[i]

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.

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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[iv] 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

[v]

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;[vi] 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[vii] 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.

[viii]

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.

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MIDWIFERY.

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.

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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.

[14]

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.

[15]

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.

[16]

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.[17] 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.

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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 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,[20] 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.

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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.

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.

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[30] 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 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.

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PLATE VII.—a.

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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;[38] 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[39] 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.

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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[48] 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.

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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 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.

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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 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:

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[55] 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[56] 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.

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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.

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.

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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[59] 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[60] 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[61] 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[62] 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.

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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.

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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.[69] 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,[70] 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.

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[71] 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[72] 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[73] 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.

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CHAPTER IV.

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.

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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[80] 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[81] 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.

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SIGNS OF PREGNANCY, AND THE MEANS OF DETECTING IT.

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

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[84] 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[85] 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[86] 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[87] 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.

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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[89] 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[90] 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.

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,[91] 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[92] 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[93] 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[94] 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.

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[95] 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[96] 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:—

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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.

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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.

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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[104] 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.

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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[110] 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[111] opened, particularly in those who have borne children before. Indeed, in them the point of the finger may be introduced, as seen below:—

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[112] 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[113] 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[114] 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[115] 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[116] 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.

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[117] 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.

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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.

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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.

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

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

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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.

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[141] 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.

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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.

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FORM AND SIZE OF THE FŒTUS AT FULL TERM.

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.

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.

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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[150] 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:—

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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.

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

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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[154] 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.

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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[156] 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.

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,[157] 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.

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[158] 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.

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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.

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[161] 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.

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[162] 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.

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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.

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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[165] 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[166] 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[167] 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[168] 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[169] 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.

[170]

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[171] 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.

[172]

[173]

[174]
[175]
[176]

[177]

[178]
[179]
[180]

[181]

[182]
[183]

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[184] 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.

[185]

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.

[186]

[187]

[188]
[189]

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.

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,[190] 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.

[191]

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[192] 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.

In this position the legs and thighs are turned up[193] 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:—

[194]

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[195] the body also rotates, to accompany the head. This state of the parts is represented in the following Plate:—

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.[196] 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.

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.

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,[197] 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.

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[198] 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.

[199]

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.

The head descends with the forehead and chin nearly on a level, and the nose occupying the middle[200] 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.

The delivery is precisely the same in all the other positions of the face, excepting that in some of them[201] 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[202] 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.

[203]

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.

[204]

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.

This is the most usual mode for the fœtus to escape,[205] in each presentation, and in every position. By referring to the following Plates, and the accompanying descriptions, it will be readily understood.

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.

[206]

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

[207]

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.

[208]

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[209] 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.

[211]

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.

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.

[212]

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.

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[213] 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.

[214]

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:—

[215]

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

[216]

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[217] 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[218] 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[219] 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;[220] 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.

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 [221]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.

[222]

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[223] 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.

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[224] 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[225] 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[226] happen very frequently, if the examination be properly conducted.

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,[227] 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[228] 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.

[229]

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[230] 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,[231] 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.

[232]

[234]
[235]

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[236] 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.

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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[238] 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.

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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[240] 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[241] 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[242] are equal to the simple contrivances above-mentioned.

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[243] 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.

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[244] 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[245] 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[246] 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.

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[247] 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[248] 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.

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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.

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.

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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[251] 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[252] 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.

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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[254] 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.