly, and appears quite well, because she may become
suddenly worse, or flooding may set in with such violence as to
endanger life in a few minutes, when unchecked.

If the patient desires any nourishment she may take a little simple
soup, or gruel, but nothing stimulating, unless a little wine be needed
from extreme exhaustion.


ATTENTIONS TO THE CHILD.

_Inspection when born_.--As soon as the child is born its mouth and
nose should be cleared from mucus, if that has not been done already;
and if it has not breathed, means should be resorted to immediately
to make it do so. Sometimes the whole head is covered with a thin
membrane, called the _caul_, or _veil_, which is most probably only a
portion of the Amnion, and which may cause suffocation. I remember a
case of this kind in my own practice, in which the caul was unnoticed
at first, and the child came near dying from it. Nothing could be seen,
and as it bent before the finger, when pressed into the mouth, it was
totally unobserved. The nurse however, called out that the child did
not breathe, and a close examination as to the cause soon revealed why.
On passing the finger under the edge of the membrane, which was round
the neck, it came off like a cap, and the child cried immediately.

_Washing the child._--The cleansing of the child may usually be safely
committed to the nurse, or other female attendants, though some of
them have very absurd and injurious practices in this respect. Thus
I have known them rub the whole body over with _whiskey_, or _raw
spirits_, before washing it, which must cause great coldness from its
evaporation, and also great irritation. The only thing required is
_perfect cleanliness_, and this should be effected in the _quickest_
and _simplest_ manner. Some very mild soap, and moderately warm water,
is all that is really needed, though a little sweet oil, or fresh lard,
or butter, rubbed on first, appears to facilitate the operation. The
drying should be done as quickly as possible, after all the mucus is
washed off, and with great care; the napkin being as soft as it can
be, and never _rubbed_ hard, for it takes but little force to remove
the skin. Many persons take great trouble, and are a long time over
this infantile wash without succeeding well with it. They are deceived
by the tough mucus slipping under the hand, but still clinging to
the body, where they leave it even after using the napkin; it then
dries on and forms a hard skin, very difficult to remove, and very
irritating. This can be avoided with care, and by using the oil first,
which appears to soften the mucus. Some persons use _flour_, or _Indian
meal_, and others _starch_, but none of these are so good as the simple
means we have described.

_Dressing the child._--After the washing and drying is completed the
child must be _dressed_, and this is a process in which comfort and
utility is frequently sacrificed to mere fashion and prejudice, as
it is in adults. The article next the skin should be of soft line
linen, which may be followed by others of warmer material, according
to the temperature. They should all be perfectly loose in their make,
and quite soft to the feel. As far as possible they should all be
fastened with _strings_, rather than _pins_. These metallic points
are troublesome to fix, and often injure the child, in spite of every
precaution. They are also apt to be referred to as the cause of the
child crying, and thus prevents other causes being sought for, which
frequently exist.

Some people put a thick flannel cap on the head, over a linen one, but
others leave this part altogether uncovered, which I think is the best
plan. At most there should only be the linen covering; the head being
better rather cool than otherwise.

The dressing of the cord is the next duty, and this is done by taking
several pieces of soft linen, oiled a little, and cutting a small round
hole in the middle of each, through which the cord is passed. The
linen then lies flat on the abdomen of the child, and the cord on the
top of that, the holes being just large enough for it to pass easily
through. Five or six pieces are usually put on, but very frequently
only one is used, and is found quite sufficient. It should be very
fine, and soft. When this is done another layer is laid over the cord,
and then a bandage of soft linen, about four or five inches wide, is
passed two or three times over it, and round the body. This completes
the dressing, and the child may now be wrapped up warmly and laid down
to sleep--remembering, as Dr. Chailly remarks, that if it be laid on a
chair, or sofa, it may be accidentally sat upon and killed, an accident
which has happened.


ACCIDENTS WHICH MAY HAPPEN.

Before these dressings are needed however, there are frequently
other things of more importance to be attended to. If the labor has
been long, or the presentation unfavorable, the child may be born
_apoplectic_, from the pressure it has received. The face will be
puffed up, and of a blue color; the body will be swollen, and the limbs
without motion, while the pulsation will scarcely be felt, either over
the child's heart or in the cord. It will feel warm, and the limbs will
be quite flexible, but still there will be no signs of life. In this
case it should be exposed naked to the cool air, and even blown upon;
and if that does not resuscitate it the cord may be cut through below
the ligature, so as to let out two or three tea-spoonfuls of blood.
After this it generally revives, and begins to move, while its face
assumes a natural color, and the swelling goes down. The mouth and
throat should also be carefully cleaned with a quill feather, of all
mucus.

A more frequent accident is _Asphyxia_, or want of breathing, in which
case the surface of the body is cold and pale, and no breath whatever
is drawn, though the heart beats quite naturally. Very weak children,
or those born before their time, are most likely to become asphyxiated,
or those delivered by instruments. The first thing to be done is to
carry the child to the open window, if it be not exceedingly cold, and
expose its head and chest to the air, while the rest of the body is
wrapped up warm. This will often make it gasp, but if it does not a
little cold water may be dashed on its face and chest, and the throat
may be tickled with a feather. The breech may also be smartly slapped,
and the chest well rubbed with the cold hand. When it begins to breathe
a little it may be put into a warm bath up to the middle, and a warm
injection may be given to it. In most cases these means will speedily
bring it round, but if they do not the attendant should place his mouth
close over that of the child and breathe into it, so as to fill the
lungs, and then press down the chest to empty them again, repeating
the process several times. This may be called artificial breathing,
and if it succeed once only there is a probability of its effecting
the desired object. The breath however, must not be blown in too hard,
or it may injure the child's lungs, nor too rapidly. Sometimes a tube
is used, which is passed down into the throat; but it is troublesome,
and not much better than the mouth, if any at all. These efforts may
be repeated twenty or thirty times if necessary, or even more. In some
cases it is requisite to continue using some, or all of these means,
for an hour or two without intermission, before the child begins to
breathe freely. I knew an instance even, where the nurse continued to
do so for _five hours_, and at last fully recovered the child, though
all present, including the doctor, had given it up. She said she did
not despair while it continued _warm_, though it was doubtful whether
the heart beat or not. This may show that the attempt should not be
abandoned too soon.

In cases of asphyxia no blood should be lost at all, but on the
contrary the cord should be carefully examined to see if it is tied
fast; the bleeding from it frequently aggravating the evil.

_Congenital weakness._--Some children are born extremely weak, and
remain constantly debilitated and cold. This is very apt to be the
case when they are born before the full term, or when the mother is
diseased. They should be carefully wrapped in cotton, or very soft
flannel, and kept warm by bottles of warm water. Many instances are on
record of these weak children becoming afterwards extremely robust, so
that they need not be regarded with unmixed apprehension, nor neglected
from a supposition that they must die.

_The child may be deformed._--The accoucheur should also carefully
examine the child, to see if it be deformed in any way, or has met with
any accident, because in some of these cases assistance is required
immediately, and may be rendered at once.

_The child's capability of endurance._--The capability of the new-born
infant to endure extremes of cold is almost as great as that of its
mother, and sometimes even it is benefitted by them. With many persons
it is customary to plunge it in cold water, immediately when born; and
in Russia, we are told, it is even _rolled in the snow_. In some cases
these extremes may be beneficial, but in others I have no doubt they
prove fatal. A medium course is best, in most instances, leaving the
extreme to be resorted to when we wish a sudden stimulus.

When all these matters are carefully attended to, and both mother and
child have remained for an hour or two without any unpleasant symptom,
they may be left to the care of the ordinary attendants, giving them
strict orders to send for proper assistance _immediately_, if anything
unusual transpires.


SUBSEQUENT ATTENTIONS TO MOTHER AND CHILD.

_The Bladder._--One of the most important points to attend to is the
urine. A few hours after the delivery is fully effected, unless the
female is reposing, she should be asked whether she has any desire to
urinate; and, if she has, the convenience should be at once afforded
to do so. There is always more or less danger of retention of urine,
from the pressure that has been exerted on the bladder; and if it be
allowed to continue too long its removal becomes exceedingly difficult.
If on making the attempt the urine does not flow, the catheter must be
used, and the sooner the better. The pain arising from retention of the
urine has often been supposed to arise from inflammation of the womb,
or bowels--neither patient nor physician knowing its real source, till
the passage by the catheter gave relief. There have even been instances
of females dying, merely from an overcharged bladder, while their
attendants were industriously treating them for uterine inflammation.
This accident therefore, should always be suspected, and a very little
attention will prevent any mistake in regard to it. When allowed to
become too full the swollen bladder may be felt, just above the pubes,
hard and tender, so that the least pressure upon it causes great pain.
If not relieved it will at last burst.

_The Bowels._--If the bowels are not opened naturally, it will be well,
the following day, to administer an injection of thin starch and water,
or to prescribe a small dose of castor oil, or a seidlitz powder. This
should also be repeated for two or three days, till the natural power
is restored.

_The Food._--But little solid food should be taken, and nothing
stimulating. Gruel, milk, toast and water, Indian meal, light puddings,
or broth, should be the chief articles for some time. Roast apples are
also very good, being pleasant and relaxing. For refreshing drinks, if
there be any fever, lemonade or tamarind tea may be taken.

_The After Pains._--After the expulsion of the after-birth most females
experience, more or less, severe pains, almost like those of labor,
arising apparently from the further contraction of the uterine walls
to expel the coagulated blood. These pains are seldom or never felt in
first labors, but afterwards they are often most acute. I have known
many patients suffer _much more_ from them than they did during labor.
They sometimes last only a few hours, or a day, and sometimes even
extend to six or eight days. Nothing that we know of can prevent them,
though many means are known of mitigating their severity. If there
be no tendency to flooding, a large poultice may be placed over the
abdomen, or it may be fomented, or covered with cloths wrung out in hot
water. An injection may also be used, either in the Vagina or Rectum,
consisting of warm thin starch, with about twenty drops of laudanum;
or either of the following recipes may be used internally:--_Pills of
Gum Camphor_, two, about the size of ordinary pills, to be repeated,
if necessary, in an hour.--Or, _Syrup of Poppies_, two drachms;
_Mucilage of Gum Arabic_, two ounces; and _Solution of Sulphate of
Morphia_, ten drops; to be made into a mixture, _one-half_ of which may
be taken at first, and the remainder in _two hours_, if the patient is
not relieved. This seldom fails.--It is necessary to bear in mind that
the pains arising from _inflammation_ have been mistaken for ordinary
after-pains, and serious consequences have resulted from the error. The
after-pains however, are concentrated, and _intermittent_, while the
sensations from inflammation are more diffused and constant, and are
also usually attended by fever.

_The Lochial Discharge._--From the time of delivery until the uterus
has returned to its ordinary condition, there is poured from it a
discharge, at first like blood, and afterwards thin and light colored,
called the _Lochia_. The duration of this discharge varies from one
week to a month, and its quantity from one ounce to six or eight
ounces, daily. It gradually diminishes however, and frequently stops
for a few days altogether. In women who do not nurse it is both more
abundant, and lasts longer, than in those who do. The bloody color
usually disappears after the first or second day, though sometimes it
will show itself again, even when the discharge has nearly ceased,
particularly if the female exert herself too soon.

It appears that this discharge is essential to health, and great
attention should therefore be bestowed on the patient, if it be too
small, or cease too soon, or too suddenly. In most cases it ceases
naturally during the _milk fever_, and of course its disappearance then
need not excite alarm. Sometimes also, it does not attain its full
quantity till some days after its commencement. If however, it remains
small past the _third_ day, or does not appear when the milk fever
is over, means should be taken for increasing it. The best means for
this purpose are _warm poultices_ and _fomentations_ over the abdomen,
and injections in the rectum of simple warm water. Some practitioners
advise _two drachms of powdered Camphor_ to be sprinkled on each
poultice, and probably it is an excellent addition. Occasionally the
lochia is very offensive, and in that case a simple cleansing injection
may be frequently used of thin starch, or Chammomile tea.

During the whole period of the Lochia in fact, even in ordinary
cases, the female will be all the more comfortable, and better, for
an occasional injection, and frequent washing. This is very much
neglected, though it never ought to be so. The only care required is
not to expose her to cold, which is quite unnecessary.

_The Milk Fever._--About the second or third day there usually
commences a peculiar temporary excitement in the system, called
the _milk fever_, which requires to be described because it may be
confounded with something more serious. It is generally ushered in by
headache, flushed face, and a hot dry skin; the pulse beats slowly, and
the breasts become hard, while the veins upon them appear very full. In
a short time however, the pulse becomes quicker, a perspiration breaks
out, and the breasts become still larger and fuller, so that the female
can scarcely bring her arms to her body. These symptoms last about a
day, or two days at most, and seldom become much aggravated.

Occasionally the milk fever is preceded by a slight chill, or by a
furred tongue, or sick stomach, but not very frequently.

The precise causes of this temporary fever are unknown, though probably
it is connected with the full establishment of the secretion of milk,
and hence its name. It is seldom very severe in those who nurse, and
frequently does not appear at all. During its continuance, and for some
time after, the female must carefully avoid exposure to cold, and keep
herself quiet; her diet should also be rather restricted, and light and
unstimulating. An occasional seidlitz powder may also be of service, or
a simple injection.

_Making the Bed._--It is not customary to disturb the female, for the
purpose of making her bed, till the milk fever is passed; or, if that
does not appear, till the tenth or twelfth day; and then it should be
done with care, and so as not to expose her unnecessarily.

_First sitting up, and Going out._--This must of course be determined
more by the condition of the patient, and the state of the weather,
than by any rules. It may be as well to remark however, no matter how
the patient may _feel_, that the _first attempt_ should always be
made with care. Very frequently she thinks herself stronger, and more
capable, than she really is, and premature or undue exertion may do
great injury. In most cases the female is allowed to rise within the
first week, and sit for a short time in an arm chair; after which she
begins to walk slowly about the room. The first going out is fixed,
_by fashion_, at one month. Many females however, are unfit to leave
the house till long after that time, and others should by no means be
confined to it _so long_. Of course these proceedings should depend,
as already remarked, upon the patient's strength and inclinations,
and upon the state of the weather, and not upon any fashionable
observances. Some females are quite able to rise, and even walk out, in
a few days, with benefit to themselves; and it exhibits as great a want
of correct feeling, or common sense, for any one to make disparaging
remarks on them for their early appearance, as it would if they were to
blame the poor invalid for keeping her bed.

The apartment should be kept constantly _well ventilated_, particularly
if the female is confined to it, and all soiled linen, or other sources
of foul air, should be removed as quickly as possible. There is reason
to believe that inattention to this, and to properly cleansing the
_person_ of the female, frequently produces _child-bed fever_.

_Attentions to the Child._--If the infant's bowels are not opened by
the end of the first day it should have a little sugar, or molasses
and water, given to it, and if this does not succeed about half a
tea-spoonful of syrup of Rhubarb may be added. This is however but
seldom needed, if it be put to the breast within a few hours, as the
first secretion of the milk possesses sufficient laxative power itself.
It should also be observed whether it has urinated, and if not it
should be placed in a warm bath immediately.

Some persons prefer to let the child wait till the milk fever is
established, before they let it nurse, but this is very improper. The
early feeding does it no good, and the purgatives it requires are
injurious. As soon as the female is sufficiently reposed, if there is
nothing special to forbid it, the child should go to the breast.

Sometimes the child will remain sleepy and dull, and not seem to
require food at all, for several days, and even die at last of
starvation, unless aroused. If this lethargy continues it should be
put in a warm bath, and afterwards well rubbed, while a little sugar
and water is poured down its throat. These attentions may be required
to be repeated for some time.

About the fourth or fifth day the portion of the cord above the knot
usually separates and falls off, if it has not already done so. If
the navel is inflamed, or suppurates, a little simple ointment may be
rubbed on, and it should be regularly and carefully washed. In some
infants it swells out very much, in which case a pad should be made of
soft linen, and laid upon it, over which the ordinary bandage may be
drawn. The complete healing of the part does not occur till about the
twelfth day, and the bandage must be carefully worn till then at least,
and is better continued a little longer, particularly if there is any
swelling, or if the child cries much, or strains.


CONCLUDING REMARKS.

From the explanations given above of an ordinary natural labor, it
will be evident that but little manual assistance is required, either
to the mother or the child, and also what really is called for is of
so simple a character as to be easily rendered. It would undoubtedly
be improper, and cruel, to leave females at such times without aid
altogether; but it is also equally improper and injurious to interfere
too much. Excepting in cases of disease and deformity, or of very
unfavorable presentations of the fœtus, Nature herself will nearly
always effect the delivery; and much better, in most cases, when left
to herself. Numerous females and infants have been _killed_, and still
more have been grievously injured for life, by rude and uncalled for
manipulations; so that it has been a question with some accoucheurs, of
great experience, whether as many would die, or seriously suffer, from
receiving _no assistance_, as do now from being improperly handled.
Without going so far, it is undoubtedly true that great mischief is
done in this way, which can only be prevented by both accoucheur and
patient bearing in mind that _Nature herself is usually competent_,
and at most only requires skillful and gentle _assistance_. Some
practitioners seem to think that labor is a mere _mechanical_ process,
like the removal of a block of stone, and hence they depend altogether
upon _force_; overlooking altogether the wonderful vital powers
inherent in the system, which operate with such certainty, and yet so
safely; and which frequently succeed of themselves when brute force is
completely foiled.

The nature of the assistance proper to be given, in any particular
stage of labor, will be evident on inspecting the structure of those
parts, of both mother and child, which are brought in connection at
the time, and by considering how their mutual relations require to
be changed and modified. If those relations are already such as are
required, and the system retains sufficient force, nothing _can_
be done with any advantage--we must _wait_, and let Nature operate
herself. Even many unfavorable conditions may be spontaneously
corrected, and it should always be a matter of consideration, when the
means of assistance are not very obvious, whether it will not be better
to rely upon the natural powers than to interfere. Great evil has
resulted from teaching females that labor _cannot_ terminate, safely,
without a great deal of assistance, which can only be rendered properly
by those who possess a vast amount of skill and experience. They are
thus led to think themselves totally dependent upon the accoucheur,
and many of them actually seem to believe that he is as necessary to
deliver the child as a dentist is to extract a bad tooth. If they were
better informed they would feel more confidence in their own natural
powers, and would not be so unnecessarily alarmed when unforeseen
difficulties occur, or when professional aid cannot be immediately
procured.

In most cases there is more danger _after the labor is over_, from
_puerperal fever_, various local inflammations and other causes, than
there was during its progress. Indeed the real danger may be said
properly to commence several days after, and the physician is really
needed then more than at the time.




SECTION VI.

PROTRACTED AND DIFFICULT LABORS.


The causes which may impede a labor, and increase its difficulties,
are numerous, and they are of several different kinds--some depending
upon the mother, and others upon the child. Some of these may be easily
removed, or modified, but others present more serious difficulty. It is
therefore necessary to enumerate and explain them separately.




CHAPTER XVIII.

THE CAUSES AND CONSEQUENCES OF PROLONGED LABOR TO BOTH MOTHER AND CHILD.


THE CONSEQUENCES OF PROLONGED LABOR.

A labor is usually called protracted or difficult, if the head
presents, when it is not completed in about _twenty-four hours_ from
its actual commencement. There are many labors however, that last much
longer, and yet terminate quite favorably, and many that are over
much sooner and yet are very difficult. Still, generally speaking,
the danger and difficulty increases as the time progresses, and it is
seldom prolonged beyond twenty-four hours without serious inconvenience.

It appears, from the statistics of the Dublin Lying-in Hospital, that
in _seventy-eight thousand deliveries_, one out of every _ninety-two_
of the mothers died, and one out of every _eighteen_ of the children
was stillborn. Of those mothers who were in labor with first children,
from _thirty to forty hours_, one in every _thirty-four_ died, and one
child in every _five_ was stillborn. Of those who were in labor from
forty to fifty hours, one died in every _thirteen_. Of those who were
in labor from fifty to sixty hours, one died in every _eleven_. And of
those who were in labor from sixty to seventy hours, one died in every
_eight_, and nearly _one-half_ of the children. It is evident therefore
that, as a general rule, the danger increases with the length of time.




CHAPTER XIX.

CAUSES CONNECTED WITH THE MOTHER WHICH MAY IMPEDE LABOR, OR MAKE IT
DIFFICULT.


INERTIA, OR WANT OF SUFFICIENTLY POWERFUL CONTRACTION IN THE WOMB.

This is most likely to occur in delicate females, and in those who are
debilitated by disease. The contractions are very feeble, and, as the
nurses say _do not tell_; the mouth of the womb dilates but slowly, and
the head descends with difficulty into the passage.

In many cases in fact the labor is so tedious, from this cause, that
the female becomes completely worn out, and finally sinks, while the
child is exposed to the greatest hazard from the delay.

It is in these cases that the patient's strength needs supporting, and
that stimulants may be useful. A little wine, or brandy and water,
will often rouse the failing energies, and bring on a series of strong
contractions that will end the labor at once.

The most usual resort however is to the drug called _Ergot_, or _Secale
Cornutum_, a fungus growth which is sometimes found on ears of rye.
This possesses the peculiar property of exciting the womb to contract,
the same as an emetic excites the stomach to vomit, and it seldom fails
in its effect; but still there are many objections to its use. It
not unfrequently causes _delirium_, great restlessness, and anxiety,
sickness, headache, and convulsions, or complete prostration, from
which the female may be long in recovering. It is also supposed by
some to be not altogether free from danger to the child. If however
no other means were known of making the womb contract, in such cases,
all the probable evils should be risked, because the labor _must_ be
completed at all hazards; but other means _are_ known, which succeed
even more certainly than ergot, and without any danger. The application
of _Galvanism_, explained in my "_Neuropathy_," and "_Practical
Facts_," will almost invariably cause the womb to contract, and
speedily bring the labor to a safe termination, without the slightest
risk or inconvenience, to either mother or child. Simple friction over
the abdomen will also succeed in many cases, and gently rubbing the
mouth of the womb with the finger in others. These simple means should
therefore always be used in preference to the ergot, but in case they
cannot be resorted to, or fail, the drug must be administered, and I
will therefore explain the manner in which this is done. When gathered
the ergot is in large irregular lumps, and should be so kept. When
wanted for use a single drachm should be finely powdered, and divided
into three parts; one of these parts to be taken first in a glass of
sugar and water, and the others at intervals of ten minutes, unless the
effects of the first are very powerful. It is often thrown from the
stomach however even in still smaller quantities, and is then given,
by some, as an injection by the rectum, in which mode it seems more
powerful, so that a smaller dose is sufficient.

Great caution should always be observed in using this powerful drug,
as it will sometimes act so energetically as to _burst the womb_; or
expel the child so suddenly as to lacerate the perineum and other
parts. The contractions produced by it are different from the natural
ones, being almost constant, without any interval, and gradually
increasing in force. They usually come on in about ten or fifteen
minutes after the last dose, and continue about an hour and a half.
Some practitioners depend almost altogether on the ergot, in every
protracted case, and even use it to bring on _premature labor_, when
that is required. Thus M. P. Dubois was once called to a dwarf, whom he
delivered with instruments, the first time, but with great difficulty
and risk. The next time she became pregnant he determined to bring on
premature labor, and accordingly he administered ergot, when she was
about _eight months_ gone. This brought on natural labor, and she was
delivered without difficulty. M. Chailly says he believes it will bring
on uterine contraction at any time, and that he has never known it to
fail. I consider however that there is always more or less risk in its
use, and I should certainly prefer any of the other means, particularly
_Galvanism_.

It is of the first importance however to be certain, before using _any
forcing means whatever_, that there is no _physical impediment_. If
the pelvis should be deformed or small, if the child's head should
be unusually large, or dropsical, or if the soft parts of the mother
should be undilated and rigid, the most serious consequences must ensue
from violent uterine contractions. In like manner if the presentation
be unfavorable, particularly if it be one of the trunk, the danger
is equally great. In every case the passage of the child must be
_physically possible_, before it is attempted to force it away. A
neglect of this rule has frequently led to fatal results. The ergot
has been given and the uterus forced to contract, while the pelvis
was too small for the child to pass through; and the consequence has
been _rupture of the uterus_, or complete exhaustion, with death to
both mother and infant. In other cases the delivery has resulted so
suddenly, from the violence of the expulsive efforts, that the vagina
and perineum have been lacerated in the most shocking manner.

The ergot is also especially dangerous to very nervous women, or to
those who are disposed to congestion, apoplexy, or inflammation.

Among the special causes which often paralyze the action of the womb,
may be mentioned a full habit of body, great distention of the uterus
from accumulations of fluid, and extreme thickness of the membranes.
In some cases in fact, the membranes will be so strong that the most
violent contractions fail to break them, and the uterus completely
exhausts itself to no purpose. It is in such cases as these, when the
mouth of the womb is fully dilated, that the accoucheur should rupture
the membranes artificially. This is usually done with the finger nail
by pinching them. Some practitioners however use a pointed instrument,
or a sharp quill; but there is always more or less danger of injuring
the child or the mother by such means. The best time for breaking
them is during a strong pain, when they are fully distended. The mere
scratching, or pushing on them will frequently suffice. I have known
cases however in which they were so strong that an instrument was
actually necessary to open them.

The death of the infant also seems sometimes to check uterine
contraction, though probably not from the mere circumstance of its
being dead, but because the womb suffers from the same morbid cause
which produced its death.

Any strong moral impression may also produce the same state of things.
Thus in some females the womb will instantly cease its contractions,
and the labor be arrested, from _fright_, or from strong repugnance
to somebody, or something, in the room. Instances have been known of
women being so alarmed on first seeing the accoucheur, or so displeased
because he was not the one they wished, that the uterine efforts
immediately ceased, and could not be again brought on for a long time.
The presence of some person who is a subject of dislike may also
have a very prejudicial effect, and if this is known they should be
immediately removed. Dr. Merriman tells us of a female who was seized
with a fit, from which she died, simply from seeing a strange doctor
enter the room.

Whatever may be the cause which paralyzes the action of the womb we
should endeavor, if possible, to discover and remove it. If however
it be beyond our reach, the patient's strength must be supported as
much as possible, and the simplest means of exciting the contractions
tried first; if these fail the more powerful ones must be tried,
always preferring the safest. Finally, if all fail, the hand must be
introduced into the womb, the child turned, and brought away by the
feet; or the forceps must be used if absolutely necessary.


RIGIDITY OF THE MOUTH OF THE WOMB, VAGINA AND VULVA.

Sometimes the mouth of the womb or other soft parts, will not give way,
but remain obstinately rigid, so as to render the continued expulsive
efforts of the womb of no avail. If this state continues too long the
parts become swollen, hot, and dry, and extremely painful, so that
the slightest touch causes acute suffering. The abdomen also becomes
exquisitely tender, fever sets in, with cold sweats, the head begins
to wander, the features express great anxiety and suffering, and the
voice alters so that it can scarcely be recognized. These symptoms will
sometimes be established, and become rapidly worse in a remarkably
short time, so that the patient will appear to pass suddenly from a
condition of comparative ease and safety to one of extreme peril and
suffering. The child also suffers in an equal degree, the continued
pressure upon its head having a most injurious effect. The bones
overlap to a great distance, the scalp is engorged with fluid, and all
its blood-vessels are ready to burst; the brain is severely compressed;
the circulation in it is suspended, and apoplexy frequently ensues.
Even when one of these protracted cases eventually terminates without
immediate mischief, there is much subsequent evil to be feared. The
bruised parts frequently slough away, so that fistulas are formed, and
the whole remain so permanently weak that they can never afterwards
retain their places.

The most usual resort in these cases of obstinate rigidity is
_blood-letting_. This frequently induces relaxation immediately,
and also checks the tendency to inflammation and fever. In many
cases however, if not in all, it may be dispensed with, and should
always be so if possible. Very frequently it produces as much evil
as good, by alarming the patient, and by creating a debility which
cannot afterwards be removed. Simple warm _fomentations_ will often
make the rigid parts give way; and so will lubricating them with
soothing ointment, or better still anointing them with the _Extract of
Belladonna_. This frequently acts like a charm, and opens the rigid
os tincæ in a few minutes. Injections of thin starch and laudanum are
also excellent, and may be advantageously administered before applying
the Belladonna. The _Galvanic Battery_ may also be employed, it having
induced relaxation in many cases, when all other means failed; as will
be seen by the cases quoted in "Practical Facts."

If the labor really does progress though slowly, it is generally best
to have patience and let it take its course. If however the patient is
likely to sink before it is completed, or if it is at a stand still,
and cannot be accelerated, artificial delivery may be necessary. It is
seldom however that all of the above mentioned means fail.


OBLIQUITIES OF THE WOMB.

Sometimes the womb is so much inclined in a particular direction that
its mouth does not present to the middle of the passage. Thus it may
lean over so much to the right side that the mouth may open against the
left wall of the Pelvis; or it may lean to the left side, or to the
front. In all these cases the expulsion of the child may be totally
prevented, because it is forced against the walls of the passage
instead of down its axis.

Obliquity is sometimes righted spontaneously, but more frequently it
requires the interference of art. The mode of rendering assistance is
to support the womb on the side to which it falls, particularly during
the pains, so that its mouth may be directed towards the middle of the
passage.


PROLAPSUS UTERI.

Falling of the womb may retard labor, but is not likely to make it more
than usually difficult, nor dangerous. It is requisite, however to bear
in mind that the head of the child may, by this displacement, be found
in the vagina, and even at the vulva, before it has passed through the
mouth of the womb, because the neck itself is already in the passage.
The head may therefore be felt low down, and the accoucheur may think
the labor will soon be completed, when in reality it has scarcely
begun. In such cases it merely requires patience and _non-interference_.

In my work on _the Diseases of Women_, will be found many curious
cases of pregnancy and delivery, occurring during partial or complete
prolapsus uteri; and also much information regarding obliquity, and
other similar derangements.


SMALLNESS OR DEFORMITY OF THE PELVIS.

These constitute by far the most serious obstacles to delivery, and are
most to be dreaded. In treating upon them it will be first necessary to
explain the chief kinds of deformities, and the cause from which they
arise, after which it can be shown how they interfere with the progress
of labor, and how they can be best remedied.

Deformities of the pelvis may either be congenital, or they may be
produced by certain diseases in after life, and also by bad physical
education. The principal causes however are two diseases, _Rachitis_,
or _Rickets_, and _Malacosteon_, called also _Mollites Ossium_, or
softening of the bones. Rachitis usually attacks children somewhere
between nine months and two years of age, and produces a variety of
well marked symptoms; such as large head and belly, protrusion of the
breast-bone, flattening of the ribs, emaciation of the limbs, and
various deformities of the bones. The patient may recover from the
disease, but the deformity of the bones often remains, and therefore no
female should become pregnant, who has had rickets, till the shape and
dimensions of her pelvis are known, or it may cost her life.

Malacosteon or softening of the bones, may come on at any period
of life, and frequently occurs without any serious constitutional
disturbance. It consists in a gradual absorption from the bones of
all their solid matter, so that they become soft, and may be bent or
twisted like horn. Sometimes this state will be reached very soon, but
at other times the disease progresses very slowly. The causes of it are
unknown, and it is incurable. I have seen a patient who could bend the
bone of her leg _nearly double_, as if it were a piece of rope.

In my work on the Diseases of Woman, I have spoken upon various other
causes which may deform the bones in young females, such as wearing
corsets, improper attitudes in sitting, and want of sufficient
_unconstrained_ exertion of the body in the open air.

The deformities may be of various kinds, and may either alter the
general appearance and the walk, or may not be discoverable except on
examination. Sometimes the pelvis is _too large_, so that the womb and
other parts are continually falling down into its cavity, but this is
very rarely seen; more frequently it is either too small, or irregular
in its form.

In all cases where the irregularity in form, or diminution in size,
is such as to prevent the passage of the child an operation becomes
necessary, either upon the mother or her infant, and great danger is
consequently incurred by both.

It is therefore the duty of every mother, if she has the slightest
suspicion that her daughter is deformed, though it may not be apparent,
to have her examined before she is allowed to marry. _Many have lost
their lives for want of this precaution._ Severe blows or falls in
early life may also create a pelvic deformity, and this, as a possible
consequence of such accidents, should always be borne in mind. The
means by which the form and size of the pelvis are ascertained, as
before stated, are simple, and such as need not in any way be feared.

To enumerate all the varieties of deformed pelvis, as described by
different authors, is unnecessary, and would not be useful here. I
shall therefore only refer to them generally. Sometimes the pelvis
is regular enough in its form, but singularly small altogether, not
larger perhaps than that of a child eight or nine years of age. More
frequently, however one part only is small, while the others are full
sized, or the different parts are not in a proper position in regard to
each other. Thus sometimes the pubic bones will be flattened backward,
near to the sacrum, so as to narrow the antero posterior diameter of
the upper strait; at other times one of the sides will be flattened
towards the other, as if crushed in, and thus diminish all the
diameters; and at other times one side will sink down lower than the
other, and thus effect similar changes in another way.

By referring to the description of the perfect pelvis, given in the
early part of the work, the nature of these changes will be readily
understood, particularly if the plates given there are compared with
those given here.


  PLATE XL.

  Represents the _standard_ form, with which the rest must be compared.


  PLATE XLI.

  Represents a pelvis which resembles that of the male in its form, and
  is therefore called _masculine_. It is deeper, and less capacious
  altogether than the standard one. This form is occasionally met with
  in females of a peculiar general conformation, and temperament,
  approaching that of the other sex. It is not a sufficient deviation
  from the natural form to create any great difficulty, though it may
  cause delay.

[Illustration: Plate XL.

Represents the _standard_ form of the Pelvis.]

[Illustration: Plate XLI.

Masculine Pelvis.]


  PLATE XLII.

  Represents the peculiar deformity most frequently produced by
  _Mollites Ossium_. The different parts are stretched out as it were,
  and crushed inwards toward each other. The size of each strait is
  diminished in nearly every diameter, and the whole form is very
  unfavorable to delivery. This is sometimes called a _cordiform_
  pelvis. Observe the difference between it and the standard one.


  PLATE XLIII.

  This is called an _Ovate_ Pelvis. It appears as if it had been
  crushed by a heavy weight, from above downward, the sacrum being
  depressed below the plane of the pubes. In this case the antero
  posterior diameter of the upper strait is so much lessened that the
  two halves appear nearly separated, and form almost a figure of eight
  (8).

[Illustration: Plate XLII.

Represents the peculiar deformity most frequently produced by _Mollites
Ossium_.]

[Illustration: Plate XLIII.

This is called an _Ovate_ Pelvis.]


  PLATE XLIV.

  This is another kind of deformity, in which one side is sunk down
  below the other, while both are twisted as it were round the sacrum.


  PLATE XLV.

  This is a section of a Pelvis to show the effect of a corroding
  disease of another kind. The whole of this is such a mass of disease
  and deformity as to preclude any particular description.

[Illustration: Plate XLIV.

This is another deformity, in which one side is sunk below the other,
and both twisted round the sacrum.]

[Illustration: Plate XLV.

The effect of corroding disease.]

Curvature of the spine sometimes affects the pelvis, when low down, and
therefore if any female is affected with it she should not marry before
being examined. Several diseases and lesions of the hip-joint, and of
the thigh, may also do the same, and should therefore be suspected.

In the great majority of cases, deformities of the pelvis remain
unknown, till the period of delivery, and all that can be then done
is to combat in the best possible way the difficulties they create.
It is evident that the amount of difficulty depends entirely on the
disproportion between the head of the child, and the passage through
which it has to be born. If the head be large and the passage small
the difficulty will be greatest, but if the head be small it may pass
through the pelvis though under its average size. The development of
the head cannot be ascertained however, before birth, except when it is
unusually large from dropsy, and it is therefore always assumed to be
of an average development, and the pelvis is compared accordingly.

The kind of assistance required in these cases depends chiefly on the
measure of the pelvic diameters, though it may be modified somewhat by
other considerations.

When the smallest diameter of the pelvis measures from _three inches
and a half to three inches_, it is customary to leave the expulsion
of the fœtus to nature, and it is generally effected, though slowly
and with difficulty. If however the patient becomes exhausted, or the
head be unusually large, the forceps are generally used after waiting
five or six hours. In these cases the head often becomes firmly fixed
in the upper strait, so that great force is needed to dislodge it. The
upper part passes through, owing to the overlapping of the bones, and
the scalp then bulges out like a large tumor, from being engorged with
blood and serum, but the lower being more unyielding remains behind.
It is therefore impossible for the head to move either way, as it is
formed like a figure 8, and held by the narrow part, as will be seen by
the following plate.

[Illustration: PLATE XLVI.

This Plate represents the head fixed, or impacted, at the upper strait
of a narrow pelvis.]

When the smallest diameter is not more than from _three inches to
two and a half_, the birth is sometimes effected by nature, but with
extreme difficulty. The accoucheur waits four or five hours, as in the
former case, and then if no progress is made he applies the forceps,
using great care in doing so. If the extraction is found impossible,
with reasonable force, the head must be opened and made smaller, even
though the child be living, because it is more proper to sacrifice it
than to risk the life of the mother. In a case like this however, no
one person would like to decide, unless in a great emergency; there
should always be a consultation if possible.

A _dwarf_, named Lepratt, who used to perform at the theatres, was
delivered with the forceps by M. Dubois, though the pelvis only
measured _three inches_. She perfectly recovered, though the child was
born dead: it was of fair average size.

It is contended by some that the delivery may be effected, under
peculiarly favorable circumstances, when the passage measures only two
and a half inches, and at all events the effort should be made; but
for the sake of the mother such cases should not be left long, as the
chance is so small, and the risk of delay so great. When the passage is
_less_ than two and a half inches, spontaneous or artificial delivery
is allowed to be impossible, and the only alternatives then are to
dismember the child or open the mother. Which of these should be done
depends on circumstances. Whenever the child _can_ be brought away by
the natural passages, though it be piecemeal, it always is so brought,
unless the danger to the mother be greater than by the cesarian
operation, in which case that operation is resorted to. By means of
an instrument called the _Cephalotribe_, which crushes the head, the
child may be brought away, unless very large, when the pelvis only
measures _two inches_. When the passage is _less than two inches_, the
only resort is to the cesarean operation, which sometimes succeeds, and
saves both mother and child, though more frequently the mother sinks.

The necessity for all these frightful operations is now much less than
formerly, _and may be done away_ _with altogether_. This important
fact should be known universally, and also the means to be resorted
to. In the first place, every young female should be examined, before
marriage, by a competent person, if there be the slightest reason to
suspect deformity; and in case the deformity is found to exist, the
consequences if she becomes pregnant, must be laid before her. If,
after being told this, she _will marry_, or has already done so, the
means of _avoiding conception_ should be placed at her disposal, so
that she may not be made, of necessity, a helpless victim. These means
need not be described here, though I have no hesitation in referring
to them. When I know that the _life_, or _life-long health_, of a
female, depends on her not becoming pregnant, I consider it my duty to
put such means at her disposal, if she desires it. In many instances I
have known females suffer, several times, the most frightful tortures,
merely to bring into the world the mangled fragments of a dismembered
child, with the greatest risk to their own lives; and in others I have
known them in constant dread of becoming pregnant, because they were
conscious it would be their death warrant. In such cases I leave it to
_humanity_, and _common sense_, as to whether such information should
be withheld? _I_ could not reconcile it with my notions of _duty_ to
withhold it.

In case pregnancy has occurred before the deformity is discovered, and
it is then found that a _full grown_ child cannot be born, premature
delivery must be brought on; or, in other words, the Uterus must be
made to expel the child before the full term, while it is yet small
enough to pass through the Pelvis. This operation is of course only
allowable when needed to preserve life, or to escape great suffering
and danger. It must always be decided upon by the medical man, and
performed by him, so that a description of it is uncalled for here.
In Europe it is quite common, and nothing has tended so much to do
away with those disgusting and horrid operations, on mother and child,
which were formerly absolutely necessary in cases of deformity. If
it is found at the first delivery of a female, or before, that she
cannot bear a living child at full term, artificial delivery is
accomplished at _seven_ or _eight_ months, thus avoiding all the
danger to the mother, and _frequently preserving the child_. In the
case of the _dwarf_ before referred to, when she became pregnant the
second time, M. Dubois brought on premature delivery, and the child
was _born alive_, with but little difficulty. According to statistics
it appears that, when artificial premature delivery has been induced,
in _one hundred and sixty-one cases_ only _eight mothers_ have died,
and all but _forty-six_ of the infants were born alive. Of the whole
number of children _seventy-three_ continued to live; and of the eight
mothers five died from other causes, leaving but _three_ whose death
resulted from the operation. Now when the fearful number of deaths
from instruments, and other operations, necessary at full term, is
recollected, the advantage of this practice will be evident. In the
Cesarian operation for instance, which is often the only remaining
resort, but _one_ female out of _six_ recovers.

The delivery should be postponed as long as possible, so as to give
the best chance for the child living. This must of course be decided
upon after the size of the pelvis is ascertained. Seven months is the
earliest time at which the fœtus is viable, and it is much better left
till eight, if the size of the parts will allow of its birth then. In
case they are so small that it cannot be born even at seven months, we
have our choice, as M. Chailly remarks, _between the dreadful Cesarian
operation at full term, and producing early miscarriage_.

M. Dubois seems to recommend premature delivery in nearly all cases, if
the smallest diameter is _under three inches_; because, as he remarks,
spontaneous delivery at _full term_ is then a very rare exception, and
the danger and suffering to the mother is so great. He also recommends
it when there are tumors, and even when the female is afflicted with
any acute disease. Of course it is always necessary, before operating,
to be sure that the child is alive.

I knew a lady myself who had given birth, at full term, to _seven_
children, all of which were torn from her with instruments, _dead_,
owing to the smallness of the pelvis. When pregnant with the _eighth_,
premature delivery was brought on, at my suggestion, at about _seven
months and a half_. The fœtus was born with comparative ease, and
_lived_. But for this operation she probably would never have been
blessed with a living child at all. Since then she has avoided
conception.


TUMORS IN THE PELVIS.

Tumors of various kinds are met with, both in the bones of the pelvis
and attached to the soft parts. They frequently offer the most serious
impediments to delivery, and baffle the skill of the most experienced
obstetricians. In fact they differ so much in their structure, their
size, and their situation, that but few general directions can be given
as to their management. In every case where one exists pregnancy
should never occur, if possible to be prevented, before it is removed;
for though it may cause no inconvenience at other times, yet during
delivery it may necessitate very serious operations, or even cause
death. Some of these tumors are mere vesicles, or bags, filled with
fluid, and may be punctured and their contents let out, so as to make
them less. Others are more or less solid but moveable, and may often
be supported above the upper strait till after the child is born. When
they are so large as to block up the passage, and are either fixed or
cannot be carried up into the Womb, there is often no other choice than
to either cut them out or open the child's head; the practice being
determined by the circumstances of the case. In some instances the
bladder itself, distended with urine, has impeded delivery, and been
mistaken for a tumor; and in other instances stones in the bladder have
caused the same error.

A specimen of one of these tumors is represented in Plate XLVII, and
one of a Polypus in Plate XLVIII.


  PLATE XLVII.

  This represents an Ovarian Tumor, which has descended before the head
  of the child, and completely blocked up the passage. The delivery, it
  will be seen, is utterly impossible in such a case, unless the Tumor
  can either be pushed away, or reduced in size.

[Illustration: Plate XLVII.

Case of Tumor.]


  PLATE XLVIII.

  This Plate represents a case which occurred in the practice of Dr.
  Ramsbotham, and which terminated favorably. The polypus had a very
  long neck, and was forced _out of the external opening_ by the child,
  which was then born with ease. I once saw a case myself, in which the
  labor was completely arrested by a large hard tumor about the middle
  of the Vagina; it could not be moved, and delivery was evidently
  impossible while it remained. In consultation it was decided to cut
  it out, as there seemed but little circulation of blood in it, and
  its situation was favorable for the operation. This was accordingly
  done with but little trouble, and the child was born without
  difficulty in about twenty minutes after. The mother perfectly
  recovered.

[Illustration: Plate XLVIII.

Case of Polypus.]


TUMORS EXTERNALLY.

Sometimes tumors exist externally, on the lips, or in the Vulva, but
as they seldom offer much obstruction, and are easily detected and
managed, but little need be said about them. They should always however
be attended to, if discovered, before labor comes on, or better still
before pregnancy.

In some instances the veins around the Vulva become much enlarged,
and resemble tumors, and sometimes even impede delivery. It is usual
then to open them, and let out the blood, but not till the head is
sufficiently low to press upon it and prevent dangerous bleeding.


OBSTRUCTIONS IN THE VAGINA, AND NARROWNESS OR OBSTINATE RESISTANCE OF
THE VULVA AND PERINEUM.

The Vagina may be partly closed by its sides growing together, or it
may be united by bands and membranes stretching across; and these
obstructions may be sufficient to impede or prevent delivery. Most
usually they give way, and are gradually broken down by the pressure
of the child's head; but if they prove too strong, after waiting a
reasonable time, they must be cut through. Cases have even been known
in which the _hymen_ has been found perfect at delivery, and even
offered considerable resistance, so as to necessitate its being cut
through before the child could be born. In such cases this membrane is
unusually strong, and conception occurs without its being broken.

When the perineum or Vulva remains rigid and hard, so that the opening
cannot be enlarged sufficiently for the child to pass, it may also be
necessary to operate with the knife. But this should never be done till
after every means of relaxation has been tried, and the head has been
kept back as long as prudent. It is however, always better to open a
passage than to let one be _torn_, because it may be made in the most
favorable place. When the perineum is allowed to be torn, the most
serious consequences often ensue, and the patient is made a miserable
sufferer for life. The Vagina and Rectum may be torn into one, or the
power of retaining the contents of the intestine, or bladder, may be
for ever lost. When an incision is made none of these evils follow; the
wound speedily heals, and in a little time no trace of it can be seen.
It has even been necessary _to cut the neck of the Womb_, when it would
not open, to prevent the organ from being ruptured; and this has been
done with perfect safety. A celebrated practitioner in this city had to
perform such an operation very recently, on a female who had injured
herself, and made the mouth of the Womb grow together, by violent
attempts to produce abortion. The delivery took place with comparative
ease, and no unpleasant results whatever followed, either to the mother
or the child.




CHAPTER XX.

CAUSES CONNECTED WITH THE CHILD, OR CHILDREN, WHICH MAY IMPEDE
DELIVERY, OR MAKE IT DIFFICULT AND DANGEROUS.


PROCIDENTIA OF THE UMBILICAL CORD.

This means the escape of a portion of the cord before the child itself.
It is most frequent in the irregular presentations, as they do not so
fully close up the mouth of the Womb, and it is most likely to occur at
the commencement of labor, though not impossible at a later stage. Very
often the cord descends when the membranes break, being carried down
by the rush of the waters; and sometimes it is already in the sack, or
bag, before the rupture takes place. This accident is comparatively
frequent, being found to occur as often as once in about three hundred
cases.

The causes which produce procidentia of the cord, are most
likely these:--A large quantity of liquor amnii, and its sudden
discharge,--Unnatural presentations,--Deformities of the superior
strait of the Pelvis,--A very long cord,--and rupturing the membranes
too early. But it may also happen from other causes with which we are
unacquainted.

There is seldom much difficulty in detecting this accident, because
if the membranes are broken it protrudes into the Vagina, and if they
remain whole it can be felt within the sack, and its pulsation will be
quite distinct. Sometimes, it is true, it may be so firmly compressed,
between the fœtus and the walls of the pelvis, that its pulsation may
be very indistinct, or even totally suspended for a time; but this only
necessitates a little extra care.

Procidentia of the cord may be very serious for the child; in fact, it
is a frequent cause of its death. The reason of this will be evident
when the functions of the cord are borne in mind. The circulation in it
is as necessary for the life of the child before birth, as breathing is
after, and when protruded first it can seldom escape being so pressed
upon as to stop its circulation, and hence the danger. To the mother
it makes no difference whatever, unless it be told and alarm her; or
unless violent efforts are made to correct it. She had therefore better
not know if it occurs.

If assistance is not rendered in this accident the consequences are
almost always fatal to the child, though in some instances the cord has
remained hanging from the Vulva several inches, for an hour or more,
and still the infant has been saved.

If the fallen cord is detected before the membranes are broken, it
may frequently be put back into the Womb without much difficulty. The
accoucheur must wait till the mouth of the Womb is fully dilated, and
then watch his opportunity, in an interval between two contractions,
to push the cord upwards, between the fœtus and the uterine walls. If
he succeeds in this, as is usually the case, he must then break the
membranes during the next pain, and this will bring the presenting part
at once into the upper strait, and so block up the passage. To effect
this manœuvre it is requisite to introduce two or three fingers, and
sometimes even the whole hand. It must never be attempted till the
mouth is fully dilated, otherwise the membranes may be ruptured too
soon, and the delivery be delayed, thus increasing the danger.

After the rupture of the membranes the replacing of the cord becomes a
much more difficult matter, and frequently cannot be effected at all;
particularly if the head be descended far down. Every effort however
must be made, and if unsuccessful the delivery should be hastened as
much as possible. In many such cases the _forceps_ are applied, and the
child brought away at once, because every moment's delay increases the
risk to its life.

Several different kinds of instruments have been invented to return the
cord, but they are seldom at hand when needed, and none of them are so
good as the hand itself.

If the return of the cord cannot be effected, and the progress of
the labor will allow of it, the hand is introduced and the child
turned, unless the position of the head will allow of the advantageous
application of the forceps, in which case they are mostly resorted
to. The only general rule is, to terminate the labor as speedily as
possible, consistent with the welfare of the mother. In spite of all
that can be done the pulsation is often found to cease, and when the
child is born it is either quite dead or breathes but a few times.

A very frequent indication that the fœtus suffers from compression of
the cord, is a greenish color of the water discharged, owing to the
discharge of _Meconium_ from the child's bowels. This is brought about,
most probably, by its straining, and its efforts to relieve itself.


SHORTNESS OF THE CORD.

The cord is sometimes too short, and this may operate very unfavorably
in many ways. It may keep the fœtus up in the Womb, and prevent it from
descending to the bottom of the Vagina,--it may cause the placenta to
be torn away too soon, and so lead to serious flooding,--it may pull
down and invert the Womb,--or it may make the labor very tedious, and
cause the death of the child.

Unfortunately there are but few signs of this accident, even after the
rupture of the membranes, and none at all before, that can be depended
upon. If the head has descended properly, and the parts be fully
relaxed, but still the expulsion is delayed from no obvious cause, it
may reasonably be supposed that shortness of the cord exists; and if so
there is very soon given a proof of it by a discharge of blood. This is
owing either to the breaking of the cord, or to the separation of the
placenta, and is frequently the first intimation the assistant has of
the accident. All that can be then done is, to conclude the delivery as
soon as possible, and in the best way that circumstances will allow.

In some cases the cord is not too short absolutely, but is made so by
being twined round the body or limbs of the child, which are often
_cut off_ by it. M. Tasil saw a case where the cord round the neck
had nearly severed the head; and Montgomery gives several instances
in which the limbs had been amputated in this way. Two of these are
represented below:--

[Illustration: PLATE XLIX.

  Fig. 1.       Fig. 2.

_Limbs cut off by the Cord._

Occasionally the cord can be slipped over the head, or limbs, when
wound round them, and the strain upon it be thus removed. If this
cannot be done however, and the danger increases, relief may be
obtained by _cutting the cord_, particularly if it be absolutely short.
But this must not be done till everything indicates that the labor will
probably soon terminate; and the end connected with the child must be
carefully held, or tied.]


DESCENT OF OTHER PARTS WITH THE HEAD.

_One Arm._--The descent of one arm along with the head may cause
some delay and difficulty, but Nature nearly always overcomes the
impediment. It is seldom that the arm can be reduced, and therefore
but little can be done at first; if the delivery be evidently arrested
by it the accoucheur must at last assist in the most feasible manner.
Sometimes even it is necessary for him to apply the forceps.

_The Two Arms._--Even this difficulty is often overcome spontaneously,
though much more rarely than the former one. As soon as it is detected,
the accoucheur must endeavor to return one or both of the limbs, if the
labor has not proceeded too far; and if he cannot succeed the delivery
must be accomplished as soon as possible, either by turning or with the
forceps, unless there be reasonable ground for delay.

_The Feet._--Either one or both of the feet may also descend with the
head, at first, though they usually recede and allow the head to be
born alone. When they are so impacted as to prevent the delivery being
completed, the accoucheur must interfere. In most cases he will find it
quite easy to push the feet above the head, and allow that to descend
alone; but if this is not possible he must introduce one hand, grasp
the feet with it, and pull them down, while the other pushes the head
up. This will turn the child, and if it be in no immediate danger, and
the mother is not suffering, the rest may be left to nature; but if
the contrary is the case, the delivery must be finished as speedily as
possible. When the head is very low down it may be necessary to use the
forceps, but great care must be observed not to grasp the feet along
with the head when using them.

_A Foot and Arm._--The proceeding is the same as with the foot alone.
If the limbs cannot be returned the head and arm must be pushed up,
while the foot is brought down.


TWINS AND TRIPLETS.

In most cases where there are two or more children the delivery is
easier than with one, because they are generally small, and the first
one so prepares the way that the rest are born without difficulty. It
is also a fact that twins are nearly always born before full term, and
consequently are not quite grown.

The expulsion of the second fœtus usually takes place, immediately
after the first, though sometimes the Womb stops contracting, and it
is not born for half an hour or more, and it may even remain for hours
or days. It is a question whether, in such a case, the second delivery
should be left for Nature to finish, or whether the accoucheur should
terminate it sooner artificially. The most general practice is to wait
only about half an hour, and then, if the Womb is still inert, use
friction, or other necessary means, to excite it, and accomplish the
second delivery as soon as possible. If there be more than two the
proceeding is still the same.

Some difficulties may arise however with twins, which it is necessary
to be prepared for. Thus the two heads may come together, and mutually
impede each other. In this case the one which moves the easiest must be
pushed up till the other is descended sufficiently low. One head may
also descend with one or two feet; in which case, if the feet cannot be
returned, the head must be pushed up, and they must be brought down.
The force exerted however, must not be very great at first, because
_one may belong to each of the children_, and much injury may be done;
a little gentle traction will soon detect this however, with ordinary
care. If two arms, or one arm and a foot descend, the same care is
also required, before pulling upon them, to ascertain that they are
not parts of the _two_ children. Sometimes when the head of one twin
descends along with the feet of the other they may, if small, descend
together. But if this is impossible, and interference is needed, we
must first try to push up the head; and if this cannot be done, _it_
must be drawn upon, not the feet; because if the feet were drawn down
the two children would soon occupy the passage together, body and head,
and would perhaps become firmly wedged. In nearly every case one of the
twins presents by the head and the other by the feet, as formerly shown.


EXCESSIVE SIZE OF THE FŒTUS, OR THE DISEASED DEVELOPMENT OF CERTAIN
PARTS.

_Fœtus too large._--It is very rarely the case that the Fœtus is so
large as not to pass easily through a well-formed Pelvis, though such
cases have been known. The mode of proceeding is of course precisely
the same as if the pelvis were too small. If no means will succeed in
abstracting the Fœtus whole, it must be made less; but Nature should be
first allowed full time to act with all her force.

_Hydrocephalus._--This consists of an accumulation of water in the
head of the child, and is usually termed watery head. The bones of the
cranium will sometimes be widely separated by it, and the head be made
so large that it cannot possibly be born till made less. The causes
which produce this disease before birth are unknown.

In cases of hydrocephalus the head does not descend into the straits,
owing to its size, and is felt to be full and firm, during a pain, but
soft and yielding during the intervals, especially at the fontanelles
and sutures, which are also very large. The bones are usually very wide
asunder, or even totally separated, as if floating in the fluid.

In some cases, when the quantity of fluid is but small, the delivery
may terminate spontaneously; the head lengthening, from being so soft,
and thus adapting itself to the size and form of the strait. Most
frequently however, assistance is rendered in such cases, either by the
forceps, which will sometimes succeed, or by puncturing the head, and
letting out the fluid. This operation has been performed and the child
saved, though such an occurrence can never be reasonably anticipated.
Such instances however, show that great care should be taken not to
injure the brain, as that would destroy the small chance there is.

Dropsy may also occur in the chest, or abdomen of the child, causing
similar difficulty with dropsy of the head. If the natural or
artificial expulsion of the child cannot be effected without, the part
must be carefully punctured, and the fluid evacuated.

_Tumors on the Fœtus._--Sometimes various kinds of tumors form on the
child's body, but they are rarely so large as to prevent delivery,
though they may delay it. If they should be too large however, it will
be necessary to remove them, as in the case of tumors in the Pelvis.


OSSIFICATION OF THE HEAD.

Occasionally the bones of the head will be so hard, and so closely
united, that they will not overlap, in which case the labor may be
very difficult, unless the head is small, or the pelvis very large.
If after waiting a reasonable time, there be no prospect of the
labor terminating naturally, and the female is exhausted, it must be
terminated artificially, as if it were a case of deformed pelvis. It is
seldom however, that the head does not eventually give way.


VARIOUS PRESENTATIONS AND POSITIONS OF THE FŒTUS, FROM WHICH THE LABOR
MAY BE DIFFICULT OR PROTRACTED.

_Presentations of the Face._--These are usually more difficult, and
longer, than those of the head. They will nearly always however,
terminate spontaneously, or with ordinary assistance; but, if they
should not, artificial delivery must be practised, either by turning,
if the case be not too far advanced, or with the forceps. Some of
the most celebrated authors recommend that all these cases should be
treated like cases of natural labor. Dr. Merriman says that in some
_very favorable_ instances turning may be practised with safety and
advantage; but Dr. Lee says, "My firm belief is, that the child, even
under such favorable circumstances, would have a far better chance
to be born alive if the labor were left wholly to Nature; or, if the
natural powers were inadequate, to be extracted with the forceps."
In such cases there is often too little patience, and too much
interference.

_The forehead inclined against the Pubes._--In this position the labor
may be long delayed, and difficult, and most practitioners endeavor
to turn the head round, if they cannot bring down the feet, or else
apply the forceps at once. Dr. Lee however remarks, and very properly,
"From all that I have seen of these cases, I am disposed to believe
that it is best to leave them to the natural efforts, and to avoid all
interference, all attempts to change the position, while the pains
continue regular, and the head advances, however slowly." If the labor
does not progress at all, or the female becomes exhausted, of course
artificial delivery is necessary.

Several _varieties_ of head and face presentations may also retard
labor considerably, but Nature nearly always overcomes the difficulty;
or if she cannot do so mere ordinary assistance is required.


PRESENTATIONS OF THE LOWER EXTREMITIES.

It has already been remarked, in another place, that breech
presentations mostly terminate spontaneously, and that but few of them
require interference. In some of them even, when the pelvis is large,
or the fœtus small, the delivery is effected quite rapidly. Still such
presentation occasionally causes delay and difficulty, and necessitate
more or less assistance.

As soon as the mouth of the Womb is opened sufficiently, unless the
labor is rapidly progressing without it, one of the fingers may be
introduced and _hooked_ over the groin, and a little gentle force
exerted upon it. This will assist very much, and will often be all
sufficient. If the pelvis is too small, or the fœtus too large, and
the delivery is evidently arrested, the breech must be pushed up, if
possible, and the feet be brought down, as in turning. The remarks of
Dr. Lee on this presentation are so plain and practical, and marked
with such good sense, that I think a better explanation of what should
be done in such cases-could hardly be given, I will therefore quote his
remarks in full:--

 "Having ascertained that the nates present, whatever the position
 of the fœtus may be, whether the abdomen look backward or forward,
 we cannot alter it with safety, and no change can be required to be
 made till the nates and lower extremities are expelled. The os uteri
 dilates slowly in most cases of nates presentation, but we cannot
 employ any means with advantage to accelerate the delivery, and in
 most cases, if we do not interfere, but wait patiently, they are
 gradually pressed lower and lower into the pelvis, and at last escape
 from the vagina without any assistance. If the os uteri and vagina
 are imperfectly dilated, and the nates are drawn down or pass rapidly
 through the pelvis, the child is often lost. The membranes should not
 be ruptured, and the expulsion of the nates should be left entirely
 to the natural efforts, unless the labor is protracted and exhaustion
 takes place. Except supporting the perineum, nothing is required in a
 great proportion of these cases before the nates and lower extremities
 have been expelled, when it becomes necessary to ascertain precisely
 the relative position of the child to the pelvis, to rectify this if
 it is unfavorable, and artificially extract the superior extremities
 and head, to prevent the fatal compression of the umbilical cord. If
 we find, after the expulsion of the nates and lower extremities, that
 the toes are directed forward, or that the child is in the position
 represented in the second figure, with its abdomen applied to the
 anterior part of the uterus, and that its back lies along the spine
 of the mother, we should wrap the nates and sides in a soft napkin,
 and turn the child very gently round during a pain, observing to
 which side the feet are inclined to turn, till its abdomen is to
 the spine of the mother, and the toes are directed backward to the
 hollow of the sacrum, or to the side of the pelvis. In many cases
 the nates turn round in the passage spontaneously, so that it is not
 required artificially to alter the position. It is necessary always
 to recollect that it is possible to turn the body of the child round
 without turning the face round into the hollow of the sacrum, and
 that the chin may be over the symphysis pubis when the front of the
 chest and abdomen are turned backward. After the lower extremities and
 body of the child have been expelled, and placed in the most favorable
 position for the extraction of the superior extremities and head, it
 is necessary to proceed without loss of time to draw these through
 the pelvis, that the child may not be destroyed by compression of
 the umbilical cord. As pressure upon the cord for a very short time
 will in some cases kill the child, it is proper to watch closely the
 pulsations of its arteries. Draw the body of the child forward as
 far as the arm-pits, and place it over the palm of your right hand
 and fore-arm, and gently draw the body towards the left thigh of the
 mother; then pass the fore and middle fingers of your left hand along
 the back part of the left arm of the child to the elbow-joint, and
 press down the arm with your lingers along the thorax of the child,
 and extract it. Then transfer the body of the child and left arm to
 your left hand and fore-arm for support, and with the fore and middle
 fingers of your right hand disengage and bring down, in the same way,
 the right arm of the child; then pass the fore and middle fingers of
 your left hand into the mouth of the child, or rather over the lower
 and upper jaw, and at the same time place the fore and middle fingers
 of your right hand over the back part of the neck and occiput, and
 with the fingers of the two hands thus applied extract the head, in
 the line of the axis of the pelvis. The perineum is very rigid in some
 cases of nates presentation, where it is the first child, and it will
 be torn if the head is extracted hastily, and not drawn forward to the
 symphysis pubis. When you feel the pulsations of the cord beginning to
 cease, you may be tempted to employ greater extracting force than the
 neck of the child and perineum can bear, and both may be destroyed.
 The only method of obviating this is to press back the edge of the
 perineum, that the air may gain admission into the mouth of the child,
 and the respiration go on, when the circulation in the cord has been
 arrested, until the perineum is sufficiently dilated to slide back
 over the face, and allow the head to pass. I have seen from twenty
 minutes to half an hour elapse in some cases, after the cord had
 ceased to pulsate, before the perineum would allow the head to escape,
 during which time the respiration was regularly performed. This is
 not a new practice; it has been alluded to by some of the older
 accoucheurs, and some others; and the advantages to be derived from
 it were fully pointed out some years ago by Dr. Bigelow, in a paper
 published in the American Journal of the Medical Sciences, 'On the
 means of affording Respiration to Children in Reversed Presentations.'
 The object of Dr. Bigelow in this paper is to show that in many cases
 the life of the child may be saved by forming a communication between
 the mouth and atmosphere previous to the delivery of the head. If the
 head be low down, the fingers alone can give the necessary assistance;
 but if it is high in the pelvis, and is reached with difficulty, the
 assistance of a tube may be necessary. He recommends a flat tube,
 which is to be guarded, and kept within the fingers of the inserted
 hand.

 "Where the pelvis of the mother is small or distorted, and the
 child large and unfavorably situated, the efforts of nature may be
 insufficient to expel the child, either alive or dead. The nates may
 become so firmly impacted in the pelvis, that they cannot advance
 without artificial assistance. A finger should be passed up to one
 of the groins, and when a pain comes on a considerable extracting
 force may be exerted with it, without injuring the child; or a soft
 handkerchief may be passed between the thigh and abdomen, and the
 nates drawn down; but this cannot be done unless they have descended
 low into the cavity of the pelvis. Where these means fail, and it is
 impossible to extract the child alive, the blunt hook or crotchet
 must be employed. In cases of nates presentation, where the pelvis
 is distorted, after the extraction of the trunk and extremities, it
 is necessary to perforate the back part of the head, and complete
 the delivery with the crotchet. In presentations of the feet and
 knees the treatment does not essentially differ from that required in
 presentations of the nates."


PRESENTATIONS OF THE SHOULDER.

These are the most dangerous of all the presentations, and most
frequently require assistance; in fact the delivery can seldom be
terminated naturally when the shoulder presents.

Sometimes the child will pass doubled up, as formerly explained, but
this must not be too confidently expected. Dr. Lee says--

 "It is now a general rule, established in all countries where
 midwifery is understood, that in cases of preternatural labor, where
 the shoulder and superior extremities of the child present, the
 operation of turning ought to be performed. But the hand must not
 be forced into the uterus, if the orifice is rigid and undilatable;
 it should be dilated nearly to the size of half-a-dollar piece or
 more, or the margin ought to be very thin, soft, and yielding, if it
 is expanded to a smaller extent than this when turning is attempted.
 If the os uteri will not admit the extremities of the fingers and
 thumb in a conical form to be introduced without much force, if it is
 thick, hard, and unyielding, some delay is necessary, that the parts
 may relax, death being almost always the consequence of thrusting the
 hand with violence through the orifice of the uterus in a rigid and
 undilatable condition, whether the membranes be ruptured or not. But
 as soon as it will admit of the safe introduction of the hand, where
 you have ascertained that an arm presents, no time should be lost in
 completing the delivery, otherwise the membranes may give way, the
 liquor amnii be evacuated, and a case of little difficulty and danger
 be suddenly converted into one equally hazardous to the mother and
 child. In all cases of labor, where the first stage is far advanced
 without the nature of the presentation being positively determined, or
 a superior extremity is felt through the membranes, the patient should
 be kept in the horizontal position, that they may not be ruptured;
 and you should remain in constant attendance upon the patient, and be
 prepared to interfere the instant the necessity arises."

Speaking of the operation of turning in these cases he remarks as
follows:--

 "In some favorable cases of shoulder and arm presentation, the uterus
 is widely dilated before the membranes are ruptured and the liquor
 amnii discharged; and no difficulty is experienced in passing the
 hand into the uterus, laying hold of the feet, and extracting the
 child by the operation of turning. If the uterus is not contracting
 strongly and at short intervals, little resistance is offered to
 the introduction of the hand, and the delivery may be speedily
 accomplished with safety both to the mother and child. But if the
 membranes have burst, the liquor amnii escaped, and the uterus has
 been contracting firmly upon the child many hours before the operation
 of turning is attempted, the child is often destroyed by the pressure,
 and the coats of the uterus exposed to great danger from contusion
 and laceration in passing up the hand and bringing down the feet. The
 shoulder and thorax become so strongly impacted in the pelvis, that
 great force is required to introduce the hand to grasp the feet, and
 much exertion necessary before the position can be changed.

 "In other cases of shoulder and arm presentation, the membranes
 burst and the liquor amnii escapes at the commencement of labor,
 and the os uteri is rigid and undilated, so that the hand cannot be
 passed into the uterus after the labor has continued many hours. The
 difficulty and danger of these cases is greatly increased when the
 uterus is contracting with violence, and the pelvis is distorted, or
 a disproportion exists between the child and pelvis from any other
 cause. The greater number of women, if abandoned to the efforts of
 nature under these circumstances--the uterus having no power to alter
 the position of the fœtus--would ultimately die undelivered, from
 exhaustion or rupture of the uterus and vagina."

Fortunately these cases are very rare, and when assistance is rendered
_early_, the difficulty is readily overcome. This is a strong reason
why all women especially should know what to do, because a little
timely help may save much suffering, or even life.




SECTION VII.

ACCIDENTS DURING LABOR WHICH MAY COMPROMISE THE MOTHER'S LIFE.




CHAPTER XXI.

UTERINE HEMORRHAGE, OR FLOODING, DURING LABOR.


This is always a troublesome, and frequently a fatal accident. It
should be always watched for, and attended to as early as possible--_a
few minutes_ frequently determining the recovery or death of the
patient.

The chief causes of flooding are, the too early or violent, separation
of the placenta; insertion of the placenta over the mouth or on the
neck of the womb; laceration of the womb or vagina; the bursting of
a swelled vein; rupture of one or more of the blood vessels of the
uterus; and breaking of the cord.

Probably the most frequent of these causes are the premature or violent
separation of the cord, and the bursting of the blood vessels. The
insertion of the placenta over the mouth of the womb, instead of on
the fundus, occurs very seldom, but when it does severe flooding is
nearly certain to follow, because the placenta has then to be torn,
by the expansion of the parts, at the very commencement of the labor,
and probably continues to pour out blood for a long time before the
child is delivered, and it can be expelled. In fact this occurrence,
unless the labor terminates very speedily, is nearly always fatal to
the mother, and frequently to the child also. In most cases there is
more or less hemorrhage from this cause during gestation, particularly
after the sixth month, when the neck of the uterus begins to enlarge
more than the placenta, and consequently tears away from it. Abortion
frequently results also, if the flooding be not stopped. Madame Boivin
tells us that in _twenty thousand three hundred and fifty-seven_
deliveries there were but _eight_ cases in which the placenta grew
over the mouth of the womb; which is equal to _one_ case in every _two
thousand five hundred and fifty-four_. Dr. Churchill has collected the
accounts of _one hundred and seventy-four cases_ of this kind, and he
finds that out of these forty-eight terminated fatally; or nearly _one
out of every three_.

The rupture of the blood vessels may occur when they are too much
engorged with blood, or when their coats are weakened and corroded
by disease. Shortness of the cord may also produce a rupture of the
vessels, by the strain it causes on them and on the membranes.

In many cases the flooding comes on suddenly, without any warning
whatever, though most usually it is preceded by a sensation of
weight, heat, and fluttering in the pelvis, pains in the thighs and
back, flushed face, headache, and dizziness. The pulse also becomes
irregular, the hands and feet grow cold, and the ears often ring, or
buzz. The only certain sign that the hemorrhage has really commenced
is the appearance of the blood itself, and this often occurs, as
previously remarked, without any premonitory sign whatever.

The danger from hemorrhage during labor is greatest when it commences
the earliest, because it has then the longest to last. From any of the
causes mentioned it is evident that it must continue till delivery is
accomplished, and therefore if it appears at the commencement of the
labor it may cause the death of both mother and child, before the
labor can be terminated. The danger is greatest however to the child,
unless the flow be very profuse indeed, and then it is equally so to
both. After delivery the danger is of course only to the mother; and
the rapidity with which it may compromise her life is in some cases
fearful. Dr. Lee thus speaks of such cases.

 "But one of the most dangerous varieties of uterine hemorrhage is that
 which follows the expulsion of the placenta, or its removal from the
 uterus by art. Sometimes the blood escapes in great quantities from
 the uterus immediately after the removal of the placenta, and the
 pulse ceases at the wrist, and consciousness is entirely lost in a few
 seconds. There is no symptom before labor has commenced, or during its
 progress, to warn you of what is about to take place. The child has
 been safely delivered, the placenta has come away in a short time, and
 while you are perhaps congratulating yourself on the happy termination
 of the labor the blood begins to trickle over the bed upon the floor,
 or the patient suddenly complains of great faintness. In such cases
 there may be either a want of uterine contraction, or the contractions
 may not be permanent, but be followed by relaxation and the effusion
 of a large quantity of blood, which may either appear externally,
 or remain to become coagulated, and distend the uterus. For several
 hours after delivery, in some cases, this alternate relaxation and
 contraction goes on, to the great hazard of the patient, and if her
 condition be not clearly ascertained, and the proper remedies be
 employed, death may unexpectedly take place."

In regard to the treatment, he gives such excellent and practical
rules, that I cannot do better than quote them.

 "By far the most important remedies in these cases of uterine
 hemorrhage are constant and powerful pressure over the fundus uteri,
 the application of cold around the pelvis, and the free administration
 of wine, brandy, and other stimulants: ergot is indicated, but it
 most frequently produces no effect. The pressure and cold are always
 within our reach, however sudden the attack may be. The hypogastrium
 should be strongly compressed with the binder, and a pad of folded
 napkins placed under it, and in addition the hand should be firmly
 applied over the fundus uteri. I do not know who it was that first
 employed compression of the fundus uteri in cases of flooding after
 the birth of the child; but it has been often recommended, and there
 are few practitioners in this country who are not fully aware of
 the importance of the binder and pad, in exciting permanent and
 regular uterine contractions. Dr. M'Keevor states, that in 1815 it
 was recommended by Dr. Labatt in his lectures, and for a number of
 years before this Dr. Labatt was accustomed to recommend a thick firm
 pad, or compress over the pubes, previous to the application of the
 ordinary binder, where, in former labors, uterine hemorrhage had taken
 place. Dr. M'Keevor states, that of 6665 women delivered during the
 years 1819 and 1820, only 25 were attacked with hemorrhage after the
 birth of the child. Of these, 15 occurred before the expulsion of
 the placenta, ten afterwards, and in all the results was favorable.
 He saw only two fatal cases during the time he was in the Dublin
 Lying-in Hospital, and he attributes this small mortality partly
 to the process of parturition being left entirely to the unassisted
 gradual efforts of the uterus; partly to the patient having been kept
 cool and quiet, free from all sources of disturbance and irritation;
 but, above all, to the careful application of the binder immediately
 after delivery, by which means the expulsion of the placenta, and
 permanent contractions of the uterus, are most effectually secured,
 and whenever any tendency to hemorrhage did occur before the removal
 of the placenta, the first point invariably attended to was to tighten
 the binder, and in the event of this not succeeding, a thick firm
 compress, made by folding a couple of large coarse napkins into a
 square form, was placed over the region of the uterus, and the binder
 again adjusted. In the great majority of instances, these, with the
 admission of cool air, checked the discharge; if not sufficient,
 additional pressure was made with the hands.

 "At the same time that you efficiently compress the fundus uteri
 with the binder and pad, cold should be vigorously applied to excite
 the contractions of the uterus. The best mode of doing this is
 to plunge a large napkin in a pitcher of cold water, and dash it
 suddenly against the external parts, the nates and thighs; and this
 should be repeated till the uterus contracts, and the violence of
 the hemorrhage is controlled. I am satisfied that this is the most
 efficacious method of applying cold to excite uterine contractions;
 it is far less formidable than pouring water from a height over the
 naked abdomen, but it is not less efficacious, and it possesses these
 decided advantages over the other method, that while the application
 is made to the external parts, nates, and thighs, the pressure of the
 binder and pad is not withdrawn from the hypogastrium, the position of
 the patient is not changed from the side to the back, the bed is not
 inundated with water, and the application can be repeated as often,
 and continued as long, as the urgency of the symptoms may require.
 The abdomen may be exposed once, and cold water poured over it from
 a height, and the uterus made to contract, and the flow of blood be
 arrested for a time, but relaxation of the uterus may follow after
 a short interval, and the hemorrhage be renewed again with equal
 violence as at first; but we cannot with propriety expose the abdomen
 a second time, and empty over it from a height the contents of a great
 decanter or kettle. Besides, by adopting this practice, we sacrifice
 the whole of the effects derived from pressure on the fundus uteri.
 The application of a napkin soaked in vinegar and water to the parts
 is often sufficient, along with the binder, to restrain the hemorrhage
 where it is not very profuse.

 "I have very seldom introduced a plug of any kind into the vagina in
 these cases, but when there has been a draining of blood from the
 uterus, after the practice now described has been employed, a large
 soft sponge passed into the vagina, and pressed up against the os
 uteri, has appeared in some cases to promote the coagulation of the
 blood. The sponge, however, cannot be employed with safety after the
 expulsion of the child and placenta, unless the uterus be firmly
 compressed above the brim of the pelvis to prevent its becoming
 distended with blood. More frequently I have had recourse with good
 effect, to the introduction of several pieces of smooth ice into
 the upper part of the vagina, and allowing them to remain there, in
 contact with the os uteri, and be dissolved, or pieces of ice have
 been inclosed in a bladder and laid over the pubes.

 "Other means besides those now described have been recommended in
 cases of flooding after the expulsion of the placenta. It has been
 proposed to inject cold water into the cavity of the uterus by means
 of the stomach pump, and favorable reports have been given of the
 practice. The effect, I think, would be similar to directing forcibly
 a stream of cold water against a stump soon after amputation; the
 coagula in the cavity of the uterus and in the orifices of the
 vessels would be all washed away: nevertheless, it might perhaps
 be advantageous in some desperate cases. Port wine and water, as
 cold as possible, Dr. Collins says, injected into the rectum, has
 been of service. Some of the earlier writers on midwifery, and many
 in the present century, have strongly recommended the introduction
 of the hand within the uterus for the purpose of removing the
 coagula accumulated within the cavity, and to excite the uterus to
 contract. But it is not necessary to pass the hand into the uterus
 for the removal of coagula, because if the binder has been properly
 applied, and strong pressure made over the fundus uteri, clots cannot
 accumulate within the uterus, and if they have been permitted to
 collect in consequence of neglect, then expulsion will immediately
 follow the use of proper compression of the hypogastrium, without
 the introduction of the hand. Nor do I consider it necessary, to
 excite uterine contractions, that the hand should ever be introduced
 into the cavity of the uterus after the removal of the placenta. I
 am fully convinced, from repeated observation, that this practice,
 which is so common as to be almost universal in this country at the
 present time, is often not only ineffectual for the purpose, in the
 worst cases of flooding, but that it is often followed by the most
 pernicious effects; the coagula which nature has formed have been
 displaced by the hand, and the uterus has not been excited by the
 stimulus of it to secure a permanent contraction. In the greater
 number of fatal cases of uterine hemorrhage after the expulsion of
 the placenta, which have come under my observation, the hand had been
 introduced into the cavity, and the closed fist had been pressed for
 a longer or shorter time round and round against the lining membrane,
 to make the uterus contract. I do not recollect a single fatal case,
 where the unfortunate result could be fairly attributed to the want
 of the introduction of the hand into the cavity of the uterus, and
 the friction of the knuckles against the lining membrane. I have
 repeatedly passed the hand into the uterus to produce contraction, but
 it has refused to obey the stimulus of the hand; it has remained like
 a soft flaccid bag, more like a piece of intestine than uterus, and
 the blood has continued to pour down the arm, until the hand has been
 withdrawn, and more efficient remedies employed. Leroux was well aware
 that the stimulus of the hand would not in all cases excite the uterus
 to contract, for he observes, "where the os uteri is contracted,
 the means indicated by Levret are very efficacious, and remove the
 hemorrhage as if by a charm. But it is not so in complete inertia of
 the uterus; often it is widely dilated, and offers no resistance to
 the introduction of the hand. The introduction even of the whole hand
 excites little sensation, and the woman will promptly perish from
 hemorrhage if other means more active and certain are not employed to
 prevent it." The tampon or plug is the remedy Leroux recommends in
 cases of flooding after delivery, and he affirms that it will often
 succeed in stopping the flow of blood when all other means fail. Dr.
 Dewees observes, that he has not found it necessary to introduce the
 hand for the purpose of stopping an hemorrhage after the expulsion of
 the placenta, during the last five-and-thirty years, as he regarded
 the practice as always frightful, and oftentimes unnecessary and
 pernicious. But it is difficult to subvert an established mode of
 practice, however unsound, and probably some of you, without much
 reflection, because you have heard this recommended, will pass up
 the hand into the cavity of the uterus after the expulsion of the
 placenta, on the very first occasion that you have an opportunity of
 doing so, remove all the coagula, and rub the inner surface with the
 fist till you are tired, without effect. I have seen cases repeatedly
 where this has been diligently performed by those who had neglected to
 apply the pad and binder, and all the other means now described. If
 you pass the hand at all within the parts, which I strongly suspect
 you will do, let me entreat you to carry it no farther than the os
 uteri, which you may, with much less risk and with greater effect,
 press and rub with the fingers and irritate than the inner surface of
 the body and fundus of the uterus.

 "Mauriceau recommends that women who are subject to flooding after
 delivery should be bled twice or thrice from the arm during pregnancy,
 and once, or oftener, after labor has commenced. There are cases of
 uterine hemorrhage after the delivery of the child and expulsion of
 the placenta unconnected altogether with the plethora, or an excited
 state of the heart and arteries, and where bleeding and low diet
 do not prevent the accident. Rupturing the membranes at the very
 commencement of labor is by far the best remedy, the only thing indeed
 upon which any dependance can be placed.

 "After attacks of uterine hemorrhage, the patient should not be raised
 from the horizontal position for several hours, and the strength
 should be supported by wine, beef-tea, and light nourishment. Brandy
 in gruel sometimes agrees when wine is rejected. A good large dose
 of the liquor opii sedativus often produces the most decided benefit
 after the hemorrhage has ceased; there are few cases before this
 in which opium does good, though it is constantly given in all the
 varieties of flooding, even when the great object is to excite uterine
 action. Where recovery is to take place after uterine hemorrhage,
 says Dr. M. Hall, the pallor of the countenance, the disposition to
 syncope, the coldness of the extremities, the feeble state of the
 pulse, and uninterrupted respiration, pass gradually away. Where
 the case is to terminate fatally, the symptoms gradually assume a
 more alarming aspect, the countenance becomes pale and sunk, the
 respiration stertorous, and the pulse cannot be felt at the wrist.
 There is great restlessness, and before death one or more fits of
 convulsions sometimes occur. Where recovery takes place, in some women
 it is astonishing how little permanent inconvenience is felt from the
 great loss of blood which they have sustained. In the course of ten
 days or a fortnight the effects have entirely disappeared; and this
 is the most common result. In some women, a violent determination of
 blood takes place to the brain, marked by heat, strong pulsations of
 the carotid and temporal arteries, intolerance of light, and all the
 symptoms of inflammation of the brain or its membranes. A strong
 febrile attack is also sometimes experienced, without an increased
 determination of blood to any particular organ. These affections of
 the brain and nervous system are aggravated by depletion. The patient
 should be kept in a cool, dark room, and mild cathartics, anodynes,
 and antispasmodics, occasionally given. Where there is much headache
 and throbbing, a few leeches should be applied to the temples, and a
 cold lotion to the scalp."

These remarks of Dr. Lee, as to bleeding frequently making the after
symptoms worse, should be carefully borne in mind. There is no doubt
but that too copious, or too frequent bleeding, during pregnancy or
labor, disposes the female to many serious dangers afterwards. I have
known some suffer constant headache, dizziness, and loss of memory, for
weeks after from it; and others have even been made light headed.

To the above remedies I would only append one other, which has, on many
occasions succeeded, when all others have failed, namely _Galvanism_.
This has, at the last moment, when the female was sinking, brought
on uterine contractions, stopped the flooding, and saved her life.
The application is very simple; one pole being placed on the back,
immediately between the hips, and the other over the uterus. Or one
of the poles may be coated with wax, all but the end, and introduced
into the vagina, so that the unwaxed part may touch the mouth of the
womb, while the other is placed over the fundus, or on the back, as
found most efficient. The power should be sufficiently strong to
produce contraction, and the application must be continued till the
contraction remains after the pole is withdrawn. No medical man should
give any female up who is flooding, no matter how severely, till he has
tried Galvanism. In my "_Neuropathy_" and "_Practical Facts_" will be
found many cases, with such plain directions that any one could follow
them and apply it.

The presentation of the placenta, or its growth over the mouth of the
womb, is the most serious cause of flooding, and generally makes any
attempt to check it of no avail, except _delivery_. The discharge
however nearly always occurs before the full period, and either causes
miscarriage or necessitates premature delivery. Dr. Lee remarks:

 "In the greater number of cases of placental presentation the
 discharge of blood takes place spontaneously in the seventh and eighth
 months of pregnancy, and cannot be referred either to bodily exertion,
 external violence, nor to any unusual determination to the uterine
 organs, or congestion of their vessels. The hemorrhage generally comes
 on suddenly, when the woman is in a state of rest, and the blood
 continues to flow until faintness or even syncope takes place. It
 often ceases entirely, and the patient resumes her usual occupations,
 and has no dread of another attack. But after an interval of several
 days, and sometimes not before two or three weeks, the flooding is
 renewed, and perhaps with increased violence, or a constant profuse
 discharge takes place, and a decided effect is produced upon the
 constitution,--the pulse becomes rapid and feeble, and the countenance
 pale. Similar attacks return at longer or shorter intervals, and if
 delivery be not accomplished by art, sooner or later death takes
 place. The first attack of flooding seldom proves fatal, but it
 sometimes does so; for in the second case related in the table, which
 occurred in the British Lying-in Hospital, the life of the patient
 was at once extinguished by a single gush of blood from the uterus. I
 examined the body after death. The centre of the placenta was over the
 centre of the os uteri.

 "When flooding takes place to an alarming extent in the seventh or
 eighth months of gestation, you ought first to ascertain, by a careful
 internal examination, whether or not the placenta be situated at the
 os uteri. It is impossible, from the manner in which the discharge of
 blood takes place, to be certain of the fact; for there are some cases
 of hemorrhage from detachment of the placenta from the upper part of
 the uterus, where the flooding occurs spontaneously, and to as great
 an extent as in cases where the placenta presents. In some cases I
 have been induced, from the symptoms, to believe that the placenta was
 at the os uteri when it was not. As the treatment and the successful
 or fatal result of the case will, in a great measure, depend on the
 correctness of the diagnosis, the examination should be conducted with
 so much care and circumspection as to leave no room for doubt on the
 subject. An ordinary examination, with the fore and middle fingers, is
 generally sufficient to enable us to ascertain the true state of the
 case, but where the os uteri is very high up, and directed backwards,
 it becomes requisite to introduce the whole hand within the vagina.
 The finger should then be passed gently through the os uteri, and,
 if the placenta adheres to the cervix, it will be distinguished from
 coagulated blood, the only substance with which it can be confounded,
 by its firmer, fibrous, vascular structure, and, above all, by its
 adhering at one part to the uterus, and being separated at another.
 If you will take the trouble to pass the finger carefully and
 repeatedly over the uterine surface of a recently expelled placenta,
 you will never, in actual practice, mistake a placenta at the os uteri
 for a clot of blood, however firm. In all cases it is requisite to
 proceed at once to determine by an examination, so carefully conducted
 as to render a mistake impossible, whether or not the placenta
 presents--even though the hemorrhage should be slightly renewed by the
 displacement of the coagula; you cannot be too early acquainted with
 the precise condition of the patient. You ought, at the same time, to
 ascertain whether the placenta adheres partially or completely to the
 cervix uteri, and whether the os uteri is in a condition to admit of
 the operation of turning being performed.

 "The operation of turning, which is required in all cases of complete
 placental presentation, is not necessary in the greater number of
 cases in which the edge of the placenta passing into the membranes can
 be distinctly felt through the os uteri. Sometimes there is profuse
 and dangerous hemorrhage where the placenta does not adhere all round
 to the neck of the uterus, but only partially. If the os uteri is not
 much dilated or dilatable, the best practice in these cases is to
 rupture the membranes, to excite the uterus to contract vigorously,
 by the binder, ergot, and all other means, and to leave the case to
 nature: by adopting this treatment the operation of turning may be
 avoided with advantage in the greater number of cases of partial
 placental presentation. But, if the hemorrhage is profuse, has
 returned at different intervals, and a great quantity has been lost,
 and the constitution is really affected, it is the safest practice at
 once, if the orifice of the uterus is in a condition to allow the
 hand to pass without difficulty, to deliver by turning the child.

 "Where the placental presentation is complete, the operation of
 turning should be performed, in all cases, as soon as the orifice of
 the uterus is so much dilated or dilatable as to allow the hand to be
 introduced without the employment of much force. It is seldom safe to
 attempt to deliver by turning before the os uteri is so far dilated
 that you can easily introduce the points of the four fingers and thumb
 within it: however soft and relaxed it may be, until dilatation has
 commenced, and proceeded so far, I am convinced there are very few
 cases in which the operation of turning will be required, or completed
 without the risk of inflicting some injury on the os uteri. This is a
 point of the greatest practical importance, but I do not know in what
 manner to communicate to you, in words, a more clear and definite idea
 of the grounds upon which you ought to proceed.

 "In every case, before attempting to turn, make a most careful
 examination of the os uteri, and endeavor, from the degree of
 dilatation, and the thinness and softness of the orifice, to form
 a correct judgment upon this point, before interfering, for the
 hemorrhage will be renewed if the attempt is unsuccessful, and the
 patient will be placed in a worse condition than she was before. When
 you have resolved to turn, let the patient lie on the left side,
 with the pelvis close to the edge of the bed, and introduce the
 right hand into the vagina as before described, and then pass the
 fingers and hand gently and slowly in a conical form through the os
 uteri, giving it time to dilate, and onward into the cavity between
 the detached portion of the placenta and the uterus: then force the
 fingers through the membranes, grasp both feet, and bring them down
 into the vagina, and _slowly_ extract the child as in the cases of
 nates presentation, and do not afterwards be in a hurry to remove the
 placenta, unless it is wholly detached and lying in the upper part
 of the vagina. This operation is easily and speedily performed when
 the os uteri is widely dilated and dilatable. It is, however, a great
 exaggeration of the facility with which turning may be accomplished in
 these cases, to represent it as a very simple process--like putting
 the hand into the coat-pocket and pulling out your handkerchief.
 At the best it is a dangerous operation, and you can never tell
 with certainty whether or not the patient will recover after its
 performance, however easily it may have been effected.

 "But there is not unfrequently most profuse and alarming flooding
 from complete placental presentation, where the os uteri is so thick,
 rigid, and undilatable, that it is impossible to introduce the hand
 into the uterus without producing certain mischief. In thirteen out
 of thirty-six recorded cases the os uteri was rigid and undilatable.
 The tampon or plug has no power to restrain the hemorrhage in such
 cases, nor do I know of any other means--either cold, quietness,
 or opium--which effectually have, and it is sometimes absolutely
 necessary under such circumstances to deliver by turning, before the
 hand can possibly be introduced into the uterus without producing
 fatal contusion or laceration of the part. I have found in several of
 these cases, however, that the delivery may be safely accomplished
 by merely passing the hand into the vagina, and afterwards the fore
 and middle fingers between the uterus and detached portion of the
 placenta, grasping with them the feet, which are generally situated
 near the os uteri, and drawing down the inferior extremities into the
 vagina, and delivering. I know that the inferior extremities may often
 be brought down in this way where it is impossible to pass the whole
 hand through the os uteri."

The same state of things may however result from other causes, and a
very different mode of proceeding may then be needed, as the doctor
very clearly shows.

 "Flooding may take place in the latter months of pregnancy, and during
 labor, where the placenta does not adhere to the neck of the uterus,
 but to the body or the fundus, and is detached by some external or
 internal cause. The separation of the placenta from the upper part
 of the uterus may be produced by violence, as blows, falls, pressure
 over the hypogastrium, and shocks of various kinds; but it arises much
 more frequently from internal causes, of which morbid states of the
 placenta, and twisting of the umbilical cord once or oftener round
 the neck of the child, are the most common and obvious. This variety
 of hemorrhage, though usually termed accidental, can rarely, however,
 be referred to accident. Sometimes the flooding occurs to a great
 extent without any assignable cause; a large portion of the whole of
 the placenta, when in a healthy condition, being suddenly detached
 from the uterus, when the patient has been exposed to no external
 accident, or injury of any kind, and when no symptoms of increased
 determination of blood to the uterus have preceded the attack. When
 this happens a large quantity of blood is poured out between the
 placenta and uterus, a small portion of which only at the time usually
 escapes from the vagina, to indicate what is going on within the
 uterus. There may be a great internal hemorrhage, accompanied with
 the ordinary constitutional effects resulting from loss of blood--as
 faintness, sickness, or vomiting, coldness of the extremities, rapid
 feeble pulse, hurried breathing; when there is little or no discharge
 from the vagina to excite alarm, or to point out the source of danger,
 when it is extreme. It is from the general symptoms of exhaustion, and
 by the disagreeable sense of uneasiness, weight, or distension of the
 uterus, experienced, and not from the quantity of blood which appears
 externally in these cases, that we are led to discover the true state
 of the patient--to suspect that internal hemorrhage is going on. But
 much more frequently only a small portion of the placenta is at first
 detached, and the greater part of the blood which is extravasated
 between it and the uterus separates the membranes, and descends by its
 weight to the orifice, and escapes through the vagina. In all cases,
 however, of uterine hemorrhage in the latter months, the danger cannot
 be so accurately estimated by the quantity of blood which appears
 externally, as by the general symptoms. The portion of placenta which
 is detached, never re-unites to the uterus, but when expelled it is
 usually seen covered with a dark coagulum adhering to the uterine
 surface.

 "When the blood escapes in small quantity, and there are no labor
 pains present, and no disposition in the os uteri to dilate, and the
 constitutional powers are not impaired, an attempt should be made to
 prevent a return of the discharge, and the occurrence of labor pains.
 For this purpose, if the pulse is full and frequent, some blood may be
 taken from the arm, and the patient should be kept in the horizontal
 position, surrounded by cool air, cold applications made over the
 hypogastrium, and acetate of lead and opium, mineral acids, and other
 remedies that diminish the force of the circulation and promote the
 coagulation of the blood, should be taken internally. The plug is
 here totally inadmissible; it can only convert an external into an
 internal hemorrhage. But where the flooding occurs at first profusely,
 and is renewed even in a moderate degree, in spite of our efforts to
 check it, the continuance of pregnancy to the full period cannot be
 expected; it will be of no avail to bleed and administer internal
 remedies, except for the purpose of checking the discharge, and thus
 averting the immediate danger until the uterus is emptied of its
 contents.

 "The operation of turning, which is required in all cases of complete
 placental presentation, is rarely necessary in uterine hemorrhage
 where the membranes are felt at the orifice. In a great proportion of
 these cases, where, on making an examination, you can feel the smooth
 membranes extending across the neck of the uterus, the flooding will
 be arrested, and the labor safely completed, if the membranes are
 ruptured, the liquor amnii discharged, and contractions of the uterus
 excited by gentle dilatation of the orifice, and other appropriate
 means. The only cases in which this treatment fails are those in which
 it has not been had recourse to sufficiently early, or where the
 whole or a large portion of the placenta has been suddenly separated
 from the uterus, and a great internal hemorrhage has taken place.
 The uterus will not contract effectually in these cases after the
 membranes have been ruptured; the pains, instead of becoming stronger,
 become more and more feeble, return at longer intervals, and during
 these the blood flows more profusely, and death would take place
 before delivery, if the child were not extracted by the forceps,
 crotchet, or by the operation of turning. In all cases, then, of
 uterine hemorrhage in the latter months of pregnancy, and in the first
 stage of labor, where the placenta does not present, and the quantity
 of blood discharged is so great as to render delivery necessary, where
 it appears improbable that the pregnancy can go on longer with safety,
 or to the end of the ninth month, rupture of the membrane with the
 nail of the forefinger of the right hand, evacuate the liquor amnii
 by holding up the head of the child, dilate very gently the os uteri
 with the fore and middle fingers expanded, and occasionally make
 pressure with the fingers around the whole orifice; apply the binder,
 give ergot and stimulants, and the uterus will, in all probability,
 contract upon its contents, and expel them without further trouble.
 If the hemorrhage should, however, continue after the employment of
 these means, delivery must be accomplished by the forceps, craniotomy,
 or by turning, according to the peculiarities of the case. In women
 who are liable to attacks of flooding after the expulsion of the child
 or placenta, rupture the membranes at the commencement of labor, even
 before the os uteri is much dilated, if the presentation is natural,
 and you will often succeed in entirely preventing hemorrhage."

The recommendation to bleed may be with good reason objected to, at
least in the great majority of such cases; and I cannot but think that
a timely and persevering use of the ordinary remedies, namely, keeping
quiet, using acid drinks, and cold fomentations to the abdomen, would
do away with any necessity for it at all. I question very much if ever
bleeding really prevented abortion from flooding, and I cannot but
think that it has often brought it on sooner. Nevertheless, if all
other means fail to arrest the discharge, and there are no decided
objections to the contrary, it might be cautiously tried; though the
policy of taking _more_ blood from a person who is already losing _too
much_, is not very evident.

I have often known the most severe flooding stopped, merely by the
female lying on her back, drinking plentifully of lemonade, and
applying cold wet cloths over the abdomen. A small dose of laudanum
occasionally is also useful; and complete rest and tranquillity of
_mind_ is as indispensable as rest of the body. Many females flood
and miscarry merely from worrying and fretting themselves, and from
passion, or strong excitement, _particularly of a certain kind_. This
in short must be carefully avoided, and the patient must live strictly
as if a widow.

This accident is likely to occur in subsequent pregnancies, at nearly
the same time, and should therefore be guarded against by a careful
avoidance of all excitement, or violent bodily exertion, during the
whole time. Keeping the bowels gently open, and practising a regular
diet, are also requisite. A good supporting bandage is also of frequent
service. For much more valuable information on this subject however,
I refer to my work on "_The Diseases of Women_," in which it is fully
treated.




CHAPTER XXII.

ECLAMPSIA, OR CONVULSIONS DURING LABOR.


Convulsions are to be looked upon as very serious indications of
derangement, during either pregnancy or labor, and are frequently
followed by fatal results to both mother and child. They may be of
several different kinds, _epileptic_, _hysteric_, or _cataleptic_,
though the epileptic form is most common. They often occur during
pregnancy, but not usually before the seventh month, though
occasionally met with much earlier. According to observations it
appears that there is not above one case of convulsions in six hundred
deliveries.

The principal cause of this disease appears to be the strong sympathy
between the womb and other organs, owing to which they are continually
disturbed by the changes it undergoes. Certain temperaments also
dispose to it, particularly the lymphatic, and also dropsy, rickets,
and other diseases. Strong moral impressions may also have a
predisposing effect, such as sudden frights, joy or anger, and also
acute pain, or the dread of it.

In most cases, and particularly during pregnancy, the convulsions are
preceded, and indicated, by severe headache, and spasm at the stomach,
with dimness of sight, bright sparks before the eyes, buzzing in the
ears, and partial difficulty in speaking. Occasionally however the fit
comes on quite suddenly, without any warning whatever.

There are few exhibitions of suffering more frightful than one of
these attacks, and none that call for more prompt and decided action.
In general females are perfectly helpless when one is attacked in
this way, and instead of being able and disposed to render proper
assistance, they either run away alarmed, or fall into hysterics
themselves. It is however of the utmost consequence that the sufferer
should be attended to instantly, and therefore every female should know
what to do in such an emergency, at least till better aid can arrive.

At the first commencement of convulsions the features become gradually
fixed, the eyes are expanded and distorted, the breath is drawn with
difficulty, and all consciousness appears to cease. The body then
begins to twitch, the mouth opens, usually on one side, the tongue
protrudes, the head turns on one side, and the blood rushes to it and
the face in great quantities. In a short time the jaws close again with
great force, and the tongue is bitten if proper care has not been taken
to prevent it. At last the eyes began to twinkle, the mouth moves as
if the patient were muttering, and the nostrils expand; the arms are
thrust straight down by the sides of the body, with the hands firmly
closed; the legs are stiffened straight out, and the body is bent
back like a bow. In short every muscle is affected with spasms, which
are sometimes fearfully violent, and may endure for a considerable
time. When they subside, the fit gradually terminates and passes off.
During the whole time the breathing is difficult, the mouth froths
very much, and the heart palpitates quickly, but irregularly. When the
spasm is over the patient falls into a perfect stupor, during which
she remains unconscious, but with all the limbs soft and moveable,
except the fingers, which appear to grasp. The jaws generally remain
closed, and so do the eyes, but they may be easily opened, and will
sometimes remain open; the breathing becomes powerful and loud, and the
pulse beats with rapidity. At last slight motions are observed, and
consciousness gradually returns, but the memory is generally gone for
some time. This state of stupor usually lasts from ten minutes to half
an hour, but has been known to continue for many hours, or even a whole
day. The spasm seldom continues more than from one to ten minutes,
though it has lasted for an hour or more.

These convulsions might be mistaken for ordinary hysteria by those
not acquainted with the difference. In hysteria however the female
moves about and struggles more; she also cries out, and retains both
sensibility and consciousness, so perfectly even sometimes that
she requests those around to hold her, which is never the case in
convulsions.

During the stupor it might be supposed, by any one not aware of
the previous fit, that the patient was suffering from apoplexy, or
intoxication, the appearance being so similar to that exhibited in
those states. This shows the necessity for careful inquiries as to what
has previously occurred.

During pregnancy convulsions generally cause abortion, either by
bringing on uterine contractions or by causing the death of the child.
Some few patients have suffered from them however, and yet gone their
full time, but this must never be expected. A gradual extinction of
the vital spark, during the stupor is the ordinary termination, though
sudden death is not unfrequent, during the fit. Gradual recovery is
occasionally witnessed, but seldom without partial loss of memory, or
some other affliction. Madame Lachapelle says that _one-half_ of the
females attacked with convulsions die, and of their children many more.

There is no doubt but that the _tendency_ to this fearful affliction
may be very much lessened in many females, by proper attention to diet
and regimen. Those who are of a full habit, and disposed to headache,
and rush of blood to the head, should live low, and carefully avoid
everything of a heating or stimulating character, and also every kind
of excitement or agitation. The bowels should be kept free, and the
skin well rubbed and kept warm, and the head cool.

_Treatment._--While the patient is in the fit, care must be taken that
she does not fall off the bed, or bite her tongue, to prevent which
the jaws must be kept apart, by putting something between, as a piece
of soft wood, or the handle of a spoon covered with cloth, or even a
knotted napkin. The face should be sprinkled with cold water, and the
whole body well chafed, particularly the hands and feet, which should
also be made warm as soon as possible. As soon as the spasm is over it
is customary to bleed, either at the arm, or by leeches to the temples
and behind the ears. Mustard poultices should also be applied to the
feet, and inside the thighs, and an enema should be given of warm water
and a table-spoonful of salt. Ice, or cold water, should be applied
to the head constantly, and if possible the body should be immersed
in a hot bath, which will, in many instances, bring the patient round
immediately without any other treatment. The bladder should be also
looked to, as well as the bowels, and if necessary the catheter should
be used. As soon as she can swallow a few drops of laudanum may be
given, or a little ether, but not a full dose by any means.

The propriety of bleeding, even in these cases, is denied by many, and
I am almost inclined to think myself, that a prompt and persevering use
of the other remedies mentioned, would be fully as successful without
it. At all events, the fearful mortality in spite of it proves that it
has not much power, and may well raise a doubt of its utility.

Convulsions however are so fearful and violent, that few practitioners
can resist the temptation to bleed, because it seems so well calculated
to give prompt relief; and besides it has popular prejudice in its
favor. Some authors however assert that it makes the danger greater of
paralysis, and loss of memory, afterwards.

When convulsions occur during pregnancy they seldom cease entirely till
the uterus is emptied of its contents. It is therefore necessary to
bring on labor, and terminate it as soon as possible, after the parts
are in a proper condition. When they occur during labor it must also
be finished in the shortest time possible, to afford the best chance
of saving the child, and also because no treatment will prevent the
attack while the patient remains undelivered. All means of bringing
on dilatation of the mouth of the womb, mentioned in the article on
_Rigidity_, may be resorted to, excepting _Ergot_, which should never
be used in these cases.

M. Chailly tells us, that in thirteen cases of convulsions _nine_ were
first pregnancies, and _seven_ of the females were dropsical. Only
_one_ was attacked during pregnancy, _ten_ while in labor, and _two_
after. Only _two_ died, and _ten_ of the children.

It is worthy of remark that where pregnant females have had
convulsions, apparently from living too high, the children have also
had them after delivery.




CHAPTER XXIII.

RUPTURE OF THE WOMB OR VAGINA.


Rupture of the womb arises from various causes, but most usually from
powerful contractions when the pelvis is small, or the fœtus large, or
when it presents unfavorably. It not unfrequently results also from
force being used, particularly with _instruments_. In fact there is
no doubt but that _numerous_ females die from this accident, brought
on by the violence, haste, and want of skill of their attendants. Few
injuries are more serious, or more beyond the reach of any remedy than
this, though it is sometimes suffered with impunity.

The symptoms of rupture of the womb are strongly marked, and fearfully
evident. When it occurs, which is most usually during a powerful
contraction, the female shrieks, and instantly complains of an
agonizing pain over the seat of the rupture; her face grows deadly
pale, her pulse falls, and she faints. In general _death_ is almost
instantaneous, though sometimes life may be preserved for an hour or
two, but very seldom. There have even been cases of recovery, but they
are very few, and regarded almost as miracles.

In most cases, directly the rupture happens the fœtus escapes through
the rent into the abdomen, and most of the fluid with it; but sometimes
it still remains in the womb, and then if the liquor amnii is
discharged there may little or nothing pass through the opening, and
the danger will be much lessened in consequence. In all cases the only
proceeding which offers any chance of recovery is, _to deliver as soon
as possible_, because when the fœtus is expelled the uterus begins to
contract, so as to close the wound, and when that is effected, if but
little fluid has passed into the cavity of the abdomen, all may yet
go well. It may frequently happen, when the hand is passed into the
womb, to turn and deliver, that nothing can be found, the fœtus having
passed through the opening into the abdominal cavity, in which case the
hand must be passed through the opening also, and the fœtus be brought
back if possible. If however the rent is too much closed, or the child
cannot be reached, the _Cesarean_ operation is the only resort.

M. P. Dubois tells us of a case of this kind which occurred in his
own practice. The female had only been in labor about an hour when
she uttered a piercing cry, and sank as if suddenly mortally wounded.
The head of the child, which was previously at the mouth of the womb,
could not be felt, and on introducing his hand M. Dubois found its feet
were passed through the opening into the mother's abdomen; he brought
them back however, and effected delivery by turning with comparative
ease. Strange to say this woman was discharged _cured_, in fifteen days
after, though the uterus was so torn that the intestines had forced
themselves through the opening into its cavity, and M. D. put them back
with his hand, which also passed clear into the peritoneal cavity. In
all cases, after the delivery is effected, the womb should be again
explored, so that if any parts have come through they may be returned
before the opening closes, which it may do very soon.

Cases are even mentioned where the child passed clear out of the womb
into the abdominal cavity, and remained there till absorbed, or
escaped through a fistulous opening many years after; while the wound
healed up, and otherwise the patient perfectly recovered. Recovery
however, in any way, is a rare occurrence.

Some females seem more disposed to this accident than others; possibly
from a peculiar tenderness in the substance of the womb. All are
however liable to it, and this liability should beget a proper caution
in all manipulations, and forbid uncalled for violence in any way.

Rupture of the vagina is much less serious than rupture of the womb,
unless it occurs at the upper part, when it may give rise to similar
symptoms and results. At the lower part the danger is much less, though
still sufficient to excite apprehension.

The treatment is the same as in the former case. Delivery must be
effected as soon as possible, and the patient kept still and cool to
avoid inflammation.

_It is generally thought that the greater part of these accidents
result from improper treatment, and particularly from using
instruments._




SECTION VIII.

OPERATIONS WITH THE HAND AND WITH INSTRUMENTS.




CHAPTER XXIV.

OPERATIONS WITH INSTRUMENTS.


The use of instruments in effecting delivery is a last resort to save
life, and ought to be intrusted only to persons of skill; it may
therefore be thought unnecessary to treat of them in the present work,
and indeed I should not have done so but for the purpose of satisfying
the natural curiosity of females themselves. The greater part of the
dread they now experience where instruments are needed, arises from
ignorance of their nature and mode of action. At the present time
nearly all the instruments used, in competent hands, are comparatively
safe and harmless, and if females generally understood how they
operated, much less fear would be excited by their use. Years ago, when
cutting and tearing instruments were employed, in nearly every case of
difficulty, the lamentable results which followed fully justified the
fears experienced, but at the present day such things are seldom seen,
except in medical museums, the same purpose being much better effected
by simpler and more harmless apparatus. I wish therefore simply to
give a brief explanation of the structure, and mode of action, of the
instruments now chiefly employed, and to show the extent of their
application and the results which have followed from it.


THE FORCEPS.

The forceps are intended to take hold of the fœtus, and assist us to
draw it into the world when the natural forces are inadequate, and no
hold can be obtained by the hands. They were first invented about the
year 1650, by an English surgeon named Chamberlin, who made a secret
of his invention and realized a large fortune from it. Since that time
they have been modified in various ways, by different practitioners,
but still remain essentially the same as when first used.

The most usual form, and probably the best, is that represented below:

[Illustration: PLATE L.

  Fig. 1.       Fig. 2.]

It consists of two blades articulated by a button, or screw joint, so
that they can be easily separated and again adjusted,--Fig. 1. Each
blade is cut out in the middle, and curved, as seen in Fig. 2.

The only part to which the forceps are intended to be applied is the
head, to the dimensions and form of which they are specially adapted.
Some practitioners have used them on the breech, but the practice is
not generally sanctioned, because they seldom retain their hold on this
part and are nearly sure to seriously injure the child when so applied.
With properly constructed forceps, rightly applied to the head, there
is but little danger either to the mother or the child; but in the
hands of an unskillful or careless person the consequences of their use
may be deplorable to both.

It is scarcely necessary to remark that the forceps are neither
_cutting_ nor _crushing_ instruments, but are simply intended to _lay
hold_, like the hand itself, and enable us to draw down the head, or
change its position. Most usually they are made long and curved, as
shown in the above plate, but sometimes they are made much shorter
and straight. They may be used upon the head when it is either at the
upper or the lower straits, or while it is in the passage; but on no
account should they be applied till the parts are fully dilated, and
everything indicates that the child _can_ pass. Thus they should never
be used when the head is too large, or the pelvis too small, nor when
there are tumors in the way. In short no attempt should be made with
them to _force_ the fœtus through a passage which will not admit it
by reasonable efforts. M. Dubois says they should never be used when
the pelvic diameter is less than _three inches_, because with such
dimensions the child is nearly certain to be crushed to death, and the
mother can scarcely escape serious bruises and lacerations. In like
manner, if they are thrust into the womb before the mouth of it is
naturally dilated they are sure to tear and injure it.

It is not necessary here to give directions for using the forceps in
every variety of presentation and position, but simply to show the mode
of applying them as they are most frequently required. The two blades
are adjusted separately, one to each side of the head, and then locked
together, so that the head is firmly inclosed between them, but not
crushed. Dr. Denman gives perhaps the best and simplest directions on
this point, and I therefore quote from his work.

 "The first part of the operation consists in passing the forefinger
 of the right hand behind the ossa pubis and the head of the child to
 the ear; then taking the part of the forceps to be first introduced
 by the handle in the left hand, the point of the blade is to be
 slowly conducted between the head of the child and the finger till
 the instrument touches the ear: there can be no difficulty or hazard
 in carrying the instrument thus far, because it will be guided, and
 in some measure shielded, by the finger. But the further introduction
 must be made with a slow semi-rotatory motion, keeping the point of
 the blade not rigidly, yet closely, to the head of the child, by
 raising the handle toward the pubes. In this manner the blade must
 be carried gently along the head till the lock reaches the external
 parts near the anterior angle of the pudendum. The point of the blade,
 while introducing, sometimes hitches upon the ear of the child, and
 it then requires a little elevation. But when it has passed the ear,
 and is beyond the guidance of the finger, should there be any check
 to the introduction either of this or the other blade, it should
 be withdrawn a little, to give us an opportunity of discovering
 the cause of the obstacle, which we must never strive to overcome
 by violence, though we must proceed with firmness. When the first
 blade is properly introduced, it must be held steadily in its place
 by pressing the handle towards the pubes, and it will be a guide in
 the introduction and application of the second blade. Let the second
 blade be introduced in this manner. Keep the blade first introduced
 in its place with the two lesser fingers of the left hand, and carry
 the fore-finger of the same hand between the perineum and head of the
 child as high as you can reach. Then take the second blade of the
 forceps by the handle in the right hand, and, conveying the point
 between the finger placed within the perineum and the head of the
 child, conduct the instrument, with the precautions before mentioned,
 so far that the lock shall touch the interior part of the perineum, or
 even press it a little backwards. In order to fix the two blades thus
 introduced, that which was placed towards the pubes must be slowly
 withdrawn, and carried so far backwards that it can be locked with the
 second blade retained in its first position; and care must be taken
 that nothing be entangled in the lock, by passing the finger round it.
 When the forceps are locked, it will be convenient to tie the handles
 together with sufficient firmness to prevent them from sliding or
 changing their position when they are not held in the hand, but not
 in such a manner as to increase the compression upon the head of the
 child. Should the blades of the forceps be introduced so as not to be
 opposite each other, they could not be locked; or if, when applied,
 the handles should come close together, or be at a great distance from
 each other, they would probably slip, or there would be a failure
 of some kind in the operation, as the bulk of the head would not be
 included, or they would be fixed on some improper part of the head;
 though allowance is to be made for the difference in the size of the
 heads of children. But if a case be proper for the forceps, if they be
 well applied, and we were to act slowly with them, there would not be
 much risk of failure or disappointment. The difficulty of applying the
 forceps is most frequently occasioned by attempting to apply them too
 soon, or by passing them in a wrong direction, or by entangling the
 soft parts of the mother between the instrument and the head of the
 child, against all which accidents we are to be on our guard.

 "When the forceps are first locked, they are placed backwards, with
 the lock close to, or just within, the internal surface of the
 perineum; and they can have no support backwards, except the little
 which is afforded by the soft parts. The first action with them
 should therefore be made by bringing the handles, grasped firmly in
 one or both hands, to prevent the instrument from playing upon the
 head of the child, slowly towards the pubes till they come to a full
 rest. Having waited a short interval with them in that situation, the
 handles must be carried back in the same slow but steady manner to the
 perineum, exerting, as they are carried in the different situations,
 a certain degree of extracting force; and after waiting another
 interval, they are again to be carried towards the pubes, according
 to the direction of the handles. Throughout the operation, especially
 the first part, the action of that blade of the forceps originally
 applied towards the pubes must be stronger and more extensive than
 the action with the other blade, this having no fulcrum to support
 it, and chiefly answering the purpose of regulating the action of
 the other blade. If there were any labor pains when the operation
 was begun, or should they come on in the course of it, the forceps
 should only be acted with during the continuance of the pains; the
 intention being, not only to supply the want or insufficiency of the
 pains, but to follow them, and imitate also the manner in which they
 return. By a few repetitions of this alternate action and rest before
 described, we shall soon be sensible of the descent of the head; and
 it will be proper to examine very frequently, to know the progress
 made, that we may not use more force than needful, nor go on with
 more haste than may be expedient or safe. In every case we ought to
 proceed slowly and circumspectly, not forgetting that a small degree
 of force, continued for a long time, will in general be equivalent to
 a greater force hastily exerted, and with infinitely less detriment to
 the mother or child. But after some time, should we not perceive the
 head to descend, the force hitherto used must be gradually increased,
 till it be sufficient to overcome the obstacles to the delivery of the
 patient. It was before observed, as the head of the child descended,
 that the face would be accordingly turned towards the hollow of the
 sacrum, without any aim or assistance on our part. Of course the
 position of the handles of the forceps, and the direction in which we
 ought to act with them, should alter; for they becoming first more
 diagonal or oblique with respect to the pelvis, and then more and more
 lateral, every change in their position will require a differently
 directed action, because the handles should ever be antagonists to
 each other. In proportion also to the descent of the head the handles
 of the forceps should approach nearer to the pubes; so that, in the
 beginning of the operation, though we acted in the direction of the
 cavity of the pelvis, towards the conclusion we should act in that
 of the vagina. When we feel that we have the command of the head, by
 its being cleared of the pelvis, and the external parts begin to be
 distended, we ought to act yet more slowly, especially in the case
 of a first child, or there would be great danger of a laceration
 of the soft parts; and this can only be prevented by acting very
 deliberately in the direction of the vagina--by giving the parts time
 to distend--by duly supporting the perineum, which is the part chiefly
 in danger, with the palm of the hand--by soothing and moderating the
 hurry and efforts of the patient--and, in some cases, by absolutely
 resisting for a certain time the passage of the head through the
 external parts."

[Illustration: PLATE LI.

_The head being drawn through a narrow Pelvis by the Forceps._

 The manner in which the forceps draw the head is well shown in the
 above plate, and also the compression of the head itself, which is
 seen to be squeezed almost to a point at its presenting part. This
 compression, however, is not likely to do serious injury, unless it be
 excessive. The child may be convulsed a little from it, but usually
 recovers, and suffers nothing afterwards.]

It is merely necessary to remark, in conclusion, that the forceps
should never be used till it is manifestly impossible for the child to
be born without them; and it should be remembered that nature alone
frequently effects delivery under the most unfavorable circumstances,
by giving her time. We should wait therefore as long as the safety of
the mother will allow, but never delay a moment when that safety is
compromised.

The accidents which have followed from the use of the forceps are
numerous and terrible, and I could give a most horrifying account of
them if it were necessary. It must be recollected however, that these
accidents have chiefly followed from want of skill in managing the
instrument, or from its being used under improper circumstances. It is
true that there is always more or less of pain and injury to be dreaded
from the forceps, even in the most favorable cases, and with the most
competent operators, but this is no argument against their employment
altogether. In every case where they are really called for, the female
would, most probably, die undelivered, or have to be cut open, so that
it is simply a choice of evils, of which the forceps are the least.

The cases in which the forceps are absolutely necessary however, are
VERY RARE, much more so in fact than many people suppose. _Patience_,
and the persevering use of ordinary assistance, would probably succeed
alone in half the cases where they are now employed.

In Murphy's lectures on _difficult Labors_, he gives us some valuable
statistics on this subject. He tells us that in _seventy-five thousand
nine hundred and eleven labors_, the forceps were used only _one
hundred and thirty-eight times_, or once in every _five hundred
and fifty_ labors. In these one hundred and thirty-eight cases
_thirty-five_ of the children died, and _ten_ of the mothers. Dr.
Murphy however, thinks that the general results, to both mother and
child, would be equally favorable if the forceps were _not used at
all_, and he gives the tables of Dr. Collins to support his opinions.
From these tables it really appears that, when all the difficult labors
were left entirely to nature, the number of deaths was _just about
the same as when the forceps are used_, in fact _rather less_, while
the accidents, and subsequent evils, were not nearly so great. Dr.
M. therefore thinks that the forceps should _never_ be used, except
in a few cases where everything is quite favorable to the passage of
the fœtus; and the uterus _cannot_ be made, in a reasonable time, to
contract and expel it; and also when _immediate_ delivery is needed
to save the mother's life, as in flooding. In cases of mere ordinary
difficulty or delay, he decries their use entirely; and he evidently
thinks that when the labor is _fit_ to be terminated by the forceps,
nature can and will terminate it herself if left alone. There is no
doubt but that they are now used a great deal _too much_, either from
a desire to _operate_, or from _want of patience_; and I have no
hesitation in expressing my opinion that more have been _killed_ than
_saved_ by them.


OTHER INSTRUMENTS.

Respecting other instruments, such as the _Crotchet_, the _Vectis_, and
the _Cephalotribe_, or _crushing forceps_, it is not necessary to say
anything here, as their use, when imperatively needed, must necessarily
be confined to the surgeon; and fortunately may now be dispensed with
altogether. The recently introduced practice of bringing on _premature
labor_, in all cases of deformity or smallness of the pelvis, entirely
obviates the necessity for any of these dreadful resorts, if the
difficulty be known in time, which it is sure to be when a sufficient
degree of knowledge is disseminated.

The _Cesarian operation_, or cutting open the womb externally; and
_Cephalotomy_, or the opening of the child's head, may also be
dismissed with the same observations. _They can always be avoided_, if
the real condition of the patient is known in time; and if from neglect
nothing else can be done, they must always be performed by a skillful
surgeon.




CHAPTER XXV.

OPERATIONS WITH THE HAND.


TURNING.

This is one of the most useful operations that the accoucheur can
perform, in many cases, and has the advantage of being altogether
accomplished _by the hand_. Its object is to change the presentation,
when unfavorable, and to facilitate delivery. Most usually the hand is
introduced into the uterus, and the _feet_ are brought down. This is
called _pelvic version_; but sometimes the head is brought to the mouth
of the womb, particularly in shoulder presentations, and this is called
_cephalic version_.

_Cephalic Version._--This can seldom be performed, and not often
attempted with safety. In some cases however, when it is ascertained
that the shoulder presents, and before the membranes are broken, an
effort may be made to remove it and bring the head in its place. To
do this the position of the head must be ascertained externally, and
one hand placed upon it; then with the two forefingers of the other
raise up the shoulder from within, as in ballotment, and endeavor to
push the head into its place. If the child be very moveable this may
sometimes be done, and will be highly advantageous; but most frequently
the substitution cannot be accomplished, and the attempt ruptures the
membranes, after which it is still more difficult, and even becomes
dangerous. Even if the head be brought down there is always danger of
its becoming displaced, and the shoulder again presented, owing to
the tendency which any presentation has to be reproduced. To prevent
this the hand should be firmly pressed on the fœtus, externally, as
soon as the head is brought down, to fix it; and the membranes should
be ruptured so that it may begin to descend, after which there is no
danger of a change.

Cephalic version can be so seldom performed however, and is so
difficult, and sometimes dangerous, that it is seldom or never
attempted; more particularly as pelvic version can always be
substituted, and is more easy and safe. It is true that presentations
of the head are the most favorable, providing they occur before the
rupture of the membranes, but after that event they may not be so
favorable as those of the lower extremities, and certainly are not so
easy or safe to induce.

_Pelvic Version._--Turning to bring down the feet is performed for
various reasons, and under many different circumstances. As a general
principle we may say that it is done either to change the presentation,
when unfavorable, or to terminate the labor when it is lingering,
or when it is desirable to have it over as quickly as possible. The
feet may be drawn through the mouth of the Womb when it is but little
opened, and when they have once passed, the limbs and body soon follow,
and the head seldom remains long behind. The fœtus may in fact be
compared to a _wedge_, of which the feet are the point, and if they
enter the passage the rest part is gradually driven after by the
uterine contractions.

The chief contingencies which call for the operation of turning are, a
protracted labor, a presentation of the placenta, causing hemorrhage,
and a wrong presentation, particularly one of the shoulder.

The operation of turning is very clearly explained by Dr. Lee, and I
know from experience that his directions can be safely relied upon.
It very frequently happens however, that there will be some peculiar
circumstances in a case, which will necessitate more or less change
in the manner of proceeding, so that the practitioner must after all
be guided, to a great extent, by the requirements and conditions then
existing. Dr. Lee's directions therefore, must merely be considered as
_general_ ones, to be modified as occasion may require:--

 "When the operation of turning is required before the membranes are
 ruptured, and when the orifice of the uterus is widely dilated, and
 there are long intervals between the pains, it is accompanied with
 little difficulty and danger. Having explained to the patient and
 her relatives the nature of the case, let her lie on the left side
 near the edge of the bed, with the knees drawn up to the abdomen. Sit
 down by the side of the bed, and quietly take off your coat; lay bare
 your right arm by turning up the shirt above the elbow, and cover
 the back of the hand and the whole forearm with cold cream, lard,
 or a solution of soap. Introduce one finger after another into the
 vagina, and slowly and effectually dilate its orifice. The hand, in a
 conical form, and in a state of half supination, must then be pressed
 steadily forward with a semi-rotatory motion against the perineum and
 sides of the passage, till it clears the orifice of the vagina. This
 should always be done very slowly and gently, as it is accompanied
 with great pain. Let the hand remain some time in the orifice of
 the vagina, that it may be fully dilated, and offer no resistance
 in the subsequent steps of the operation of turning. When the hand
 has dilated the vagina sufficiently, in the absence of pain gently
 insinuate the points of the fingers and thumb into the os uteri in a
 conical form; and if it is not sufficiently open to allow the hand to
 pass, you must proceed next to use artificial dilatation here also,
 very gently and slowly, always stopping as soon as a pain comes on,
 but not withdrawing the fingers altogether at the time from the os
 uteri. Having succeeded in dilating the part without rupturing the
 membranes, slide the hand up between the membranes and the anterior
 part of the uterus into the cavity, and grasp the feet when the
 membranes give way. Most frequently the membranes burst as the hand is
 entering the uterus, before it reaches the feet, and the liquor amnii
 rushes out and is lost, if it is not prevented by pressing the hand
 forward firmly into the orifice. Never be contented with one foot when
 it is possible to grasp both; and this can always be done when the
 liquor amnii has not escaped, and the uterus is not closely contracted
 round the body of the child. Seize both feet and legs, and when
 there is no pain, draw them down into the vagina; and as the nates
 descend through the os uteri, the shoulder and arm will gradually
 recede or be retracted, and will offer no obstacle to the remaining
 part of the operation, which should be completed as if the nates and
 inferior extremities had originally presented, and which has already
 been very fully described. In actual practice, except in twin cases,
 the membranes have been ruptured and the liquor amnii is gone, in a
 great proportion of cases--in about ten to one--long before we are
 called upon to deliver by turning, and the operation is then a much
 more serious affair. Sometimes, when the os uteri is half dilated,
 there is an interval of freedom from pain for several hours after the
 rupture of the membranes, and partial escape of the liquor amnii. Here
 it is advisable to turn without delay; and the hand can be passed up
 into the uterus and the feet brought down with little more difficulty
 than if the membranes had not been ruptured."

The operation of turning is however beset with many difficulties, and
unless the conditions for it are very favorable, and the operator
skillful, it may cause greater mischief than it is intended to remedy.
The probability is, as in the case of other operations, that it would
seldom or never be needed if proper means were used in time, and
perseveringly; and it is yet a question whether the prospect, for both
mother and child, would not be more favorable if the delivery was
always left to nature, in those cases where version is now attempted.
Dr. Collins says, "As to turning, the risk to the mother is, in the
majority of cases, so great as to forbid its employment, nor do I think
the practitioner justified by the circumstances in so greatly hazarding
his patient's life."




PART II.

THE DISEASES OF WOMEN DURING PREGNANCY, AND IN CHILD-BED.


Women are liable during pregnancy, and after childbirth, to most of
the diseases which afflict them at other times, and also to many
derangements peculiar to those periods. As a general rule either of
those conditions somewhat modifies the disease, and also necessitates
certain differences in its treatment. My former work on the _Diseases
of Women_ having treated on all those affections common to every other
period, I shall in this confine myself chiefly to those peculiar to
the two conditions referred to; giving their causes, symptoms, and
treatment, with practical hints for their prevention.




SECTION IX.

THE DISEASES OF PREGNANCY.


The diseases which are found during pregnancy are of two kinds; the
first kind called _Sympathetic_, or nervous, consist of various
derangements of different parts of the system, produced chiefly by
nervous sympathy with the Womb. The second kind, called _Idiopathic_,
are real primary derangements of the Generative Organs themselves, or
of those intimately connected with them. Each of these kinds will be
treated of separately.




CHAPTER XXVI.

SYMPATHETIC DISEASES OCCURRING DURING PREGNANCY.


SICKNESS AND VOMITING.

Nausea, or sickness, with or without vomiting, is one of the most
frequent and troublesome accompaniments of pregnancy. It is so general,
in fact, as to be looked upon as one of the earliest and most reliable
signs of that state. It is undoubtedly caused, in the earlier stages,
simply by the intimate sympathy which exists between the stomach and
womb, and which causes one of those organs to be temporarily deranged
whenever the other is in any unusual condition. In the latter months
it is also produced by the enlarged womb pressing on the lower part
of the stomach, as it rises in the abdomen. In many diseases of the
womb, particularly in enlargements, and tumors, the stomach will become
deranged in precisely the same manner as during pregnancy, and the
patient is frequently deceived thereby as to her real condition.

In most cases the sickness does not begin till about the second month,
and it seldom lasts beyond the third or fourth. There are some however,
with whom it commences almost immediately after fecundation, and others
with whom it lasts till the very commencement of labor. I have even
known persons who always experienced the nausea _at the very moment of
conception_, and who were thus aware when that event took place. With
some persons the trouble occurs only during certain parts of the day,
most usually in the morning, while with others it comes on irregularly,
or even endures constantly. In most cases it is not very severe, and
causes but little distress; occasionally however, it is very serious,
and may even lead to fatal results, in spite of all that can be done.
Abortion is frequently brought on by it; and so are faintings, and
spitting of blood. Many women however, will vomit with violence, during
almost the whole period, without either accident or evil effect. The
treatment must vary according to the cause of the derangement, its
violence, and the effect it produces. In regard to diet but little can
be said that will be found generally applicable. Mild and light food
is generally recommended, but is not always the best, for some females
can only keep on their stomachs the most indigestible articles. Perhaps
nothing more can be said, with propriety, than that the patient should
take _whatever she can retain_, particularly if she has become weak
from want of nourishment, which is often the case. Some females can
only keep down a little broth, or tea, or sweetened water, while others
find solid food the best, or fruits. I have known many able to take
_Gum Arabic_, either solid or dissolved in water, and retain it, when
nothing else could be borne. This is nourishing, and may often keep up
the strength till the sickness abates.

There are many remedies that will sometimes relieve, though frequently
they are of no use whatever. A little wine or brandy, or orange flower
water;--a few drops of laudanum, or ether, or essence of peppermint,
may be tried. One or two ipecac, or cayenne, or camphor lozenges,
will sometimes be efficacious, and so will a little Port wine and
Peruvian bark, or a seidlitz powder, or even common soda water. A
tea-spoonful of powdered charcoal succeeds occasionally, or some very
strong bitters, or a cordial, such as a wine-glassful of curacoa. A
plaster of opium may also be placed over the stomach, or one of meal
wet with laudanum. A mustard poultice over the stomach, will frequently
relieve when everything else fails;--sometimes it is more effective
however, when placed on the spine, opposite the stomach. As a general
rule the bowels should be kept free, either with injections or with
mild purgatives, as castor oil, or manna. _Regular bathing_ will
often act as a complete preventive or cure, and the vomiting may be
frequently stopped by simply dashing cold water over the stomach. Some
practitioners recommend _emetics_, and bleeding if the patient be of
a full plethoric habit. Leeches and cups have also been used over the
stomach, and sometimes with good effect. Ether and chloroform have also
been inhaled, and have operated favorably in a few instances. Plentiful
draughts of cold water, or swallowing bits of ice will likewise afford
relief to some.

In several instances the vomiting has been so violent, and the patient
has suffered so much, and become so exhausted from want of nourishment,
that it has been absolutely necessary, after all other means have
failed, to cause miscarriage, as the only means of saving the patient's
life.

Whenever the trouble _can_ be borne, _Patience_ is the grand specific.
The sufferer must recollect that it will surely cease with delivery,
and most probably before.


PTYALISM, OR EXCESSIVE SALIVATION.

Some pregnant females will secrete an immense amount of saliva for
weeks and months in succession, as if they had been salivated. I have
never known a case in which this discharge caused any evil, even when
very great, though it is often troublesome. It would probably not be
judicious to stop it, even if we could do so, as long as it does no
harm, though it may be advisable at times to moderate it. The only
treatment proper to effect this is, to keep the bowels free and the
body well bathed, and to gargle the mouth with mint or balm teas, or
canella water, or a little syrup of poppies.

This discharge, like the vomiting, arises from the sympathetic action
of the uterus, and it generally ceases about the fourth month, though
with some it will last the whole time.


ODONTALGIA, OR TOOTHACHE.

This is also a very general trouble during pregnancy, and sometimes a
very severe one. Like several other sympathetic affections it is very
irregular as to its first appearance and duration, some suffering from
it most of the time, almost without intermission, while others only
have it at intervals, and but slightly.

It sometimes depends upon unsound teeth, but is frequently experienced
without any such cause, and is then a true _neuralgia_. When it arises
from a bad tooth, the pain is usually confined more or less to the
neighborhood of the tooth, but when it is neuralgic it extends over the
greater part or the whole of the jaw and face, and darts about from
one part to another. In true toothache there is also usually more or
less inflammation and swelling, while in the most agonizing neuralgia
nothing of the kind can be seen.

The treatment must be regulated by circumstances. If the pain appears
to be kept up by an unsound tooth, it should by all means be extracted,
unless the patient be so exceedingly nervous and irritable that
abortion is to be feared, in which case the pain must be alleviated as
well as it can be, though there is almost as much danger in leaving the
tooth in such cases as in extracting it. A few leeches to the gums will
sometimes relieve, or a mustard poultice to the cheek, or a blister
behind the ear. The stomach or bowels being out of order may also keep
up the irritation, and regulating them may materially assist in giving
relief. Some persons are relieved by lotions of camphor, or laudanum,
and others by washes of cayenne tea, or alum water. In the neuralgic
form, when no particular tooth can be found in fault, the treatment
must be more general than local. The _Carbonate of Iron Pills_, which
can be purchased at the druggists ready made, have frequently an
excellent effect; from two to four may be taken at a dose, twice a
day, the bowels being kept open, if necessary, by a little tincture of
rhubarb. If the pain comes at regular intervals, or intermits, it may
frequently be stopped by quinine. _Two_ of the ordinary _quinine pills_
may be taken every _five hours_, for two or three days. If the head
feels oppressed by their use, the dose must be lessened to _one_. M.
Guillemeau recommends the following to be tried if other means fail,
and I have known it to be of decided benefit. Take the whites of _two
eggs_, and _two ounces of common black pepper_, in powder, and beat
them well together. Spread this on some tow or cotton, and lay it on
the cheek. It may be kept on till it causes considerable irritation,
and sometimes may be used on both sides.

Some females have been relieved by bathing the face in _cold_ water, or
keeping _ice_ in the mouth, and others by hot fomentations. It has also
been recommended to fill the mouth with cold water, and bathe the cheek
with hot at the same time!

Occasionally an abscess, or gum boil will form, and when there seems a
tendency to that it may be promoted by keeping a roasted fig in between
the cheek and gum, over the part where the abscess points; when full,
it should be lanced, as the discharge usually gives relief.

This pain is however very obstinate sometimes, and defies all
treatment, but is seldom of such long duration when so severe.


DERANGEMENTS OF THE APPETITE.

The powerful sympathetic action of the womb on the stomach produces not
only nausea and vomiting, but various derangements of the appetite and
taste also. All of these require notice, and some need attention.

_Anorexia._--This means a complete distaste, or even disgust, for food,
sometimes of particular articles only, and sometimes for those of every
kind. It seldom lasts beyond the fourth month, but occasionally during
the whole period. It is remarkable how some females will be affected in
this way, and how little they will eat, for several months together.
This however is scarcely ever of any consequence, for the system does
not seem to suffer in the slightest degree; on the contrary, the
mother will remain quite stout, and the child be born fully developed,
though the quantity of food taken has apparently been scarcely
sufficient to sustain life.

In many cases there is even a decided benefit from this state of
things, particularly in those who are of a too full habit.

As long as the loss of appetite is merely of a sympathetic or nervous
character it is not necessary nor advisable to resort to any special
treatment. But when it arises from indigestion, or a foul stomach, it
is necessary to attend to it. A mild emetic of ipecac or warm mustard
and water, may be given, or a dose of Epsom Salts. This state will be
recognized by a furred tongue, unpleasant breath, and uneasiness at the
pit of the stomach; while in the purely nervous anorexia nothing of the
kind is observed. Sometimes it may arise merely from debility of the
stomach, and in that case a few of the _Carbonate of Iron Pills_ will
be of use. In general the patient is benefited rather than injured by
this voluntary fasting.

_Boulimia._--This state is the reverse of the former, meaning a
ravenous appetite. Some females exhibit it in a most extraordinary
degree, and will eat to excess of anything that comes in their way.
Many injure themselves in this manner, by causing indigestion,
flatulence, heartburn, vomiting, and even inflammation of the stomach.
It is of no use reasoning with them, for the appetite is so strong that
they will eat let them suffer ever so much.

All that can be done in such cases is, to drink freely of various
nourishing liquids, such as soup, broth, rice milk, or chocolate; and
by eating jelly, arrow-root, and eggs. These contain much nourishment
in a small space, and satisfy the hunger without overloading the
stomach. The appetite may also be deadened considerably by eating figs,
dates, sugar, or chocolate; and by drinking soda water.

_Capricious Appetite._--Sometimes a female is found to have an
inordinate desire for some one particular article of diet, which she
will eat to excess, but will not touch anything else; this is called
_malacia_. Others will have a craving for some article not proper for
food;--this is called _Pica_. They will devour chalk, cinders, earth,
wood, flies, spiders, charcoal, and various other things, sometimes
of the most disgusting kind, though ordinarily they may be quite
fastidious in their diet. This unnatural desire is also frequently seen
in hysteria and chlorosis, and in several uterine diseases.

It does not appear that a moderate indulgence of these unusual tastes
is at all injurious, unless the article wished for be of a decidedly
hurtful character. On the contrary, it is reasonably conjectured, by
many physiologists, that they arise from a real want in the system of
the very substances longed for. For instance, there may not be in the
mother's blood sufficient _lime_ to form the bones of the child, and
this deficiency is intimated by her desire for chalk or plaster; nature
having no other mode of making her wants known, or of causing them
to be supplied. As a general rule, so long as the indulgence is not
obviously improper, it should be allowed to a reasonable extent, both
to gratify the patient and to answer to what are probably the demands
of nature.

It is seldom that interference is needed in these cases, except when
there is danger of the patient doing herself harm; we may then try to
alter the condition of the stomach, and so change the taste. A gentle
emetic will sometimes do this, or a saline purgative. If these fail use
a few of the _Carbonate of Iron Pills_, or some good strong bitters, or
teas, drunk freely, such as Cammomile, Boneset or Centaury.


PYROSIS.

This disease is more frequently called _water brash_ and sometimes
_heart burn_. It is characterized by the raising of a hot acrid fluid
into the throat, causing a sensation of burning from the stomach
upward, even to the mouth. It is a very frequent attendant upon many
forms of dyspepsia, and is generally experienced more or less by most
pregnant females, arising either from improper diet or from mere
sympathetic derangement. If it arises only from errors of diet, a
reform in that particular is all that is needed, but if it is merely
sympathetic nothing can be done beyond palliating it, to give temporary
relief. For this purpose the patient must take a spoonful of lime
water, in half a tumbler of milk two or three times a day, or some
carbonate of soda, or magnesia, with a few drops of laudanum if there
be any pain. In those cases which resist such remedies a little of the
_compound iron mixture_ may be of service, such as can be obtained at
the druggists. A nourishing diet should also be observed, and plenty of
exercise should be taken in the open air.


DYSPHAGIA.

Difficulty of swallowing, which is meant by this term, is a more
troublesome and alarming affection, frequently attendant on pregnancy.
There is however nothing dangerous in it, except that it frightens
the patient. Some will gasp and be unable to swallow, or even speak,
for a considerable time, and will think they have something in the
throat. It is however entirely a nervous symptom, arising from uterine
irritation, and seldom lasts beyond the third or fourth month. A little
cordial, wine, or brandy, will frequently relieve it, or some spirits
of camphor rubbed on the neck. M. Colombat d'l'Isere recommends the
following ointment, to be rubbed on the neck. Extract of Belladonna
forty-seven grains,--Extract of Strammonium fifteen grains,--white wax
one ounce,--oil of lemons twelve drops.--These must be warmed and well
rubbed together. A dash of cold water on the throat and chest will
often succeed better than anything else.


GASTRALGIA.

This is commonly termed cramp at the stomach, or nervous colic.
It consists of a severe kind of cramp, with dragging and cutting
sensations in the stomach, as if it were being tied in knots and cut to
pieces. Sometimes the attack will only last for a few minutes, and then
totally pass away, at other times it will remain for half an hour or
more, and cause the most intense suffering. The patient will be drawn
together, or doubled up, with her hands placed on her stomach, and will
groan and exhibit in her features the greatest agony; sometimes even,
she will faint away with it.

This affection may, like the others, be merely nervous, and then it
is attended by nothing but the pain. It may also arise from real
inflammation of the stomach, and then it is attended by fever,
excessive soreness and tenderness of the stomach when touched, and by
a hot, dry mouth. In the nervous spasm the pain is frequently relieved
by pressure, but when inflammation exists the pressure increases it.

Some females always have these attacks whenever the stomach is empty,
and they pass away immediately anything is taken to eat or drink. With
others they are often brought on by overloading the stomach, or by
eating some improper articles.

To relieve the spasm, one of the best things is a _tea-spoonful of
Compound Spirits of Lavender_, taken without water. This nearly
always gives relief in ten minutes at most; but if necessary a second
spoonful may be taken in a quarter of an hour. A little brandy, or
peppermint, or curacoa cordial will also succeed in many instances,
or simply drinking freely of any hot tea, or swallowing half a
tea-spoonful of common pepper. A mustard plaster put on hot over the
stomach will scarcely ever fail, even without anything being taken
internally. M. Colombat gives the following recipe as one which he
has found efficacious, and it is certainly a pleasant one. Orange and
Linden Flower waters each two ounces; Syrup of Ether and of Valerian
each one ounce; Syrup of Poppy heads half an ounce. Of this mixture a
tea-spoonful may be given every quarter of an hour till the pain abates.

To prevent the return of the attack, the patient must carefully avoid
everything that disagrees with the stomach, or creates wind; she must
keep the bowels free, and accustom herself to regular bathing or
rubbing the body. If the stomach appear weak, which is often the case,
some Boneset tea, or Port wine and bark, or a few of the Carbonate of
Iron Pills may be advantageous. If there be acid on the stomach, use
the means recommended for heartburn.


CONSTIPATION.

This is a very common trouble with pregnant females, and one that may
lead to many others. Very frequently it arises merely from the pressure
of the expanded uterus upon the large intestine, but it may also arise
from a simple want of power, the uterine action having apparently
weakened the force of all the neighboring organs. It is advisable to
correct it as soon as possible, let it arise how it may, as it is very
apt to cause various derangements of the stomach and intestines, and
even inflammation of the womb itself. As a general rule, not more than
three days should elapse without the bowels being moved, though some
will remain a week or more without any apparent inconvenience; but
there is always danger in such delay.

Many females do themselves much harm by taking what they call opening
medicines, the action of which is often more injurious than the
constipation itself. All drastic purgatives, such as aloes, gamboge,
colocynth, and jalap should be carefully avoided, as they not only
make the costiveness worse after their action is over, but they also
frequently produce inflammation, and even abortion, by the violent
straining they cause. The best medicines, when they are really needed,
are manna, seidlitz powders, or castor oil. Enemas are better however,
as a general rule, such as those of thin starch, or molasses and water,
to which may be added a little castor oil. The grand aim should be, in
all such cases, to stimulate the bowels to an increased action without
medicines, by a properly regulated diet! Salads may be eaten when they
do not cause derangement of the stomach, and ripe or stewed fruits,
particularly figs, dates and prunes. Soups are also good, except they
contain rice, or vermicelli, or maccaroni. Bran bread should be eaten
regularly, and not white. The only meats should be veal or poultry.
As a drink lemonade is excellent, with a little cream of tartar, or
tamarind tea, or barley water sweetened with honey. With some patients
a cup of coffee, or a glass of beer will always relieve the bowels,
especially if a glass of water is also drank after it. I have known
persons neglect the bowels so long that they have become completely
impacted, by the hard fæces, and could be relieved only by instruments.
It is very important to attend to this affection in time, and to
persevere with the means of permanent relief regularly.


DYSENTERY AND DIARRHŒA.

It is frequently the case that pregnant females, instead of being
constipated are afflicted with severe diarrhœa. This may arise from
inflammation, and is then attended by fever, and extreme tenderness and
soreness of the bowels. Most usually however it is entirely nervous,
and arises from the sympathetic irritation of the womb. There is then
no tenderness or soreness, no fever, no derangements of the appetite,
nor in fact any other symptom of any consequence. If it remains long
unchecked blood will be discharged, from the extreme irritation of the
intestines, and it is then called dysentery. This is nearly always
accompanied by fever and general irritation. Sometimes there will be a
constant and painful desire felt to move the bowels, but with little
power to do so, and at the same time a burning heat and unpleasant
sensation at the fundus. This is called _tenesmus_, and the straining
from it has frequently produced abortion.

If the diarrhœa is not excessive, and the female does not lose her
appetite, or strength, it is better let alone, particularly if she
be of a full habit, and disposed to fever. If thought desirable to
check it a little, this may usually be done by a change in the diet.
Rice milk, sago, tapioca, and arrow-root may be taken, white bread
may be used, and not much fluid drunk. If such means are insufficient
an injection may be thrown up the rectum in the morning, of thin
starch, with a tea-spoonful of laudanum. The abdomen may also be well
fomented, and a dose of Tincture of Rhubarb taken occasionally. If
the tenesmus is very troublesome, an injection of tepid water may be
used, and the female should sit occasionally over the steam of hot
water: in extremely painful cases a few leeches may be used round the
fundament, and a hot flaxseed poultice placed over the abdomen. A warm
bath is also an excellent remedy with many. When the diarrhœa still
continues notwithstanding the above remedies, resort should be had to
tonics and opiates. The patient should take Port wine and Peruvian
bark, or some _Gentian wine_, and use injections of Starch and Laudanum
regularly. Cammomile tea may also be freely drunk, and an opium pill
may be taken at night. Above all, the patient must endeavor to avoid
all mental agitation. When dysentery sets in, every effort should be
made to subdue it as early as possible. Half a pint of rice milk, with
ten or fifteen drops of laudanum may be taken two or three times a
day, and an injection may also be used night and morning of flaxseed,
with fifteen or twenty drops of laudanum. M. Colombat recommends the
following recipe as seldom failing to cure. Take the whites of six eggs
and beat them up in a quart of water; then use one-third as a drink,
and the rest as an injection. A neat spoonful should be drunk every
ten minutes, and an injection used every two hours, but not more than
one small syringeful at a time. A tea-spoonful of syrup of poppies,
with some loaf sugar, may also be added to every spoonful that is
drunk. Eggs, jellies, and rich soups, with meat and wine, if there be
no inflammation, may be taken regularly, in addition to the articles
already mentioned.


DYSPNŒA, OR DIFFICULTY OF BREATHING.

There are but few pregnant females who do not complain more or less of
difficulty of breathing, and this difficulty may arise from different
causes. In the earlier months it is caused by sympathetic irritation
only, the same as difficulty of swallowing. In the latter months it is
caused by the enlarged womb filling up the abdomen so much that the
lungs in the chest are pressed upon and have not sufficient room to
play freely. It may also be caused by a plethoric or too full habit,
the lungs then being in reality congested.

The temporary difficulty of breathing which is felt in the early
months, from nervous sympathy, needs scarcely any kind of treatment,
as it passes off naturally in a short time. In severe attacks the same
remedies may be used as for difficulty of swallowing before referred to.

That which arises in the latter months, from pressure of the womb,
can frequently be relieved only by the patient remaining as long as
possible in certain favorable positions. I have known many who could
never sleep except when propped nearly upright, by means of pillows
and cushions, as immediately they assumed the recumbent position the
upward pressure became so great they were nearly suffocated. In such
cases the patient should be careful never to eat or drink to excess,
nor take anything likely to produce wind, because the least increase in
the size of the abdomen adds to the difficulty. The bowels should also
be kept free, and nothing tight or heavy in the way of clothing should
be worn.

This difficulty is most frequently seen in those who have contracted
chests, and in those who have been accustomed to wear corsets and tight
dresses. A deformed pelvis may also give rise to it by forcing the womb
above its usual position. Many females both create and increase this
difficulty by binding themselves tighter than usual during pregnancy,
under the mistaken idea that it enables them to support their burden so
much easier.

When the dyspnœa arises from a full habit the patient must live low,
keep the body regularly bathed and rubbed, and the bowels freely
open by an occasional seidlitz powder, or dose of Epsom Salts. If
the difficulty becomes at any time suddenly great and alarming, the
feet should be placed immediately in hot water, while the patient is
upright; a mustard plaster should also be put upon the chest, and an
opening injection of starch and Castor Oil administered as soon as
possible. The usual practice in such cases is to bleed from the arm,
to the extent of eight or ten ounces, and in case no other means give
relief, this may be tried.


COUGH.

Like the previous affection cough is most usually produced during
pregnancy by sympathetic irritation. It may arise, however from a
partial congestion, or inflammation of the lungs or bronchial tubes,
produced by a too great determination of blood to them. In the merely
nervous cough, there is no expectoration, nor any soreness or pain in
the chest, and it will frequently disappear for several days together.
No particular attention need be bestowed upon this cough, unless
it become so violent as to threaten abortion. In that case a pill,
containing one grain of opium, may be taken, or from ten to fifteen
drops of laudanum, whenever the attack is severe. Barley water, or
gum arabic water, may also be freely drunk, with a large spoonful of
Syrup of Poppies added to each pint. A small dose of Hive Syrup, or
Paregoric, will also be found sometimes better than anything else. An
enema of Starch and Laudanum, as formerly described, will also relieve,
in some cases, better than anything taken by the mouth. The body should
be kept warm, particularly the feet, and a mustard poultice may be
placed over the chest, if the straining at any time becomes too great.
Some patients experience relief from an assafœtida pill, or a little
musk, and others from a small dram of cordial, or wine.

If there be expectoration, with fever, and tenderness in the chest,
or sharp pains when a long breath is drawn, there is reason to fear
inflammation of the lungs, or bronchitis. In this case all the above
means, except the wine and stimulants, may also be used only more
freely, and the mustard poultice must be kept on till it makes a
blister. The patient must live low, her feet must be frequently bathed
in hot water, and her bowels regularly opened either with saline
purgatives or enemas. All that is requisite is to keep the inflammation
from extending till after delivery, when it usually subsides without
any further trouble. As soon as the womb is emptied, its pressure
upon the abdominal aorta ceases, and the blood can then flow freely
to the lower extremities, and thus the lungs become relieved and the
inflammation goes down.


PALPITATION OF THE HEART.

This is also a frequent accompaniment of pregnancy, and one that is
likely to cause alarm sometimes, from its violence. Unless dependant
upon organic disease of the heart however, it is in general only
a nervous affection, and passes away with delivery. We may always
reasonably suppose it to be nervous when it occurs only during
pregnancy, and particularly if it is irregular in its frequency and
violence. I have known females who were always attacked with it about
the same period, and who could therefore always tell when it was coming
on, and sometimes even how long it would last. It will sometimes come
on during sleep, and so forcibly as to waken the patient instantly. At
other times while awake, it will commence so suddenly that she will
sink down as if struck by a powerful blow.

The only directions that can be given for alleviating it are, to keep
as quiet as possible, use the bath regularly, avoid constipation,
and live rather low, particularly if the patient be of a full habit.
Exercise should also be taken regularly in the open air, but not of a
violent kind. She should also sleep with the head on a high pillow,
and never eat late suppers, nor take any food that disagrees with the
stomach.

All kinds of stimulants, such as wine, coffee and spices, should be
abstained from, and all powerful emotions carefully guarded against.
During an attack a few drops of Laudanum, or an Opium pill may be
taken, and the feet placed in hot water. An Assafœtida pill is
sometimes good, or a little Ether. Bleeding is generally practised in
extreme cases, but there is often considerable danger in it.

A too full habit is often the exciting cause of the palpitation, as may
be seen by the patient being always liable on the slightest exertion
to flushed face, dimness of sight, ringing in the ears, swelling of
the limbs, and puffiness of the gums, sometimes to such an extent that
the mouth will taste of blood. Such persons should carefully observe
a moderate unstimulating and simple diet, and never allow the bowels
to remain constipated more than a single day. They should also rub and
wash the skin well, and study calmness and quiet.


SYNCOPE, OR FAINTING.

In this condition, which is just the reverse of the former, the heart
suspends its action altogether; the breathing ceases, all power of
motion and feeling is lost, the face turns ghastly pale, the eyes
close, and the individual seems as if actually dead. It seldom lasts
however more than five minutes, when the pulse gradually begins to
beat, the color returns, and the individual slowly recovers. Some
females are liable to such attacks once a month, others once a week,
others every few days, and some at irregular periods. They are
generally preceded by a dull pain at the pit of the stomach, fullness
in the head, yawning, and loss of sight, or ringing in the ears.

The causes that predispose to this fainting are not very well
understood, though there is no doubt but it is mainly dependant upon
uterine disturbances. In some females it is brought on by the sudden
motions of the fœtus, or by their remaining too long in one posture.
In others it is produced by straining from constipation, or by sudden
fright or anger. In very nervous persons it not unfrequently arises
from unpleasant sights, smells, and sounds. In fact it is caused in
them much the same as a common hysterical fit, such as is described in
my _Diseases of Woman_. A full habit, and over feeding, or drinking
stimulating liquors may also bring it on, and so on the contrary may a
state of weakness and exhaustion.

This accident is more alarming than dangerous, except to the child,
which may lose its life if the fainting lasts too long.

To recover a person from one of these fainting fits, she should be laid
upon her back on a level place, and every part of her dress should
be carefully loosed. Some strong odor should then be applied to the
nostrils, such as hartshorn, vinegar, burnt feathers, or smelling
salts. The body should be well rubbed over the heart and lungs, either
with the hand or with a soft, dry napkin. Cold water may also be
dashed on the face, and the hands may be well chafed. If the fit still
endures, a mustard plaster may be placed on each arm, or the whole body
may be placed in a warm bath, if convenient. Care should also be taken
to admit the fresh air freely. As soon as she begins to show signs of
consciousness, a little wine or brandy may be placed in the mouth, and
the body may be elevated a little.

To guard against such attacks, the same precautions as to diet and mode
of life must be observed as were directed in the article on palpitation
of the heart; and, as this accident is most frequent in those of a
hysterical habit, they should carefully follow the advice given in the
article _Hysteria_, in my _Diseases of Woman_.


HEADACHE AND DIZZINESS IN THE HEAD.

Each of these distressing affections, both of which are very common
during pregnancy, may arise either from nervous excitement or from a
full habit and determination of blood to the head. Nervous headache
is generally met with in the earlier months of pregnancy, and is
characterized by being frequently periodical, and often confined to
particular spots. It also commences suddenly, from some excitement
or depression of mind, and leaves little or no distress when it is
gone. The headache, which arises from a too full habit, commences with
flushing of the face, heaviness in the eyes, dull pain in the forehead,
and a sense of uneasiness, with disposition to sleep or dose. It seldom
comes on much till the latter months of gestation. Headache may arise
also accidentally, from derangement of the stomach, but this cause is
easily ascertained by the furred tongue, loss of appetite, and bitter
taste in the mouth; it is also felt most acutely in the back of the
head, down by the neck, and passes away immediately the stomach is
corrected by an emetic, or by fasting.

Nervous headache during pregnancy often defies all our attempts to
alleviate it, though we sometimes succeed in doing so. The best general
remedies are warm baths, and, if the bowels are constipated, enemas of
starch and castor oil daily. To these may be added occasional small
doses of Laudanum, or an Opium pill, or two grains of Camphor. Smelling
odors, such as Camphor, Cologne, or Hartshorn, will relieve some, but
will make others worse; so that its utility can only be determined by
experience. When a severe attack comes on, the patient should put her
feet in warm water, or use a warm bath, take a few drops of Laudanum,
or a little Musk, or Valerian, and then try to go to sleep. To guard
against the attack, she must never overload the stomach, nor take
anything indigestible; and never think too much nor allow herself to
become excited or depressed.

When the trouble is caused by a too full habit, she must observe the
directions given in the articles on palpitation of the heart, and
Syncope. The diet must be mild and not too nutritious, the bowels must
be regularly moved every day, chiefly by Epsom Salts and Seidlitz
Powders, and regular gentle exercise must be taken in the open air.

In the latter months it is especially important to attend to a severe
headache _immediately_, particularly when the pain is seated _at the
top of the head_, because it is very likely, if unchecked, to terminate
in convulsions. The means above recommended must be carefully and
perseveringly applied; the feet must be kept warm, the bowels freely
opened, and the head kept cool by wet clothes, or cold lotions, or ice.
It is the general practice in all such cases, if the pain does not
abate soon, and the pulse be full and quick, to bleed freely at the
arm, and the most eminent physicians of the Allopathic school assure
us, that the life of the patient frequently depends upon its being done
promptly. I have no doubt, however, but that relief can be generally
obtained by the simple means described, if they are used early and
perseveringly.


INSOMNIA, OR SLEEPLESSNESS.

There are few affections that cause more real distress during pregnancy
than this. Many females will be utterly unable to sleep for many days
and nights together, and others can only obtain a few minutes broken
and unrefreshing sleep at distant intervals. There is danger, when this
state becomes highly aggravated, that it may lead to delirium, or that
the want of rest may wear away the strength to such a degree, that
the patient will sink from mere exhaustion. There are some females,
however, who will remain without sleep, or at most take but very
little, for a long time, without suffering any inconvenience.

This affection is essentially a nervous one, and the only means likely
to relieve it are those that have a tendency to soothe and calm the
nerves. If the patient be surrounded by any irritating circumstances
they should be at once removed, or she herself removed from them.
Particular attention must be paid to the diet, so that no derangement
of the stomach or bowels be kept up, and a regular system of out-door
exercise must be practised. A warm bath just before going to bed, with
a good rubbing of the skin, will frequently act like magic in procuring
rest. As a general rule narcotic drugs should not be used, but in
extreme cases they may be resorted to sparingly. A single Opium pill,
or a few drops of Laudanum may be taken after the bath. If the patient
be thin and delicate, she should eat meat, eggs, and milk, and take a
little wine, if it causes no unpleasant symptoms. Indeed a glass of
wine will frequently act better than Laudanum, and so will ale with
some, and coffee with others. If the patient be of a full habit these
things will be improper, and may injure. She should then be kept quiet,
and fed sparingly. _Music_ has a powerful effect in many of these
cases:--a slow, solemn air, played while the patient is reclining after
her bath, seldom fails in inducing sleep.


TEMPORARY AFFECTION OF THE SIGHT, HEARING, AND SMELL.

These disorders are quite common during pregnancy, particularly in the
latter months. Some females will be utterly unable to distinguish any
odors, even the most powerful; others completely lose their taste, and
others again become deaf or blind. When they are caused only by the
sympathetic action of the womb, such deprivations are seldom of long
duration, though they may recur at frequent intervals. In some cases
they remain a considerable time, and great fear is felt that they may
become permanent, but there is little danger of such a result. I knew
a lady who suddenly lost her sight when about two months gone, and who
remained totally blind till about three hours after her delivery, when
her sight returned in a moment as perfect as before. The same thing
has frequently been observed of the other senses. In some cases the
vision will not be lost but perverted, and the patient will then see
everything double, or larger or smaller than natural, or always of a
wrong color. In like manner some will hear imaginary conversations, or
will fancy everybody is shouting, or perhaps only whispering, though
they are all the time speaking in their natural voice.

These perversions, when thus produced, need occasion no alarm, and
seldom require attention, unless accompanied by other urgent symptoms.
They may arise however, from a fullness of blood in the head, in which
case they are accompanied by a flushed face and drowsiness, and are
preceded by bright sparks flashing before the eyes, or by ringing in
the ears.

The treatment of all these affections should be the same as that
recommended for most of the previous derangements, particularly for
_Headache_, _Syncope_, and _Palpitation of the Heart_. If there be
nervous excitement merely, it must be calmed in the same way as
recommended in the articles referred to, and also in the last one on
sleeplessness. If the female be of a full habit, and there is evidently
a pressure of blood on the brain and nerves of the special senses, the
same means should be adopted to reduce the system, and draw the blood
to the extremities, that have already been described.

In such cases these sudden deprivations of sight and hearing sometimes
indicate the commencement of Convulsions, or Apoplexy, particularly
if they occur during labor, when every means should be resorted to
_instantly_ to relieve the pressure on the brain. If no simpler means
succeed in a reasonable time, it is the general custom to bleed freely
from the arm, and there is no question but this frequently removes the
difficulty at once, whatever objections may be made to the practice.
It is also proper to say that many eminent practitioners, who are not
advocates of the lancet in general, strenuously urge that it should be
used immediately if the sight or hearing suddenly disappear in this
way at any time. And I certainly have myself known these accidents
sometimes followed by a fit of Apoplexy, or Convulsions, and even
death. Such was the case with a friend of one of my patients. She
found one day, quite suddenly, that she could only see _half_ of any
thing she looked at, and at times it even disappeared altogether.
Nothing was done for her, and in about five hours after the first
attack she fell speechless and died before they could lift her upon
the bed. It will therefore be a necessary precaution, in all pregnant
females of a full habit, to attend rigidly to the advice that has been
given, because _simple_ means, used in time, and regularly, may prevent
the necessity of stronger ones altogether. In purely nervous cases of
this kind no apprehension whatever need be felt, and no such practice
as bleeding is required.


DISORDERED JUDGMENT, INCLINATIONS, AND PROPENSITIES.

The sympathetic irritation of the uterus, in some females produces
extraordinary phenomena of this kind, from simple desire to the most
furious craving, and from mere caprice to actual insanity. There is no
doubt but that many of these unusual desires, or _longings_ as they
are called, are either produced or much aggravated by the imagination
of the patient, and frequently would never be experienced at all,
if the idea was not suggested by other people having had the same.
Custom and imitation are very powerful in such cases, particularly
when the nervous sensibility is much exalted. Still the most singular
aberrations of this kind will often arise without any such adventitious
aid, and the fact should be borne in mind, so that these temporary
vagaries may be regarded with proper charity and forbearance.

Some females will entirely change in their dispositions at these
times, the most amiable and mild becoming positively ill-natured and
malicious;--the gentle will turn headstrong, the haughty and proud will
become humble, and the gay will become melancholy, or the sad will
madly seek every kind of gaiety. Such things however should never be
remembered, nor be brought up against them afterwards, for truly at
such times _they know not what they do_!

Women have been known while in this state, to become thievish, or to
have an irresistible propensity to burn or kill. Some have even been
known to exhibit great talents for music or poetry, though ordinarily
without any capacity for such things. Some will suddenly exhibit a
most extraordinary intellect, while others will become quite silly. A
medical writer tells us an instance of one female who always had an
excellent sound judgment while pregnant, but _no memory_, while in
her ordinary state she had a poor judgment but _a most extraordinary
good memory_. The celebrated Baudelocque gives an account of another
who could scarcely eat anything but what she _stole_, while going to
market; and another writer mentions a lady who longed till she was
almost delirious to bite a piece out of a baker's shoulder, who worked
opposite her window. There is even an account of one who longed to eat
some of her husband, whom she dearly loved, and who actually killed
him to satisfy her appetite, and then salted pieces of the body to
keep for future use. A writer named Vives also tells us of a female
whose husband paid a large sum of money for her to be allowed to bite
a young man's neck, it being evident that she would be nearly certain
to miscarry unless so gratified. In the year 1816, at Mons, in France,
an unfortunate woman in this condition was seized with an irresistible
impulse to destroy her children, and actually drowned three of them,
and herself afterwards. She had previously sent a poisoned cake also to
one at school, but fortunately it was not eaten.

Generally speaking all these things pass away with delivery, if not
before, unless it be actual insanity, which sometimes remains. All
that can be done is to attend strictly to the general health, keep the
skin, bowels, and stomach, in good action, and remove all depressing
or irritating circumstances. If there be a propensity to anything
decidedly injurious or dangerous, the patient must be strictly watched,
but without its being perceived or known by her, for fear of exciting
suspicion in those who would be disposed to be cunningly secret or
revengeful. Proper diet, regular bathing, and out-door exercise often
correct many of these things.


HÆMOPTYSIS, HÆMATEMESIS AND EPISTAXIS.

These three terms mean _spitting of blood_, _vomiting of blood_,
and _bleeding from the nose_, all of which frequently occur during
pregnancy.

Spitting of blood is most usually observed in nervous women, and in
those of a full habit. It is caused partly by sympathetic irritation,
and partly by the womb pressing upwards against the diaphragm and
lessening the size of the chest, which deranges the circulation in
the lungs, and causes rupture of their blood vessels. The premonitory
symptoms are pains round the waist, cold extremities, creeping of
the skin, and a sensation of anxiety or depression round the heart.
The attack begins by difficulty of breathing, heat in the chest, and
dry cough, followed by spitting up more or less bloody frothy mucus;
all which symptoms are much increased by violent exercise, or a hot
atmosphere. In ordinary cases a mere spitting of blood need occasion no
great alarm, unless attended by symptoms of inflammation, or unless the
patient has had cough, and other indications of pulmonary derangement
before conception.

In hæmatemesis the blood is vomited from the stomach, and is in black
clots, frequently mixed with the food, or bile, while that which comes
from the lungs in spitting on the contrary is bright red, and quite
fresh. In vomiting of blood also, there is seldom any cough or exertion
of any kind.

The treatment of spitting of blood must be nearly the same as for many
other derangements already described. When there is a full habit, the
patient must live low, keep the bowels free, and the skin in good
order, and avoid all agitation of mind or over exertion of body. An
Opium pill occasionally will be useful, or a few drops of laudanum. The
cough must be combatted in the way recommended in my previous article
on _Cough_. Lemonade or tamarind tea, with some Syrup of Poppies
added, may be freely drunk, or some of the black currant root tea. The
treatment of Hæmatemesis is precisely the same. Occasionally however
the blood will pass into the intestines and occasion colic, and then it
must be removed by administering an enema of starch and castor oil, or
a little manna may be taken.

Epistaxis, or bleeding from the nose, is much more frequent than either
of the preceding, but is seldom of much consequence. In many cases in
fact it is highly beneficial, as it relieves the head from pressure,
and thus obviates many inconveniences. If it continue too long, or
becomes excessive, it may generally be arrested by putting cold wet
cloths between the eyes, and on the cheeks, while the head is kept
elevated. The feet and hands should be kept warm, and the air breathed
should be as cold as possible. In extreme cases, the nostrils may be
plugged with bits of sponge, or cotton, or some powdered alum may be
snuffed up them. The best plan is to raise the hands above the head and
put something very cold, as a lump of ice for instance, or a piece of
cold iron, between the shoulders; this seldom fails.


VARICOSE VEINS.

Very often in pregnant women the veins in different parts, but
particularly of the thighs and legs will swell out in knots, either
singly or in bunches, sometimes like strings of beads, or like the
links of a chain. These are called _Varices_, and occasionally they
attain a large size, and extend to various other portions of the body,
as the external lips, vagina, and mouth of the womb. Some women in fact
have them over nearly the whole body. They are caused by the pressure
of the womb on the large abdominal veins, preventing the return of the
blood and disturbing the balance of circulation between the veins and
arteries. In the majority of cases, unless very large, they cause but
little inconvenience, and may be let alone, but sometimes they cause
pain, or become so full that there is danger of their bursting, and
then it is necessary to interfere.

The first thing to be done is to relieve the abdominal veins from the
pressure of the womb, and this may be done by the patient keeping more
or less the horizontal position, and carefully avoiding all violent
exertion. The swelling is always worse during the latter part of the
day, particularly if the woman has been much on her feet, she should
therefore apply a cloth roller round the limbs before she rises in
the morning. If this be carefully put on, just tight enough not to
interfere with the motion of the limbs, nor totally obstruct the
circulation, it will prevent the varices to a great extent, if not
altogether. Brisk friction with the hand will disperse the swelling
in many persons, or warm fomentations, but sometimes _cold_ bathing
answers better. It is advisable always to disperse them as soon as
possible, for if they remain too long that part of the vein becomes
permanently weakened by being overstretched, and will be always liable
to swell again from any slight cause. It is particularly advisable in
these cases to avoid constipation, and also to keep the skin in good
action by bathing and frictions.

If at any time one of these varices should burst, it need occasion no
alarm, unless it be seated on a large vein, and the bleeding becomes
profuse. To stop it, bind on firmly over the rent any firm _cold_ body,
as a flat stone, or a large silver coin, passing the bandage several
times round. In slight cases a simple cold compress will be sufficient,
or a little powdered alum, or some vinegar and water. In short any of
the usual remedies for stopping bleeding from wounds. The female must
be quite still till it is stopped, and must be careful when she begins
to move about again, because it is liable to break out afresh. Those of
a very full habit must live low, and avoid all stimulants, so as not to
increase the quantity of blood in the body more than is necessary. It
is advisable to remove the varices, as much as possible, before labor
comes on, particularly if they are situated on the lips, or in the
vagina, because they may burst during delivery and cause considerable
inconvenience, or even danger. It is rare that these swellings continue
after delivery, but if they should do so, the same treatment must be
persisted in as before.


HÆMORRHOIDS, OR PILES.

These are troublesome annoyances at any time, but particularly during
pregnancy, and unfortunately they are very common at that time. They
are, no doubt, chiefly caused in the same way as varicose veins, that
is by the enlarged womb preventing the proper flow of the blood in
the small veins, and so causing them to swell, and form tumors. They
may in fact be called varices, as truly so as those on the limbs.
In many persons however they are undoubtedly brought on merely by
_Constipation_, which will undoubtedly either cause them or make them
much worse when otherwise produced. In general they become worse as the
pregnancy advances, because the womb becomes larger and the bowels are
more apt to be confined.

As long as they only cause inconvenience, without any particular
distress or urgent symptom, they may be let alone, or be slightly
treated in the way of palliation, till after delivery, when they
will disappear. Occasionally however, they grow to a large size, so
as to hinder the passage of the bowels, and prevent the patient from
sitting down or walking. They may then cause inflammation, and bring
on falling of the intestine, or abortion, by the straining which they
necessitate when the bowels are moved. And even if these extreme
results do not follow, there may be serious derangements of the general
health, indicated by difficulty of breathing, sleeplessness, headache,
and fever. In short there are few of the derangements incident to
pregnancy so annoying as this, and unfortunately, from its nature, the
sufferer dislikes to speak of it and seek the necessary assistance.
Many prefer undergoing the most excruciating agony for months, rather
than complain, which shows the necessity for females knowing how to
treat themselves, when possible.

The bleeding which sometimes takes place from Piles is more often
beneficial than otherwise, unless it becomes excessive, from rupture
of a large vessel, in which case, if the wound is external, it may be
treated the same as the ruptured varicose vein; if it be internal, the
remedies must be injected with a syringe, or a large roll of lint or
cotton may be soaked in alum water and passed up the rectum. Frequently
bathing the thighs and perineum with cold water will be sufficient.

To relieve the pain and swelling, the female should sit over the
steam of hot water, and use the warm bath. If the piles are external,
they should be bathed with hot milk and Laudanum, or rubbed with any
soothing ointment, particularly the _Cucumber Ointment_, mentioned
in my Diseases of Woman, or with _Stramonium Ointment_. If they are
internal the milk and Laudanum should be injected if possible, or some
thin starch and Laudanum, and a stiff roll of cloth may be smeared with
the ointment and introduced. In general, ointments or other greasy
matters are not so good as the milk or starch. In conjunction with
this, the bowels must be kept free, either with enemas or castor oil,
or by using a seidlitz powder in the morning. This is indispensable,
for if constipation exists, no applications can render much service.
The patient must also avoid fatigue, and not remain too long upon her
feet, nor sit long, particularly on a hard seat, and if she be of a
full habit she must live low, to avoid making too much blood. It is
also important, at all times, to avoid using drastic purgatives, such
as Aloes, Colocynth, or Gamboge, as they always make piles much worse,
or even cause them.


ŒDEMA, OR WATERY SWELLINGS.

This affection also appears, like the preceding, to arise from
obstructed circulation, but instead of the blood accumulating it is
merely the serum, or watery portion of it. The swellings are generally
whitish, and spread about, and a small pit remains in them when pressed
with the finger. They are found on various parts of the lower limbs,
and on the groin or abdomen, and also upon the external lips, in which
place they are often exceedingly troublesome. As a general rule these
swellings are of small account, and as they disappear with delivery,
but little attention need be bestowed upon them. Sometimes, however,
they become very extensive, and so engorged that they inflame and are
extremely painful. They have even been known to mortify, and cause
considerable sloughing, particularly when chafed and afterwards wet
with the urine. In these extreme cases there may be serious disturbance
of the general health, from the constant irritation, and from the
patient being unable to walk about. I have often known the limbs and
vulva covered with patches of Erysipelas from this cause. Sometimes the
swellings even become so large that they interfere with the process of
delivery.

The treatment of this affection consists in rest, particularly lying
down, saline purgatives, regular, and frequent washing the parts with
cold milk and Laudanum, or with a solution of Borax, half an ounce to
a pint of water, to be used cold and with a tea-spoonful of Laudanum
added to it. Simple cold water is frequently quite sufficient. In
general all kinds of ointments are injurious, but if other means fail
to give relief, the _Cucumber Ointment_ may be tried. The wash should
always be used after urinating, and the parts must not be rubbed, but
lightly dried with a piece of soft linen. Fullers earth is often an
excellent application when there is chafing.

If the patient be of a full habit, she must carefully diet herself,
and bathe regularly. If she be thin and weak, a generous diet will be
advisable, with meat and even a little wine.


HYDRORRHEA, OR PROFUSE DISCHARGE OF WATER.

This consists in a discharge of water, more or less profuse, from
the vagina, at various periods during pregnancy. Some females will
only discharge a small quantity, at intervals, others will have a
constant dropping, and others again will pour out an immense quantity,
sometimes several pints, or even quarts, in the course of a few days.
In general this water is quite limpid and colorless, but sometimes it
contains much mucus, and at other times it is tinged with blood. It
does not appear that this discharge leads to any evil result, even when
excessive, and I only refer to it to relieve anxiety. The origin of
this water is not yet ascertained, but it is generally thought to be
secreted between the membranes and the womb, and to be quite distinct
from the liquor amnii.


PUSTULES, AND MUCOUS DISCHARGES.

Occasionally the external lips will be covered with pustules during
pregnancy, and frequent discharges of mucus will occur from the vagina.
They are both however caused by the unusual action of the uterine
system, and merely require frequent bathing of the parts with milk and
Laudanum, and regular action of the bowels. The most important thing to
remark in connection with them is that they have often been mistaken,
even by medical men, for the effects of syphilitic disease, and much
distress has resulted from such mistakes.


DERANGEMENTS OF THE URINARY ORGANS.

Several derangements of the urinary organs are liable to occur during
pregnancy, partly from sympathetic irritation, and partly from mere
pressure. Some of these may be partially relieved, others have to be
borne as patiently as they can be till delivery removes them.

The swollen womb often presses on the neck of the bladder, and hinders
the passage of the urine, or even obstructs it sometimes altogether,
and thus causes straining, burning heat, and great distension of the
bladder. In some instances this passes off as the pregnancy advances,
owing to the womb rising higher in the abdomen, but in other cases
it remains more or less, during the whole term. It is particularly
important, in such cases, that the female should not let the difficulty
remain too long unremedied, for if the bladder be very full it may
become utterly impossible to empty it by natural effort. Sometimes the
difficulty is much lessened by lying on the back a short time before
attempting to urinate, or by raising up the abdomen with the hand at
the time. Many females can urinate with tolerable comfort while lying
on the back or abdomen, and others are much relieved by constantly
wearing a bandage. Constipation always makes this difficulty worse,
and sometimes even causes it, by keeping the rectum full and thus
increasing the pressure. In all such cases it will be readily seen,
that forcing medicines are not only useless, but liable to cause
injury. The change of position, rest, and supporting the abdomen are
the means to be relied upon. If these fail, and the urine accumulates,
the catheter must be used. A warm bath, or fomentation with warm water
and Laudanum, will assist, and sometimes relieve alone. To ease the
burning and distress the patient must drink freely of gum water, or
barley tea, with a little Syrup of Poppies.

There is one manœuvre which, if practised aright, will nearly always
allow the female to urinate with ease, and fortunately she can practise
it herself. It consists in introducing two of the fingers into the
vagina, and raising up the womb, as if practising the _ballotment_.
This removes the pressure from the bladder, and the urine then escapes
by natural effort. A few trials will soon enable any one to do this,
particularly if they notice well the form and position of the parts, as
shown in the plates of this work. A lady who heard me mention this in
one of my Lectures, afterwards stated that the knowledge of it enabled
her to dispense altogether with the catheter, which she was previously
necessitated to use during most of her pregnancy.

When there is merely a nervous irritation causing the difficulty,
the warm bath, or fomentation with warm water and Laudanum will be
sufficient, or a little Belladonna Ointment may be rubbed over the
meatus urinarius, while some starch and Laudanum is injected carefully
into the vagina.


CRAMPS.

These arise from the womb pressing on the nerves of the sacrum, and
are therefore not under the control of medicine. All that can be done
is to change the position of the body as much as possible, from lying
down to standing up, and by turning from one side to another. Brisk
rubbing with the hand will also assist in giving relief. The cramps
however usually disappear after delivery, and must therefore be borne
as patiently as possible till that takes place.


PRURITUS, OR ITCHING OF THE EXTERNAL PARTS.

Having treated this affection fully in my _Diseases of Woman_, I cannot
do better than extract the article from that work on the subject.

 "This disease, though not so immediately dangerous as some others, is
 perhaps the most distressing that can be met with.

 "It consists in an intolerable and incessant itching of the parts,
 which nothing seems to allay. Sometimes it is so bad that the female
 is almost tormented to death; she cannot see company, or walk out, and
 often shuts herself up alone in her agony. Many have fainted from it,
 and some have even become delirious. I have seen patients whose hands
 it was necessary to tie, to prevent them tearing themselves to pieces.

 "The causes of pruritus appear to be most of those that produce simple
 inflammation, which it very frequently accompanies or precedes.
 Pregnant females are very liable to it, and in some it will continue,
 in spite of all that can be done, till after delivery, when it
 usually disappears. I have known it produce abortion. Some females
 always have it at the menstrual period, and others during nursing.
 Occasionally there is a little eruption attending it, but not
 always, though the parts are generally swollen and red. Parasites
 are sometimes the exciting cause, and should always be destroyed
 immediately.

 "The treatment consists in first attending strictly to the diet, which
 must be light and unirritating, and to the regular action of the
 bowels and womb; and in using the cooling washes and lotions before
 mentioned. If the itching still continues, use either of the following
 washes to the parts:--Sub. carbonate of potash three drachms, water
 four ounces; put a tea-spoonful of this into a quart of warm water,
 and use it three times a day.--A tea-spoonful of Eau de Cologne to a
 pint of warm water.--Sulphate of Zinc, half a tea-spoonful to a quart
 of warm water. Both these may be used many times in the day.--Borax
 half an ounce, Sulphate of Morphia six grains; pure water half a pint.
 This last seldom fails of giving relief. It should be applied three or
 four times a day, with a piece of soft linen, the parts being first
 washed with warm soap and water. A tea-spoonful of laudanum will
 sometimes answer as well as the six grains of Sulphate of Morphia.

 "Caustic has been employed, and blisters to the inside of the thighs,
 but such violent remedies are seldom either necessary or serviceable.
 I have known the parts to be deeply scarified with the lancet, and
 even burnt with a _red hot iron_, without at all alleviating the
 pruritus.

 "In young persons it seems to be often produced by constipation,
 worms, and gravel; but it most probably depends, essentially, on some
 impurity, or irritating quality, in the blood, or in the natural
 secretions of the parts, which should therefore never be allowed to
 remain long unwashed.

 "Sitting in cold water, and the application of ice to the parts, has
 given relief. I have also effected many cures, almost instantaneously,
 by means of a small _Galvanic plate_, so constructed as to be worn
 just within the vulva.

 "All remedies must of course be applied with caution during pregnancy;
 and it must be recollected that sometimes the disease _will_ continue,
 more or less, till after delivery, though the distress from it may be
 much alleviated."




CHAPTER XXVII.

IDIOPATHIC, OR PRIMARY DISEASES INCIDENT TO PREGNANCY.


FLOODING, OR HEMORRHAGE.

Flooding is one of the most dangerous accidents that occur during
pregnancy, its consequences being often of the most serious character.
The causes that lead to flooding are very numerous, some of them
predisposing to it, and others immediately exciting it. Among these
may be mentioned a too full habit, violent exertion, falls, coughing,
vomiting, straining from costiveness or violent purgatives, forcing
medicines, criminal attempts at abortion, overwalking, blows on
the abdomen, too much dancing, or running up stairs, strong mental
emotions, fright, or anger, and _certain excesses_. The immediate
cause is the separation of the membrane in which the fœtus is inclosed
from the walls of the womb. Flooding may however result from the
placenta growing over the mouth of the womb, and being torn as that
opens--usually about the sixth or seventh month.--(See the article
_Flooding_ during Labor.)

In most cases flooding is preceded by dull pain in the loins and
groins, and a sensation of weight and dragging. Similar sensations
however are often produced by other causes, which makes it difficult to
predicate, with any degree of certainty, whether the patient is about
to flood or not. The very first appearance of blood from the vagina
must therefore be watched for carefully, as that removes all doubt,
and warns us to be prompt with the proper remedies. Sometimes a female
will flood internally, the blood being retained by the passage being
closed or plugged up by clots, or by its passing behind the membranes,
or under the centre of the placenta. These internal or concealed
hemorrhages are very dangerous, as the patient may lose much blood
before her condition is suspected. It is therefore necessary to bear
this in mind, and carefully use every means to ascertain whether such
an accident has occurred or not. In general the indications are pretty
plain, the patient suffering from deep seated and distressing pains in
the back and groins, with great weakness in the limbs, faintness, weak
pulse, dimness of sight, ringing in the ears, coldness of the hands and
feet, swelling of the abdomen, and finally fainting, particularly if
the retained blood suddenly escapes, which it usually does.

In the early months there is more danger to the child from flooding
than there is to the mother, because it is nearly certain to lead to
abortion. In the latter months, on the contrary, the mother runs the
greatest risk, as the child may then live if it be expelled, while the
mother may sink and die from excessive loss of blood. There are many
females of a very full habit, who suffer but little from hemorrhage,
unless it be excessive, indeed some seem to be benefitted by it, and
are thus relieved from headache and convulsions. It should, however, be
carefully watched, and its effects duly noted.

The treatment of flooding must depend materially upon its severity, and
the time when it occurs. In the early months, when the discharge is
slight, and when it causes little distress, simple means will answer.
The patient must lie on her back, on a hard mattress, with the pelvis
raised, by means of a pillow, higher than the rest of the body. The air
must be kept fresh and cool around her; she must keep herself quiet in
body and mind, live rather low, and drink freely of cooling drinks,
such as soda water, lemonade, tamarind tea, or ice water. [The fullest
directions for making and using all these drinks will be found in my
"Diseases of Woman."]

If the flooding does not stop with these simple means, external
applications must be made, of cold, wet cloths, or even ice, over the
abdomen, and inside the thighs. Finally, if further treatment is still
needed, cold astringent injections may be carefully thrown into the
vagina. Cold water is perhaps as good as anything for this purpose,
and I have frequently known a most severe flooding checked immediately
by injecting cold water into the vagina and rectum, and applying cold
wet cloths over the abdomen, and inside the thighs. Some astringent
drink may also assist, such as a little syrup of comfrey, or extract of
Rhatany, and particularly a tea made of the root of the black currant,
as recommended in my "Diseases of Woman."--[A handful of the root may
be boiled in two quarts of water, for twenty minutes; it should be
sweetened to taste and drunk freely. The common blackberry, or the dew
berry, is also excellent, though not so good as the black currant.]--If
the patient be nervous and irritable, or suffer much from pain, an
opium pill may be taken, or from ten to twenty drops of laudanum.

The general practice in these cases is to _bleed_ freely and _give
opium_! And as this practice certainly does succeed in many extreme
cases, I should certainly recommend, if the simpler means fail, to
resort to it at once. I dislike bleeding very much, in any cases, and
here it seems particularly inappropriate; I should therefore say _try
almost anything and everything first_, but never obstinately refuse to
do it if nothing else succeeds.

In some cases a plug or tampon is used, to fill up the vagina. It
may be made of a roll of cloth, cotton, or a piece of sponge. This
practice, however, is useless in the latter months of pregnancy, and
very often fails even at other times. When it succeeds it causes the
blood to coagulate, and thus closes up the mouths of the vessels. Quite
as often, however, it only keeps it in, and makes it accumulate in the
womb till it all rushes away at once; still it may be tried.

If the hemorrhages should occur so frequently, or be so excessive, in
spite of all treatment, as to endanger the safety of the patient, there
is no other resource left to save her life but to produce abortion,
because the presence of the fœtus and its appendages is evidently then
the irritating cause which keeps up the discharge, and it cannot be
expected to stop till the womb is emptied.


ABORTION, OR MISCARRIAGE.

When the fœtus is prematurely expelled before it can survive, it is
called an _Abortion_, but if its expulsion take place so late that
it can live, it is called _Miscarriage_. Both these are serious
accidents. In abortion the child is lost, as a matter of course, but
in miscarriage it may live, after the seventh month. The danger to
the mother is considerable from both, though greatest probably from
abortion. It is probable that many very early miscarriages take place
unperceived, the female suffering but little from the accident, and the
embryo being too small to be seen, unless carefully looked for.

The most frequent periods for such accidents are found to be six
months, five months, and three months; and what is very singular, a
much greater number of male children are aborted than females, the
proportion being about sixteen to eleven.

These accidents are so intimately connected with flooding, that many
writers always treat of them together, considering the flooding merely
as the most frequent cause and symptom of miscarriage or abortion. In
speaking therefore of the immediate causes of premature expulsion of
the fœtus, we place hemorrhage first, and the causes before enumerated
which produce that as being its most frequent remote ones.

A full habit, with tendency to local congestion, seems to predispose
a female very much to miscarriage; every one so constituted should
carefully avoid luxurious living and an inactive life. Violent bodily
exertion, falls, or blows, or strong mental excitement are most usually
the immediate causes, though with some it will come on spontaneously
without any such exciting agencies. Some females will miscarry many
times in succession, and always so near the same period, that they can
tell to a day or two when it will happen. It seems to become a habit of
the womb with them to contract at that particular time, and the only
way to break through the _habit_ is for them to avoid becoming pregnant
for some considerable time, say two or three years after, they may then
go the full time, but will seldom do so if they conceive immediately
after having miscarried. In some persons miscarriage is caused by a
_too eager_ gratification of certain desires; but in others it may
arise _from the opposite cause_.

There is a disease of the womb also by no means unfrequent, though but
little understood, which undoubtedly causes much miscarriage, and that
is _Rheumatism of the Womb_! This mostly exists before the pregnancy
however, and should be then treated according to the plan laid down in
my "Diseases of Woman."

Miscarriage also arises in many females from a rigid state of the
muscular fibres of the womb, which not relaxing sufficiently to allow
that organ to expand become irritated by the pressure they experience,
and begin to contract. This contraction of the womb of course soon
leads to the expulsion of its contents, the same as in real labor.
Women with their first children are more liable to miscarriage than
others on this account, the womb not having become habituated as it
were to the necessary relaxation.

And this is the reason also why some females, after suffering from this
accident many times in succession at last escape it. In general they
miscarry early the first time, from the womb not relaxing sufficiently,
but go a little longer the next time, and longer still the next, and
so on till they reach the full period. The fibres of the womb have
gradually become accustomed to relax, and have borne the irritation
longer and longer each pregnancy, till at last they have forborne
to contract till the proper time. I knew one female who miscarried
_twenty-one times_ in succession, getting gradually nearer to the full
period each time, till at last she reached _nine months_, and was
rewarded with a living child.

Sometimes the accident may be produced by a uterine tumor, by a great
quantity of water in the womb, or even by there being more than one
child, because in either of these cases there is required more room
than ordinary; and of course from the greater expansion required, the
liability is increased. Various womb diseases may also be mentioned
as causes, or adhesions of its walls or ligaments to the walls of
the abdomen, and also a diseased state of the placenta. The pressure
of corsets and tight dresses also not unfrequently lead to the same
result. Some general diseases undoubtedly often cause miscarriage, such
as measles, jaundice, scarlet fever, consumption, and probably many
others, particularly those in which the quality of the blood is much
altered, or the nervous power much exalted or depressed. Convulsions
have already been mentioned as being frequent causes of miscarriage,
and all strong mental or moral impressions. Indeed these last causes
operate more than is suspected, and make it necessary for a pregnant
female to be kept as calm in her mind as it is possible for her to be.
I have even known one to miscarry from a fright _in a dream_.

It is also a fact, though not generally known, that there are
certain diseases _of the father_ that may produce miscarriage, and
unfortunately they are of that kind that often remain for a long time
in the system without much external manifestation, so that many persons
think they are perfectly free from them even while they are working
such mischief.

The death of the child also is sure to produce miscarriage, and this
may result from various causes, such as external injuries and violence,
or from remaining too long in the warm bath and thereby causing
congestion of blood in the womb. Small pox and syphilis in the mother
may also cause the death of the child, though not always. Many having
been born at full term with these diseases upon them.

In general the fœtus is expelled very soon after it dies, but
occasionally it is retained for a considerable time, and may not
pass away till it is completely decayed. It has even been known to
become almost fluid, and several months elapse before it was entirely
expelled. Most women know when it dies, by its seeming to fall down to
the bottom of the abdomen, like a dull weight, and also by its feeling
very _cold_. Very often, however, there is no indication of its death
whatever. M. Chailly mentions a case where the embryo died, probably
when about fifteen days old, but the placenta continued to grow, and
the lady was delivered when about six months and a half gone of the
dead embryo, only about a quarter of an inch in length, though the
after-birth was nearly large enough for one of the usual size. In this
case it had died but not decayed, and remained in the womb six months
and a half. In cases of twins also, one will sometimes die at an early
period, but remain till the other is born at full term.

The _growth of the placenta over the mouth of the womb_, and _shortness
of the chord_, have already been referred to as causes both of flooding
and miscarriage; and to these may be added monstrous or deformed
fœtuses, which rarely reach the full term.

It is probable that there are many constitutional and individual
peculiarities predisposing to miscarriage, with which we are not
much acquainted, and which may account for the constant occurrence
of that accident in many females, notwithstanding all we can do. A
_scrofulous_ taint is with good reason supposed to be one of these, and
it is probable that the _disease of the placenta_, and its consequent
separation from the womb, before referred to, is mostly caused by a
taint of this kind. In many instances, where a female has miscarried
from no apparent cause, if the placenta be carefully examined it will
be found dotted here and there with diseased spots, sometimes _like
scrofulous sores_! It is advisable always to ascertain this, and to
carefully examine the fœtus and its appendages. In all cases the advice
I gave to _keep from being pregnant for some time_, will be found most
likely to succeed in averting the accident, both because it gives the
womb time to regain its strength and break through its _habit_, and
also because it gives us time to operate upon the constitutional taint,
if there be reason to suppose it exists.

It is a curious fact, but one often observed, that _living in certain
localities_ even predisposes to miscarriage. There is a certain
district in France where the females are so liable to it, that all who
can do so leave the place when they become pregnant, and thus escape
the greater risk. Miscarriage also becomes epidemic at certain times,
and prevails like contagious diseases; several instances of this are
recorded in history.

Bleeding is also supposed to be a cause of abortion, and probably
it may lead to it in certain states of the system, but by no means
so certainly as many suppose. Instances have been known of pregnant
females being bled from ten to twenty times without any evil result,
even though carried so far as to make them faint. Mauriceau tells us
of one who was bled _ninety_ times, and yet was delivered of a healthy
living child at full term. In like manner many other ordinary causes
of abortion will often fail entirely of their usual effects. Thus
Mauriceau informs us that a female seven months gone fell upon the
hard pavement from _a three story window_ and broke her arm, but yet
did not miscarry. Madame Lachapelle also tells us of a young pregnant
woman who threw herself down stairs purposely, from fear that she
should have to submit to the Cesarean operation, she having a deformed
pelvis. The fall caused her death soon after, but did not make her
miscarry. Certain powerful medicines are also taken by some, a very
small quantity of which, in most cases, produces abortion immediately,
but without effecting what they desire, though it sometimes poisons
themselves.

Indeed the power which the womb sometimes exhibits to retain its
contents in spite of the most violent disturbing agencies, is truly
astonishing. Cases have been known even where the womb itself has been
severely wounded, and yet miscarriage did not take place; as in the
case of a poor country-woman whom I heard of, who accidentally fell
upon a sharp wooden stake, and run it far into the body, injuring the
womb in a terrible manner, but strange to say, though far advanced
in pregnancy, she recovered and went safely through her full time. I
have often known women begin to flood and suffer from dreadful pain,
with other common symptoms of abortion, as early as the second month,
and yet they went safely the full time, though these signs continued
the whole time. In some cases the waters have even been partially
discharged, and yet abortion did not result. M. Velpeau tells us of an
instance where the bag of waters broke, in a female six months gone,
and one arm of the child even came down into the vagina, and yet the
arm returned, the discharge ceased, and she went her full term.

The _progress of a miscarriage_ varies according to the time at which
it occurs, and the causes from which it arises. When it results from
any violence or accident, it usually takes place in a short time,
and is preceded by abundant flooding, which comes on immediately.
The discharge of blood however, is lesser the nearer we approach the
full term, so that a female six months gone is not in nearly so much
danger from flooding as one only two or three months gone. The reason
is this, in the early months nearly the whole of the fœtal membranes
are attached to the womb, so that in case of their being separated, it
bleeds from nearly all its internal surface, but in the latter months
the only point of attachment is the placenta. In the latter months
also the womb contracts vigorously, and so closes its vessels, but in
the early months its contractions are comparatively feeble. In those
cases also, where the child has been dead a considerable time before
its expulsion, there is seldom much flooding, the connection between
it and the mother having been more or less destroyed by decay of the
parts. The same result mostly follows a miscarriage from internal
disease, particularly of the placenta. Indeed in some of these cases,
the blood-vessels connecting the fœtus with the mother have been so
completely destroyed, that no blood whatever could escape from them.

In regard to the probable consequences of premature delivery, it
has already been remarked that it is more dangerous in the early
months than the latter. It may also be added that it is much more
dangerous, at any time, when caused by violence of any kind, or by
forcing medicines, than when it occurs naturally. The danger is much
increased if it occurs during fever, or any eruptive disease, or if
the patient be suffering from diarrhœa or convulsions. As a general
rule we may say, in all cases, that miscarriage or abortion is always
more dangerous to mother and child than natural labor, both in its
present and in its future consequences. During an attack of jaundice an
abortion may terminate fatally in a few hours; and very frequently the
trouble with the after treatment is very great and long-continued.

The treatment in an accident of this kind must vary according as we are
required to prevent it, or to remedy the evils that follow when it has
occurred.

If an abortion be threatened from any cause, the same general practice
must be adopted as recommended for _flooding_, the indications being
the same. I believe myself that in most cases, except from accidental
violence or internal disease, miscarriage may be averted. I knew a
lady who had miscarried many times, always at the same period, who
avoided it at last by simply _preventing constipation_ from the first
commencement of pregnancy, and by using an enema every evening of warm
starch and water, pretty thick, with about thirty drops of laudanum.
This was administered by means of a common injection pipe, just before
going to bed, and continued till after she had quickened, and repeated
occasionally after that, if she felt any premonitory symptoms of
uterine disturbance. If the patient be of a full habit, she should
also, _from the very beginning_, live low, keep the bowels free, and
the skin in good action, and take gentle regular exercise in the open
air.

When all the means used are found of no avail, and it becomes evident
that the fœtus must be expelled, every endeavor should be used to
assist nature in its removal as early and as safely as possible. For
this purpose the same treatment, as far as practicable, must be pursued
as in a real labor. If the hand can be conveniently introduced, without
undue force, it may be so, to remove clots, or to take hold of any
part of the fœtus which may present, and assist in its extraction.
In the early months considerable help may be given, sometimes by
introducing the finger into the mouth of the womb, with a little
extract of Belladonna, to promote its relaxation, but no _force_ must
be exerted in doing so. If any part of the after-birth can be laid hold
of it should be withdrawn, but no extraordinary effort must be used
to reach it. Frequently it happens that a portion of the after-birth
remains in spite of all attempts to take it away, and there is a
_possibility_ that it may produce inflammation of the womb, but no very
serious apprehensions need be felt of such a result, providing the
patient is properly attended to in other respects. The retained portion
gradually decays, and passes away, merely occasioning inconvenience
and being very offensive. The danger from leaving it except at a very
late period, is generally thought to be less than that from using any
forcible means to remove it.

The best means for correcting the offensive discharge are cleansing and
antiseptic injections. Warm soap suds are very good, or a decoction of
Peruvian bark in water. Strong _coffee_ is also excellent, or a weak
solution of chloride of lime. The bowels must be kept free, and the
skin carefully cleansed and well rubbed. On all occasions when the hand
can be introduced with moderate and safe efforts it should be so, and
the after-birth removed.

In conclusion it should be remarked, that the tendency to miscarry,
like many female diseases, is undoubtedly owing, in great part, to the
general debility and weakness which characterizes so many women at
the present day, and which is brought on chiefly by neglect of their
physical education when girls, and by their artificial mode of life
afterwards.




SECTION X.

THE DISEASES OF WOMEN IN CHILDBED, AFTER LYING IN.




CHAPTER XXVIII.

DISEASES OF CHILDBED.


PUERPERAL FEVER, OR CHILDBED FEVER.

This is undoubtedly the most serious of all those maladies that so
often follow labor. It appears from medical records that puerperal
fever has been known from very remote times, and that it has
frequently become _epidemic_, or has spread from one to another,
like the Cholera. In hospitals this has often been observed, and
also in cities, sometimes almost every female delivered in the place
having been attacked while it prevailed. There is also no doubt but
that it is _contagious_, or capable of being transmitted from one
person to another, like small pox. Numerous instances have been
known where nurses and physicians have conveyed it to all whom they
attended, during a long period after having been with a single case.
One physician, after attending a case of puerperal fever, lost nine
patients successively from the same disease, before he suspected the
cause, and an old nurse assured me, that when she was a young woman,
she was the unfortunate means of conveying it to two females whom
she visited, by merely having been in the room a short time with one
who was suffering from it. It is therefore highly important that all
persons who may happen to be with a female so affected should not
attend another case of childbirth for some time, and particularly that
they should not wear any portion of the same clothing they had then
on, and that they should bathe the whole body several times. If a
case occurs in a hospital or other public institution, the female must
be carefully isolated from all the others, and none of her attendants
must be permitted on any account, to visit other puerperal patients,
till after a sufficient time has elapsed, and every precaution has been
taken.

The causes that produce this terrible disorder are not very well
understood; some of them probably predispose to it before delivery,
or even before pregnancy, while others are connected with labor and
its consequences. Among the former may be mentioned, improper diet,
an inactive life, anxiety of mind, bad air, a damp situation, a full
habit, or great weakness, the frequent use of stimulants, and _certain
excesses_! The principal causes operating immediately are difficult
labors, violent treatment, the use of instruments, tearing away the
placenta too soon, retention of the lochia, cold, rising from the
bed too soon, depression or excitement of the mind, over exertion in
talking to and seeing company, and neglect of cleanliness. The most
frequent cause probably is cold or damp, which checks the lochia and
the perspiration, and leads directly to inflammation. It is on this
account that the complaint is nearly always worse in winter than
in summer, and prevails most in low damp situations, and in badly
ventilated apartments, or in those insufficiently warmed. In most warm
countries, and in those of an equable temperature, where the females
remain much in the open air, and use regular exercise, puerperal fever
appears to be but little known.

The nature of this complaint appears to be a severe and sudden
inflammation, commencing either in the womb or some of the neighboring
parts, which, if not arrested, rapidly extends to all the organs of
the pelvis and abdomen, and hastens to a fatal termination with
fearful speed. The precise seat, and place of commencement, of the
inflammation, varies in different cases, but this makes little
difference either in the symptoms, consequences, or treatment of the
disease, and it is of but little use to give a separate name to all
these various forms. Uterine Phlebitis, Metro Peritonitis, Puerperal
Metritis, and Puerperal Peritonitis, are all essentially the same
complaint, and identical with what is called Puerperal, or Childbed
fever.

The disease generally appears from the second to the fifth day after
delivery, but may be delayed as late as the fifteenth or twentieth day,
or commences as early as two or three hours after; and has even been
known to show itself before labor came on.

It usually begins with headache, general debility, uneasy feelings,
creeping of the flesh, and chills: then follow tremblings, numbness of
the limbs, cold feet and hands, with a burning heat in the body. The
abdomen gradually gets tender, so that it cannot bear the slightest
pressure, sharp pains are felt in various parts of it, and the patient
continually complains of twisting and burning within. She prefers to
lie on her back, with the head raised and the knees drawn up, so as to
relax the abdominal muscles. Very soon she complains of great thirst,
and cries out repeatedly from the sharpness of the pain; the headache
increases, and the breathing becomes laborious. Hiccough generally
occurs at an early stage, and is usually accompanied or followed
by vomiting and diarrhœa, but sometimes by obstinate constipation.
The abdomen continues to swell, and becomes still more tender, the
face is pale, bathed with cold perspiration, and indicates in every
line the anxiety and suffering under which the patient labors. The
features seem to be drawn upwards, and all together, or _pinched up_,
and indeed the whole body seems to _shrink_. In general the lochial
discharge either stops altogether or lessens very much, the breasts
remain empty or nearly so, and the pulse is weak and irregular. In some
few cases however, the lochia continues to flow, or even increases,
and the breasts remain full up to the time of death. The urine is
high colored and thick, and causes smarting and burning as it passes
away. The tongue furs and becomes pointed, and pale colored. The eyes
often seem much engorged, and the white part become yellow, as indeed
the skin does over the whole body, owing to derangement of the bile,
and alteration in the character of the blood. In most cases the mind
retains its faculties nearly till dissolution, but there is frequently
a vague sense of uneasiness and fear, with great depression of spirits
and weeping. Some even feel assured, from the beginning, that they will
never recover, and occasionally become delirious.

The duration of this disorder varies considerably, though in most cases
it carries off the sufferer in a short time, frequently even in two or
three days. It may however last five, ten, or twelve days, and has been
known to do so fourteen.

The manner in which it terminates is also different in different cases.
The fluid resulting from the inflammation may either be absorbed, or
suppuration may ensue, and the matter be discharged, either from one
of the natural passages or from an artificial opening; or it may not
be discharged at all. Sometimes gangrene or mortification ensues,
and sometimes the inflammation partly subsides and becomes chronic.
When it terminates by resolution, which is the most favorable mode,
the patient begins to improve about the fourth or fifth day; the
pains become less acute, the swelling and tenderness become less, and
the milk, lochia, and other secretions that were suppressed begin
to reappear. The patient is also able to lie either on the back or
sides, and soon feels conscious herself that she is improving. But
even when a turn for the better has decidedly taken place, too much
confidence should not be prematurely felt, nor should there be any
relaxation of attention, for the slightest causes may bring back all
the symptoms with more than their former severity. When suppuration
ensues, which is most commonly the case, a mass of fluid forms in
the womb or abdomen, and is plainly indicated, either by its moving
about or by a portion escaping from the body. In this case also the
pain and tenderness decreases, and the abdomen seems less hard, but
the pulse becomes weaker, a sense of weight is felt about the womb,
the extremities become cold, chills come on, and gradually the powers
of the system seem to fail till complete exhaustion ensues. When
gangrene or mortification ensues, the termination is nearly the same,
but more rapid, and all the above symptoms are more marked. When it
passes into the chronic form, there is but little permanent abatement
in the severity of the symptoms for some time; they partially lessen
at intervals, but return again, sometimes with renewed vigor, and it
remains long a matter of doubt whether the disease has really passed
the critical period or not. Recovery takes place occasionally in this
form of the disease, but more frequently the patient becomes daily
weaker and more emaciated, diarrhœa and slow fever set in, the vital
powers steadily sink, and at last death ensues. This fatal termination
may however be delayed for an indefinite period, and may ultimately
result from Consumption or Dropsy, both of which frequently follow
chronic puerperal fever.

In regard to the probable termination of this disease, but little
hope can be entertained that it will be favorable. Nor are there many
indications that can be relied upon with certainty, as to what course
it is likely to take. In general it is favorable when the swelling
subsides, and the pains abate in severity, and particularly if the milk
and lochia begin to be secreted again. The indications are also good
in proportion as the symptoms are mild, and when there is no great
sympathetic disturbance of other parts of the system. It is regarded as
unfavorable when the pain and tenderness extends over a large portion
of the abdomen, and when the attack commences very suddenly. The danger
is also considered greater in proportion as the disease begins nearer
to delivery; and when its first symptoms exhibit themselves before
labor it is always considered mortal. It is likewise more dangerous
with twins than with a single birth, and with first children than
afterwards. It is seldom possible however to come to any probable
conclusion till between the fifth and tenth day, and even then it is in
general a matter of great uncertainty.

The best treatment of this fearful disease is one of the greatest
problems in medical science. So many different plans have been adopted,
and with such various success, that the history of past cases affords
but little reliable data to guide us in future ones. In general the
most powerful _antiphlogistic_ measures, or those thought most likely
to reduce the inflammation at once, are immediately resorted to, such
as bleeding, purgatives, and cold bathing. Bleeding is in particular
the great agent depended upon, either from the arm, or by cups and
leeches to the abdomen and vulva. Dr. Gordon, of Aberdeen in Scotland,
who once met with a regular epidemic of puerperal fever in that city,
assures us that nothing else succeeded in arresting the disorder but
copious and frequent bleeding, at the very commencement. He carried it
so far as to take _twenty-four ounces_ at once, and he says that when
he did so the patient was nearly sure to recover, but that at first,
when he only abstracted about twelve ounces, she was as nearly sure
to die. In about fifty cases to which he was called in time, he only
lost _five_, and taking the average of all he attended the recoveries
were about two-thirds of the whole number, which is above the usual
proportion.

It appears however, from the experience of the most eminent
practitioners, that the bleeding must commence early; that the first
abstraction should not be omitted beyond twenty-four hours after
the first symptoms of the disease, and should be as much earlier as
possible. With very few exceptions they also think Gordon's standard
of twenty-four ounces not too much. Indeed it is generally admitted
that if the blood be not drawn _at first_ and in _large portions_, it
had better not be drawn at all. There may be of course many peculiar
circumstances that will make bleeding improper, which nothing but
experience and observation will teach a practitioner, but the number of
such cases is thought to be small. The use of leeches meets with but
few advocates, and certainly they seem to have had but partial success,
compared with the lancet. Dr. Collins of Dublin depended chiefly upon
leeches and Calomel, but he tells us that in _eighty-eight_ cases
_fifty-six_ died when so treated, while in _fifteen_ that were freely
bled from the arm only _eight_ died. In short it appears that the
bleeding must be carried far enough, _at the very beginning of the
disease_, to cut it short at once, or it will be of no avail, it being
of little or no use merely to _check_ it! In conjunction with the
bleeding it is also usual to give enemas of starch and castor oil, or
something similar, and to bathe the extremities in hot water.

I know that this practice of bleeding meets with strong opposition from
many physicians, and that it is objected to by patients generally. I
myself am as much opposed to it as any one reasonably can be, and I am
well aware of the numerous evils which follow it, but still it cannot
be denied that Dr. Gordon's plan has cured a greater number of cases
of _puerperal fever_ than any other yet tried. It is true that many
of those thus cured may have afterwards died of dropsy, convulsions,
typhus and other diseases _produced by the bleeding_, but then the risk
they run of dying from these was less than that from the puerperal
fever, and in a choice of evils we ought to choose the least. It should
also be remembered that some eminent practitioners assert, if this plan
be adopted _promptly_ and _fully_, it will _always cure_, or at least
with very few exceptions.

Several other modes of treatment have also been adopted to dispense
with bleeding, some of which have been much more successful than
others, though none so much so as we could desire. Thus some
practitioners resort immediately to hot fomentations and sweating
medicines, or a hot bath if convenient, together with brisk purgatives,
and injections. Some depend upon Calomel in large doses, with leeches
to the groins and vulva. Others again use cold fomentations, and
cold injections both to the rectum and to the vagina. Others again
use blisters over the abdomen, in conjunction with purgative enemas
and moderate bleeding; but this mode seems to do but little good.
Another plan is to give about six grains of ipecac, and to repeat the
dose several times, at intervals of an hour or less, in conjunction
with purgatives and warm fomentations. Turpentine has also been used
internally and by enema, but seems to have accomplished little good.
Perhaps the most frequent plan after bleeding, is to rub one or two
drachms of _Mercurial Ointment_ well on the skin, over the abdomen,
every two or three hours, sometimes for several days regularly; eight
or ten grains of Calomel being also given daily, at the same time.
This brings on salivation, and in many cases the symptoms begin to
abate in severity as soon as that commences. I am not aware however,
that this treatment is any more successful than bleeding, nor do I
think the consequences afterwards, in a case of recovery, are any
less to be dreaded. It is difficult in fact to say what plan can be
best recommended, even in the majority of cases, and certainly no one
yet tried is applicable to all, on account of the peculiarities and
varying circumstances of each. If the practitioner or patient is not
decidedly opposed to the bleeding plan, that has undoubtedly the best
recommendation, from former success. Next to that perhaps comes the
mercurial treatment, which usually meets with as much opposition as the
bleeding, but which certainly has been frequently found efficacious.
The other plans have met with but little favor, though possibly they
might sometimes succeed when the rest fail.

If I were asked what I should advise for those who _would not_ submit
to the use either of the lancet or mercury, I should say, commence with
a strong dose of Epsom Salts, or Jalap, and repeat it in about five
hours after its full operation. Also apply warm fomentations to the
abdomen, or put upon it a flannel bag full of hops soaked in vinegar,
as hot as it can be borne, and put mustard poultices on the feet, and
inside of the thighs. The hands must also be kept as warm as possible,
and the head cool. The diet should be very spare, and contain nothing
heating or stimulating, and cooling drinks, such as ice water, or cold
lemonade, should be drunk freely. The purgative should be repeated at
least every day, for two or three days, or more if the symptoms are not
modified, and the mustard poultices may be regularly used to various
parts of the limbs, for the same length of time. In conjunction with
these means the breasts should also be kept warm, to promote the flow
of the milk, and injections of starch and castor oil should be thrown
up the rectum daily. The object being, as far as possible, to keep the
surface of the body warm, and to cool the internal fever, at the same
time that all the natural secretions are excited as much as possible
to remove any morbid matter that may be formed. It should also be
mentioned that the urine sometimes stops, or at least becomes very
scanty and thick, in which case a little sweet nitre may be given, or
if necessary the catheter must be used. Some bitter tea, as boneset
or chammomile, should also be taken occasionally, and a James's Fever
Powder with it once or twice a day, to promote perspiration; or if
there be severe pains, a dose of Dover's Powders may be used instead.

If the disease passes the acute stage and becomes chronic, the same
means must be pursued, and with strict regularity, or there will be
danger of its again becoming acute. In all cases send for the most
experienced practitioner _as early as possible_, and whatever his plan
may be, if his past success proves it to be tolerably successful,
_submit to it_, whether it be bleeding, salivation, or anything else.
If there be no one at hand on whom dependence can be placed, follow
the plan I have laid down as nearly as circumstances will allow, but
practise it fully without delay, and till a change takes place. Those
persons who make light of this disease, and pretend to say that this
or that simple treatment is all-sufficient, either deceive themselves
or wish to impose upon others. There are few affections more serious,
as will be evident when it is borne in mind that, on an average, _two
females die out of every three attacked by it_. To avoid all liability
to it as far as possible, attend well to the general health during
pregnancy, have everything comfortable, clean, and wholesome, during
labor, and be careful to avoid cold, damp, and all kinds of mental
and bodily excitement afterwards. The assistant also, whoever it may
be, must be as careful and as gentle as possible, so as to avoid all
violence or undue force, and _not to hurry nature_. A want of attention
to such simple details has, undoubtedly, brought on many attacks of
this fearful disease that otherwise would never have been experienced.


AFFECTIONS OF THE BREAST OCCURRING AFTER PREGNANCY.

The functions of the breasts are liable, from many causes, to become
deranged, and such derangements may lead to serious results, both to
the mother and the child. It is a common opinion that females who
nurse are not so liable to suffer in this way as those who do not, but
experience proves this opinion to be untrue; nevertheless, as it is the
duty of mothers to nourish their own offspring, it should be a subject
of careful study to relieve them of this liability as far as possible,
or to assist them when necessary.

_Galacterrhœa._ This means an overflow, or excessive secretion of the
milk, which sometimes takes place, particularly in those who do not
nurse. At the commencement of the milk fever, Galacterrhœa needs but
little attention, but if it continue to the second or third day, proper
remedies should be applied to correct it. These consist in complete
rest, both of body and mind, cooling drinks, and spare diet. If these
do not correct it soon, a flaxseed poultice should be placed on each
breast, and the patient should be made to perspire, either by warm
teas and clothing, or by means of steaming. The bowels should also be
freely opened with castor oil, or a seidlitz powder, and it will often
benefit very much to give warm water freely to drink, with ten grains
of nitrate of potash (_saltpetre_) to the pint.

In those that nurse it is very seldom the case that the secretion of
milk is too profuse, unless the child has been kept too long from
the breast. As a general rule it should be put to nurse in a few
hours after birth, even if there be no milk, because its suction will
materially help to bring on the flow. It frequently happens, when the
child is kept away till the milk comes, that the breasts have swelled
so that the nipple is buried and cannot be laid hold of well by the
mouth, in consequence of which the child does not get nourishment
enough, and the breasts not being well emptied become engorged, and
their functions deranged. All this may be avoided by putting it too
early. Sometimes however notwithstanding every precaution, the flow of
milk is excessively great, and constitutes a real disease, which may
cause great weakness and debility. In such cases it will generally be
found that the diet is too stimulating or too rich, or that the bowels
have been too inactive, and the first step towards an improvement must
consist in correcting these faults. The skin should also be kept active
by frequent bathing and good friction, and the quantity of nourishment
taken should not be greater than the mere healthy support of the body
requires. In particular no stimulating liquors should be used.

_Agalaxy._--This complaint is the reverse of the former, as it consists
in a deficient secretion of milk. The causes of this deficiency are
various; sometimes it arises from a constitutional inertness of the
breasts, sometimes from insufficient nourishment, and sometimes from
profuse discharges in other parts. All excesses also tend to decrease
the quantity of the milk, _particularly those of a certain kind_; and
it is seldom so abundant or lasting either in extreme youth or advanced
age. The appearance of the menses in like manner generally causes the
flow to become less, and it ceases naturally in some much earlier than
in others. Sometimes there is a deformity in the child's mouth, which
prevents its sucking properly, and the milk may stop for want of being
completely drawn. The breasts also may be diseased, or the nipple not
sufficiently prominent, and the same difficulty be thus produced in
another way.

In treating agalaxy, therefore, the first thing is to ascertain if
there be no deformity or disease in either mother or child, which
prevents proper nursing. If there be nothing of the kind, it must
next be ascertained whether the mother has any excessive secretion
elsewhere, such as diarrhœa, great flow of urine, or heavy sweats; if
she have, these must be corrected. It must next be seen if she takes
sufficient nourishment, and of a proper kind for her stomach and
bowels. Sometimes a little spiced wine is excellent, or some porter,
with white meats, and arrow-root milk. If she be of a full habit,
however, and makes much blood, the contrary course must be pursued, and
the diet be made low and unstimulating, while the bowels are kept free
and the skin in good action.

In many cases when the nipple is small, it may be much enlarged by
titillation, just before the child is put to it, after which the
suction will increase it still more.

If the female be advanced in life, or very weak, or if she becomes
pregnant, it may be better to procure a nurse than to attempt to
stimulate the flow at all. The appearance of the menses need not
occasion a suspension of nursing, unless it evidently deranges the
secretion of the milk, or affects the health of the mother; in either
of which cases the child should be weaned at once.

_Engorgement of the Breasts._--The breasts are liable to become
swollen, or engorged, from colds, blows, hard nursing from the child,
over feeding, and from soreness or excoriations preventing them being
fully emptied. This state may occur at any time, but is most frequent
a few days after delivery. In general there is no danger from it,
unless it be very bad or continues too long; it may then inflame and
discharge, or become permanently hardened. To prevent such accidents
the breasts should always be sufficiently emptied, either by the child
or by artificial means, and every precaution should be used against
cold or violence. Constipation must also be guarded against, and the
diet and drink must be carefully observed, so that it be not too
feeding, or too stimulating. Warm fomentations or poultices may also be
used when the breasts are painful, and a Dover's Powder may be given at
night, after bathing the feet in warm water, to promote perspiration.

_Inflammation of the Breasts._--This is only a more advanced stage
of the previous malady, produced by the same causes, and by want of
timely attention. Like simple swelling, it may arise at any time
during nursing, but is more frequent a few days after delivery. As
soon as the inflammation commences the breasts become red, swollen,
and excessively tender, particularly at one point, which soon begins
to project like a nipple, if the disease is not stopped, and at last
bursts and discharges the contained pus. Sometimes the inflammation
is comparatively superficial, and extends only over a small portion
of the surface, but at other times it goes deep and spreads wide. In
proportion to its extent is the severity of the symptoms, which are
those of inflammation in general, such as headache, thirst, fever,
general uneasiness, and cutting pains in the part affected.

As soon as the abscess is formed and can be plainly discovered, it is
usual to open it immediately, because the longer it remains the more
extensive it becomes, and the larger portion of the breast becomes
diseased. It is necessary however to be _certain_, before making an
opening, that it is really an abscess on which we are going to operate,
for sometimes a healthy part of the breast feels very much like one,
and a mistake may easily be made; in fact such a mistake has often
been made, and by men of experience too. In the early stage of the
inflammation every effort should be used to prevent an abscess from
forming, by the use of purgatives, sweating medicines, low diet,
cooling drinks, and warm fomentations over the whole chest. Some
females practice _cold_ fomentations over the breasts, and with good
success, in the commencement of the inflammation, but it may increase
the difficulty with others, and, so far as I have seen, is no more
generally useful than the other method. The warm bath all over the body
is also very serviceable in a number of cases.

It usually happens however, in spite of every precaution, that matter
will form, and its discharge become necessary. As soon as this is
evident, it should be promoted as much as possible, by hot fomentations
and poultices, till the head of the abscess is sufficiently distinct
for it to be safely opened. While the swelling is going on the pain
is often very severe, and it should be eased as much as possible, by
using laudanum in the fomentations, or by putting on an opium plaster.
After an abscess has opened and discharged, it should be kept open for
some time, by little pledgets of lint, to prevent its closing up too
soon, otherwise a portion of the matter may be shut in by the wound
healing over it, and another abscess will form. Warm poultices and
lotions should also be used afterwards, to promote the discharge as
much as possible, but they should not be used after it has evidently
begun to cease naturally. In short every means pointed out should be
used energetically in the first stage, to _prevent_ the gathering, but
if it takes place in spite of them, then it should be _hastened_ and
_discharged_ as early as possible, to prevent its extending. After
this, when it has evidently all escaped, the wound may be suffered to
heal, and the patient must be enjoined to be very careful in future,
for the same accident will be very liable to reappear.

Sometimes these abscesses become very extensive, and remain for a long
time. I have known ten or twelve on one breast, and I have known them
to continue open for many months. When this is the case it is much
to be deplored, as it is very likely indeed to destroy the breast,
and may even lead to more serious results. Attention therefore cannot
be bestowed upon them too early or too unremittingly, particularly
if the female be scrofulous, or of a very full habit. Sometimes the
inflammation attacks both breasts, and at other times only one, in
which case every effort should be exerted to prevent its extending
to the other. In many persons the same side is always affected, and
becomes a scape-goat as it were for the other.

When the means used succeed in scattering the swelling, its dispersion
is usually followed by some critical discharge, such as diarrhœa, or a
great flow of urine, or even by profuse perspiration, which shows how
nature operates in removing the diseased matter, and cautions us not
rashly to check such discharges.

It is a very serious matter for the swelling to _indurate_ or harden,
as it sometimes will, without either scattering or dispersing, as it
is then constantly liable to become worse again, besides destroying
the structure of the gland. Every means should therefore be used to
prevent this, by promoting its dispersion or discharge, in the way
already pointed out. It is also very good in these cases to bathe
frequently with alum water, or decoction of white oak bark, or even to
rub on some of the _Ointment of Hydriodate of Potassa_, diluted with
an equal weight of fresh lard. A piece as large as a hickory nut may
be well rubbed on twice a day, for three or four days, but it should
be stopped immediately the swelling begins to subside, and not used
again unless it still remains or again increases. In many cases pretty
frequent friction, with the hand anointed with a little oil, will be
all sufficient, especially if a hot fomentation be used afterwards.

_Excoriations, or Cracks in the Breasts._--The annoyance from this
cause is sometimes very great, the pain which is experienced when the
child begins to nurse being so acute that it is impossible for the
mother to allow it to remain. Frequently I have known it compel weaning
much earlier than was desirable, and sometimes it has even been so
bad, that the dress could scarcely be borne against the breasts. The
precise cause of this liability to crack is not known, nor do we know
of any certain means to prevent it. In many cases however I have known
it prevented, to a great extent, by having the nipple gently sucked,
very frequently, for six weeks or two months before childbirth. This
hardens it, and if a wash of borax water be also used, after each time,
it will be gradually prepared for its proper use. Our means of curing
this troublesome affection are very limited, and frequently everything
fails that is tried. The mucilage of Quince seed, prepared by bruising
and boiling them in a small quantity of water, rubbed over the sores
with a soft feather, immediately after nursing, often does much good.
The mucilage from the tender tops of young sassafras sometimes succeeds
better than that from the Quince, and a bruised leaf from the large
_horse-shoe Geranium_, laid on like a poultice, is sometimes better
than either. A good lotion may also be made with a quarter of an
ounce of borax, and a tea-spoonful of laudanum, to half a pint of
warm water, to be used frequently during the day. Some females use a
wash made of saleratus, with considerable benefit, and others find
relief from one made of nut galls, or white oak bark. Most of these
means however are well known, and many others also, which, like them,
sometimes succeed and often fail. The artificial nipple, or _shield_,
should be tried if none of these means succeed, and frequently it
will enable the mother to allow the child to nurse, though it may not
altogether prevent the pain.

It not unfrequently happens that the child's mouth may be diseased,
particularly with _apthæ_, or thrush, and this may possibly keep up
the excoriations; in like manner the state of the breasts may also
influence the mouth, and therefore the condition of each should be well
ascertained when anything is the matter with either.


BRONCHOCELE, OR SWELLING IN THE THROAT.

This is often observed in childbed, and sometimes even comes on
during labor. It is usually attributed to cold, and no doubt it often
does arise from cold, but more frequently it is owing to sympathetic
derangement, and from violent attempts to swallow during and after the
pains. Many females in fact cry out at those times, that something has
_broken_ in the throat, and they fear they are going to suffocate. As a
general rule the swelling gradually subsides in a short time, without
any special treatment, but sometimes it increases and inflames, and an
abscess forms which may become very troublesome, and even dangerous.
To prevent this it should be frequently treated with warm fomentations
and poultices, till the inflammation subsides, and then with the same
washes recommended for indurated or hardened breast, in the preceding
section of this chapter. If the swelling becomes hard, and remains
indolent, the ointment of hydriodate of potassa may also be prepared
and used, as there recommended.


PHLEGMASIA ALBA DOLENS, OR MILK LEG.

This is a painful tumefaction or swelling of one or both of the limbs,
which comes on from the fifth to the fifteenth day after delivery. It
generally commences with slight pain, or stiffness, or cramp, becoming
more painful as it proceeds; but, sometimes, shooting, cutting pains,
of great violence, are felt suddenly, at the very commencement. The
swelling, also, sometimes comes on gradually, but, at other times,
rapidly. In most cases the patient complains of a sudden pain in the
groin and thigh, which is preceded by a chill followed by fever, and
then the limb begins to enlarge. Most frequently the lower part swells
first, and then it extends upward, sometimes, even to the hip. The
skin, on the swollen part, looks white, shining and tight, as if ready
to break; it is also extremely painful, so that pressure upon it can
scarcely be borne. It looks in fact like a thin bag of skin filled with
milk, and hence the name _milk leg_, from an idea that it was really
filled with milk, which had, by some means, reached there from the
breast. This idea is erroneous, in the sense it is usually taken; the
milk does not flow into the leg as many imagine, nor is anything like
it to be found there, except a peculiar thin, white matter, when it
breaks. Still, however, a sudden stoppage of the milk may cause such
a swelling, like a sudden stoppage of any other secretion, but in no
other way. It is, probably, most frequently produced by sudden cold,
which checks that profuse perspiration into which females gradually
fall immediately after delivery, and so drives the perspirable
matter within, and causes inflammation and suppuration. A difficult
or prolonged labor may also lead to it, by preventing, for a long
time, the proper circulation of the blood through the large veins of
the pelvis, and so engorging those below. Or the veins may become
paralyzed, as it were, by the pressure they have sustained, and so
become, for a time, unable to transmit the blood. In fact, both the
veins and lymphatics become engorged, as if tied above the limb, and
exhibit knots and bundles, like bunches of grapes.

Sometimes the fever will occur some days first, and the female cannot
tell what it is owing to, till the swelling comes on; and even this
may take place so gradually, and with so little pain, that the limb
may be very large before it is observed. I have known females complain
of a slight fever only, on going to sleep at night, and wake up in the
morning with a confirmed case of milk leg; and I have known others
start with a sudden pain in the groin, or hip, and be affected in the
same way, in less than two hours.

The disease usually lasts from a month to seven or eight weeks, and
terminates, either by a gradual resolution, or scattering, of the
fluids, or by suppuration and discharge. When suppuration ensues, there
will, sometimes, form one or more very large abscesses, which it may be
difficult to heal, and which may lead to serious results, either from
their extent, or from the constitutional irritation they produce.

The treatment, at first, consists in warm fomentations, such as
those of poppy-heads, or hops, with cooling drinks, purgatives, low
unstimulating diet, and occasional doses of James's Fever Powder, to
promote perspiration. This is intended to disperse the swelling, and,
in general, it does so. If, however, the abscess forms and breaks, in
spite of all the means used, it must be treated the same as abscess
in the breast, previously described. In ordinary practice, it is the
general custom to _bleed_ at the commencement of the disease, or to
apply leeches to the groin. This sometimes does good, but frequently is
of no service at all, even if it does not make matters worse. I would,
however, make the same remarks on bleeding here, as I did in regard to
its use in _puerperal fever_, to which milk leg has a resemblance, in
some respects.

Another practice is to use tight bandages, the same as for varicose
veins, but I think the plan is not, in general, a successful one,
though it may be occasionally. Plunging the limb in cold water,
or keeping it wrapped in cold wet cloths, has succeeded much more
frequently, and is, with some, a favorite remedy. Stramonium leaves
boiled in vinegar, and laid on hot, will also effect a cure sometimes;
and so will bathing with hot lye or alcohol. A large poultice of hops,
soaked in hot vinegar, has also been found useful.


TROUBLE WITH THE URINE.

The bladder, from its position, is very apt to be inconveniently
pressed during the passage of the child, and to be temporarily affected
for a short time after, in consequence. Sometimes, the neck of the
bladder will be _paralyzed_, and the urine cannot be discharged. In
this case, fomentations of warm milk and laudanum must be used, or a
warm hip bath, if there be no danger of flooding, and the bowels must
be freely opened. If this does not relieve, the catheter must be used,
and always before the bladder is too full. To avoid its becoming so,
the attendant should inquire of the female, during the first day, if
she has urinated, or feels any inclination that way, so that he may
know in time if the difficulty exists. In general, this paralysis
passes off in the course of a day, but may endure longer sometimes;
in which case the patient herself should speak of it. Cases have been
known where the bladder has become so full as to _burst_ through
inattention to this matter. The contrary difficulty is occasionally
observed, and the urine cannot be retained, but it flows away as fast
as it is secreted. It is very seldom, however, that this state remains
more than a single day and, more frequently only a few hours. A dash of
cold water on the pubes, and against the meatus urinarius, has often
corrected it at once, and so has a single purgative dose. If it remain
after the first two days without amendment, it is customary to put a
small blister on the abdomen, which usually relieves in a short time.




APPENDIX.

ON PREVENTING PAIN IN CHILDBIRTH.


USE OF CHLOROFORM IN MIDWIFERY.

AN ENQUIRY INTO THE UTILITY AND PROPRIETY OF PREVENTING THE PAIN AND
SUFFERING WHICH USUALLY ATTENDS CHILDBIRTH, WITH AN ACCOUNT OF THE
MEANS TO BE EMPLOYED FOR THAT PURPOSE.

In the preface to this work I remarked that a great part, and, perhaps,
nearly the whole, of the suffering and danger to which parturient
females are exposed, arises, undoubtedly, from their bad physical
education and mode of life; and that, in a more rational state of
existence, it was probable that both would be so slight as to excite no
apprehension. This improved state of things is much to be desired, and
should, of course, be striven for by all friends of humanity. But, in
the mean time, it is proper to consider whether there are any means by
which those now living can be relieved in their hours of distress. The
agony which many females endure at this time is so great that there are
few circumstances under which relief is more needed, or would be more
acceptable; and I, for one, cannot subscribe to the doctrine that such
relief would be improper, unless it prove to be injurious. There are
some persons, I know, who say that this suffering has been _ordained_
for woman, and that it _ought to be_ endured. This notion, I think,
needs no refutation, it being just as unreasonable as to say that the
sick should be allowed to suffer and die without assistance, because
_their_ condition has been ordained. There are others, and men of
science, too, who think that the pains of childbirth are necessary to
its safe accomplishment, and that they are also valuable in a _moral_
point of view. This opinion will be examined by and by, and the facts
on which it is founded, carefully analyzed; but it is first necessary
to state the means of prevention usually employed, and to note their
mode of action, and effects.

Some years ago, a celebrated physiologist, who supposed that the chief
cause of pain and difficulty in labor was the size and hardness of the
child's _bones_, advanced the theory that if these bones were less
developed, and softer, the pain and difficulty would be materially
lessened, if not entirely removed. He proposed, therefore, since the
hardness of the bones is caused by the deposition of _lime_ in them,
which is derived, of course, from the blood of the mother, that she
should avoid taking anything to eat or drink, during pregnancy, that
contained lime. This, he supposed, would keep the bones of the child
soft till after birth, and so allow them to give way and crush together
during delivery, and thus prevent the suffering and difficulty usually
experienced. It was also thought that the bones of the mother would be
partially softened at the same time, and give way a little, so as to
facilitate the process still more.

I am not aware, however, that this theory has ever succeeded in
practice, either in the human species or in the lower animals, though
frequently tried. Nature will work on her own plan, and will develop
the bones of the fœtus, while in the womb, to a certain extent,
providing she has the means to do so; and if these are withheld, she
is very likely to suspend its development altogether, rather than send
it forth imperfect. I have known cases where everything was withheld,
for the whole period, that contained a particle of lime, and yet the
child's bones were as hard at birth as in any other case; the material
being, probably, taken from the bones of the mother, which might be
thus weakened, and made liable to displacement, without any good result
whatever. It is also a question whether such a course, supposing it
to succeed, might not be dangerous in another way, by causing an
imperfection in the child which its future growth could not overcome.
I have known some cases where this practice appeared to have caused
abortion from imperfect development, and several others in which there
was too much reason to fear that the child was injured, though safely
born. As this is, therefore, at best, a very uncertain and ineffective
process, and is also, probably, dangerous to the mother or child, or
both, it does not appear to me worthy of further attention, and I
merely allude to it in order to make the present sketch of such means
complete.

The other means are such as do not interfere, in any way, with the
natural processes, but merely prevent sensation or feeling at the
time of delivery. _Mesmerism_ has been recommended, and, in some few
instances, tried, for this purpose, but its success has either been so
small, or its action so uncertain, that no dependance can be placed
upon it, notwithstanding many persons assert its power. Opium and other
powerful drugs have also been given, but so much of them is required,
at that time, to produce a sufficient effect, that their use becomes
dangerous. Other substances, in the form of _vapour_, or _gas_, have
also been used, the effects of which only last for a short time, and
are not, generally speaking, at all dangerous. Among them may be
mentioned nitrous oxide, or _laughing gas_, carbonic acid, sulphuric
ether, and chloric ether, all of which were first employed in severe
surgical operations.

The success of these agents, especially _ether_ and _chloroform_, in
_preventing pain_, is undoubted; nor do they appear to have any other
effect, nor to prevent any necessary effort or process of nature,
except in a few cases which will be mentioned further on. Many hundred
operations of the most severe kind, such as cutting off limbs, removing
tumors, stones, and so forth, have been performed while the patients
were under the influence of these agents, and without causing them
_the slightest pain_; in fact, many remain, during the whole process,
in a pleasant dream, and cannot be persuaded, when they wake, that
the dreaded operation is over. The same thing has also been observed
in hundreds of cases of midwifery, both in natural labor and when
instruments have been used. In numerous instances the female has been
_put to sleep_, and safely delivered, without knowing or feeling
anything whatever, during the whole time; the first intimation that
she had become a mother, being the cheering cry of her newborn babe.
In some instances, the state of insensibility has been continued for a
long time, and during its continuance, the most hazardous operations
have been safely performed.

So far as can be safely judged, from the limited time during which such
means have been used, it appears that there is no danger whatever,
from their employment, except when improperly administered, and in
certain peculiar conditions of the system; which causes of danger
will, of course, be removed by competent experience and knowledge. It
is highly encouraging however, to note, though ether and chloroform
have both been used so extensively and indiscriminately, both by those
who understood their nature and those who did not, that the cases in
which they are proved to have done injury, are _not more than two or
three_; and in all those that I have heard of, some obvious impropriety
had been committed in their use. It should be borne in mind, however,
that even if the danger from them was considerable, we might still be
justified in their use. It is well known that, in numerous cases, the
_fear_ of suffering, beforehand, and its severity while being endured,
produce the most serious, and even fatal results. Many a patient has
passed safely through the ordinary effects of a painful operation,
and yet sunk from the mere effects of _fear_ and physical suffering.
Instances have even been known in which a fear of this kind has caused
_death_, and frequently it has given a shock from which the patient
never fully recovered. There is also, frequently, great danger from the
violent efforts and struggles of a person in pain, and many necessary
operations are even prevented altogether by them; this is often
observed in difficult labors. When insensibility is produced, however,
all these causes of difficulty and danger are removed; the patient's
_fears_ are quieted, suffering is entirely prevented, and there is no
struggling to prevent the necessary assistance. Supposing, therefore,
that the ill effects of these agents were more certain and greater in
amount than has yet appeared, it would still be a question whether the
evil they really prevent is not greater than that which they possibly
_may_ cause.

In regard to the two agents now chiefly used, _ether and chloroform_,
there is no difference in their mode of action, but the chloroform
appears to be more speedy, certain, and efficacious, and is,
therefore, the most valuable, but proportionably more dangerous when
improperly administered. There are numerous instruments or _inhalers_,
for administering these vapors, most of which are both costly and
complicated, and all of which may be easily dispensed with. A very good
plan is to take a large sponge and dip it in hot water, then squeeze
out the water and pour on the ether or chloroform, and hold it over the
mouth and nose. In two or three minutes consciousness and feeling will
both be gone, and the patient will sink into a calm sleep which will
last sometimes ten or fifteen minutes, and may be kept up as long as
desired, by putting the sponge to the mouth for a few minutes whenever
there are signs of waking. When it is left off the patient gradually
comes round as if waking from ordinary sleep, and frequently speaks of
having been in a dream, sometimes of a very pleasant character, but
never knows what has taken place. No ill effects follow, but sometimes
there is a little drowsiness or stiffness of the limbs, which soon
passes off. A pocket handkerchief soaked in the fluid, and held over
the mouth and nose will answer equally well; but whatever is used, _it
must not be pressed close_, because a portion of air ought to enter
with the vapor to prevent suffocation; and it should also be removed
immediately the effect is produced. When it is borne in mind how much
these requisites have been neglected, and how _impure_ the ether or
chloroform has often been, it is wonderful that more accidents have
not occurred; and the fact that so few have happened under such a
state of things, and with our little experience, goes far to prove
that there is little or no danger at all in competent hands, with
pure materials. The accounts circulated in the papers of "_death from
ether_," and "_fatal effects of chloroform_," have mostly been gross
exaggerations, and frequently false altogether. In most of the cases
where death has _followed_ from the use of these agents, it has been
proved to arise from other causes, and would have happened if they had
not been used. In one or two cases, however, of surgical operations,
the ether itself appears to have caused death by producing suffocation,
or congestion of the lungs; but, even in these, it has been shown that
it was used in an improper manner. Thus a young woman in Newcastle in
England, inhaled ether to have a diseased toe-nail cut off, and died.
It appears, however, that there was an evident disposition in her to
congestion or rushes of blood, and therefore she was not a fit subject,
and besides, the ether was poured on a _thick table cloth_, which, of
course, prevented the entrance of _air_ along with the vapor, and thus
suffocated. I believe there is _not a single case_ on record of injury
resulting when due precautions have been used, and I have not heard of
one at all in midwifery practice.

_Ether_ having been the first article used, I shall first give an
account of its effects, and then proceed to chloroform, explaining the
mode of administration, and other incidental matters, as I proceed. The
best article on ether which I have met with, is a review in the British
and Foreign Medical Review for April, 1847, of some pamphlets on the
subject, from which I shall make an extract.

 In the state of perfect etherization we believe all sensation
 is abolished; in a less perfect state an obscure perception of
 external objects remains, while the sense of pain is extinct. The
 psychical state is various. Generally speaking, the sense of external
 impressions becomes at first confused, then dull, then false, with
 optical spectra or auditory illusions, general mental confusion,
 and then a state of dreaming or utter oblivion. In the majority of
 cases the mind is busy in dreaming, the dreams being generally of an
 active kind, often agreeable, sometimes the reverse, occasionally
 most singular; and, frequently, a great deal is transacted in the few
 short moments of this singular trance. Many of the patients who have
 undergone the most dreadful operations, such as amputation of one or
 both thighs or arms, extraction of the stone, excision of bones,
 extirpation of the mamma, have readily detailed to us, and most with
 wondering thankfulness, the dreams with which, and with which alone,
 they were occupied during the operations. The character of the dreams
 seemed to be influenced, as in ordinary cases, by various causes,
 immediate or remote, present or past, relating to events or flowing
 from temperament.

 A good many seemed to fancy themselves on the railway amid its whirl
 and noise and smoke; some young men were hunting, others riding on
 coaches; the boys were happy at their sports in the open fields, or
 the filthy lane; the worn Londoner was in his old haunts carousing
 with his fellows; and our merry friend, Paddy, of the London Hospital,
 was again at his fair, wielding his shelala in defence of his friends.
 Others, of milder mood, and especially some of the women patients from
 the country, felt themselves suddenly transported from the great city
 and the crowded hospital-ward to their old quiet home in the distant
 village, happy once more with their mothers and brothers and sisters.
 As with the dying gladiator of the poet, the thoughts of these poor
 people--

  "Were with the heart, and that was far away."

 Some seemed transported to a less definite but still happy region,
 which they vaguely indicated by saying they were in heaven; while
 others had still odder and warmer visions, which need not be
 particularized.

 For the purpose of obtaining information on all the points of this
 most interesting subject, we personally questioned all the patients in
 the London hospitals, who, at the period of our visits, still remained
 in the wards after the ether-operations. They were in all fifty-four,
 and the great majority had been the subjects of capital operations.
 They were unanimous in their expressions of delight and gratitude
 at having been relieved from their diseases without suffering. In
 listening to their reports, it was not always easy to remain unmoved
 under the influence of the conceptions thereby communicated, of the
 astonishing contrast between the actual physical condition of the
 mangled body in its apparent tortures on the operating table of a
 crowded theatre, and the really happy mental state of the patient at
 the time.

This perfect freedom from pain is proved by every case wherein the
vapor has been efficiently administered, although there are frequently
the same cries uttered, and the same motions practised as when pain
is experienced which proves that nothing is prevented but the mere
_feeling_, which it can be of no use whatever for any one to suffer
from.

_Chloroform_ has been more recently introduced than ether, but has
nevertheless been used quite as much, or probably more, and, in
general, with still more success. It was first described, I believe, by
Professor Simpson of Edinburgh, at a sitting of the medical society of
that city, in November, 1847, and several cases were narrated, two of
which I quote.

 I have employed it in obstetric practice with entire success. The
 lady to whom it was first exhibited during parturition, had been
 previously delivered in the country by perforation of the head of the
 infant, after a labor of three days' duration. In this, her second
 confinement, pains supervened a fortnight before the full time.
 Three hours and a half after they commenced, ere the dilatation of
 the os uteri was completed, I placed her under the influence of the
 chloroform, by moistening with half a teaspoonful of the liquid, a
 pocket-handkerchief, rolled up in a funnel shape, and with the broad
 or open end of the funnel placed over her mouth and nostrils. In
 consequence of the operation of the fluid it was once more renewed in
 about ten or twelve minutes. The child was expelled in twenty-five
 minutes after the inhalation was begun. The mother subsequently
 remained longer soporose than commonly happens after ether. The crying
 of the child did not, as usual, rouse her; and some minutes elapsed
 after the placenta was expelled, and after the child was removed by
 the nurse into another room, before the patient awoke. She then turned
 round and observed to me that she had "enjoyed a very comfortable
 sleep, and, indeed, required it as she was so tired, but would
 now be more able for the work before her." I evaded entering into
 conversation with her, believing, as I have already stated, that the
 most complete possible quietude forms one of the principal secrets for
 the successful employment of either ether or chloroform. In a little
 time, she again remarked, that she was afraid her "sleep had stopped
 the pains." Shortly afterwards her infant was brought in by the nurse
 from the adjoining room, and it was a matter of no small difficulty
 to convince the astonished mother that the labor was entirely over,
 and that the child presented to her was really her "own living baby."

 Perhaps I may be excused for adding, that since publishing on the
 subject of ether inhalation in midwifery, seven or eight months ago,
 and then for the first time directing the attention of the profession
 to its great use and importance in natural and morbid parturition,
 I have employed it, with few and rare exceptions, in every case of
 labor that I have attended, and with the most delightful results.
 And I have no doubt whatever, that some years hence the practice
 will be general. Obstetricians may oppose it, but I believe our
 patients themselves will force the use of it upon the profession. I
 have never had the pleasure of watching over a series of better and
 more rapid recoveries, nor once witnessed any disagreeable result
 follow to either mother or child, whilst I have often seen an immense
 amount of maternal pain and agony saved by its employment. And I most
 conscientiously believe that the proud mission of the physician is
 distinctly twofold--namely, to alleviate human suffering, as well as
 preserve human life.

In another part of the same publication Professor Simpson has another
list of cases, all equally favorable. In some of these the labors were
protracted _many hours_, and in others, operations with instruments
were performed, of the most terrible character, such as would, under
ordinary circumstances, have been attended with the most horrible
suffering. As this article gives an instance of nearly every kind of
delivery under the influence of chloroform, and contains also some
admirable reflections upon its employment, I quote it in order to make
the present account complete.

 CASE 2.--Seen with Mr. Carmichael; a second labor; she began
 the chloroform inhalation before the dilatation of the os uteri
 was entirely completed; the child was expelled in fifty minutes
 afterwards. I kept her under the chloroform for a quarter of an hour,
 till the placenta was removed, the binder applied, and the body and
 bed-clothes were arranged and adjusted. On awaking she declared that
 she had been sleeping refreshingly; she was quite unaware that the
 child was born, till she suddenly heard it crying at its first toilet
 in the next room. An hour afterwards she declared she felt perfectly
 unfatigued, and not as if she had borne a child at all. In her first
 or preceding confinement she had been in severe labor for twenty
 hours, followed by flooding. No hæmorrhage on the present occasion.

 CASE 3.--Patient unmarried; a first labor; twins; the first child
 presented by the pelvis, the second with the hand and head. The
 chloroform was exhibited when the os uteri was nearly fully dilated;
 the passages speedily became greatly relaxed, (as has happened in
 other cases placed under its full influence,) and in a few pains the
 first child was born, assisted by traction. I broke the membranes
 of the second, pushed up the hand, and secured the more complete
 presentation of the head; three pains expelled the child. The mother
 was then bound up, her clothes were changed, and she was lifted into
 another bed; during all this time she slept soundly on, and for a
 full hour afterwards, the chloroform acting in this as in other cases
 of its prolonged employment, as a soporific. The patient recollected
 nothing from the time of the first inhalations, and was greatly
 distressed when not one but two living children were brought in by the
 nurse to her. Dr. Christison, who was anxious to observe the effect of
 the chloroform upon the uterus, went along with me to this patient.

 CASE 4.--Primipara; of full habit; when the first examination was
 made, the passages were rigid, and the os uteri difficult to reach.
 Between six and seven hours after labor began, the patient, who was
 complaining much, was apathized with the chloroform. In about two
 hours afterwards, the os uteri was fully dilated, and in four hours
 and a half after the inhalation was begun, a large child was expelled.
 The placenta was removed, and the patient bound up and dressed before
 she was allowed to awake. This patient required an unusual quantity
 of chloroform, and Dr. Williamson, who remained beside her, states to
 me, in his notes of the case, "the handkerchief was moistened often,
 in order to keep up the soporific effect. On one occasion I allowed
 her to emerge from this state for a short time, but on the accession
 of the first pain, she called out so loudly for the chloroform that it
 was necessary to pacify her by giving her some immediately. In all,
 four ounces of chloroform were used." Like the others, she was quite
 unconscious of what had gone on during her soporised state, and awoke
 altogether unaware that her child was born.

 CASE 6.--Second labor. The patient--a person of a small form and
 delicate constitution--bore her first child prematurely at the
 seventh month. After being six hours in labor, the os uteri was
 fully expanded, and the head well down in the pelvic cavity. For two
 hours subsequently it remained fixed in nearly the same position,
 and scarcely, if at all, advanced, although the pains were very
 distressing, and the patient becoming faint and exhausted. She
 entertained some mistaken religious feelings against ether or
 chloroform, which had made her object to the earlier use of the
 latter; but I now placed her under its influence. She lay, as usual,
 like a person soundly asleep under it, and I was now able, without any
 suffering on her part, to increase the intensity and force of each
 recurring pain, by exciting the uterus and abdominal muscles through
 pressure on the lower part of the vagina and perinæum. The child was
 expelled in about fifteen minutes after the inhalation was commenced.
 In a few minutes she awoke to ask if it was really possible that her
 child had been born, and was overjoyed to be told that it was so.
 I have the conviction, that in this case the forceps would in all
 probability have been ultimately required, provided I had not been
 able to have interfered in the way mentioned. I might, it is true,
 have followed the same proceeding, though the patient was not in an
 anæsthetic state; but I could not have done so without inflicting
 great agony upon her.

 CASE 7.--A third labor; the patient had been twice before confined of
 dead premature children; once of twins, under the care of Mr. Stone,
 of London; the second time of a single child under my charge. The
 liquor amnii began to escape about one o'clock, A.M., but without
 pains for some time. I saw her between three and four o'clock, with
 the pains commencing and the os uteri beginning to dilate. In two
 hours afterwards, the third stage was well advanced, and the pains
 becoming very severe, she had the chloroform exhibited to her, and
 slept soundly under its influence. In twenty minutes the child was
 born and cried very loudly without rousing the mother. In about twelve
 or fifteen minutes more she awoke as the application of the binder was
 going on, and immediately demanded if her child was really born alive,
 as she thought she had some recollection of hearing the nurse say
 so. She was rejoiced beyond measure on her son being brought in and
 presented to her.

 CASE 9.--In the Maternity Hospital; first child. Labor began at 10
 P.M., (Nov. 21st.) I was desired to see her at six A.M., (22nd.)
 The os uteri was well dilated, but it was evident that the pelvic
 canal was contracted throughout, and the head was passing with unusual
 difficulty through the brim. The patient was complaining much of
 her sufferings. It was evident that it would be a very tedious, and
 probably, at last, an instrumental case, and one therefore calculated
 to test the length of time during which chloroform might be used.
 She began to inhale it at a quarter past six, A.M., and was kept
 under its influence till a quarter past seven, P.M.,--the date of her
 delivery--_thirteen hours_ in all. From the time it was begun till
 the time delivery was completed, her cries and complaints ceased,
 and she slept on soundly throughout the day. The bladder required to
 be emptied several times with the catheter. The head passed the os
 uteri at ten A.M., and during the day, gradually descended through the
 pelvis. At seven P.M., I at last deemed it proper to deliver her by
 the forceps; the head, which was now elongated and œdematous, having
 by that time rested for some hours against the contracted pelvic
 outlet, with little or no evidence of advancement; the bones of the
 fœtal cranium overlapping each other, and the fœtal heart becoming
 less strong and distinct in its pulsations. A warm bath, irritation of
 the chest, &c., were necessary to excite full and perfect respiration
 in the infant. Whilst we were all busied with the infant, the mother
 lost some blood, but the placenta was immediately removed, and the
 uterus contracted perfectly. On afterwards measuring the quantity of
 blood lost, it was calculated to amount to fifteen or eighteen ounces.
 The mother's clothes were changed, she was bound up, and removed to a
 dry bed before she awoke. She had at first no idea that the child was
 born, and was in no respect conscious of being delivered. In fact, she
 had been "sleeping," according to her own account, from the time she
 had begun the inhalation, and thought she remembered or dreamed that
 she heard Dr. Williamson, the house-surgeon, speak near her once or
 twice. Dr. Beilby, Dr. Ziegler, &c., saw the case with me. Three days
 afterwards I found the mother and child perfectly well. She continued
 to recover so rapidly, that she insisted on leaving the hospital on
 the tenth day after delivery.

A sufficient number of such accounts as these could be collected to
fill a large volume; but these are quite sufficient for our purpose.

In regard to the objections to using chloroform or ether, in midwifery,
it will be thought by most persons, and with good reason, too, that the
safety and success which has attended their use, is itself a sufficient
answer to all objections.

It was at first thought, by some physicians, that the expulsive force
of the womb was lessened when the pain was prevented; but this is not
the case; on the contrary, it has been, in many cases, much increased.
It was also thought by others that there was more danger from flooding,
and convulsions, than in ordinary cases; but this is also equally at
variance with truth, for it appears, beyond doubt, after a careful
examination of all the cases recorded, that there is much _less_
danger, particularly from convulsions, than when the patient is allowed
to be tortured and terrified by feeling pain. Dr. Simpson remarks in
another part of the article above quoted:--

 The question which I have been repeatedly asked is this--Will we
 ever be "justified" in using the vapor of ether to assuage the pains
 of natural labor? Now, if experience betimes goes fully to prove to
 us the safety with which ether may, under proper precautions and
 management, be employed in the course of parturition, then, looking
 to the facts of the case, and considering the actual amount of pain
 usually endured, I believe that the question will require to be quite
 changed in its character. For, instead of determining, in relation
 to it, whether we shall be "justified" in using this agent under the
 circumstances named, it will become, on the other hand, necessary to
 determine whether, on any grounds, moral or medical, a professional
 man could deem himself "justified" in withholding and _not_ using any
 such safe means, (as we at present presuppose this to be,) provided he
 had the power, by it, of assuaging the pains and anguish of the last
 stage of natural labor, and thus counteracting what Velpeau describes
 as "those piercing cries, that agitation so lively, those excessive
 efforts, those inexpressible agonies, and those pains apparently
 intolerable," which accompany the termination of natural parturition
 in the human mother.

 Since the latter end of January I have employed etherization with
 few and rare exceptions, in every case of labor which has been under
 my care. And the results, as I already stated in THE LANCET, have
 been, indeed, most happy and gratifying. I never had the pleasure of
 watching over a series of more perfect or more rapid recoveries; nor
 have I once witnessed any disagreeable result to either mother or
 child. I do not remember a single patient to have taken it who has
 not afterwards declared her sincere gratitude for its employment, and
 her indubitable determination to have recourse again to similar means
 under similar circumstances. Most have subsequently set out, like
 zealous missionaries, to persuade other friends to avail themselves
 of the same measure in the hour of suffering. And a number of my
 most esteemed professional brethren in Edinburgh have adopted it
 with success and results equal to my own. At the same time, I most
 sincerely believe that we are, all of us, called upon to employ it,
 by every principle of true humanity, as well as by every principle of
 true religion. Medical men may oppose, for a time, the superinduction
 of anæsthesia in parturition, but they will oppose it in vain; for
 certainly our patients themselves and their friends will force the use
 of it upon the profession. The whole question is, I believe, even now,
 one merely of time. It is not--Shall the practice come to be generally
 adopted? but--When shall it be generally adopted? And, for my part,
 I more than doubt if any man (rejecting willingly its benefits) is
 really justified, on any grounds, moral or medical, in deliberately
 desiring and asking his patients to shriek and writhe in their agonies
 for a few months, or a few years longer, in order that, by doing so,
 they may defer, forsooth, to his professional apathy, or pander to his
 professional caprices and prejudices.

Another objection has also been advanced against the employment of
ether or chloroform, the force of which must be estimated by every one
for themselves. It is well known that many, if not most of the lower
animals during labor, or immediately afterward, _experience certain
feelings and desires stronger than at any other time_; and it is
supposed that such would be the case, as a general rule, with human
beings, if it were not for the _pain_ which overpowers everything
else. This supposition has, in fact, been partly verified in a few
cases; several females having confessed, after recovering from a
painless labor under the influence of ether, that their dreams during
the sleep were of _a peculiar warm character_! How far this may be
_generally_ the case, of course, we have no means of ascertaining, nor
do I consider it to be practically of any consequence to know, because
it can in no way interfere with the safe progress and termination of
the labor, which alone is what we are properly concerned in. I have
merely thought it proper to state the fact as being a singular one,
and to make my readers acquainted with it. Physicians are well aware
that the peculiar feelings referred to are frequently produced by
various causes which act on the nervous system, such as _mesmerism_,
and even by _strong devotional excitement_. I have known females with
strong moral impressions who always carefully avoided _both_ the above
causes, from having discovered their liability to produce such effects;
in fact, this has been one objection raised to allowing mesmerists to
operate upon young persons, and several cases of moral failing having
been attributed to this cause. It is not at all improbable, therefore,
that such results may occasionally occur during labor, though we are
not at all justified in assuming that they will in any particular case.
How far this may be considered an objection to the employment of such
means, must be however, as I before remarked, decided by all persons
_for themselves_, and _for themselves only_! It is not a _medical_
question at all.




Notices of Dr. Hollick's Lectures.


DR. HOLLICK AND PHYSIOLOGY.--The second of a series of Lectures, by
this gentleman, on human physiology, and the all important truths
connected with our physical constitution, was attended by a full
house, in National Hall, last evening. The time was well spent, and
so appeared to think the audience. On the delivery of the first of
these Lectures on Tuesday evening, the speaker in a comprehensive and
well-digested exordium, placed himself and the subject right with
the public. His manner, language and style, did the first; his sound
logic, his argument, his candor and research, accomplished the second.
Apart from the interesting and apposite details of the wonders of
reproduction, the illustrations of the immutable wisdom of nature,
which teem in the animal and vegetable worlds--which

  "Glows in each stem, and blossoms in each tree;
  Lives through all life, extends through all extent,
  Spreads undivided, operates unspent."

Apart from all this, Dr. Hollick's Lecture was excellent as a defence
of truth, a vindication of the right of free and unshackled inquiry,
and as a convincing refutation of that silly, but far too prevalent
opinion that there are truths of which it is better to remain in a
state of ignorance. Had nothing else been imparted in the forcible and
well defined exordium of Dr. Hollick than this judicious demolition
of that fallacious, silly, but injurious twaddle which would forbid
research to pass in advance of the old landmarks prescribed by custom,
ignorance, or a spurious morality--even that would well deserve the
public patronage. Truths, well set forth, will make an impression,
whether their investigation be fashionable or not. There is an affinity
between the capacity to learn, and the truths to be learned, which
always results, when a fitting opportunity is presented, in a free
inquiry, and the gentleman who is bringing, in a judicious and elevated
manner, a knowledge of those fundamental principles of our corporeal
existence which are abused because unknown, will accomplish more good
than half a dozen teachers of higher pretensions, and lower ability.
It was gratifying to observe the decorum--the sense of respect for
both speaker and subject, that was observed throughout the evening,
which evidently shows that those who go there are actuated by higher
motives than mere curiosity; by desires more ennobling than a passing
gratification; in a word, it was clear that those who composed Dr. H.'s
hearers, were men who know and dare to think, and who will profit by
these most useful discourses.--_New York Herald, Aug. 7, 1844._


THE ORIGIN OF LIFE.--We attended Dr. Hollick's Lecture at the Masonic
Hall, on Monday evening, and if we were to say we were delighted, we
should but feebly express the gratification we experienced. It was,
in fact, a whole series of anatomical lectures crowded into one, and
that one so divested of technicalities, and rendered so concise, so
intelligible to the most illiterate mind, and withal couched in such
delicate as well as perspicuous language, that the most fastidious
could find no fault, nor the idlest curiosity go away uninformed.
The human figure--a French model, made, we believe, of _papier
mache_--is beautifully constructed, and every trifling organ is not
only an accurate counterpart of nature, but can be taken apart,
opened, examined, &c., with an ease that renders the study as perfect
as an actual dissection, without the _desagremens_ that attend a
scrutiny of the real subject. We advise all who love knowledge, and
particularly a knowledge of their physical organization, to attend
these lectures.--_Phila. Spirit of the Times_, Dec. 4, 1844.


At a Meeting of the Class attendant upon Dr. Hollick's Select Lectures
on the Physiology and Philosophy of the "Origin of Life" in Plants and
Animals, held at the Lecture Room of the Museum, Wednesday evening,
December 1, 1844, George G. West, Esq., was called to the Chair, and
Samuel W. Black appointed Secretary.

_Resolved_, That we have listened with unfeigned pleasure and interest
to the Course of Lectures delivered by Dr. Hollick, and now brought
to a close, and that we deem it an act of justice to him and the
community, to express our entire confidence in his character, ability,
and the manner of illustrating his subject, which, to use the words of
a daily journal, "is couched in such delicate as well as perspicuous
language, that the most fastidious could find no fault, nor the idlest
curiosity go away unimproved."

_Resolved_, That a committee of three be appointed to tender to Dr. H.
the thanks of the Class for his courtesy to the members in affording
them every facility for obtaining information upon the subject of his
Lectures, and that he be requested to repeat the Course at the earliest
period consistent with his other engagements.

Published in all the Philadelphia daily papers of December 14, 1844,
and signed by _one hundred and forty_ of the most respectable and
influential inhabitants.

(See similar Resolutions, with _over two hundred names_ attached, in
the Philadelphia daily papers of March, 9, 1844; also of March 16; and
on several other occasions.)


_From the Philadelphia Daily Papers, Feb. 21, 1845._

At a meeting of the Ladies composing Dr. Hollick's Class, held on
Wednesday afternoon, February 19th, in the Lecture Room of the Museum,
the following Resolutions were unanimously adopted, and ordered to be
published in one or more of the city papers:

_Resolved_, That we have listened with great pleasure and interest to
Dr. Hollick's Lectures, and are happy to add our testimony to the many
already recorded in behalf of such Lectures: and regarding Dr. Hollick
as a benefactor of his race, and especially of our sex, we cordially
wish for him abundant success, and ample reward in the consciousness of
doing good.

_Resolved_, That we will exert ourselves to induce our female friends
and acquaintances to avail themselves of the great and rare privilege
of obtaining the valuable instruction imparted in these Lectures in so
chaste and dignified a manner.

           Signed on behalf of the meeting by
  SARAH WEBB, Sec'y.                  SUSAN WOOD, President.

--> With over 50 names attached thereto.

(See also similar Resolutions, with numerous names, on Feb. 27, 1846,
March 20, 1846, and on April 10, 1846, with over _three hundred names
attached_.)


DR. HOLLICK'S LECTURES.--These Lectures continue to attract much
attention, and are commended by all who hear them. During the past week
Dr. H. has given a private Lecture and exhibition of his models to
many of our prominent Senators and public men, all of whom expressed
themselves highly gratified, and desirous that another class should be
formed to accommodate their friends who had not attended.--_National
Intelligencer, Jan. 30, 1846._


DR. HOLLICK is a gentleman of no less knowledge in his profession than
eloquence in his means of imparting it, and he is certainly deserving
of great credit and support for his exertions in a new field of such
universal importance. We commend these Lectures with the fullest
confidence to the attention of our citizens.--_N. Y. Sun, Aug. 6, 1845._


"LETTERS FROM NEW YORK, NO. 11."

"* * * * There have been several courses of Lectures on Anatomy, this
winter, adapted to popular comprehension. I rejoice at this; for it
has long been a cherished wish with me that a general knowledge of the
structure of our bodies, and the laws which govern it, should extend
from the scientific few into the common education of the people. I
know of nothing so well calculated to diminish vice and vulgarity as
universal and rational information on these subjects. But the impure
state of society has so perverted nature, and blinded common sense,
that intelligent women, though eagerly studying the structure of
the Earth, the attraction of the Planets, and the reproduction of
Plants, seem ashamed to know anything of the structure of the human
Body, and of those Physiological facts most intimately connected with
their deepest and purest emotions, and the holiest experience of
their lives. I am often tempted to say, as Sir C. Grandison did to
the Prude--'Wottest thou not how much _in_-delicacy there is in thy
delicacy?'

"The only Lectures I happened to attend were those of Dr. Hollick,
which interested and edified me much. They were plain, familiar
conversations, uttered and listened to with great modesty of language,
and propriety of demeanor. The Manikin, or Artificial Anatomy, by
which he illustrated his subject, is a most wonderful machine invented
by a French Physician. It is made of _papier mache_, and represents
the human body with admirable perfection, in the shape, coloring, and
arrangement, even to the minutest fibres. By the removal of wires it
can be dissected completely, so as to show the locality and functions
of the various Organs, the interior of the Heart, Lungs, &c.

"Until I examined this curious piece of mechanism, I had very faint and
imperfect ideas of the miraculous machinery of the house we live in. I
found it highly suggestive of many things to my mind." * * *

    L. M. C.

[Extract from a Letter in the "Boston Courier" of Monday, June 3d,
1844, by Mrs. L. M. Child.]


DR. HOLLICK'S LECTURES.--We cordially say to those who love a
scientific treat not to fail to attend. More instruction is contained
in those three Lectures, than can be mastered by a twelve month's
reading.--_Baltimore Clipper, March 30, 1847._


WRITING DESK AND GOLD PEN PRESENTED TO DR. H. By ONE OF HIS LADY
CLASSES.

[Illustration]

DR. HOLLICK--Dear Sir: The members of your class, desiring the
gratification of offering you some testimonial of their personal
regard, and grateful appreciation of the benefits which you are
conferring upon them and their sex generally, respectfully request your
acceptance of the accompanying writing desk.

Were it necessary, we might repeat our assurances that your services to
humanity will be, by us, long and gratefully remembered. The women of
this generation have reason to rejoice that, by your efforts, a new and
extensive field of information has been opened to them, whence they may
derive treasures of knowledge, of immense importance to themselves and
their posterity, hitherto concealed within professional enclosures.

Wishing you health and happiness, we beg leave to subscribe ourselves,

              Truly your Friends,
    Signed on behalf of the class by,
                                  M. G.
         (500 present.)           O. W. B.

_Philadelphia March 20, 1845._

[Illustration]




NOTICES OF BOOKS.


_From the New York Herald._

OUTLINES OF ANATOMY AND PHYSIOLOGY, WITH A DISSECTING PLATE OR THE
HUMAN ORGANIZATION, by Frederick Hollick, M. D. We regard this as one
of the most valuable works issued in a long time. It is a complete
general treatise on anatomy and physiology, and the dissected plate
answers the purpose of a model of the human frame. Dr. Hollick is
entitled to great credit for his laudable desire to disseminate a
knowledge of subjects that are of such vital consequence to all, but
which hitherto has been monopolized by the medical profession. We
commend it to all as a work of great merit and usefulness.


_From the Patriot, Baltimore, March 24th, 1847._

OUTLINES OF ANATOMY, &c.--Dr. F. Hollick, whose history as the
great _simplifier_ of the human anatomy, so well known throughout
the country, and whose public Lectures have won for him so high a
reputation, has just published a work which he designates "Outlines
of Anatomy and Physiology for Popular Use." This book contains a very
curiously and ingeniously arranged plate, which opens by pieces, so
that the different parts of the organs of the human system may be seen
in all their variety, all of which are fully explained in English.
The second part of this invaluable work gives a general description
of these organs and parts of the system, under the division of bones,
muscles, arteries, veins, &c., &c. This work should fall into the hands
of every family.


_From the New York Argus, January 9, 1847._

NEUROPATHY.--This is a new name, but a good one, being the title of a
work by Dr. F. Hollick, whose excellent Lectures on various subjects
will be remembered by many of our citizens. In this work is explained
the action of Galvanism, Electricity and Magnetism; Homœopathy
and Allopathy are contrasted in theory and practice; Mesmerism is
discussed, and other subjects "too numerous to mention," treated in a
manner at once novel and instructive. Dr. Hollick has also published
a work on "Anatomy and Physiology for Popular Use," illustrated with
a new dissected plate of the human organization, of most ingenious
construction. Of this work we shall have more to say anon. It is no
ordinary production.


_From the New York Sunday Times and Messenger, Jan. 10, 1847._

"OUTLINES OF ANATOMY AND PHYSIOLOGY, FOR POPULAR USE," illustrated
by a new dissected plate of the human organization, and by separate
views. The work is designed either to convey a general knowledge of
these subjects in itself, or as a key for explaining larger and more
complete works. These Outlines should be in the hands of every body;
and Dr. Hollick, or any one else, is a public benefactor who furthers
the publication of such able, interesting, and truly important works.


_From the Pennsylvanian, (Philadelphia,) Jan. 26, 1847._

The following in regard to two works from the pen of Dr. Hollick, of
this city, we copy from the Washington Union, of the 20th instant:--

OUTLINES OF ANATOMY AND PHYSIOLOGY FOR POPULAR USE. _By Frederick
Hollick, M. D., Lecturer on Anatomy, Physiology, &c._--We regard
this as an eminently useful publication. It gives in a form far
more condensed and intelligible than we have before seen, a very
comprehensive view of the human organization. The dissected plate of
the human anatomy, which forms an interesting feature of the work, is
to us at least a novelty. The explanations are drawn up with great
simplicity, and cannot be misunderstood by the general reader, while
they, with the illustrations, will often serve to render more clear and
precise the views of scientific and professional students.


_From the Sunday Mercury, New York._

DR. HOLLICK'S LAST WORK--_The Diseases of Woman, their Causes and
Cure familiarly explained, with Practical Hints for their prevention,
&c._--We regard this as an invaluable production, the most useful,
in many respects, which has yet emanated from this distinguished
author and practitioner. It is just the kind of work which has ever
been wanted, and is just suitable to the excellent purpose for which
it was intended; this it accomplishes most fully, and its extensive
circulation must be productive of vast practical benefit. It is works
of this nature and CHARACTER which really do good; which exhibit
plain facts in a plain manner, and record in language simple and
intelligible, knowledge of the most vital importance to the health
and consequent happiness of every daughter, sister, wife, and mother
in the land. The work is dedicated to the LADIES OF AMERICA, and we
congratulate them upon the possession of a friend at once so able, so
sincere and valuable as Dr. Hollick. Burgess, Stringer & Co., of this
city, are the publishers.


_The New York Sun says of this Book_:

"BURGESS & STRINGER have just issued a most invaluable work, being a
treatise upon the diseases of women, by the celebrated Dr. Hollick.
We have thoroughly examined the work, and can say without hesitation,
that it should be in the hands of every mother who cares for the health
of her daughters, and every woman who values physical and mental
well-being. Dr. Hollick and his publishers have done a public benefit
by issuing such a book."


_From the New York Sunday Times._

DR. HOLLICK'S great work, THE DISEASES OF WOMAN, which will be found
advertised in another column, is truly a valuable production, and
well sustains the author's well-earned reputation. It is a complete
practical treatise on female diseases, scientific enough for a
medical man, and yet so plain that every body can understand it, and
so delicately written that even the most fastidious cannot object
to a single passage. Much of the matter it contains is quite new in
this country, even to medical men, and of the greatest interest and
importance. The anatomical plates are superb, and the whole book is
excellently got up. Every adult female in the land should read this
book; the information it gives would prevent an incalculable amount of
disease and suffering, if possessed in time; or it will teach the best
way to cure it when unfortunately established.




WORKS PUBLISHED BY DR. HOLLICK.


  OUTLINES OF
  ANATOMY AND PHYSIOLOGY,

  BY FREDERICK HOLLICK, M. D.

This is the most complete, and at the same time most simple work ever
issued on the subject. It is illustrated in a novel manner, by a
_large colored Plate_ of the Human Organization, which _dissects_ by
means of separate layers, _from the surface of the Abdomen down to the
Spine_, showing all the Organs in their proper places, all connected
together, and many of them in sections! the whole being colored to
life. This plate is on an entire new plan, nothing of the kind having
ever before been invented; it is almost as complete as a model, and is
invaluable for private study, for teachers, and for Medical students.
The explanations are familiar, and divested of technicalities: and it
is still further illustrated by separate wood-cuts throughout the work,
and a beautifully engraved portrait on Steel of the author. One volume,
quarto, bound, price One Dollar. Third Edition.


  NEUROPATHY;
  OR,
  THE TRUE PRINCIPLES OF THE ART
  OF
  =HEALING THE SICK=.

  BY FREDERICK HOLLICK, M. D.

Being a complete practical treatise on the use of GALVANISM,
ELECTRICITY, and MAGNETISM, in the cure of disease, and a comparison
between their powers, and those of Drugs or Medicines.

These two works are published by T. B. PETERSON, No. 98 Chestnut-st.,
Philadelphia, and for sale by Booksellers and News Agents generally
throughout the United States.


THE ORIGIN OF LIFE.

A complete popular Treatise on the _Philosophy_ and _Physiology_ of
REPRODUCTION, in Plants and Animals, with a detailed description of
human generation. Illustrated by colored plates of the male and female
systems. New being at every stage, &c. Published by Nafis & Cornish,
268 Pearl street, New York. Price $1. _Thirtieth Edition_, with
additional Plates and various improvements.

N. B.--This is the only popular and yet strictly scientific work on the
Generative Functions ever yet published.


  THE
  =DISEASES OF WOMAN=,
  THEIR CAUSES AND CURE
  FAMILIARLY EXPLAINED;

With PRACTICAL HINTS for their prevention and for the preservation of
Female Health. By F. HOLLICK, M. D. _Especially designed for every
Female's Private Use_. BURGESS, STRINGER & CO., corner of Broadway and
Ann streets, New York, and for Sale by all Booksellers. Second Edition.
Price $1--300 pages, beautifully bound, and illustrated with numerous
splendid ANATOMICAL PLATES. By remitting $1 in a letter to T. W.
STRONG, 98 Nassau-st., N. York, it will be forwarded to any part of the
Country.

--> _No Female should be without it._


The above works, along with the present one, constitute a complete
practical and popular Library of Anatomy, Medicine and Physiology.
They have all been purposely designed for the instruction of
non-professional readers, but at the same time are so scientifically
correct, and so complete, that they would serve as text books for
Medical students. The favor they have already met with, and the
extensive circulation they have attained, is proof that they both meet
the wants of the public and enjoy its approbation.


_From the Boston Mail, March 7, 1848._

DR. HOLLICK'S SEPARATE LECTURES TO LADIES AND GENTLEMEN ON
PHYSIOLOGY.--The importance of adult persons, of both sexes,
understanding themselves, and their natural relations, must be obvious
to every thinking mind. The present ignorance on these matters is,
undoubtedly, the chief cause of the vices and sufferings which so
extensively prevail, and our only hope of a beneficial change must be
founded on a proper system of public instruction. This instruction
is difficult to impart we admit, and there are but few men qualified
for imparting it. We have no hesitation, however, in saying that Dr.
H. is one of these men. He knows how to preserve in his subject all
that intense interest which it intrinsically possesses, and yet to
divest it of everything in the slightest degree obnoxious to censure,
or even distrust. He has a happy faculty of making every thing easy
to be understood, and yet avoiding the slightest approach to undue
familiarity. All who attend, express themselves both surprised and
delighted, and unhesitatingly recommend his Lectures wherever they go.
Many of the most eminent Ladies in our city were among his auditors
last week, and were unreserved in their expressions of approbation,
both for the Lecture itself, and for the becoming modesty and true
refinement that characterised its delivery. The present series, which
commence to-day, has been anxiously expected, and will no doubt be
numerously attended by both sexes, but particularly by the Ladies, many
of whom were unable to gain admission last week.


[Illustration: THE GOLD MEDAL PRESENTED TO DR. HOLLICK,

BY

THE

LADIES OF PHILADELPHIA.]




IMPORTANT NOTICE TO LADIES!


THE PATENT ELASTIC AND MEDICATED PESSARY;

FOR THE RELIEF AND PERMANENT CURE OF

PROLAPSUS UTERI, OR FALLING OF THE WOMB;


Prolapsus Vagina, Rupture of the Bladder or Intestine into the Vagina;
Retroversion, or Anteversion of the Womb; and also, in many cases,
of LEUCORRHŒA, or Fluor Albus; invented by DR. HOLLICK, and first
described in his "Diseases of Woman."

This Instrument is CERTAIN TO CURE all the above named diseases, WHERE
A CURE IS POSSIBLE. It can be worn with perfect ease by young or old,
summer or winter, night or day, without the slightest inconvenience.
It is made of a soft elastic material, which never corrodes, and which
gives way to the slightest motions of the body. It can never become
displaced, nor fail to effectually support the parts, and is so light
that it only weighs _one ounce_.

--> This is the only Instrument of the kind ever invented,
and certainly the only one that can CURE FALLING OF THE WOMB; or be
worn with ease, to relieve it, when incurable. DR. HOLLICK is the only
person who keeps it, as he has NO AGENT ANY WHERE, at present.

N. B.--The article is PATENTED: but, besides this, NO IMITATIONS,
however similar, can be depended upon, because the Original is
impregnated, in a peculiar manner, KNOWN ONLY TO THE INVENTOR, with a
substance which imparts its MEDICINAL Power, and without which it would
be comparatively inefficacious.

All the old fashioned TRUSSES, SUPPORTERS, PESSARIES, &c., are entirely
superseded by this Instrument, which can only be obtained from _Dr.
Hollick_, _New York_, who will also give the necessary directions as
to its use and application. _It may be sent any distance. Price--Five
Dollars._


ADVERTISEMENT.

DR. HOLLICK is daily receiving numerous Letters from all parts of the
country, the answering of which has hitherto been a great tax on his
time, already sufficiently occupied; he is therefore compelled to
announce, that in future he cannot attend to any which merely request
advice, unless they contain the customary fee of FIVE DOLLARS. Address,
_Dr. Hollick_, _New York_.



       *       *       *       *       *



Transcriber's Notes

Page 39 states, "In Plate VII. the line marked † crosses the upper
strait, or brim of the Pelvis," but there is no † in the original image.

On page 341, Chapter XXIII was incorrectly labeled Chapter XXII. That
has been corrected here.

Minor punctuation errors were corrected on pages vi, 4, 13, 19, 90,
141, 151, 200, 202, 206, 215, 258, 271, 301, 313, 323, 346, 457, 460,
464.

Inconsistencies in hyphenation and capitalization have been retained.
Original spellings have been retained except in the cases of these
apparent typographical errors:

Page 29, "situate" changed to "situated." (This is the part situated
between...)

Page 53, "tha" changed to "that." (Thus some authors asserted that...)

Page 56, "barenness" changed to "barrenness." (...or, in other words,
which produce barrenness...)

Page 64, "Tincœ" changed to "Tincæ." (The Os Tincæ, or mouth of the
Womb.)

Page 116, "is" changed to "in" in two instances. (...Womb in a first
pregnancy, and in a female...)

Page 138, "expeeted" changed to "expected." (...or before the expected
period...)

Page 156, "foetal" changed to "fœtal." (...and covered with the fœtal
membranes...)

Page 183, "rotale" changed to "rotate." (...the head is compelled to
turn, or rotate...)

Page 203, "cephalio" changed to "cephalo." (...it is called the right
cephalo iliac position...)

Page 238, "langour" changed to "languor." (...falls into a quiet and
pleasing langour...)

Page 240, "signs" changed to "sign." (...and if there is no sign of its
coming...)

Page 243, "subseqnent" changed to "subsequent." (...being done in their
subsequent labors.)

Page 247, "asphyxated" changed to "asphyxiated." (...are most likely to
become asphyxiated...)

Page 253, "capble" changed to "capable." (...she thinks herself
stronger, and more capable...)

Page 255, "presentatious" changed to "presentations." (...very
unfavorable presentations of the fœtus...)

Page 257, "unforseen" changed to "unforeseen." (...alarmed when
unforeseen difficulties occur...)

Page 281, "developement" changed to "development." (The development of
the head cannot be ascertained...)

Page 307, "cause" changed to "causes." (Still such presentation
occasionally causes...)

Page 311, "presentatations" changed to "presentations." (...most
dangerous of all the presentations...)

Page 313, "and" changed to "any." (...child and pelvis from any other
cause.)

Page 323, "recommeuds" changed to "recommends." (Mauriceau recommends
that women...)

Page 333, "continuanee" changed to "continuance." (...the continuance
of pregnancy to the full period...)

Page 333, "inadmissable" changed to "inadmissible." (The plug is here
totally inadmissible...)

Page 341, "honr" changed to "hour." (...may be preserved for an hour or
two...)

Page 341, "amni" changed to "amnii." (...and then if the liquor
amnii...)

Page 349, "introdueed" changed to "introduced." (When the first blade
is properly introduced...)

Page 371, "distate" changed to "distaste." (This means a complete
distaste...)

Page 380, "meat" changed to "neat." (A neat spoonful should be drunk...)

Page 385, "weaknes" changed to "weakness." (...a state of weakness and
exhaustion.)

Page 385, "chlid" changed to "child." (...than dangerous, except to the
child...)

Page 395, "unles" changed to "unless." (...unless very large, they
cause...)

Page 397, "truely" changed to "truly." (...as truly so as those on the
limbs...)

Page 408, "mattrass" changed to "mattress." (...lie on her back, on a
hard mattress...)

Page 409, "accummulate" changed to "accumulate." (...and makes it
accumulate in the womb...)

Page 413, "ocurrence" changed to "occurrence." (...which may account
for the constant occurrence...)

Page 418, "ccnclusion" changed to "conclusion." (In conclusion it
should be remarked...)

Page 422, "temblings" changed to "tremblings." (...then follow
tremblings, numbness of the limbs...)

Page 426, "spmptoms" changed to "symptoms." (...after the first
symptoms of the disease...)

Page 436, "two" changed to "too." (...or too unremittingly,
particularly...)

Page 441, "oocasional" changed to "occasional." (...occasional doses of
James's Fever Powder...)

Page 441, "James' fever powders" changed to "James's Fever Powder."
(...occasional doses of James's Fever Powder...)

Page 445, "recommened" changed to "recommended." (Mesmerism has been
recommended...)

Page 445, "develope" changed to "develop." (...will develop the bones
of the fœtus...)

Page 450, "crowed" changed to "crowded." (...on the operating table of
a crowded theatre...)

Page 452, "minmtes" changed to "minutes." (...the child was expelled in
fifty minutes afterwards.)

Page 455, "throngh" changed to "through." (...with unusual difficulty
through the brim.)

Page 457, "humau" changed to "human." (...natural parturition in the
human mother.)

Page 459, "coporeal" changed to "corporeal." (...principles of our
corporeal existence...)

Page 460, "1840" changed to "1846." (March 20, 1846)

Page 464, "Peansylvanian" changed to "Pennsylvanian." (From the
Pennsylvanian, (Philadelphia,) Jan. 26, 1847.)

On page 240, an extra "an" was removed from the phrase "...to wait more
than an hour..."

On page 456, the word "of" was missing from the phrase "...after a
careful examination of all the cases recorded..."

On page 457, an extra "of" was removed from the phrase "the superinduction
of anæsthesia."