The Matron_s Manual of Midwifery_ and the Diseases of Women During Pregnancy and in Childbed Frederick Hollick 822 downloads.pdf

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Title: The Matron's Manual of Midwifery, and the Diseases of Women
During Pregnancy and in Childbed

Author: Frederick Hollick

Release date: January 1, 2015 [eBook #47836]
Most recently updated: October 24, 2024

Language: English

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*** START OF THE PROJECT GUTENBERG EBOOK THE MATRON'S
MANUAL OF MIDWIFERY, AND THE DISEASES OF WOMEN
DURING PREGNANCY AND IN CHILDBED ***

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
295
Vagina,
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.
ateral 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.)

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

PLATE II.
ront 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.

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.

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.

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.
ig. 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.
ig. 2. Represents the natural appearance, the fibres not being quite so
distinct, though sufficiently obvious.—a. a. The orifices of the Fallopian
Tubes.
n both Figures the Womb is supposed to be turned inside out, its peculiar
structure being more readily seen interiorly than exteriorly.

Fig. 1 Fig. 2

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.

Fig. 1

Fig. 2

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.
he 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.
he 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.
. 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.

Plate VII.
Bones of the Pelvis.

PLATE VII.—a.

This represents the Male Pelvis, to show the difference in structure.
The letters correspond with those in Plate VII.

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

Plate IX.
Diameters of the Upper Strait.

PLATE X.
he 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.

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.

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.
ection 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.

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. 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.

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.

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

igure 2, the same at about the seventh month.
igure 3, the same at the ninth month.
he 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.

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.

PLATE XV.

Primipara, Woman
or the first who has
Pregnancy. borne
children
a. a. The neck of the Womb.—b. before.
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.
his 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.
he 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.
, 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.
he 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.

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:—

PLATE XVII.

Neck of the Womb in Neck of the Womb in
a first Pregnancy, very a female who has
slightly opened. borne children before,
showing how it
This is at the end of the Fifth admits of the
Month, and the drawings are about introduction of the
one-third of the natural size. finger.

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.

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.
his Plate represents the Fœtus in the most usual position, the head
downwards, and the back of it presenting to the left side.
he 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.

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

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.
his Plate shows the position of the Fœtus in a presentation of the Pelvis, or
breech, which happens, comparatively, but seldom.
he black spot a, denotes the situation of the heart, which is here above the
line, instead of below.

n 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.

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.

his represents the position of Twins, as most usually observed, one having a
head presentation, and the other a breech.
he black spot a, on both, denotes the position of the heart, which in one case
is above the line, and in the other below.
he 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.

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.

PLATE XXIII.
Fig. 1. Fig. 2.

The neck of the The neck of the
Womb, at near the end Womb, at near the
of nine months in a end of nine months, in
primipara. a woman who has
previously borne
Ballotment is now more obscure children.
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.
he head is generally divided into the Cranium, or that part which contains the
brain, and the Face.
he 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.
he 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.

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:—

PLATE XXV.
Diameters of the Head.
Fig. 1. Fig. 2.

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:—

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.
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.

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.
econd 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.

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.

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

PLATE XXX.
Fig. 1. Fig. 2.

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.
his 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.

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:—

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:—

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.

PLATE XXXIV.
Fig. 1. Fig. 2.

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.

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.

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.

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.

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:—

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

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.

Plate XL.
Represents the standard form of the Pelvis.

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.
his 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).

Plate XLII.
Represents the peculiar deformity most frequently produced by
Mollites Ossium.

Plate XLIII.
This is called an Ovate Pelvis.

PLATE XLIV.
his 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.
his 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.

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

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.

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.
his 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.

Plate XLVII.
Case of Tumor.

PLATE XLVIII.
his 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.

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:—

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:

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."

PLATE LI.
The head being drawn through a narrow Pelvis by the Forceps.

he 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